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Fall 2008 | Volume 2 | Issue 2 ISSN 1918-7653


Lab to Village Interviewing Dr. Abdallah Daar and Dr. Peter Singer on bridging biotechnological innovations in developing countries

Where do we go from here? Environment and Health • OHIP Fallacy • Mental Health Barriers • Humanitarian Conflicts • Tackling HIV/AIDS




Volume 1 | Issue 1 | Fall 2005 Health and Human Rights

SPONSORSHIP DIRECTOR Faraz Siddiqui SPONSORSHIP ASSOCIATES Gabriel Fung, Vincent Khang, Yaru Lin


Dimitri Bollegala, Catherine Brown, Lauren Chakkalackal Benjamin Kwan, Ashley Lee, Sana Malik, Faraz Siddiqui COPY EDITORS Ailsa Chau, Stephanie Gan, Sarah Koerner Alec Barclay Mears Volume 1 | Issue 2 | Spring 2006 Poverty, Affluence and the Social Gradient

PHOTO EDITOR Chantelle Carneiro PHOTO CREDITS Mary Cameron, John Pringle, UN Photos COVER PHOTO CONTRIBUTORS Mary Cameron, Benjamin Kwan, Kate Jongbloed, Sonia Kalyniak, Ashley Lee, Nicodemus Oey, John Pringle, Chris Stamler, Jennifer Wang, Shane Shucheng Wong, Diane Wu, Kristen Yee


Special thanks to Dr. Abdallah Daar, Dr. Peter A. Singer and Munira Tayabali of the McLaughlin-Rotman Centre for Global Health and Dr. Clare Pain of the Toronto Addis Ababa Psychiatry Project. Volume 2 | Issue 1 | Fall 2007 Fear and Empowerment

For full manuscripts with reference, please email Juxtaposition.

Website: Email: Address: 21 Sussex Avenue, Toronto, Canada M5S 1J6


4 Editor’s Note

6 From Lab to Village

An introduction to the current issue and what lies ahead from Juxtaposition’s Editor-in-Chief.

We sit down with Drs. Daar and Singer, co-directors of the McLaughlinRotman Centre for Global Health, to discuss how biomedical advances are being employed to address global health issues.

by: Shane Shucheng Wong


by: Dr. Abdallah Daar, Dr. Peter Singer

UofT Launches Safe Drinking Water Campaign - Cambodia by: Mary Cameron

One sixth of the world’s population lives without regular access to safe drinking water. Author Mary Cameron describes her experience with the Centre for International Health from the University of Toronto in their quest to provide clean drinking water to families in Cambodia.



Health’s Waiting Game by: Chris Stamler


Desertification: Sands of Change by: Jennifer Wang

Canada has taken pride by providing universal health care to every citizen and permanent residents, but why is there a three-month lag period for immigrants in Ontario, Quebec, British Columbia or New Brunswick?

A changing tide of sand and ecological cost, desertification threatens both the local and global community as migration and disease escalate and the voice of caution remains neglected.



Military Invasion of Humanitarian Space by: John Pringle

All too often we see images of friendly soldiers interacting with civilians. Could military and humanitarian actions be compatible?


The Key Population by: Diane Wu

A Bleak Future? UNDPKO & Sex Abuse

by: Kristen Yee

Once a greatly respected division of the United Nations, the Department of Peacekeeping Operations is being scrutinized for accusations of sexual abuse as peacekeeping personnel continue to exploit their position of power despite the UN’s attempts to impede the offences.


Gender Education & HIV/AIDS in Lesotho by: Sonya Kalyniak

Like viral Russian roulettes, sex workers are at high-risk in becoming the epicenters of HIV transmission. What can we do to help this vulnerable population?

Help Lesotho is a Canadian based organization helping to prevent HIV/ AIDS in the country of Lesotho, located in the southern region of Africa. Author and intern, Sonya Kalyniak, addresses issues of gender inequity through education.



Combating HIV/AIDS through Empowerment by: Kate Jongbloed

To address the complex underlying issues of HIV/AIDS, we need multifaceted approaches such as economic empowerment projects that help to tackle the social and economic causes of HIV/AIDS.

Vitamin A: A Life’s Work

by: Benjamin Kwan, Dr. Alfred Sommer

Dr. Alfred Sommer, a physician and public health advocate from the Johns Hopkins School of Public Health shares with us his work on combating micronutrient deficiency.


Perspective, education, global awareness Since the inception of Juxtaposition 5 years ago, the magazine has grown to over 25 staff members and now reaches over thousands of readers internationally. We have achieved several milestones starting with our last issue, Fear and Empowerment, when we launched our first-ever print production to compliment our online pdf format. Insightful discussions have been generated among our community and the magazine itself has served as an effective platform in harnessing student creativity and fostering new partnerships and collaborations.

Dr. Clare Pain, director of the Toronto Addis Ababa Psychiatry Project (TAAPP), to illuminate a segment of public health that is often overlooked and given low priority by the healthcare community. Issues stemming from HIV/AIDS continue to bear high significance on the international agenda. Located in the southern part of the African continent, Lesotho has one of the highest HIV infection rates at 23%. Sonya Kalyniak reflects on her experience as a social worker involved with Help Lesotho, a Canadian based organization that aims to address gender-related determinants of HIV/AIDS through education. Additionally, Kate Jongbloed discusses economic empowerment projects that help to tackle the social and economic causes of HIV/AIDS. Examining the most vulnerable population of HIV/AIDS, the sex workers, Diane Wu shares with us her observations and stories from her fourmonth long internship with the Canadian International Development Agency.

This past year, we were extremely excited to receive recognition and financial support from both the Postgraduate Medical Education Office of the Faculty of Medicine and the McLaughlin-Rotman Centre for Global Health. In particular, we wish to extend our gratitude to Dr. Sarita Verma, Dr. Abdallah Daar and Dr. Peter Singer. With a long-term goal of sustainable sources of funding, we strive to keep Juxtaposition in print format. Our 3rd issue was a huge success in this regard and has been a great medium for student engagement.

While the world’s attention is currently fixated on global warming and renewable energy, we should not forget the impact of our surroundings on our health. Mary Cameron describes her experience with the Centre for International Health from the University of Toronto in their quest to provide safe drinking water to families in rural Cambodia. Jennifer Wang investigates the effect of desertification on health both at the local and global level as migration and disease escalate, and the voice of caution remains neglected. In addition, Nicodemus Oey takes us on a journey through Borneo with Rural Community Health Improvement program and documents health challenges faced by the remote villages in the rainforest.

In an effort to further broaden the scope of each issue, we have moved away from an overarching theme, which allows us to present a diversity of topics pertaining to global health. We are pleased that this issue is a culmination of work that includes University students from Toronto and Yale, prominent public health researchers from Toronto and Johns Hopkins, as well as student interns and Médecins Sans Frontières staff in Africa - all working towards making a better tomorrow around the world.

We finally take on issues of conflicts faced by aid workers and Peacekeepers as well as policy shortcomings. John Pringle argues that military should not engage in humanitarian actions to prevent blurring of their functions and endangering aid workers, while Kristen Yee scrutinizes the sex abuse allegations on UN Peacekeepers. Bringing the attention back home, Chris Stamler then questions the existence of a three-month lag period for new immigrants to be accepted into the Canadian healthcare system in provinces such as Ontario, Quebec, British Columbia and New Brunswick.

We kick off this issue with an interview from two renowned global health advocates and researchers here in Toronto, Dr. Abdallah Daar and Dr. Peter Singer, discussing the ethical, political and social implications of biomedical innovations for low-income countries. As co-directors of the McLaughlin-Rotman Centre for Global Health, Drs. Daar and Singer continue to facilitate and strengthen the role of biotechnology in the North-South collaborations between Toronto and countries in Africa and Asia with due diligence, helping to link translational research from the lab to the villages. To further showcase work of other researchers in applying biotechnology to global health research, Benjamin Kwan speaks to Dr. Alfred Sommer, Dean Emeritus at the Johns Hopkins School of Public Health, who shares with us his research on vitamin A deficiency and his role in reducing global blindness. Adding to these two interviews, Shane Wong discusses barriers in providing mental healthcare in low-income countries with

While the complexity of issues in global health remains persistent, the tireless dedication and innovative contribution of people working this growing field provide much hope. As you go through this issue, may you be inspired to make a difference to others around us - to ultimately make issues of poverty and injustice an obsolete footnote in our history.

Shane Shucheng Wong Editor-in-Chief 2007/2008 4

At the heart of the availability of innovative health technologies is the problem of the uncertain path and unacceptable time lag from discovery and development to commercialization and delivery of appropriate and affordable products to people in the developing world. The McLaughlin-Rotman Centre for Global Health is a researchbased academic centre at the University Health Network and University of Toronto. Our Mission is to conduct translational research in global health and help researchers and companies get their life sciences technologies to those who need them in the developing world. Our Vision is to illuminate the path towards a world where everyone benefits from new diagnostics, vaccines, drugs and other life science solutions. We have created a unique approach to address the lab to developing world problem through the following two programs: The Sandra A. Rotman Laboratories strive to solve clinically relevant and priority problems in global health with the modern tools of molecular discovery, and an emphasis on translational research. The Program on Ethics and Commercialization focuses on developing new models and approaches to commercialization by linking science and business, and involving the domestic private sector in the developing world.

For more info visit Join us on Facebook at Global Health Engage 5

FROM LAB TO VILLAGE An Interview with two leading doctors from the McLaughlin-Rotman Centre for Global Health’s Program on Ethics and Commercialization


recent years, there has been a burgeoning interest in harnessing biotechnological innovations for the improvement of health in developing countries. Innovations surrounding vaccine development and other technological interventions have increased dramatically to meet pressing needs for disease amelioration in malaria and AIDS. However, while scientific knowledge is of crucial importance, commercialization of such innovations is an essential next step.

Dr. Abdallah Daar Dr. Peter Singer

for which we work with the African governments to help accelerate their commercialization and it has been featured in an article published by the MIT Innovations Journal.”

“Since your 2001 article titled Harnessing Genomics and Biotechnology to Improve Global Health Equity, what sustainable examples of genomerelated biotechnology have been successful in addressing real problems within developing countries?“

Fundamental to the progression of this field has been the development of the McLaughlin-Rotman Centre for Global Health (MRC) based at the University Health Network and University of Toronto. MRC is a affiliated research organization with the clear mandate to translate biomedical breakthroughs into cost-effective technologies that will improve global health. Additionally, it seeks to further engage Southern collaborators in establishing sustainable initiatives that will support local innovation in developing countries. To enhance our understanding of current research, Co-Directors of the MRC’s Program on Life Sciences, Ethics and Policy, Dr. Abdallah Daar and Dr. Peter Singer, sat down with Juxtaposition to discuss current trends in global health, with a focus on how to take science “from the lab to the village”.

Dr. Daar: “It is more important to identify the overarching trends than to focus on individual examples. Enormous changes have taken place in the last 7 years in the consciousness of the world with regards to science and technology after that paper was published. For example, almost all countries in Africa have committed to spending 1% of their GDP on science and technology, which didn’t

“Almost all countries in Africa have committed to spending 1% of their GDP on science and technology.” exist 7 years ago. Secondly, because of its enormous resources, there has been a particular focus in Africa, on harnessing the life sciences in the areas of health, agriculture, mining, environment, etc. I am part of the African Union High Level Panel commissioned by the African Union that put out a recent report entitled “Freedom to Innovate” that examines this potential. It has recommendations that have informed a 20-year African strategic plan for harnessing life sciences. Big groups such as the G8, TICAD, etc for example, have focused on Africa over the past three years and are thinking of putting in more resources into science and technology. All of the aforementioned are new developments. Thus, there has been a huge shift in the way developing countries think about science and technology and its potential applications. Around 2003, we published a series

Juxtaposition: “What are the key challenges in global health that you feel the MRC is addressing?” Dr. Daar: “There are a number of ways to talk about challenges. I will start with our work with the Bill and Melinda Gates Foundation’s ‘Grand Challenges in Global Health Initiative’ which outlines 14 challenges such as developing vaccines that don’t require refrigeration, creating vaccines that can be given at birth, and discovering drugs and delivery systems that minimize the likelihood of drug-resistant microorganisms. Our long term goals are to ensure that these technologies are developed rapidly, and delivered to where they are needed safely and affordably. In the end, we want to achieve our ultimate aims which are to save lives and improve health in the developing world. We are also interested in the use of science and technology for development generally.”

DR. ABDALLAH DAAR is the Director of the Program on Ethics and Commercialization at the McLaughlin-Rotman Centre for Global Health. Dr. Daar is also a Professor of Public Health Sciences and of Surgery at the University of Toronto. He won the 2005 UNSECO Avicenna Prize for Ethics in Science.

Dr. Singer: “Additionally, the MRC has two components - a discovery and development side as well a delivery and commercialization side. On the discovery and development side, we have Dr. Kevin Kain and Dr. Conrad Liles who are doing some exciting work on malaria. On the delivery and commercialization side, we do four things. Firstly, we help launch grand challenges that Dr. Daar has described. Secondly, we provide ethical, social, cultural and commercial consults to grand challenges programs. Thirdly, we work on emerging economies in commercialization. For example, we had a conference last May with biotechnology companies from India and China with a global health focus to foster partnership. We also published a series of articles of Indian and Chinese biotechnology companies. And fourthly, we have the MaRS Africa program

DR. PETER A. SINGER is the Director of McLaughlin-Rotman Centre for Global Health. Dr. Singer is also Professor of Medicine at the University of Toronto and was the recipient of the 2007 Health Researcher of the Year Award from the Canadian Institutes of Health Research.


of papers that looked at Cuba, Brazil, Mexico, South Africa, Egypt, China, India and for comparison, South Korea and how those countries are harnessing biotechnology for health. Mexico has established an institute called The National Institute of Genomic Medicine, which is probably one of the most advanced in the world in linking public health and genomics. Other countries such as Brazil and China are also doing a lot of work in this area. In fact, China has always been at the forefront of genomics: it was the only developing country in the Human Genome Project featured in the publication reporting the sequencing of the human genome.”

the price as well. India took the insulin cost from more than 400 rupees per vial of 100 IU down to less than 100 over a period of a year or two. All these are important and they are sentinels of what’s coming down the road. The key to sustainability is affordability and autonomy in development and production.”

“What are the political trends in funding pertaining to the global health field? While the governments especially the US are investing more and more in research and health care, how does this impact your vision and mission within the realm of business entrepreneurship?”

Dr. Singer: “The ones that are closer to success are for example the malaria vaccine which is going into phase III trial which is exciting. Some of the needlefree vaccine technologies are getting closer as well. There are other examples of technologies that are close which weren’t the case 7 years ago when our paper was published. There have also been disappointments – the Merck HIV vaccine trial as well as the two microbicide trials published to date have been a

Dr. Singer: “There is definitely a lot more funding now - $70 billion endowment at the Gates foundation spending $3 billion per year. There is a huge set of investments by the US under PEPFAR and so on, but still mostly on the delivery side. Even in the last federal budget this year, $50 million goes towards the Development Innovation Fund which is about science and the developing world. You see a big increase in funding for global health and funds that can be generated for global health; most of it is for access to products and delivery, but you also see an increase in the amount of funding that goes into innovation - a few billion into the advance market commitments for the pneumococcal vaccines, for example. In addition, the Grand Challenges project is a $500 million program. A lot more funding is available now - most in delivery so far but some are moving upstream into development and discovery. It’s actually a much more optimistic situation now in terms of funding compared to 7 years ago when we wrote that article.”

“ When you are in the high risk area of technology, you have to toughen yourself up for some disappointments and build on your successes.” huge disappointment which is to say that when you are in the high risk area of technology, you have to toughen yourself up for some disappointments and build on your successes.”

“Are there ethical criteria for private sector relationships within developing countries? If so, what are they and are they realistic?“ Dr. Singer: “When we say the private sector, we start by thinking about the small to medium enterprise sector in the developing world themselves. Take a concrete example of A to Z Textile Mills in Tanzania which is the largest manufacturer of the long-lasting insecticide treated malaria bednets in Africa. It’s a private company that makes 10 million nets a year and it employs 5500 people. If there was not only one, but 100 businesses like A to Z in various sub-sectors in Africa manufacturing products operating on a sustainable basis tackling health, we would be better off. We feel strongly that the private sector has a strong role to play, primarily those that are small to medium enterprises. You cannot deliver on scale products and services to four billion people in the developing world without the strong participation of the private sector.

“What key innovations hold promise within the developing world? Are they sustainable?”

Dr. Singer: “You can generally think of global health innovation in three phases. In the first phase, which is between pre-history and 1996, there was almost no innovation in global health; there was the yellow fever vaccine, malaria blood smear, and Koch discovered tuberculosis bacillus. That is the age of empty pipeline. Around 1996, the first cases of product development and public-private partnerships arose such as the International AIDS Vaccine Initiative. This is really about the public and private sectors getting together to make the pipeline move forward. There are now 60 products or so in the pipeline entering field trials; a lot of these have been funded by foundations such as the Gates and Rockefeller. This was a great phase but has been more focused on Northern Multinational corporations also have a role to play in fostering that sector. innovations for Southern problems. The phase we are in right now is the phase Having said that, one needs to look at how companies behave. The starting of global innovation. You’ve got stories point has to be meeting the health needs. like Shantha Biotechnics that brought The issues of corporate responsibility “ The phase we are in right now is are also very important. We have a book the price of the hepatitis B vaccines down. That is what is going to make of case studies of bioscience companies the phase of global innovation.” it sustainable in the long-term; people that addresses ethics and some of the closer to the problems innovating on the key things are reporting and maybe even problems and participating in the global value chain of innovation.“ auditing, both financially and socially. This is a very effective mechanism for large companies in seeing that the mission and vision around the ethics plays into Dr. Daar: “The Indian company that Dr. Singer talked about, Shantha Biotechnics, their human resource policy for example. Without the strong participation of the was able to also dramatically decrease the cost of hepatitis B vaccine from $13-14 private sector especially the small to medium enterprises in the developing world, to about 39 cents a shot. This means that millions of people now can get access it would be impossible to solve this conundrum of global health inequities.” to it. Another example is the insulin which is controlled by 3 companies, but now locals can make insulin by recombinant technology that drastically dropped


best one; there are only three or four others of real small to medium enterprises outside of South Africa that are innovating on global health problems. In a country like Tanzania, you’ve got good research and commercialization, but they are like parallel tracks on the railroad and they don’t meet. We were in a meeting in Dar es-Salaam, Tanzania and we met this person who stood up and started talking about his malaria research on insecticides and bednets for the past 25 years and his products are papers in other academic journals. At the same time, the people from A to Z stood up and talked about their bednets, which they obtained the license to produce from a large Japanese company called Sumitomo that provides the technology to improve the longevity of the bednets or otherwise, the insecticide is removed in the wash.

“How do you perceive ownership and patent laws within the context of private sector relationships?“ Dr. Daar: “This is inherently a hugely complex subject. Intellectual property (IP) regimes are not fixed in stone. To give you an example, we travel a lot and we come across this problem frequently: a scientist has discovered something but he or she does not want to tell his or her lab colleagues because there is no patent existing in that country to protect its invention. As a result, that invention gets bottled up and fails to get disseminated; even he or she doesn’t benefit from it because there’s no patent. If you ask me who really needs the patent system to serve real needs, it’s more the developing than the developed world – the latter is already reaping the profits. In the early days, the US ignored European IP rights and broke the rules in order to build up its innovation system. You can’t get away with that today but you can legislate what suits you best, and you can work within the global system and you can be smart to get what you want out of it.

There is very little in invested life science venture capital in Africa outside of sub-Saharan Africa. There is tremendous wastage of the ideas - a young African scientist has to yet to attain the capacity to take an idea for a product, finance and develop and finally deliver it to the community. You can do it here but not there. Talent and bright ideas are world-wide. Why do you think large multinational corporations are scouring China and India for talents and not in Africa? It’s just being wasted or lost through brain drain. This needs to be addressed.”

Countries have the opportunity and power to do what they want with IP. You can use IP to do three things at different levels of development. Firstly, you

“ If you ask me who really needs the patent system to serve real needs, it’s more the developing than the developed world.”

“Speaking of which, what are your perspectives on the brain drain since there is a massive health care disparity between developed and developing world?”

can use IP simply to create access to health goods. Secondly, you can use IP regimes to build scientific capacity, which is an intermediate step. Thirdly, when you do have the infrastructure, you can use IP regimes to serve the purpose of capturing the value of your research and development so you can get profit out of it. Developing countries need to be smart about what they want with IP, and they need to understand the flexibility built into it so they can legislate the way they want with it with certain minimum constraints when they sign on to the World Trade Organization.”

Dr. Daar: “This is a very important question that illustrates the spectrum of issues that need to be addressed. Doctors and nurses trained in the developing world are leaving their own countries. In some countries, Ghana for example, half of the doctors are leaving to work in the West or in other countries in Africa. It’s a huge problem in those countries. The real question is whether this can be stopped and the answer till now is that it cannot. People will find a way to leave. What do you do? We did a study of diaspora populations working in three biotech clusters in Toronto, Montreal, and Vancouver that was subsequently published in Science. We were interested in how you can convert from brain drain to brain gain. What can those diaspora scientists and entrepreneurs contribute without going back to their countries of origin? They have managerial capacity, knowledge, networks, ability to invest, to go back and teach and take on graduate students here, etc without going back permanently to their countries if they don’t wish to. One thing we know for sure is that all the people we talked to in that study were very keen to help their countries back home but didn’t have the means to do so. There is no government policy in Canada or in other receiving countries to make it possible to help them help their original countries. We came up with a few

Dr. Singer: “In addition, India and China for instance have agreed and are implementing TRIPS (Trade-Related aspects of Intellectual Property Rights) heavily starting in 2006 which in the long term is good for global health because countries are taking local innovations seriously. The African countries have until 2016 because they are less developed; what they should be doing now is building their capacity so that when TRIPS comes in 2016 or possibly later in Africa, they are ready to take full advantage of it.”

“How are countries managing to engage and recruit domestic firms to the challenge of global health inequity?” Dr. Singer: “There is a lot that Indian and Chinese companies are already contributing to global health. You’ve got the example of Shantha Biotechnics innovating in hepatitis B vaccines and making it more affordable. You’ve also got Shanghai United Cell Biotech that is one of the only two manufacturers in the world that makes oral cholera vaccines. As they develop early on, they almost only focus on their local markets. The challenge over time as local companies face the multination corporations is - how do you make sure they stay focused on global health instead of coming up with another blockbuster drug for hypertension that they want to sell in the US? In terms of Africa, you’ve got only a few examples like A to Z which is the

Dr. Peter A. Singer and Dr. Abdallah Daar with members of Juxtaposition


“ What kind of world is it when you can live to 80 but if you are born in the rural setting in some parts of Africa you get to live to half of that age? This is the mother of all ethical challenges and this is a very strong motivating force. ” policy recommendations in our article. At the moment we’ve just reached stage one, which is to recognize that there is a problem and there are potential creative solutions. There are also, of course, circumstances whereby people will return.”

This has to do with focusing on the use of science and technology knowledge in terms of creating products initially for local problems, then regional and global markets. You can not develop economically without that focus on domestic innovation.”

Dr. Singer: “A good example of people returning to their home countries is the “sea turtles” in China (The term “sea turtle” in Chinese is a pun that refers to people who have returned to their home country). We have featured on our China paper in Nature Biotechnology Ge Li, a “sea turtle” who founded WuXi Pharma Tech in China which mainly does outsourcing of research and development. This shows that it is possible for people to return to their home countries.”

“ It’s really a golden era for global health.”

“Is it possible to establish real 50/50 partnerships with developing countries (i.e. North- South collaborations)? With so many of these countries still heavily indebted and reliant on donor funds, how are these “equal” collaborations facilitated? “ Dr. Singer: “That’s ideal, isn’t it? In theory it’s possible. Certainly in terms of the moral commitment, it’s mandatory. In terms of the actual science, it’s a matter of mutual respect among people and that’s what you strive for. There are inequities in scientific knowledge. This is part of the way to build capacity to make it more sustainable. The equal partnership is a great ideal and that’s what everyone should strive for. You build it in the programmatic initiatives, but you don’t want to use it as ideological hammer to hit people over the head with because then you won’t get the discoveries you need.What is at stake here is how you move from the lab to the village. The process of moving from lab to village has gone unconscionably slowly. The hepatitis B virus was discovered in the 70’s, the first vaccine was discovered in the 80’s but it wasn’t until the 90’s when Shantha made it affordable and even now, hepatitis B is a huge problem and there are lots of primary liver cancer. Why does it take so long from discovery to delivery? What kind of world is it when you can live to 80 but if you are born in the rural setting in some parts of Africa you get to live to half of that age? This is the mother of all ethical challenges and this is a very strong motivating force. The other point is that I’ve been so impressed with the motivation and engagement of young people who are really going to move this along. I’m hugely optimistic because you see all this attention and funding on global health especially on Africa and new products in the pipeline, it’s really a golden era for global health. The issue is to translate that money, enthusiasm and attention into the discovery and development that are needed. We need to rethink foreign aid. There’s a strong role for humanitarian assistance but there’s also a strong role for making sure what you are doing has some chance of leading to a situation where the country you are helping won’t need your help in 20 years. Fifty years ago, the GDPs of Ghana and Korea were the same. Today, Ghana and Korea are totally different countries.


University of Toronto Mary Cameron Launches Safe Drinking Water Campaign in Rural Cambodia The United Nations has declared World Water Day on March 22nd 2008 to promote action to increase access to clean drinking water and raise awareness of its importance to health. Yet, what does clean water mean to us in Canada? For most of us, clean water means turning on the faucet of our kitchen sink. However, for much of the world, it is a rare luxury to which only the privileged have access. Since we cannot survive without it, clean drinking water should be considered a fundamental human right. Sadly, one sixth of the world’s population live without regular access to safe drinking water and are forced to drink whatever they can find. Further, lack of access to portable water is inextricably linked to poverty and inequitable access to education, health care, sanitary infrastructure and other resources. Cambodia’s limited resources are highly concentrated in its urban centres, rather than the rural areas where the vast majority of the country’s poor population resides. This means that adequate health care, sanitary infrastructure and other resources are inaccessible to those who need them most. As a result, poor people, who are often the majority in many countries, are forced to expend considerable energy confronting illness, disease and death instead of pursuing education and improving the social and economic standing of their people. In short, the poor become trapped in a cycle of disease and poverty where the burden of their illness prevents them from living a productive life.

vast majority of Kep does not have running water or a waste disposal system even in the local public health centres, and most residents of Kep obtain their water from streams, ponds and dug wells. These water sources are extremely vulnerable to contamination by various pathogens in the environment. In 2007, students from the University of Toronto sampled and tested the quality of 158 drinking water sources in the 16 villages of the Kep Municipality; it was found that 75.8% contained unsafe of levels of E.coli., the same type of bacteria involved in the Walkerton Tragedy in Ontario in 2000. These results astonished the investigators as well as the local health authorities, and it was evident that measures had to be taken to improve the community’s access to safe drinking water in order to avert widespread illnesses and waterborne diseases in the region. Waterborne illness is one of the primary causes of mortality in Cambodia. By failing to provide adequate protection of water sources and effective treatment, the community is exposed to the risks of epidemics of intestinal and other infectious diseases including diarrhoea, dysentery, typhoid fever, cholera, hepatitis, parasites and gastroenteritis. In fact, it is estimated that 41% of deaths in Cambodia are attributable to lack of access to clean water and adequate levels of sanitation. Supporting this estimate is a 2005 CIH study carried out by University of Toronto student researchers who found that 15-30% of subjects surveyed in the Kep region had experienced symptoms of waterborne disease within the two weeks prior to the study.

Since 2002, the Centre for International Health (CIH) from the University of Toronto has been working in Cambodia to promote community health and conduct research to advise public health initiatives on issues of clean drinking water. Over there, nearly two thirds of the rural population and one quarter of city dwellers still rely on unsafe water sources. Under a multidisciplinary collaboration of faculty, students, and staff from the University of Toronto’s Faculty of Medicine, the CIH aims to improving global health status through research, teaching, and fieldwork. CIH’s Cambodia Program conducts most of its research and activities from its field station in the Municipality of Kep, which is located on the southeast coast of Cambodia.

To combat these issues, water filtration systems such as ceramic water filters have been found to significantly decrease bacterial loads in drinking water, thereby reducing illness and disease. However, as 35% of Cambodians (and up to 79% in some rural areas) are living below the poverty line (about $0.45 US per person per day or $2.25 per day for a family of 5), a ceramic filter is simply unaffordable for many families in Kep. In fact, University of Toronto student researchers in 2005 found that in most villages in the Kep Municipality, 75-90% of households did not own water purifiers, primarily due to a lack of money. More recently in 2007, CIH found that 75% of families surveyed were still drinking untreated water.

Kep is a rural area with a population of about 37 000 spread over 16 villages. The

“We shall not finally defeat AIDS, tuberculosis, malaria, or any of the other infectious diseases that plague the developing world until we have also won the battle for safe drinking water, sanitation and basic health care.” - Kofi Annan, former United Nation Secretary-General 10

In response to these findings, the CIH has launched a campaign to provide ceramic water filters for the most vulnerable families in Kep to increase access to safe drinking water and improved health, which are “luxuries” that would otherwise be restricted to the affluent. These ceramic water filters are produced by Resource Development International Cambodia, a non-profit organization dedicated to developing low-cost, low-tech solutions to improve water quality and sanitation in Cambodia. The filters consist of a large plastic storage container lined with a specially constructed ceramic pot and plastic faucet installed at the bottom of the container from which to draw the filtered water. Easy to use, these ceramic water filters work by simply pouring the contaminated water through the top of the container into the porous ceramic pot inside which filters out the germs, bacteria, and other impurities. The filtered water is collected at the bottom of the container and is drawn from the plastic faucet. This system is especially valuable in areas where electricity is not available or where minimal understanding of germs and water born illness is prevalent, such as in Kep. The ceramic water filters are reusable and often last several years, making them a culturally-appropriate and long-term approach in improving water quality and reducing waterborne disease in Kep. To determine the recipients of the filters, the CIH’s safe water campaign has joined up with its Most Vulnerable Family List (MVFL) Project in Kep. The MVFL project, a community-based initiative, is part of a National Strategy to identify the country’s poorest households. By linking these two projects, CIH has been able to target water filter distribution to those who are in most need. Moreover, CIH has coupled the distribution of the filters with health education so that recipients understand the importance of clean water to their family’s health and how waterborne disease can be avoided. Thus, this campaign has allowed CIH to reach the region’s most vulnerable families and deliver not only a safe water source but also the knowledge required to maximize the benefits to their health. Community health projects such as the safe water campaign and the Most Vulnerable Family List project are only one component of the CIH’s activities in Kep, which also include research, health promotion, clinical care and training. This year the CIH will be focusing its research on maternal and mental health, health equity funds, and the emergence of “Western” diseases such as diabetes. In health promotion, the CIH is conducting community education on priority health issues such as HIV, tuberculosis, malaria, dengue fever and breastfeeding. With the help of volunteer physicians from Canada, the CIH is also able to provide outreach clinics to remote areas of Kep that would not otherwise receive medical care. Furthermore, the CIH has made an even greater clinical impact with its medical training programs for local health workers, such as the recent training on enhanced obstetrical care for local midwives conducted in March of this year.

Mary Cameron is a University of Toronto alumnus who has been living and working in

Kep, Cambodia for the last six months through an internship program funded by the Canadian International Development Agency. During her internship, Mary worked with the Centre for International Health field staff on community health project development and research. Mary is beginning her Master of Science in Epidemiology and Community Medicine this fall at the University of Ottawa.

The ultimate goal of the safe water campaign is to provide each family identified by the Most Vulnerable Family List project with a ceramic water filter and awareness of water and sanitation issues in their community, i.e. the tools required to ensure that safe drinking water and freedom from waterborne disease is attainable for all members of the Kep community, regardless of their socioeconomic status.


Examining the OHIP Coverage Waiting Period in Ontario

Chris Stamler



ANADA’S health care system provides universal coverage for both emergency and primary care services and should be available to every Canadian citizen and permanent resident living in the country. Yet four provinces do not provide health care insurance to the vast majority of permanent residents during their first three months of residency in Canada: Ontario, Quebec, British Colombia and New Brunswick. This three month delay significantly hinders settlement, particularly if newcomers are faced with unexpected medical emergencies.

Waiting Period in Ontario is unnecessary, impedes access to primary health care and can place a devastating financial burden on new immigrants following medical emergencies. Healthy Immigrants Face an Unhealthy Policy Acquiring permanent resident status as an economic class immigrant in Canada is a long, rigorous and detailed process. According to CIC, 80% of economic class immigrant applications require an average of 45 months to finalize and applicants are not guaranteed approval.

The case of Manuel Vergara truly puts this issue into perspective. In 2003, Vergara arrived in Quebec and did not have health insurance for his family. Shortly after arriving, Vergara’s daughter experienced severe abdominal pains caused by an inflamed appendix that eventually ruptured, resulting in a hospital bill of over $18,000. These unforseen financial costs far exceeded the reaches of Vergara’s capability, especially as a newcomer to Canada. Unfortunately, Vergara’s experience is not an isolated incident. This article will discuss the health insurance waiting period and its resulting impact, using OHIP as an example.

Twelve months prior to becoming a permanent resident in Canada, all applicants must pass a medical examination conducted by a medical practitioner designated by the CIC and paid for by the applicant. The application can be judged inadmissible if the medical examination reveals that the applicant either: 1) poses a danger to Canada’s public health and safety and/or 2) would place excessive demand on health care or social services in Canada. Family members of the applicant are also required to undergo the same medical examination, even if they do not intend to travel to Canada. Given this lengthy immigration process that entails thorough medical screening, new immigrants arriving in Canada are likely to be in good health and therefore are not expected to place a burden on the health care system.

Immigration in Canada Canada’s diverse and dynamic landscape is significantly shaped by the skills, efforts and character of immigrants. On average, 225 000 newcomers become permanent residents of Canada every year. In 2006, over 125 000 permanent residents settled in Ontario. Without this influx of immigrants, Toronto’s workforce population would have actually declined in recent years. Thus, Canada has economic and social reason to value immigrants and maximize their unique capacities in Canada.

In fact, evidence indicates that new immigrants have lower rates of diabetes, high blood pressure, heart disease and cancer than the Canadian-born population. This phenomena has been termed the “healthy immigrant effect”. However, the healthy immigrant effect is transient; studies suggest that after several years of living in Canada, the health of newcomers deteriorates and eventually converges with native-born Canadians.

Migration is dependent on personal factors and global events including conflicts, politics, economics and natural disasters. For this reason, migrants are classified according to their reasons for migrating. In Canada, migrants are categorized as economic class immigrants, refugees and family class immigrants. Over half of all new permanent residents in Canada are economic class immigrants. They are admitted to Canada based on their professional expertise and anticipated contribution to the workforce. This differs from refugees who are identified as protected persons by the government and are awarded permanent residency status based on humanitarian and compassionate grounds. Lastly, family class immigrants are spouses, dependents, parents and grandparents of the sponsor.

Given the emphasis on good health prior to arriving in Canada as well as the healthy immigrant effect, immediately establishing health care coverage in Canada would facilitate continuity of immigrants’ good health status. In the case of economic immigrants, optimal health is vital to securing and maintaining employment. Medical emergencies that immigrants and their families may face during their first three months in Canada, as illustrated in Vergara’s situation, are unforeseen and without adequate health insurance coverage, warrant extraordinary costs to newcomers. Paying a Price for Health During the OHIP Coverage Waiting Period, the Ontario Ministry of Health and Long-Term Care recommend that immigrants purchase private health insurance schemes. Timing is fundamental to acquiring health insurance; the Canadian Health and Life Insurance Association strongly suggest newcomers apply for private health insurance within five days following arrival in Canada. Applications made after this five-day window are considered to be “high-risk” and risk disapproval by health insurance companies.

Regardless of the reason, relocation to a new setting is inevitably associated with struggle. Newcomers to Canada must adapt to their new social, political, economic and cultural environment. The ability to adapt successfully requires many factors such as experience, networks and importantly, good health. To facilitate smooth and efficient integration into Canadian society, Citizenship and Immigration Canada (CIC) offers new immigrants a number of social programs that increase employability and improve language skills. On the other hand, the government fails to ensure immediate access to health insurance coverage for recent newcomers in some provinces, such as Ontario. The OHIP Coverage

Generally, private health insurance programs cover medical emergencies,


necessary treatments and related medical tests. However, they do not cover medical treatment for conditions that developed before private insurance was purchased, even if the patient was unaware of the pre-existing condition . For example, treatment for diseases such as malaria would not be covered by private health insurance schemes. Additionally, private health insurance does not cover regular primary care screening nor disease prevention.

If economic immigrants serve a vital role in the maintenance and growth of the economy, then the OHIP Coverage Waiting Period for new immigrants negatively impacts Ontario’s economy. For example, a newcomer who suffers from an injury during their first three months in Ontario may not receive necessary medical care if they are unable to afford a private health insurance plan. Lack of health care in this period may exacerbate their injury, potentially leading to increased pattern of disease and a loss of employment productivity. Moreover, as Vergara’s case exemplifies, the financial and emotional impact of an unanticipated medical emergency on the entire family must also be recognized.

Premiums for private health insurance may cost between $180 and $720 CDN for a three month period depending on the individual’s risk category. It is therefore not surprising that many new immigrants do not have any health insurance coverage. While some Community Health Clinics in Toronto treat patients without health insurance documentation, many report operating at full capacity. Therefore, new immigrants in Ontario with limited finances are left with little choice but to live without any type of health insurance during their first three months in the province.

Policy Recommendations Perhaps the single, most important amendment that can be made to provide newcomers with access to publicly-funded health care is to remove barriers such as the OHIP Coverage Waiting Period. Certainly, many provincial groups have been advocating for such a policy change, including the Ontario Council of Agencies Serving Immigrants. Their rationale, as reflected in this article, is that the OHIP Coverage Waiting Period prevents particularly vulnerable groups of immigrants (those living in poverty, notably from racial communities) from obtaining health care should any health complications arise during their first three months in Ontario. They state that the often expensive private health care alternatives are not viable for these groups, and have strongly urged the Ontario government to provide immigrants with immediate access to OHIP.

Why Three Months? The Medical Care Act of 1966 outlines the original intent of the three month wait period. One of the principles of this act describes the portability of health insurance. To paraphrase, the act states that when an insured resident moves to another province, the province of origin will provide medical care benefits during the period in which insurance is not yet available to the individual in their province of relocation. Specifically, the act states that no province can impose a wait period longer than three months.

It would be beneficial for the Ontario Ministry of Health to encourage new immigrants to visit a family doctor immediately after arrival to the province. This would help establish a doctor-patient relationship and initiate primary healthcare screening and disease prevention. Unfortunately, this strategy can not effectively be implemented with the current OHIP Coverage Waiting Period in place.

The purpose of this policy was to ensure continuity and standard health insurance to Canadian citizens and permanent residents migrating within Canada. This three month time limit forced each province to process applications from new residents in a reasonable and timely fashion. The portability principle carried over to the more recent Canada Health Act of 1984. As a result, new immigrants arriving to Ontario, Quebec, British Columbia and New Brunswick must reside in these provinces for at least three months before acquiring provincial health insurance coverage.

Conclusion Historically, immigrants have been instrumental throughout Canadian history and currently play an essential role in the workforce of Ontario. The OHIP Coverage Waiting Period for accessing health insurance is an unnecessary barrier for these new immigrants and their families. The magnitude of the problem is difficult to appreciate but it most likely places an added strain to the Ontario economy. This policy impacts over 100,000 immigrants arriving in Ontario every year. Ontario should follow the lead of the majority of Canadian provinces and abolish the OHIP Coverage Waiting Period for new immigrants.

Removing the OHIP Coverage Waiting Period The case for abolishing the three month wait period for new immigrants in Ontario is strengthened after examining Regulation 552 of the 2007 Ontario Health Insurance Act. Here, groups exempt from the OHIP Coverage Waiting Period are outlined. Many of these exemptions have been added as amendments to the original act in recent years. For example, refugees, children under the age of 16 who are adopted by an insured person, or inmates who are released from a penitentiary or correctional institution can access OHIP immediately upon arrival in Ontario. Most relevant to the category of economic immigrants are seasonal workers who, authorized under the Caribbean Commonwealth and Mexican Seasonal Agricultural Workers Program, are also exempt from Ontario’s OHIP Coverage Waiting Period. This seasonal work program was initiated between 1966 and 1974 to encourage skilled agriculture laborers to work in Canada during the periods of high farming demand. In 2002, over 10,000 seasonal Mexican workers came to Canada to work on farms; in Ontario, all had access to OHIP immediately upon arrival. In the same vein, economic immigrants fill a void in the workforce and should also be provided immediate health insurance coverage.

Chris Stamler is currently in his second year of medicine at the University of Toronto. He

has recently worked with Access Alliance Multicultural Health and Community Services on assessing primary care screening protocols for refugees and immigrants. Prior to entering into medicine, he was an NSERC post doctoral fellow at the University of Northern British Columbia in Prince George, where he studied impacts of environmental pollution on Inuit and other Arctic communities. He has also completed a PhD in environmental health at McGill University and a BSc and MSc at the University of Ottawa in biochemistry.


DESERTIFICATION The Sands of Change Jennifer Wang D

ESERTS: they affect the lives of millions, hold keys of political balance, play a vital role in the global ecosystem – but most importantly, they are changing. The year 2006 was declared the International Year of Deserts and Desertification by the United Nations in order to recognize the growing pressure that deserts face and the ways in which these changes impact our global community of humans and the environment. In addition, this year is the International Year of Sanitation and the International Year of Planet Earth. These U.N. dedications highlight once again the interconnected scope of environmental issues and reinforce the most important message of all: change is happening now, and it is affecting every aspect of our planet. Loss of biodiversity, changing biomes, and abuse of resources are just some of the associated effects of desertification.

drylands that are threatened with desertification, the public conscience is still unaware that such a problem even exists. The Human Cost Whether we are watching or not, desertification comes at a terrible price. Famine in the deserts is accompanied by malnutrition, causing intrauterine growth retardation of fetuses and increased susceptibility to disease. Meanwhile, the increasingly arid conditions of these areas play host to massive dust storms that can cause everything from asthma and other chronic respiratory diseases to burn injuries and meningitis. These dust storms further pollute sources of clean water and increase the spread of waterborne diseases and infections such as cholera, typhoid, and diarrheal diseases. Since 1947, dust levels in the Saharan atmosphere have increased five to six-fold, and the rate of respiratory disease has increased by at least 40% during the dry season. To compound the problem further, most of the developing nations plagued by these problems have already weak health care infrastructure and cannot cope with additional health issues.

Unfortunately, these are but parts of the total problem. The hidden effects of desertification include increased airborne dust particles and the resulting exacerbation of disease spread, as well as the growing number of desert refugees due to loss of biodiversity. Under the shadow of the global climate change debate, we often forget that in addition to the environmental damage, desertification is also creating a significant, real, and immediate human cost.

Countries without famine-stricken areas are just as vulnerable to the effects of desertification. Populations without access to clean water or fertile land cannot grow their crops or feed their livestock. For them, only one choice remains: leave behind their homeland and their way of life. These environmental refugees have been flooding into neighboring regions, places that are unequipped to deal with the recent waves of mass immigration. Between 1997 and 2020 alone, some 60 million people are expected to move from the desertified areas in Sub-Saharan Africa to Northern Africa and Europe.

Drought, Disease, and Death The Desert Biome is composed of geographic regions with sparse vegetation, an average annual rainfall less than 20% of the amount needed for optimum plant growth, and plants and animals adapted to long periods of drought. Desertification is the slow, naturally occurring process of land becoming desert, a development that results in little change of desert borders over time. Recently, however, human activities have accelerated the rate of desertification far beyond the natural pace of ecological change.

Unfortunately, people are not the only migrating entities in this story. Increased volumes of African dust particles are traveling across the sea, bringing bacteria, fungi, and allergens as far west as the Americas and as far north as Scandinavia. One traveling fungus is Coccidioides fungus, commonly known as Valley Fever or Desert Rheumatism - and to the U.S. Department of Health and Human Services and the U.S. Department of Agriculture, as a Level 3 pathogen. Meanwhile, dust particles less than 2.5 micrometres in diameter penetrate deep into the lungs and increase the risk of death from respiratory and cardiovascular disease; dust particles as small as 2.2 micrometres have been found in West Germany, and particles with diameters of 1.0 micrometres and smaller have been recorded in the continental United States. These facts send one pointed message: for such a complex issue, there will be no simple solution.

To illustrate this acceleration, consider that rainfall in the Sahara has decreased by 40% in the last several decades, while temperatures have increased by as much as 8 degrees Celsius. This combination of less moisture and more heat proved deadly for the Sahel region of the Sahara; land degradation and drought caused widespread famine and death in the 1970s, causing the United Nations to convene on the issue of desertification for the first time in 1977. We have even seen the effects of desertification in places far removed from naturally occurring deserts—the plains of the American and Canadian West, for instance, were transformed into dust bowls during the “dirty thirties.” Presently, drought, disease, and death on the drylands affect 41% of the world’s land surface and the lives of approximately two billion people. While over 110 countries have

Barriers to Progress Desertification is a serious matter—yet deserts remain a cold spot on the

“ Presently, drought, disease and death on the drylands affect 41% of the world’s land surfance and the lives of approximately two billion people.”


international agenda. Countries that can make the greatest resource contribution to finding a solution are far removed from the problem. For example, most of the literature on the Sahara has roots in Africa and is written in French. According to Dr. John Newby, CEO of the Sahara Conservation Fund, this material is rarely disseminated to the general public, let alone in the English-speaking world. Romanticized notions also lend detachment from the real issues of desertification; the word “desert” evokes images of barren landscapes radiating heat under the midday sun, and we forget that there are actually people who are struggling through drought and malnutrition to inhabit these lands, even as you read this sentence. The developed nations of the world are further removed from affected countries by the disparity in wealth, living conditions, and geographic distance. The average North American does not directly experience the cost of desertification, leaving the problem to stew in the forgotten corners of the public conscience.

and their expertise was used to create livestock development plans to be implemented in Africa. If one tries to put cattle on land that was never meant to hold large numbers of cattle, however, not even the best cattle breeders in the world can prevent the desertification of that land. The dry fate of American pasture grounds—barren dust bowls—makes this reality all too clear. The initial sum of money put into foreign aid development programs was exciting and notable, but the damaging results have Dr. Newby posing a greater question: “How much of that misery could have been avoided had people gone about using development aid for pastoral development in a different way?”. Moving towards more local projects may remedy these issues grassroots initiatives are likely to have a smaller impact and an approach more tailored to the environment.

Lack of visibility is a difficult predicament, as public awareness is critical to increasing the prominence of environmental issues on political agendas. Unfortunately for the desertification debate, other scientific issues often overtake the media and capitalize on public perception to media attention and monopolize research grant money. Furthermore, as Martin Fischer of Fauna and Flaura International points out, evidence of desertification has been difficult to substantiate. The acceleration of desertification has happened within such a small ecological timeframe that it is difficult to make any definitive generalizations. While the concern about certainty is noteworthy, the greater cost is if the desertification debate becomes an extended argument that does not produce any foreground changes in our current practices, while the consequences continue to grow in the background.

Reversing the Tide Though distant and nebulous, desertification is a growing crisis that requires urgent attention. We are used to reacting to the symptoms of problems rather than taking a stance to remedy the causes: the few times that individual citizens have been successfully entreated to contribute to a global cause have been to address a publicized disaster such as a tsunami or earthquake. While there are measures being developed to combat desertification, they are struggling to capture the public eye and ear. Individuals have the power to collectively demand government responsibility for the use of aid funding; likewise, groups have the strength to demand accountability and good practices from government and industries implementing projects that affect the local ecology. The more an area becomes desert-like, the more likely it is to remain that way. Desertification is extremely difficult to reverse, and reactive measures are simply not enough.

Political Plays This is not to say that nothing has been done. The United Nations has held several conventions on desert topics, and some foreign governments have taken a stance on desertification. The problem is that when governments address the issue, many often invest in misguided development that worsens the environmental situation. Developed nations tend to invest their aid money into big development projects, and developing nations would seem foolish to refuse. Large scale endeavors such as pastoral development and borehole drilling for well water are popular because they produce tangible changes that win the popular vote, both for the donating and the receiving country.

The mechanics of the world are such that all nations and environments are inescapably tied together in a global balancing game. Though the designated International Year is constantly changing, the price inflicted by desertification continues to accumulate interest paid with both environmental and human capital.

The problem arises when developers ignore the long-term consequences of ecological change in favor of the short-term benefits, such as positive political maneuvering. Unsustainable procedures such as overgrazing, over-extraction of water, and salinization of soils are all malpractices that are quickly turning viable land into deserts and aggravating the problem. Twenty billion dollars of development aid sounds impressive, especially when the ecological damage is kicked under the dusty rug as the media sounds in.

Jennifer Wang is a second-year Biology (Molecular, Cellular, and Developmental Biology)

student at Yale University. While she has officially declared her major within the sciences, she pursues a wide variety of interests ranging from inter-collegiate debate, solo performance and chamber music, Model United Nations, and urban development work. She is currently involved on the environmental front as an organizer for the We Are Many Festival, an arts and environmental festival scheduled for August 2008 and taking place in her hometown of Saskatoon, Saskatchewan.

Countries around the world are guilty of this type of carelessness. One example comes from the pastoral development programs funded by American foreign aid. Many of the best cattle breeders in the world are from the United States,







September 18, 2006, Canadian soldiers in Afghanistan were handing out candy to a group of children when a suicide bomber attacked, injuring several Afghan children. On November 18, 2007, American soldiers in Iraq were handing out toys to children in a playground when a suicide bomber attacked, killing three children and injuring seven. In both cases, the soldiers seemed kind and charitable, so how could things have ended so tragically?

John Pringle

We must think critically of soldiers in terms of their presence around civilians and children. Handing out candy may seem kind and charitable, but putting children in harm’s way is not. During war, soldiers are combatants, and combatants are targets. For this simple reason, soldiers ought to keep away from civilians, particularly children. Many of us unfamiliar with war carry the image of the benevolent soldier, one who fights evil while protecting the innocent. This portrayal may stem from military public relations and popular media. The aforementioned incidents were surely meant to foster the compassionate image despite the tragic outcomes.

Why would military strategists want the public to see their soldiers interacting with civilians, especially children? Repeatedly, we see these images with Canadian soldiers in Afghanistan and American soldiers in Iraq. One likely explanation is that it is meant to divert our thoughts from death and suffering, and to convince us that these soldiers are acting as humanitarians. This may be for the psychological benefit of the occupied; military forces often utilize psychological operations such as dropping humanitarian rations of food along with military pamphlets from warplanes which further blur military and humanitarian interventions. This

However, the danger of soldiers approaching children symbolizes the danger of the military encroaching into humanitarian space. Insofar as this connection between soldiers and children blurs the distinction between military operations and humanitarian ones, it endangers not only the children and their families involved, but the very practice of providing aid to populations in danger.


may be for the psychological benefit of the public back home; the use of the image of the benevolent soldier is particularly evident in military recruitment campaigns such as those shown in Canada. A recent ad campaign focuses on military rescue and protection operations using the captions “Fight Fear, Fight Distress, and Fight Chaos”, but fails to mention “Fight War”. This may also be for the psychological benefit of the soldiers themselves; it has been estimated that of all the U.S. soldiers who fought in Iraq, about one in eight reported symptoms of post-traumatic stress disorder. Perhaps by increasing their interaction with local civilians, the military aims to make fighting war more psychologically bearable.

We as humans have a right to receive humanitarian assistance and an obligation to provide assistance when needed – this is the humanitarian imperative (ICRC). Unlike soldiers, humanitarian aid workers strive to provide life-saving assistance impartially (based on need and without discrimination) and neutrally (without preference to any one party and without participating in hostilities). As a result, humanitarian aid workers must act and be perceived to be acting independently from political and military forces in order to promote safe access to populations in danger. When militaries are involved in organizing or delivering humanitarian aid, it can be regarded by their opponents as an act of war and legitimized attacks can ensue. This threatens civilians, aid workers, and humanitarian access to populations in danger.

Indeed, the image of the benevolent soldier has its uses, and is even consistent in part with international humanitarian law in that occupying forces have a duty to protect essential public health infrastructure. However, the unintended effect of this image undermines the ability of humanitarian aid workers to help populations in greatest need. The real damage is in blurring the lines between military operations such as protection, rescue and development operations, and true humanitarian aid. True humanitarian aid is guided by and founded upon humanitarian principles. As Nicholas de Torrente of Médecins Sans Frontières (MSF) writes:

War, however justified, is not a form of humanitarian aid. Armed intervention, even to prevent genocide or to protect human rights, is a military intervention and not a humanitarian one. As David Rieff, an expert in humanitarian affairs, argues, “A humanitarianism that supports the idea of war carried out in its name is unworthy of that name. […] Call it politics, call it reason of state, call it nation building, but don’t call it humanitarianism.” Humanitarian war is a contradiction in terms. Using the term humanitarian to describe or to justify war implicates humanitarian aid workers and threatens their true purpose.

“The most important principles of humanitarian action are: humanity, which posits the conviction that all people have equal dignity by virtue of their membership in humanity; impartiality, which directs that assistance is provided based solely on need without discrimination among recipients; neutrality, which stipulates that humanitarian organizations must refrain from taking part in hostilities or taking actions that advantage one side of the conflict over another; and independence, which is necessary to ensure that humanitarian action only serves the interests of war victims, and not political, religious, or other agendas.”

As illustrated by the two tragic incidents in the beginning paragraph, blurring the lines between war and humanitarian aid is tragically deceptive. Humanitarian aid workers specialize in saving lives, alleviating suffering, and reaffirming human dignity. Soldiers wage war which inevitably involves violence, killing, hatred, torture, rape, destruction, trauma, environmental devastation, epidemics, poverty, and suffering. It is misleading to think that war is primarily bad for soldiers – UNICEF has estimated that during all wars in the 1990s, 90 percent of all deaths were of civilians. In some cases, half of the civilian deaths were children. By the end of 2006, there were 9.9 million refugees worldwide in addition to the


humanitarianism – impartiality, neutrality and independence – are more important in effective aid delivery than military wealth and power. Take for example the American bombardment around Herat in Afghanistan. At least three densely populated villages were hit by American cluster bombs, killing several civilians. Cluster bombs are comprised of sinister little bomblets. Many of these bomblets do not explode on impact, but scatter over wide areas. I have seen these bombs up close in a war zone, and they look like little yellow plastic balls, but they are deadly. Those that do not explode on impact will wait to explode in the hands of curious children. At the same time as the U.S. military was dropping their cluster bombs, they were also dropping food packets in nearby areas. Not only did some of the food packets damage houses when they fell, but they were the same bright yellow colour as cluster bombs. One 15 year old child mistook a cluster bomb for a food packet which “blew his head off”, according to the report. At least one other child lost his hand and forearm for making the same mistake. We can assume that many more children were maimed or killed by these actions, although it is unlikely we will ever learn the actual number. Now compare military spending with that of MSF, an international nongovernmental medical humanitarian aid organization. MSF offers life-saving emergency assistance during humanitarian emergencies to those most in need, while observing impartiality, neutrality, independence, and universal medical ethics. To ensure access to and care for the most vulnerable, MSF remains scrupulously independent from governments, militaries, and religious and economic powers. In 2006, while responding to humanitarian emergencies across the globe, MSF undertook over nine million medical consultations and hospitalized almost half a million patients. MSF treated close to two million people for malaria and provided one hundred thousand HIV/AIDS patients with daily anti-retroviral therapy in over thirty countries. MSF accomplished this and more with a total annual expenditure of approximately $800 million or about three days of the cost of the Iraq war.

4.4 million of Palestinian refugees, and 12.8 million of internally displaced persons. Sadly, the global number of refugees increased for the first time in five years. These data from war-torn areas demonstrate that war causes the very disaster that demands a humanitarian response. Because of the devastating effects of war, the lives of civilians depend on a humanitarian space free of agents of war in any form. Humanitarian space necessitates humanitarian aid workers who are guided by the principles of impartiality, neutrality, and independence. In the midst of the horror of war, the lives of aid workers and their beneficiaries depend on the absolute separation of the theatres of war and humanitarian aid. Yet we are seeing an invasion of humanitarian space by multinational military forces, particularly by U.S.-led coalition forces. Why does this invasion take place? Perhaps, given the atrocious impact of war on civilians, military leaders are evolving a social conscience. However, it is likely that this invasion is simply about expanding military domination. I believe (as do many of my humanitarian colleagues in the field) that it is about exerting control over populations in and around the battleground, controlling human need and using it as a tool. An example of this is when coalition forces threatened to suspend aid to populations in southern Afghanistan if the civilians there refused to provide information about the Taliban. Also in Afghanistan, the U.S. military subverted humanitarian projects with soldiers in civilian clothing who were armed. This is an example of soldiers using humanitarian aid work as a cover for information gathering, clearly violating the principle of neutrality. This intentional deception deepens the blurring of the critical line between combatant and humanitarian aid worker, further increasing the likelihood of indiscriminate attacks. For humanitarian aid workers, this is the chance of being killed by mis-association. Humanitarian aid workers are driven by the needs of the populations they serve while militaries are driven by self-interest. This inherent clash of objectives makes it impossible for them to operate in tandem.

The relative inefficiency of military interventions that use a humanitarian guise argues against purely humanitarian objectives for the campaigns. According to some journalists, the U.S. military involvement in Afghanistan and Iraq is to further U.S. foreign policy rather than to assist civilians in desperate need. Moreover, the extent of the media reporting on these supposedly humanitarian gestures by the military suggests that the gestures are meant to win the hearts and minds of the occupied and voters back home, not to reduce the suffering of affected civilians in a meaningful way.

Some may argue that western coalition forces are better-equipped to deliver humanitarian aid. Despite all the reasons against having combat forces organizing or delivering aid, the size and wealth of militaries may outweigh the humanitarian principles of impartiality, neutrality, and independence. It is true that the resources of humanitarian aid organizations cannot compete with global military spending of $1.12 trillion. However, the three tenets of


NGOs such as MSF have come out against the military invasion of humanitarian space. In a 2007 press release, they claimed: “The violence directed against humanitarian aid workers has come in a context in which the U.S. backed coalition has consistently sought to use humanitarian aid to build support for its military and political ambitions. MSF denounces the coalition’s attempts to coopt humanitarian aid and use it to ‘win hearts and minds’. By doing so, providing aid is no longer seen as an impartial and neutral act, endangering the lives of humanitarian volunteers and jeopardizing the aid to people in need.” Despite the incompatibility of military and humanitarian actions, the U.S. military continues invading humanitarian space for military objectives. Colin Powell, the former U.S. Secretary of State, proclaimed that “NGOs are a multiplying force of our combat team”. This disingenuous comment has had disastrous effects. Tragically, on June 2, 2004, five MSF humanitarian aid workers were murdered while traveling in a clearly marked MSF Toyota Landcruiser in northwest Afghanistan. The vehicle had been shot through the front windscreen, through the front passenger window and through the back windscreen. There was shrapnel embedded in the side of the car indicating a grenade had been detonated. Nine days after the attack, a Taliban spokesperson stated, “Organizations like Médecins Sans Frontières work for American interests and are therefore targets for us”. This incident led to MSF’s withdrawal from Afghanistan after 24 years of delivering critical aid to its civilian population. While it is now doubtful that the Taliban was responsible, many still feel that blurred lines between military and humanitarian operations contributed to the attack.

John Pringle is a Registered Nurse with his BScN from McMaster University. He worked

as a northern outpost nurse for Health Canada before joining MSF in 2001, helping to provide primary health care in refugee camps along the Eritrean-Ethiopian border. He then earned his MSc in Community Health & Epidemiology from Queen’s University, and did another mission with MSF in 2006 as a field epidemiologist, investigating meningitis outbreaks across northern Nigeria. He is currently a PhD candidate in Public Health Sciences and the Joint Centre for Bioethics at the University of Toronto. His research focus is the effects of war on public health and global health ethics.

International humanitarian law, codified in the Geneva Conventions and their Additional Protocols, applies in situations of armed conflict. Its purpose is to prevent the human catastrophe that would require a humanitarian response. A catastrophe results when political and military powers do not honour their obligations in violation of international humanitarian law. For these same forces to feign an interest in assisting is a show of duplicity. Humanitarian space is the last area of hope for many civilians traumatized by war. For the sake of aid workers and the populations they serve, this space must be purely humanitarian. War results in suffering beyond comprehension. It stems from and results in the militarization of our societies. Many of our world’s resources are appropriated for war while poverty and disease flourish. So long as militaries continue imposing war and violence on civilian populations, there will be a need for humanitarian aid workers whose lives and work depend on impartiality, neutrality and independence. A humanitarian space can only be achieved when humanitarian aid workers and military personnel keep to their own theatres of war.


A BLEAK FUTURE? an honest look at the UNDPKO and allegations of sexual abuse Kristen Yee


2004, there have been an increasing number of allegations of sexual abuse and exploitation of local and refugee populations by the United Nations (UN) peacekeepers. The situation is complex and requires consideration on many levels. The UN seems crippled in its ability to prevent and prosecute proven offenders. How, then, can justice be served to those affected? Again, the answer is complicated. The UN is doing its utmost to use what resources it has available to address the situation – but it’s just not enough.

civilian and uniformed personnel alike, in the field. The allegations include rape, pedophilia, and prostitution – all of which are prohibited under the United Nations Staff Regulations and Rules and reiterated elsewhere. Although only a small minority of the UN’s staff have been named as official offenders, the situation has hurt many and has harmed the UN’s reputation. Post World War II, the UN was established as a means of promoting peace and security throughout the world. One of the most respected and renowned departments within the UN is the Department of Peacekeeping Operations (DPKO). The DPKO’s peacekeeping forces are composed of soldiers, military officers, police and civilian personnel from countries all over the globe. The DPKO’s mission statement affirms that “all [missions] share certain common aims – to alleviate human suffering, and create conditions and build institutions for self-sustaining peace” in conflict affected areas. Basically, all peacekeepers are mandated to assist the local population(s) in realizing their rights to peace and security. However, in light of the sexual abuse and exploitation allegations, something has been lost in the translation.

“Every time I’m made aware of an allegation of sexual exploitation and abuse, I’m outraged. I’m outraged at every level, as a peacekeeper, as a professional, as a colleague of the tens of thousands of men and women who serve honourably in peacekeeping.” - Jane Holl Lute, UN Assistant Secretary-General for Peacekeeping Operations This statement expresses the UN’s general frustration and disappointment over the recent allegations of sexual abuse and exploitation by UN peacekeepers,


The disconnect - discrepancies in policy and practice within the UN In 2004, a UN report found that a substantial number of UN peacekeepers had engaged in the sexual abuse and exploitation of local girls in the Democratic Republic of Congo (DRC). By November of that same year, allegations numbered 150, citing incidents of rape, pedophilia, and the solicitation of prostitutes. This blatant disregard for human security by peacekeeping staff becomes more distressing by the position of the abusers – the local populations are being exploited by the very people who are mandated to protect them.

Taking action - the UN steps up In an effort to reverse and permanently stop the incidences of sexual abuse and exploitation in the field, the UN has put forth a number of strategies. Following the 2004 report by the Secretary General’s Special Advisor, Prince Zeid Ra’ad Zeid alHussein, the UN initiated a policy of ‘zero tolerance’ against acts of sexual abuse committed by UN staff. Later in November 2005, new Conduct and Discipline Units were initiated in the UN’s eight largest missions to increase staff awareness of expected standards and to address all forms of misconduct committed by UN peacekeeping personnel. Plans have been made to have Conduct and Discipline Units in virtually all UN missions around the globe. More recently, a strategy was adopted by the UN General Assembly in December 2007 that is designed to assist the victims directly through the provision of medical treatment, legal services and material care. Moreover, the UN has committed itself to assist all children born as a result of sexual abuse and exploitation. This strategy is in its infancy and it will take some time to take effect.

Although the story was covered sporadically by most media sources, the news spread quickly to humanitarian agencies throughout the world. The international outrage that followed, including from within the UN itself, left a significant dent in the UN’s reputation. The UN then quickly moved to address the situation. The initial findings in the DRC prompted the commencement of fifteen more investigations in UN peacekeeping missions worldwide. Soon after, similar allegations emerged elsewhere such as in Côte d’Ivoire, Haiti, and Liberia. The UN reported that from 2004-2006, 319 peacekeeping personnel were investigated, resulting in the dismissal of 18 civilians and the repatriation of 17 police and 144 military personnel from their respective peacekeeping missions. In fact, these incidences are not new – accusations of sexual abuse and exploitation against peacekeepers have surfaced before. In 2002, the Office of the United Nations High Commissioner for Refugees (UNHCR) and Save the Children-UK released a joint report reviewing allegations of sexual violence and exploitation of refugee children in Guinea, Liberia and Sierra Leone. The report’s findings implicated UN staff members, among other humanitarian workers, of committing such offences. Although there may have been a variety of reasons for the deficient follow-up to these allegations at the time, it is no excuse.

But abuses continue... Despite their efforts, the number of allegations of sexual exploitation and abuse reported to the UN in 2006 were consistent with previous years, indicating that “the problem of sexual exploitation and abuse will continue to pose significant challenges for the United Nations in the future,” according to the most recent post by the Conduct and Discipline Unit. This suggests that the disconnection between policy and practice remains. Although the UN is beginning to take measures to address the consequences of misconduct in their ranks, it is obvious that more work needs to be done to address the situation, if not to prevent the occurrence of sexual abuse altogether.

“ ...319 peacekeeping personnel were investigated, resulting in the dismissal of 18 civilians... 17 police and 144 military personnel...”

What is frustrating about these sexual offences is that the UN is quite limited in the actions it can take to dissuade and punish individuals who are found to have committed such crimes. The UN does not have the ability or the capacity to investigate and prosecute offenders. Peacekeeping staff suspected or found guilty of sexual abuse and/or exploitation are customarily released and repatriated to their home countries, where they are supposed to be prosecuted. This has, more often than not, posed serious problems as troop contributing countries (TTCs) have rarely followed up on these allegations, and therefore no justice is served. Nevertheless, after the UN report in 2004, it seems as though more TTCs are stepping up to the plate. After allegations that their troops were responsible for sexual violence, the governments of Morocco and Sri Lanka maintained that they will continue to work with the UN to persecute their military forces.

Civilians directly affected by conflict face a breakdown in familial and community networks, a lack of income and access to basic needs, increased sexual violence and abuse, and lack of access to health care and education. People’s lives essentially disintegrate around them. With the collapse of social and infrastructural norms, sexual violence, exploitation, and incidents of rape have generally been shown to increase, making women and children especially vulnerable to predation regardless of whether or not they are non-displaced, internally displaced or refugees. In instances where UN peacekeeping personnel have taken advantage of the precarious situation of women and children in conflict zones, they are abusing their position of relative power and the trust placed in them to provide the protection from harm.

Negotiating accountability How is justice served if the UN is unable to ensure the prosecution of offending peacekeepers? Although there are no real solutions at the moment, there are two issues which help to shed light on the problem. Firstly, there is no such thing as a ‘UN soldier’. The UN does not have its own group of military personnel; it relies on the contributions from the UN Member States. Therefore, in its reliance of others, not only does the UN not have the ability to prosecute offenders, it does not have the ability to hand pick its troops in the first place. The UN has to take whatever human capacity it can get. Secondly, some of the top TTCs include many states such as Pakistan, China, and Nigeria that have received serious human rights violations against them, trends which then tend to manifest themselves in UN missions.

Speaking at the opening of the UN High Level Conference on Eliminating Sexual Exploitation and Abuse by UN and NGO Personnel in 2006, former UN Secretary General Kofi Annan asserted his frustrations with the allegations of abuse. He said, “Even if it is only a few who take advantage of our positions of relative power in the countries where we operate, it is a few too many.” He continued his address by expressing his disappointment and concern, “Such acts violate the trust and respect placed in us by the communities we are sent to help. They cause great harm to women and children who already face extreme hardship and violations in their daily lives. And they overshadow in the eyes of the public our many achievements.” As a means of regaining the trust and faith it lost, the UN has begun planning on how best to address the accusations.


Despite these sexual allegations, the UN continues to foster essential collaborations among nations in bringing aid and attention to pressing international issues. It is important to recognize that UN peacekeeping missions play one of the most important roles in maintaining peace and security in some of the world’s most volatile regions. In their own words, DPKO believes that “[p]eacekeeping missions [are] deploy[ed] where others cannot or will not and play a vital role in providing a bridge to stability and eventual long-term peace and development.” The DPKO cites a distinct correlation between the decrease in civil wars since the end of the Cold War and an increase in UN missions over that same period. To put the allegations of sexual abuse and exploitation into perspective, there are approximately 200,000 UN staff rotating through missions every year. Therefore, from 2004-2006, there were over 400,000 field personnel in UN peacekeeping missions around the globe. Over the same period, the UN lists approximately 200 confirmed cases of sexual abuse and exploitation among its ranks. This means that less than 0.0001% of peacekeeping personnel are responsible for sexual abuses and exploitation. Nevertheless, this does not in any way lessen the seriousness of the allegations of sexual abuse and exploitation experienced by women and children in conflict zones. Rather, it puts the situation in context, which is something international media sources have failed to do. The only way to truly eradicate sexual abuse and exploitation in UN peacekeeping mission is to make significant changes to the UN structure and to the address the questionable actions of many Member States. This is a formidable task. In light of this, it seems as though the UN has little choice but to continue its efforts to diminish abuses through education, monitoring, and taking any necessary remedial action. Although this outlook is perhaps rather bleak, it is important to remember that, overall, UN peacekeeping missions do make positive impacts on the people they are meant to serve and protect. Kristen Yee is a fourth year Peace and Conflict Studies student at the University of Toronto. ‘A Bleak Future?’ is her first publication. Throughout her undergraduate career, she has worked extensively on migrant and health issues. She hopes to continue this focus when she eventually goes to grad school. Kristen is currently in Namibia doing community outreach work.

“Despite these sexual allegations, the UN continues to fosteressentialcollaborationsamongnationsinbringing aid and attention to pressing international issues.”


THE KEY POPULATION Behavioral patterns of sex workers

Diane Wu


on a Monday night in Mengla County in Yunnan Province, China, and I’m counting barbershops from the back of a motorcycle. Zhang Nan, a young staff member of the Yunnan Health and Development Research Association (YHDRA), a Chinese NGO, is tense and slightly wary as he steers the motorcycle deftly through traffic. The streets are crowded even at this time of night. Clusters at a time, we pass salons on the dimlylit road – a suspiciously high number of beauty parlours for such a seedy area. I keep a discreet tally by drawing lines on the back of my hand. It doesn’t take an observant person to notice that the barbershops don’t offer the standard cut-and-dry. None of the parlours are even open before dark. Flooded with heavy pink light, they are the shops of commercial sex workers, where men go to buy unnamed, yet auspicious “services” from bored-looking girls. My tally is important for Zhang Nan, who is studying the sociology of sex workers. To many researchers like him, understanding sex workers is the key to unravelling the mechanisms which may be used to prevent further spread of HIV/AIDS into China. But the sex industry in southern Yunnan is highly regulated by the local mafia, a wary group ready to use violence on any suspected undercover policemen. With such heavy-handed control on the sex trade, it’s not surprising that sex workers can’t easily be studied. It may seem odd that a NGO in China would focus on HIV/AIDS prevention. At 0.08%, China has one of the lowest HIV infection rates in the world – lower even than Canada and the United States. A large number of counties have never had a single recorded case of the illness. But considering China’s enormous population base, 0.08% still means over 40,000 people are suffering from the disease, and the vulnerability of the population in a society plagued with stigma spells fast growing numbers with little to no help for those afflicted (UNDP 2003).

for high infection rates and fast clinical progression, is highly prevalent in China. The recent detection of its cousin, HIV-2, adds additional concern (UNDP 2003). Furthermore, fearing ostracization from an HIV-positive label, infected people are afraid of announcing their status to their community especially if, as a sex worker, infection status determines one’s ability to earn a living. This stigma against HIV makes it triply hard to treat and prevent further infections.

The first recorded appearance of HIV/AIDS in China was in a foreign tourist in 1985. In the next 10 years, the disease spread quickly through China, leaving no province untouched - by 1998, even sparsely-populated Inner Mongolia had reported cases of HIV infection. The presence of HIV in every corner of the country has underlined the urgency of the Chinese situation.

Chinese commercial sex workers, unlike Canadian street prostitutes, normally have a “store” where they can advertise and perform their services. According to Xia Guomei, the Chinese advisor for the Joint United Nations Program on HIV/ AIDS, business sites range from an expensive hotel to an upscale karaoke bar to a hairdressing salon “of a dubious nature”. Guomei describes many reasons why girls tend to become sex workers in China: a considerable income (a normal sex worker in Mengla can earn 5000 RMB a month (roughly $800CDN), 2.5 times more than a county physician), retaliation against a failed relationship, trickery and coercion, curiosity, and the possibility of marrying a wealthy client (UNDP 2003). By understanding the reasons behind their choices to enter the Chinese underworld, Guomei hopes to create a platform for intervention.

To start, it is important to understand what caused the disease to spread in the first place. HIV has disseminated through the Middle Kingdom in three main ways: unscrupulous needle-sharing among drug users in the remote west and tropical south, distribution of contaminated blood supplies in the central regions (notably creating the tragic HIV villages in Henan Province), and sexual contact through the east. Now, transmission is occurring more and more through heterosexual contact, and the fast-growing migrant population is the perfect group for the virus to infect: young, single, male, and doing business far from the responsibilities of home.

Sex workers can be epicentres of HIV transmission, a high-risk group offering services akin to a viral Russian roulette. Public health officials balk at the mention of sex workers, who bear a large part of the blame for the spread of HIV/AIDS in south China. At the same time, they are a dangerously vulnerable population who

The Chinese HIV threat has two main issues. Eight types of HIV are prevalent in the country, making China’s virus one of the most genetically diverse, and therefore the most difficult to treat. Worse, the dangerous HIV-1 recombinant virus, known


have little say in minimizing their own infection risk. The glaring inequity between rural Chinese men and women is amplified in the sex trade, where business is dictated by customer satisfaction. It allows precious little room for negotiation over wearing a condom, currently the only widespread method of preventing HIV transmission by sexual contact. In many respects, a condom protects a woman more than a man - women are biologically 3.5 times more likely to contract HIV through sex; this number is higher if the woman has one of many common gynaecological infections (World Health Organization). But poor sanitation, little knowledge of proper care and ineligibility for health insurance exacerbate the problem, leaving sex workers with few options for treatment. This is where NGOs step in. Through workshops and education materials, the YHDRA has fought alongside many local and international NGOs to eradicate antiHIV stigma among a society that turns a contemptuous eye to sex out of wedlock. In every hotel room, especially in those areas frequented by traveling businessmen, HIV/AIDS pamphlets can be found alongside a rubber condom. For sex workers, NGOs like Population Health International have established free treatment centers and support networks. In addition, the YHDRA has taken on many projects to educate society about prevention; projects have alternately focused on children to doctors to migrant workers. Although one of the most important continuing efforts is research, Zhang Nan’s work with the sensitive subject of sex workers is a dangerous foray. To encounter his study population, Zhang Nan poses as a client and enters parlours alone. Yet an educated, well-groomed, inquisitive client hardly puts a gang’s nerves at ease – Zhang Nan has been threatened several times with physical violence, and treats his study sites as one-time-use-only for fear of repeat run-ins with unfriendly bouncers. I look inside one of these pink parlors, where five girls politely and silently peer out at me, brushing their hair and painting their fingernails. Some are young, while others look in their 30s. Although the shops look employed to full capacity, they all sport advertisements publicizing that they are “seeking female labour”. When I first saw the shops, I was overcome with anger at the Chinese social support system, which creates such major economic incentives for girls to go into this line of work. “The first thing you want to do is to tell them to stop,” says Zhang Nan. “Then you realize the complexity of their reasons for entering the trade, and you realize that they won’t stop just because you tell them to. They have their reasons. So it’s up to you to understand and protect them in any way you can.” Notwithstanding the nature of their work, each face represents a story of a broken home or a dysfunctional relationship, but also a resilient and unbreakable will to continue fighting for a living. “I really admire these girls,” Zhang Nan continues. “Coming with such sad histories, many people give up their life, or become beggars. But these girls work and make money to support themselves.” The central government should first collaborate with universities and NGOs to understand sex workers’ behavioural patterns and risk factors, and then create effective intervention methods and support systems. Instead, the People’s Party is still a breeding ground for ignorance and hate – in November 2006, Guangdong Province organized a public shaming of hundreds of sex workers that recalled similar activities during the Cultural Revolution over 40 years prior. The government urgently needs education, knowledge, and a fast establishment of key prevention mechanisms. Only through liberalization of their policies can China hope to protect the health and well-being of a very vulnerable population.

Diane Wu is a fourth-year undergraduate specializing in Human Biology. Last year, Diane

undertook a four-month CIDA internship to China to study barriers to healthcare access among rural Chinese women. She also worked with the YHDRA and local government leaders to initiate a new HIV/AIDS prevention project on the Laos/China border, and participated in regional healthcare assessments for rural children.


A Case Study:

Gender Education & HIV/AIDS in Sonya Kalyniak

LESOTHO training and in school HIV/AIDS clubs. The modules include topics of stereotypes, discrimination, understanding the difference between sex and gender, understanding gender roles in a Lesotho context, gender discrimination and gender equality. An interesting area that can be a struggle for Canadians as well is discussing the definitions of sex and gender; basically, sex is biological where gender is socially and culturally defined concepts of masculinity and femininity. This promotes the idea that gender roles can evolve and have changed in the participants’ lifetimes. Young people gave examples that in the past, girls could not attend school or work, whereas now these things are becoming socially acceptable. Games and activities are incorporated to help participants understand these concepts.

Learning the context of HIV/AIDS Education in Lesotho As a young social worker about to embark on a six month internship to Lesotho, a small developing country surrounded by South Africa, I spent hours reading and learning about the beauties and hardships of this kingdom. Lesotho has a population of 1.8 million with an official HIV prevalence of 23%, one of the highest rates in the world. My mind numbed learning about the amount of sexual violence in Southern Africa and the realization that addressing the gender inequality present is necessary to slow the spread of HIV. The statistics I read about came to life two weeks after arriving as I drove down a highway just after dark and a fourteen year old girl ran directly towards into our speeding car. She was desperate to escape a man who was chasing her and had torn away her clothing in an obvious attempt to rape her. Explaining this event to my Basotho colleagues, I heard many similar stories. Indeed what I witnessed was not a rare event but something becoming close to normalcy.

Reflecting on Experiences My experiences have been varied, thought-provoking and challenging, and as I learned about people’s perceptions, I found myself reflecting on my own gender values and how these were formed. In my attempts to be non-judgemental throughout these processes, I recognized the need to analyze my own reactions and balance my personal viewpoints within Lesotho culture. This was not easy, and the

In a country so affected by HIV/AIDS, it is impossible to speak about women and children’s health without addressing gender issues. Women are more vulnerable to HIV infection than men, partially due to gender equality related factors including access to resources, education, employment and also the need for many women to be dependent on men for survival, making it difficult to negotiate sexual encounters. Until women, including the youngest of girls, are able to negotiate their bodies and sexual relationships, men will continue to have the power to make life-altering decisions such as when to have sex and condom use. . Lesotho is a culture that is generally male-dominated, and although things are changing, many women have little to no sexual decision-making power. In speaking to a male Mosotho colleague, he explained that it is a new concept for a woman to be able to decline sex. Although men are starting to understand that ‘no means no’ in the capital, Maseru, it is a developing recognition in the rural areas. It is heart-breaking to see young women forced to leave school for becoming pregnant, some without understanding how pregnancy happens. Also devastating is the increasing stories of grandmothers being raped as they are seen as generally HIV negative. During my time in Lesotho, every person I met was somehow affected by HIV, from a colleague supporting her orphaned teenaged neighbours to a local grandmother being left to care for seven children after her daughter passed away.

“ In a country so affected by HIV/ AIDS, it is impossible to speak about women and children’s health without addressing gender issues.” deeper the conversations became, the more I struggled. As I tussled with thinking about my own perceptions, I realized how much the young people I was working with must also be actively reflecting to fit these concepts into their perceptions. A crucial part of gender training is encouraging thought processes to help know oneself and learning different ways to look at self and society. One example that appears to open minds to a new level is discussions with young men about having a partner who will love and respect rather than fear. The topic of respect versus fear is also influential in talking to our young women.

Developing Methods of Gender Education Understanding the influence of gender-related determinants of HIV/AIDS infection has grown in the past decade with a multitude of techniques about how to put this knowledge into gender education . Gender education basically involves teaching people about masculinity and femininity and how these concepts affect social roles. In Lesotho, with memorization being the key to academic success, there is little room for developing critical thought. Gender education is about opening participant’s minds to a new way of thinking about themselves as male or female and how they relate to their society, along with what it means to respect those of the opposite sex. It is also about giving young girls and women information to know how valuable they are as individuals and they have the right to make decisions to protect themselves. The modules Help Lesotho have developed involve working with children, adolescents and teachers and is presented in our youth leadership

One interesting challenge I faced in this training was when young people questioned me about my culture. These questions mainly arose through messages North American media dispels into African society through MTV and white-male dominated politics. I readily admitted that ‘western’ culture has a ways to come. As a young woman in a female dominated profession, I thought a lot about how I became a social worker and if this was a result of the gender roles in my society. Although Lesotho has a way to come in gender relations, the government is addressing some issues through progressive stances to set 30% of local government seats to women. I question what a similar policy would look like in Canada. Areas for Growth Gender education is not something that can produce instant results; it takes


time, reflection and incorporating new ideas into an already formed value base. It is something that cannot happen by only working to empower women, but will take an exceptional amount of work having intimate and thought provoking conversations with young boys and men. This is an area where Help Lesotho hopes to grow by developing more workshops and training and holding male-based conferences. At the recent Leadership Camp, young men had the opportunity to learn about gender in discussion based groups led by a Mosotho man eager to bring new perspectives to young minds. As Help Lesotho continues to grow, more will become possible by training young people who have battled with these concepts and are confident enough in their own gender roles to work in their schools and communities. Through gender education, there are hopes that equality will grow and bringing stronger prevention practices to cease the spread of HIV/AIDS. About Help Lesotho Help Lesotho has been working in remote communities of Lesotho since 2004 to address issues of gender inequity and HIV/AIDS. Their work involves supporting orphans and vulnerable children, leadership training for young adults and supporting grandmothers caring for orphans. Help Lesotho is a small but rapidly growing organization that survives off the support of donations. Please visit for more information. Sonya Kalyniak completed her Master of International Social Work at the University of

Calgary in 2004. She spent nearly three years working in London, UK, with unaccompanied refugee youth. Sonya has recently completed a six-month CIDA funded internship with Help Lesotho. Her areas of interest are HIV/AIDS education and prevention, immigration and refugee policy and culturally competent social work practice.

“Although Lesotho has a way to come in gender relations, the government is addressing some issues through progressive stances to set 30% of local government seats to women. I question what a similar policy would look like in Canada.�


COMBATING HIV/AIDS THROUGH EMPOWERMENT Kate Jongbloed In Sub-Saharan Africa, it is estimated that 25 million people are living with HIV/ AIDS, and 2 million have already died. There are hundreds of organizations working to eradicate the pandemic through prevention, care and treatment. Dominant prevention approaches focused on education have been met with mixed results, leading to questions about the underlying causes of HIV/AIDS. Gender inequality and poverty continue to play a significant role in HIV vulnerability, and until these factors can be addressed, education alone will not be enough to stop the pandemic. Economic empowerment projects, such as microfinance and microenterprise initiatives, provide an opportunity to tackle the social and economic causes of HIV/ AIDS among the most vulnerable. This article looks at one individual’s experience working on an economic empowerment project for adolescent orphans in Ethiopia and its potential for decreasing vulnerability to HIV/AIDS.

When Knowledge is Not Enough Pioneered by the Grameen Bank’s microcredit projects in Bangladesh , the microeconomic development approach is gaining steam as a response to a wide variety of development problems including HIV/AIDS. Traditionally, HIV/AIDS prevention has been approached through education campaigns, relying on individuals to change their behaviour based on the HIV messages in mass media. An example is the controversial “Abstain, Be Faithful, Use Condoms” (ABC) campaign. The huge posters and billboards depicting ABC slogans that I saw everywhere in Ethiopia are evidence of the popularity of the approach, despite questions about its effectiveness. However, because HIV/AIDS communication strategies are comparatively easy to scale up, they continue to receive the biggest slice of funding for HIV prevention.


The ABC approach assumes that everyone is equally at risk for HIV infection, and that knowledge about the virus is the crucial component in prompting individuals to protect themselves. It has become clear, however, that AIDS is by no means a “democratic disease”. In Africa, HIV/AIDS infection rates are highest among 15 to 24 year-olds, with women in this age group three times more likely to contract the virus than men. Risk clearly goes beyond biological susceptibility; social and economic factors are crucial in understanding who is most likely to get infected by HIV. The problem with the education-based approach is that while it provides information about the disease, it does not necessarily provide at-risk individuals with the tools needed to protect themselves.

between two corrugated iron walls, down a narrow pathway, I enter the two-room house of Makeda Girma. I am meeting with Makeda as part of my internship with a non-profit organization in Ethiopia working to combat HIV/AIDS. At 18, Makeda has been responsible for her 4-year-old daughter and her younger brother and sister since her mother died of AIDS three years ago. As the translator introduces us, I ask myself where Makeda fits into the HIV/AIDS pandemic that is ravaging the African continent. Makeda holds a unique place within the tragedy of HIV/AIDS. Though not infected, she is affected by the pandemic through the loss of her mother, and her new responsibilities as the head of her household will make it difficult for her to remain HIV negative. Pressures to care for her family put Makeda in danger of entering the sex trade or ‘trading’ sex to meet basic needs. Her low-income status puts her at risk of sexual violence and makes it less likely that she can access important information about the virus.

In Africa, and many other resource-poor settings, HIV/AIDS is mainly transmitted through heterosexual intercourse. Pervasive gender inequality and poverty in this context create obstacles to safe sex that make it difficult for individuals to protect themselves even if they know how. An oft-cited example is when women are unable to negotiate condom use with unfaithful husbands for fear of losing the economic security they provide. Another obstacle, sometimes referred to as “prioritizing risk”, arises when protection against HIV/AIDS becomes secondary to the immediate needs of food and shelter, leading young women to become involved in unequal relationships with older men. As well, women who work as domestic servants – one of the few jobs available to women of low-socioeconomic status in Ethiopia – are at risk of sexual abuse, and are often isolated from community networks and information about HIV/AIDS. Makeda’s experience of sexual

Last year, Makeda participated in a project that gave her training in hairdressing, and is now preparing to establish a salon business. Economic empowerment projects like the one I worked on are increasingly being used to tackle the underlying issues of poverty that lead to higher rates of HIV infection among certain groups. The financial, social and environmental impacts of economic empowerment projects make them a powerful new tool in the HIV/AIDS prevention toolbox.


violence is another good example: community stigma and her inability to afford secure housing put her at risk of rape, and possibly infection. In these situations, individuals may know that they are at risk, but are powerless to do anything about it.

As I tried desperately to balance my notebook and tape recorder on my lap in the absence of a table, he explained that as neighbours watched him attending vocational training regularly, they began to see him as an asset to the community, even going so far as to suggest others follow in his footsteps.

Poverty and HIV/AIDS - Breaking the Cycle New approaches to prevention help high-risk individuals to protect themselves against HIV infection by tackling sexual violence, gender inequality, economic dependence and lack of safe housing or jobs. Recently, development practitioners have seen potential in linking the hugely successful micro-credit model with HIV prevention efforts. The economic empowerment approach to HIV/AIDS works explicitly to dismantle factors that push women and other vulnerable groups into dangerous situations which leave them open to infection.

Participants used the project as an entry point to connect with other youth in similar situations and build a support network. Through several attempts at translation, I learned that one participant referred to other youths in her community as “shiny,” whereas she felt dull. When surrounded by other project participants, she felt like she was on equal footing. This interaction with peers also provides opportunities for informal discussion about HIV/AIDS, caring for younger siblings, sex and relationships

Economic empowerment projects against HIV/AIDS continue to operate on a While in Ethiopia last year, I saw an economic empowerment project in action, and smaller scale than other prevention initiatives, like the ABC programs. Both the witnessed its impact first-hand as I collected data for my thesis. The organization I comparatively high implementation cost-per-person and the need to adapt and represented, Canada-Africa Partnerships for AIDS (CAPAIDS), partnered with two improve approaches for each group make this type of project difficult to scale up Ethiopian organizations working to combat HIV/AIDS in their communities. The to a macro level. As a result, vulnerable groups who could benefit from economic goal was to deliver vocational training and microfinance to a group of adolescent empowerment are missing out. In addition, prevailing norms of the sex trade and orphans, like Makeda, who became responsible for their younger brothers and sexual violence still exist within the communities where economic empowerment sisters after the death of their parents. Over the course of my research, sixty youths projects are implemented, so inhabitants will continue to face risk, even if it is were trained in carpentry, minimized. leatherwork and hairdressing Risk clearly goes beyond biological and began to form cooperative Former UN Secretary-General Kofi susceptibility; social and economic factors are Annan has called for a “deep social businesses with others in the program. At the bustling and that transforms relations crucial in understanding who is most likely to revolution chaotic graduation ceremony of between women and men, so that get infected by HIV. the 20 women who participated women will be able to take greater in hairdressing training, the control of their lives - financially, as pride and confidence they exuded was palpable. well as physically” as an important element of HIV/AIDS prevention. Though they operate on a micro level, economic empowerment projects have profound impact The power of these programs to reduce HIV/AIDS vulnerability lies in their impact on the vulnerable communities they target. As well, programs like the CAPAIDS on participants’ economic situation and environment, as well as in improving selfdo not operate in a vacuum: their impact goes beyond HIV/AIDS to affect several esteem, reducing stigma and building social networks. I visited each participant to other development issues. see how the program impacted their lives, navigating my way to their workshops and homes via public transit in the middle of Addis Ababa’s rainy season. When I left Ethiopia, several participants had taken jobs in the private sector as they waited to secure workplaces and formalize their cooperatives. All the participants Many of the male participants I spoke to had given up work in the informal sector I spoke to felt hopeful and empowered. By providing vocational training and to join the program, and consequently experienced a dip in income. They felt that microfinance to men and women facing high HIV risk, it is possible to influence the immediate benefits were control over their own productivity and the hope and empowerment and the way income is earned, as well as challenging traditional self-respect that came from building their own business. The women involved had gender roles and attitudes towards women. often relied on husbands and family members for income prior to the project, so the change they experienced related directly to an increase in income and greater During my last visit, Makeda was passing on hairdressing techniques to her younger independence. As well, some participants were able to leave the sex trade to sister, with the hope that they would open a salon together. She also understood embark on a new profession. With a proud smile on her face, one of the members that having some sort of skill would, in turn, help her sister become less vulnerable. of a carpentry cooperative described to me that she now slept in a bed that she made The broad range of impacts of this type of program on the underlying causes of with her own hands. HIV/AIDS make it an exciting new opportunity for tackling the pandemic and preventing new infections. More than just Increased Incomes Changes in the economic situation of participants were accompanied by several Kate Jongbloed is a student in UofT’s International Development Studies Program. She social changes that play an important role in reducing HIV vulnerability. All has recently returned from a 10-month work placement in Addis Ababa, Ethiopia with two participants experienced an increase in confidence, often in dramatic opposition non-governmental organizations, CAPAIDS and Canadian Physicians for Aid and Relief. She to their desperation prior to the project. When I went to visit a group on their first is currently writing her thesis on the impact of economic empowerment projects on HIV/ day of business in a new leather craft workshop, one of the members told me that AIDS, and looks forward to returning to Africa as soon as possible! he had been perceived as a hooligan within his community before getting involved with the project.



Vitamin A: A Life’s Work

An interview with Alfred Sommer, MD, MHS Benjamin Kwan

Dr. Sommer speaks to Juxtaposition about his research in vitamin A deficiency, biotechnology and his role in reducing global blindness. He was the dean of the John Hopkins Bloomberg School of Public Health (JHSPH) in Baltimore, Maryland, United States. As a Professor and Dean Emeritus at JHSPH, he continues to teach Epidemiology, International Health and Ophthalmology (at the School of Medicine). More information about Dr. Sommer, as well as his Micronutrient Deficiency Study, can be found at:

essentially what we [in North America and Europe] do in the form of dairy products, eggs and liver. Vitamin A deficiency was actually a problem at the turn of the 19th century in America and Europe, which introduced synthetic vitamin A into diets. Most of the vitamin A that is provided to children in the developing world has been purchased with grants from Canada; Canada is a leader in solving the vitamin A deficiency. Mr. Kwan: Is blindness a problem in North America? Dr. Sommer: In North America, Europe, Japan and other wealthy countries, the blindness rates are roughly 0.5%. In parts of the Middle East, Africa and Asia where there is insufficient treatment, such as cataract surgeries, the rate may be as high as 3%. In some areas like Asia the blindness rate has decreased with the increase in cataract surgical rate, although whether they are reaching the poorest of the poor is not entirely clear.

Mr. Kwan: What are your research interests are and why did you choose medicine as a profession? Dr. Sommer: I chose medicine as a profession largely because I was interested in biology and biochemical mechanisms but also enjoyed working with people. Medicine has a lot of academic potential, job security and it was one of those few things that you can take anywhere in the world. I gravitated towards public health because of its impact on populations or as our tagline developed here at the [John Hopkins] School of Public Health, “saving millions at a time”.

Mr. Kwan: Do you see a role for genomics in ophthalmology at the moment? Dr. Sommer: For the moment we have only a limited number of practical uses for which we have been able to use genomics and personal medicine. In the last year researchers have found 3 to 4 genes that can be used for identifying nearly half of people who would become blind due to macular degenerations. From my

Mr. Kwan: What inspired you to become involved in vitamin A research? Dr. Sommer: I was interested in ophthalmology and eye disease. While in Baltimore, I was asked by a not-for-profit organization that thought vitamin A may be a cause of global childhood blindness to think through this. We didn’t know how extensive Vitamin A deficiency was, how much blindness it caused amongst children nor what was the most efficient way to treat it. We developed a relatively large research agenda and went to Indonesia for 3 years to study vitamin A deficiency. We discovered that giving an oral form of vitamin A was equally effective and more cost-effective than treatment given by needles. As I was analyzing this massive amount of data, I also realized the relationship between vitamin A status and childhood mortality. While we understood the relationship between vitamin A and blindness, institutes were concerned about childhood mortality since 1/3 of children died before age 5. To move beyond an association, we conducted randomized trials and saw that we could reduce overall child mortality rate by about 1/3 by giving children vitamin A once every 6 months. Nothing in medicine is this cost effective. We also found that if a baby received vitamin A within two days of birth, we could achieve approximately a 20% reduction in childhood mortality within the first 6 months of life. This is nearly equal to the benefits of giving vitamin A twice a year for the next 4 and a half years of life. Thus, we have another approach to reduce neonatal mortality.

Most of the vitamin A that is provided to “children in the developing world has been purchased with grants from Canada; Canada is a leader in solving vitamin A deficiency.

perspective, the genomic revolution has allowed us to focus our attention on people who are at the greatest risk for clinical entities and who would benefit from early intervention. Many people think that personalized medicine entails people making drugs especially for you. Maybe one day that will be possible in a cost effective way but right now the pharmaceutical industries make all their money by getting everyone use one drug whether you need it or not. Once each person’s experience can be optimized by having tailored drugs there is much less of a financial incentive for the pharmaceutical industry. At the moment, genomics is used primarily for identifying people with high relative and absolute risks to diseases and to determine certain drugs a person will best respond to.

Mr. Kwan: Is this to all children or specific children? Dr. Sommer: Vitamin A deficiency may afflict anybody in a rural area and anybody who is not middle-class, which is most of the developing world. Their diet is so deficient in vitamin A that they must obtain vitamin A from supplements, which is

Mr. Kwan: What other other economically feasible supplements or medicine show promise in helping the developing world?


Dr. Sommer: There are 3 to 5 major new initiatives underway, largely because the company that makes these drugs agreed to make them free if appropriately used in national programs. Mectizan by Merck is used to treat river blindness, the major cause of blindness in much of Africa. In some parts of Africa river blindness has been eradicated by killing the fly vector. However, other areas it is impossible to get rid of this vector, and Mectizan helps suppress the disease which is now a mere fraction of what it was 10 to15 years ago. There is a similar program for trachoma which is a major cause of infectious blindness in any area with poor sanitation. As a multifaceted program, we encouraged people to wash their faces but most importantly, the use of an antibiotic called Zithromax [by Pfizer] made the most impact. In the non-drug arena, nutrients such as iodine are critical for health. During the past 35 to 45 years there have been programs around the world that have fortified their salts with iodine any yet it is still only about 70% there. Challenges include small scale salt farmers and a lack of regulation. Iron deficiency is particularly important to women during pregnancy. Global policy required women to take iron tablets but the women don’t like to take it because it causes gastric distress. Now there is a simple intervention that costs peanuts but is not used. Zinc deficiency has been shown to be an important cause of diarrhea. It has been shown that taking zinc supplements can reduce the diarrhea period and potentially limit the number of diarrheal episodes. Now, there is a global strategy that zinc should be available for the treatment of diarrhea but the challenge is developing a means to deliver it to those in need.

Administering a vitamin A supplement to a Nepali child with xerophthalmia (1998)

Benjamin Kwan is a research student at The Hospital for Sick Children with Dr. Stephen

Scherer, where he studies the genetics of autism through genome-wide assessment of copy number variations. He is a student in the Pathobiology Specialist program at University of Toronto. His interests are the utilization of genome-wide technologies to understand disease and translating basic research for medical diagnostics/personalized medicine.

Examining the eyes of a young Indonesian child with xerophthalmia from vitamin A deficiency (1976)


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Volume 2 | Issue 1 | Fall 2007


Profile for Juxtaposition Global Health Magazine

Juxtaposition 2.2  

From Lab to Village, Juxtaposition 2.2, Spring 2008

Juxtaposition 2.2  

From Lab to Village, Juxtaposition 2.2, Spring 2008