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when Passion Meets Purpose Interviewing Dr. Raghu Venugopal of MSF Canada

The Art of Global Health Lessons learned from Dignitas International in Malawi

Virus in the Desert A photo essay on the HIV/AIDS epidemic in Namibia Also, Reviews of Fall 2010 Conferences:

OMWHO and CUCOH


The Global Health Specialist and Major Programs provide interdisciplinary undergraduate programs of study that include courses from the various medical departments, life sciences, social sciences, and humanities leading to an honours B.Sc. degree. The emphasis of these programs is to integrate the study of health sciences with select courses in the social sciences and humanities. Students will receive a solid foundation in life science courses together with insights from the humanities and social sciences and, at the same time, fulfill their distribution requirements. The Global Health programs are intended for a specific cohort of students who are interested in applying their experiences in the health sciences and related disciplines to assist with health issues, particularly in developing countries. For example, knowledge of several science-related disciplines, including ecology, environmental issues, and resource management will assist with the logistics of foreign aid to developing countries to help deal with natural disasters. The Global Health programs allow students to integrate courses in sciences, political science, resource management, ecology, and the environment, in addition to courses from the humanities and social sciences. The goal of the programs is to provide a multi-disciplinary education focused on global health issues relevant to humans while maintaining flexibility within course selection. For more information visit http://www.hmb.utoronto.ca

Juxtaposition would like to thank the following sponsors:


Juxtaposition Global Health Magazine Download previous issues at

Spring 2011 Volume 4 Issue 1 Movers and Shakers

www.juxtaposition.sa.utoronto.ca

Fall 2010 Issue 3.2

Editors in Chief

Jennifer Kwan Jacqueline Wong

Editorial Division Managing Editors

TRANSCENDING BORDERS

Editors

Innovative approaches to health care delivery

Featured Articles

Realizing Global Mental Health Genomics and Global Health Power of Integrated Health Care www.juxtapose.ca | ISSN 1918-7653

2010 Volume 3 Issue 2 Transcending Borders

Lucy Duan Jill Murray Sarah Dawsom William Fung Athena Hau Charlotte Hunter Michelle (Yunjeong) Lee Kathleen Nelligan Jennifer Siu William To Bing Wang

Executive Division Administrative Director Productions Editor Productions Associates

At Home & Abroad

Sponsorship Director Sponsorship Associate Publicity Director Webmaster Strategic Advisors

Tackling health issues in Canadian and global contexts

Cover

Spring 2010 • Volume 3 • Issue 1

2010 Volume 3 Issue 1 At Home and Abroad

ISSN 1918-7653

Jacky Chan Maggie Siu Michelle Lee Bing Wang Corina Wong Gretta Moy Raissa Chua Sarindi Aryasinghe Andrey Mikhaylov Kadia Petricca Brian Park Michelle Lee

Website: www.juxtaposition.sa.utoronto.ca Email: juxtaposition.ezine@utoronto.ca Address: 529-21 Sussex Ave, Toronto, Canada M5S 1J6

Spring2011 | Juxtaposition 3


5 Letter from the Editors Features 6 When Passion Meets Purpose:

An Interview with Dr. Raghu Venugopal of MSF Canada Jennifer Kwan and Jennifer Siu

11 The Art of Global Health:

How To Be Both a Teacher and a Life-Long Pupil Stephanie Tom

15 Virus in the Desert:

A Photo Essay on the HIV/AIDS Epidemic in Namibia Charlotte Hunter

20 2010 Conferences In Review:

Table of Contents

The Ontario Model World Health Organization and The Canadian Undergraduate Conference on Healthcare Jillian Murray and Lucy Duan

4 Juxtaposition | Spring2011

Opinion 22 Lessening the Cost of Our Secrets:

What We Spend on Mental Diseases Without Acknowledging Them, and What We Can Do About It Athena Hau

24 Note to Self: Stop Breathing William Fung

26 American and Canadian Health Care Reform: A Need for Proactive Health Care Policy Kathleen Nelligan and William To


In the past few decades, an increasing number of organizations have emerged with mandates to serve communities abroad. Some focus on a specific issue, such as the provision of care for individuals with HIV/AIDS in developing countries. Other organizations aim to deal with broader issues, including the allocation of emergency relief in the face of crises. These organizations occupy a diverse array of niches, yet are unified in their efforts to improve the status of health care abroad. Together such organizations have helped to craft a culture of volunteerism and advocacy that has pervaded our generation. This issue, entitled Movers and Shakers, focuses on the work that is carried out abroad by students and faculty members at the University of Toronto. We begin this issue by providing a glimpse of the organization Médecins Sans Frontières (MSF) through the eyes of Dr. Raghu Venugopal, who has served on the board of directors of MSF Canada. This interview by Jennifer Kwan and Jennifer Siu highlights the various challenges of providing health care abroad as well as the need for more volunteers. Stephanie Tom, a current medical student at the University of Toronto, then introduces a perspective on the efforts of Dignitas International, a medical humanitarian organization that specifically deals with HIV/AIDS in developing countries. Stephanie has worked with Dignitas in the Zomba Central Hospital TB/HIV clinic for the past two summers. We then enter the Communicable Disease Clinic (CDC) in Oshakati, Namibia through Charlotte Hunter’s photo essay entitled Virus in the Desert. Her photographs offer an intriguing portrayal of her summer visit to the CDC. As well, Lucy Duan and Jill Murray share their experiences at the Ontario Model World Health Organization (OMWHO) and the Canadian Undergraduate Conference of Healthcare, hosted by the University of Toronto International Health Program and Queen’s University respectively. These annual events are aimed to engage students in global health. One such global health issue that is in need of change is the public perception of mental health disorders. Athena Hau deconstructs this dilemma in Lessening the Costs of Our Secrets. William Fung then takes us into a discussion on the need for pollution reduction in his essay entitled Note to Self: Stop Breathing. Finally, Kathleen Nelligan and William To delve into an in-depth analysis on the current status of the health care reform in North America and offer a perspective on how it can be improved. The collection of articles in this issue surveys some of the opportunities available to students, researchers, and clinicians to engage with communities abroad. We hope that these articles offer a glimpse of the actuality of global health advocacy and a lens through which the state of global health can be considered. Together we can use these lessons to become active rather than passive global citizens, strengthening our society and our world at large. Sincerely,

Letter from the Editors

Dear Readers,

Jennifer Kwan & Jacqueline Wong

Editors in Chief 10/11, Editorial and Executive Divisions

Spring2011 | Juxtaposition 5


Feature

When Passion Meets Purpose An Interview with Dr. Raghu Venugopal of MSF Canada

Correspondence by: Jennifer Kwan1 and Jennifer Siu2 1 2

Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada Department of Physiology, University of Toronto, Toronto, ON, Canada

Médecins Sans Frontières (MSF or Doctors Without Borders) is a well established medical relief organization with a mandate to provide emergency relief to populations facing various disasters across the world. On November 4, 2010, Juxtaposition interviewed Dr. Raghu Venugopal, who served on the board of directors of MSF Canada. The interview was conducted with the intent to understand more about this renowned organization and to gain an insider’s perspective on volunteering abroad through Dr. Venugopal’s numerous experiences in the field. Dr. Venugopal also imparts some advice for students who are interested in the global health field.

MSF in Burundi. Burundi is one of the poorest countries in the world and lacks many of the basic health care services. Dr. Raghu Venugopal was part of the MSF medical team that was sent to Burundi in 2006. Photo credit: MSF Canada.

Juxtaposition: How did you end up working abroad with NGOs (non-governmental organizations), such as MSF? Also, how did you get involved specifically with the projects in Burundi (Africa), Tanzania (Africa), the Balkans (Europe), and the West Bank (Middle East)?

6 Juxtaposition | Spring2011

Dr. Venugopal: I thought that medicine was an excellent tool for social good in our country and abroad. I did not initially have an interest in MSF. While I was in medical school, James Orbinski was the president of MSF International and when James accepted a Nobel prize, it obviously jarred a

lot of attention [for the organization]. But, I worked with many NGOs before MSF. I got to work with a lot of NGOs that didn’t work as well [because of financial situations and distribution of resources] and I graduated my way up to MSF. I wanted to work with what was considered a really good


Field mission to the Central African Republic. Children, ages 6 months to 5 years, are in a vulnerable age group and are often seen by the MSF medical team. Pediatric malaria, pediatric respiratory infections, and pediatric gastrointestinal infections have high incidence rates. This child was examined by Dr. Raghu Venugopal during his MSF field mission in 2009. Photo credit: MSF Canada.

professional medical organization so that’s what led me to MSF. I also liked MSF’s attitude and its courage, its fearlessness to say what needs to be said. It may not be something that everyone wants to do. The combination of journalists, doctors, and nurses together appealed to me so it seemed like a good fit. There was a lot of passion and intensity in MSF.

of where you want to go, but to go where there is a clear need. [Briefly], my work in Tanzania and West Bank Gaza was through a program at Johns Hopkins University. I was sent by an American organization to work in the Balkans around the time of the conflict in Kosovo and Serbia.

I think that the best approach is not to have an idea of where you want to go, but to go where there is a clear need.

What are the main differences between your work in Canada versus abroad?

My very first involvements were during medical school helping to organize the annual meeting in Canada, being involved in the association as a volunteer, and getting involved in public education. After gaining my medical skills and public health skills, I was deployed to the field. I had my first deployment in 2005. In MSF you don’t get to pick where you want to go, you can only pick where you do not want to go. Burundi was available as a posting. I wanted to work in Central Africa and so when I was asked to go to Burundi, I was excited to go. I think that the best approach is not to have an idea

The differences are incredibly immense. The only similarities are the human body, the human mind, and the fact that you are working with human beings who have the same hopes, dreams, and physiology. But, the types of disease are completely different. I would say in the field, we’re dealing mostly with pediatrics because they are the most vulnerable age group between 6 months and 5 years old. The top killers are pediatric malaria, pediatric respiratory infections, pediatric gastrointestinal infections, meningitis, measles, burns, trauma, skin infections, and malnutrition. But then, back home here as an emergency doctor, I mostly deal with adults and I normally deal with problems like heart attacks, strokes, the impact of excess alcohol use, minor trauma, and complications of chronic diseases such

as kidney failure or diabetes. The pathology is very different, the spectrum of disease is very different, and the differences are not just in the diseases but what we can do about them.

…the only similarities are the human body, the human mind, and the fact that you are working with human beings who have the same hopes, dreams, and physiology. Here in the Canada, we can do exceptionally complicated, life-saving maneuvers with critically sick patients to preserve life and limb. Seemingly we have inexhaustible resources such as diagnostic imaging, medications, intensive care, access to surgery, and access to potent antimicrobials; there’s no comparison. In the field, we have to make difficult decisions like who gets the last pint of blood, we have to work with limited resources (five antibiotics, two anti-malarials), sometimes we can’t transfer patients easily, surgical services are not easily available, and there is often no imaging, such as chest x-rays or CT scans. Spring2011 | Juxtaposition 7


The expectations are very different as well. The mothers and fathers are very grateful if you try to help because they understand that not everything can be done. In my experiences even with children who end up dying at a young age, who in this part of the world could be saved, the mothers and fathers are just grateful that you tried and touched their family member because oftentimes the child won’t even be examined in countries let alone offered free medication as we do. The diseases are different, the treatments are different, the expectations are different, and the outcomes are different. But, that being said, in the field, we have an incredible opportunity to save an incredible number of people with relatively uncomplicated treatments. It is very gratifying in that you can take an exceptionally sick child, and with a few simple maneuvers like rehydration, anti-malarials, and antibiotics, you can easily save a child’s life.

…in the field, we have an incredible opportunity to save an incredible number of people with relatively uncomplicated treatments. Do you feel your training as an emergency doctor has made you better equipped to work abroad during a medical crisis? There are a few medical backgrounds that are very useful in the field. I think family medicine is excellent, as well as pediatrics, internal medicine, general surgery, and emergency medicine, which I practice. Emergency medicine is a great background because we are able to deal with the main populations of patients, which are children, pregnant women, and adults with tropical medicine problems, trauma, or general surgical problems. So those are the main categories of patients. As an emergency physician you are able 8 Juxtaposition | Spring2011

to approach all of those problems and not be stranded without an approach to a child who is convulsing, an adult who is unconscious, or a woman who is bleeding out from having a child. So you are able to approach all of those [situations]. As an emergency physician I feel comfortable doing all of those things.

of people with very little equipment. You have a lot of sick patients with very little resources and you have to do your best to keep people alive. Sometimes that doesn’t happen and patients die and you feel great emotion because many of the patients that die are often children and this is very different to our experience here in North America.

What challenges do you face in the field and how do you stay focused and motivated given all of these obstacles?

…you have to be like MacGyver and roll with the punches. If you’re not flexible and can’t adapt quickly both medically and in all other realms…you’ll have a hard time.

I would say that the challenges are innumerable, but part of the challenge is safety because in areas of conflict, you have to be conscious of your safety and have what I call situational awareness. You have to be cognizant of the fact that there may be rebels, bandits, or criminality, because it is not your country. It’s rural and there’s often an absence of law where we are working. The other challenge is staying healthy because it is unsanitary conditions, you’re stressed, and you’re dealing with very sick patients. Your health goes down the tubes very quickly. You’re working hard, you’re dehydrated, and the climate is very hot, so it is very easy to get malaria, gastroenteritis, or heat stroke. Other challenges are working with an international team that you don’t share the same cultural beliefs with, the same ethics, the same style of getting things done. Here in North America, we have a certain way of doing things and that is not shared around the world. We have certain ethical notions, we have a certain respect for different cultures, and for different genders. Working in tight quarters is really difficult as well because you eat, sleep, and work with the same people day in and day out, seven days a week and so that is a challenge as well. Other challenges would be to adapt, you have to be like MacGyver and roll with the punches. If you’re not flexible and can’t adapt quickly both medically and in all other realms like cooking, eating, sleeping arrangements, and workload, you’ll have a hard time. Then, there’s just taking care

I think staying focused and motivated is difficult. I think a pearl that I’ve learned the hard way is being humble and modest. Everywhere I’ve worked there’s always an expression for that, which is “gently, gently”. It just means that you can’t save the world. You can take care of a few people, take on a few projects, make a small contribution, and be humble and thankful that you were able to save a mother’s life, father’s [life], or a child’s life today. You can’t save everyone, but you can certainly do your best. Humility and modesty is a great way to deal with it. I don’t think MSF can change the world, but we can change lives and so if I focus on changing lives, I don’t get dismayed by the fact that all around me is suffering and people in privation and distress. I don’t focus on the big picture; I actually focus on the small picture. [To keep motivated,] other ways are to have things to do other than health care: we had Saturday night dance parties in the jungle with our favorite tunes back home, going for daily walk, reading a good book, watching lots of movies, taking breaks, pacing oneself and not trying to do everything at once. I think those are the strategies on how most of us stay focused.


In your opinion, what are the key challenges being tackled by MSF at the moment? I would say that the biggest challenges that MSF is facing today is working in hostile environments. All around the world there are hostile environments like Sudan, Darfur, Iraq, Afghanistan, and Somalia where access to patients is very difficult. MSF was founded with a goal to work in conflict. That remains one of the most challenging goals today: getting access and being able to safely operate in areas of war and conflict. As an MSF-er, I can’t speak on behalf of the organization, [but] in my opinion that is one of our top challenges. What also remains exceptionally challenging is trying to balance the two fundamental goals of MSF. Our top priority is medical action, professional medical intervention to save lives, and to alleviate suffering, but second to that is our notion to describing what we see and speaking out on behalf of the population. Increasingly in polarized contexts where there is an anti-Western sentiment or a strong armed government, it is very difficult to speak out and describe what we are seeing, while at the same time remain on the ground with safe access to our patients. Balancing that action to speaking out and maintaining

that balance has been very difficult in my opinion. That will remain a major challenge. Other major challenges include dealing with special populations that were not present when MSF was founded. The major refugee crisis of the ‘80s and ‘90s are not so frequent now, rather we are seeing urban violence, internally displaced people, and victims of environmental disasters. Other populations that have been challenging and different include patients with chronic diseases such as HIV, TB, and diabetes, who don’t fit the classical emergency paradigm of MSF, but rather require lifelong treatment. For example patients with MDRTB (multi-drug-resistant tuberculosis), will require treatments for much longer than most standard protocols. Other challenges include pushing the boundaries that we previously thought we couldn’t do much about, [for instance treatment of] premature babies. Lastly, as in all forms of medicine, ethical issues remain a great challenge.

How is MSF dealing with sustainability in their projects? I don’t think sustainability is a formal goal of MSF. MSF is an emergency organization. There are a lot of good organizations that do sustainable projects, but I don’t think MSF

should be one of these. For example, if you went to the emergency room for high blood pressure, you wouldn’t expect the doctor to call you a week later to see if your blood pressure was better. That’s more the role of the family physician or other health care professionals. If these health care workers focused on everything, then no one would be able to get into the emergency room. If we tried to take care of everyone’s blood pressure, we wouldn’t be able to see all the patients with head injuries, appendicitis, pneumonia, or have an ectopic pregnancy. So, it’s humility to not be sustainable. To try to be sustainable in all circumstances is immodest in my opinion. It is politically correct, but not realistic. To be disciplined and focused is our reality. But what we do aim to do is put choices in the hands of people who don’t have choices – to be an emergency response when there are no other [professionals] that are capable or willing to respond. Whenever possible, our role is to responsibly hand over those projects to entities like the Ministry of Health, who normally [deal with long-term care]. What MSF is about is showing that there is way to show people that there is hope; for instance, we can treat HIV in Eastern Congo [and] a gunshot wound in Somalia deserves medical treatment, but

MSF in Northern Central African Republic. Malnutrition is one of the top killers in the field. During his trip with MSF to the Central African Republic in 2009, Dr. Raghu Venugopal cared for this malnourished Chadian child in addition to many others. Photo credit: MSF Canada

Spring2011 | Juxtaposition 9


I wouldn’t say that sustainability is our [priority]. That said, on the ground, on the individual level we will look for sustainable solutions. For example, I try to work with the nurses and local staff to try to train them to do anything that I can do. So in that way, that’s my contributions to sustainability: making sure that when I leave, I’ve left something behind that hopefully will outlive my presence.

on possible collaborations that suit our needs and our goals. The next steps also include finding a way to better proactively speak out on behalf of populations on some of the most difficult conflicts that exist [especially] where speaking out is very challenging. It’s about [sending] coherent, timely messages that don’t jeopardize our access to populations. [However], the bread and butter of what we do has not changed.

What are MSF’s next steps?

What advice would you give to students who are interested in global health?

Some next steps in MSF include assessing [the contributions of] our presence and gaining better access in crises such as Somalia, Iraq, Afghanistan, CAR, Eastern Congo. Other challenges include trying to understand the perception of MSF by non-MSF entities. We have engaged a project called the “Perceptions Project” where we have gained contact with community leaders [by] talking to other stakeholders whose voices are important in understanding how our actions are perceived so [that] we can better understand how MSF fits within the societies that we work in. Our challenges also include strategically working with other global health entities in a way that guards our independence [and] capitalizing From left to right. Jennifer Siu, Jennifer Kwan, and Dr. Raghu Venugopal.

10 Juxtaposition | Spring2011

I would say the most important message for students that their talent, their energy and motivation are definitely appreciated. An organization like MSF very much requires the new blood and the new passion of trainees and students. I [encourage students] to immerse themselves in what they are passionate about and [in a career that] gives them professional skills to work in the field.

An organization like MSF very much requires the new blood and the new passion of trainees and students.

MSF aims to employ a third of all of its international volunteers as first-mission volunteers. I think this is very important because it is [these] first missions that capture the passion and ingenuity that keeps this organization with vitality and a cutting edge approach. What we want to be is an avant-garde organization that thinks and moves in different ways. We are always [trying] to push the frontier [and] that is encouraged by new members. My first message is that I believe there is a place for new people in MSF [and] that they are welcome. My second piece of advice is to gain lots of skills both personally and professionally. Language skills, particularly French and

Spanish [are very useful abroad], but we have also seen Arabic [as a beneficial asset]. [Additionally] students need to gain professional skills. They need to be professionals in business, nursing, engineering, medicine…. whatever they do. These skills and experiences [gained] in their home society are very important. I would also ask students to consider the importance of personal strengths and not just professional skills. We are not just looking for technically savvy people, but we are looking for well-rounded people. Such people are those who have a well balanced lifestyle, who have happiness and fun in their life, and not just [have] their nose in the books. I don’t think that what makes a good MSF-er is just medical skills, but also people skills [like] being able to deal with diversity and friction, and being flexible.

Somewhere out there is the next James Orbinski, and we need to find him or her.

Finally, I would also say that a lot of us currently in MSF were in the shoes of students once, and we’ve all gone through the long road of being a trainee. I would ask people to not lose hope and to keep that fire alive by travelling, by going to educational seminars, by [being] engaged in either the school of public health, medical or nursing, [and keeping the] passion and interest alive. Somewhere out there is the next James Orbinski, and we need to find him or her. Profile: Dr. Venugopal is an emergency physician at Toronto General Hospital and Western Hospital, assistant professor at the University of Toronto, and he also served on the board of directors of Médecins Sans Frontières Canada. He obtained his public health training at Harvard University, finished an international emergency medicine research fellowship at Johns Hopkins University, and completed his specialization in emergency medicine at McGill University.


Feature

The Art of Global Health:

How To Be Both a Teacher and a Life-Long Pupil

Stephanie Tom MD Candidate 2012, Faculty of Medicine, University of Toronto, Toronto, ON, Canada

Global health is a term that often conjures up images of mud huts, African children and foreign humanitarian workers. But as I worked alongside my colleagues of Dignitas International at Zomba Central Hospital in Malawi, it became clear that successes in global health on the ground are not achieved through the name of charity, but instead through a collaborative desire to improve a community. As students, it is possible to integrate yourself into communities and adopt a global health mindset by finding your own niche, adapting to the local context and most of all, recognizing both your potential to contribute and nuances of how your involvement will affect your experiences and long-term project sustainability. Dignitas International clinical staff members at Zomba Central Hospital. From left to right: Paul (clinical officer), Stephanie Tom (medical student), Chrissie Gondwe (nurse) and Alice Kadzanja (nurse).

I panicked as I looked down the road ahead of me. A woman with her baby tied on her back was walking away from my direction; a man was cycling towards me on the other side; a pothole that looked much too deep lay right in the middle of the dirt road. My clunky Land Cruiser moaned and groaned as I shifted from third gear to second while my blood pressure skyrocketed, dipping only slightly after I

managed to pass between the streams of pedestrians going to or away from market day, not to mention the chickens, goats, dogs, cows and children playing, in tall fields of grass.

What is global health? Global health is a term that often conjures up images of mud huts, African

children and foreign humanitarian workers. But working with Gabriel Mateyu at Pirimiti’s rural health centre or with Chrissie Gondwe at Zomba Central Hospital’s TB/ HIV clinic, it became clear that the power of global health on the ground is not done in the name of charity. In fact, doesn’t the term “global health” itself beg the question of why global health is different from any other form of health? Although the term Spring2011 | Juxtaposition 11


Malawi village. The children and neighbours of Stephanie Tom during her visit to Malawi in 2010.

may bring up images of exotic locales, a more accurate and comprehensive approach is to see global health as the desire to “recognize the global community and [our] responsibility as advocates” and to approach our work – as a physician, nurse, or student – with a “global state of mind… [that] whatever affects one directly, affects all indirectly.” 1 During my time in Malawi in the summers of 2009 and 2010, this acknowledgment of a global context within one’s own work was what allowed for the creation of effective working partnerships between communities, each with their own areas of expertise. Too often are projects implemented in the name of giving – only to have optimistic results dissipate with funding cuts, departure of foreign 12 Juxtaposition | Spring2011

consultants or simply, the passage of time. Although much progress has been made towards reducing HIV transmission in sub-Saharan Africa, the recent economic crisis has further highlighted the frustration of donor countries as HIV, tuberculosis, diarrhea and malaria continue to kill or incapacitate millions of individuals every year. These disturbing trends continue despite the billions of dollars that have poured into funding health services, programs, outreach and infrastructure abroad. In Malawi, some hospital wards overflow with patients while others remain empty due to staffing shortages. According to the World Health Organization, the continent of Africa has 25% of the world’s burden of diseases yet only has 1.3% of

the world’s health workforce.2 Malawi’s only medical school was established in 1991 and until recently, most of their training was completed in the UK. With a population of 13 million and only 260 doctors, the Ministry of Health has enrolled hundreds of clinical officers and nurses to ensure staffing at hospitals and rural health centres.3 Although clinical officers were initially touted as a temporary solution to bridge the health care worker shortage gap as physicians underwent their extensive training, they are now the primary caregivers for most of Malawi’s population as they prescribe drugs, operate, deliver babies and even help track disease patterns. With the price tag of tertiary education remaining out of reach for most Malawians, the South-North brain drain, retirement


and other losses to the workforce (including health care professionals needing to care for themselves or sick family members), health care worker shortages remain a crucial limiting step in health care delivery. Building hospitals, schools or water pumps are concrete goals – you can see them, you can feel them and hopefully, you can also use them. Knowledge and skill capacity, however, are much less directly visible. Like public health, their results are often appreciated only indirectly by others with the story of a healthy child, a healthy adult, a healthy population, or as statistics. Therefore, knowledge and expertise – although non-photographable – should not be overshadowed by the towering structure of a new hospital in terms of both funding and perceived importance when it comes to discussing health care. On the other hand, knowledge, like infrastructure, needs to be built and maintained over the years in order to function effectively and serve its purpose. So how does this question about the importance of knowledge, expertise and infrastructure apply to global health? Without laboratory technologies and medications, health care workers would be limited in their daily work. Moreover, these issues would remain important areas of advocacy as they are dependent on donor funding. However, without education and medical training, these individuals would be unable to provide any patient care. Medicine is an art as much as a science and with ongoing new developments in evidence-based guidelines and studies, it is an evolving field that requires updating and adapting practices to continuously maximize on windows of opportunity for prevention, diagnosis or treatment. With millions still dying from preventable illnesses, maintaining the status quo is clearly not enough.

What can students do? As students, where do, or can we stand in this vast field of opportunities and

how can we apply this sense of mindset known as global health? Many of us are still undergoing our studies – whether in medicine, nursing, health sciences, biology, engineering or liberal arts and we often find ourselves at both extremes of the time spectrum. On one hand, we are limited by the duration of our summers but on the other hand, we are often more available to take on multi-year projects abroad once we graduate without having to consider mortgages, spouses or kids. Nonetheless, for those who are interested in learning more about underserviced communities, the plethora of ways to become involved may seem overwhelming rather than presenting themselves as a logical map of options. A general approach to getting started with global/local health issues includes the following:

1. Find your niche and be specific about it. With the multitude of non-governmental organizations (NGO), governmental agencies and institutions, there are many mandates and projects to choose from. There is something for everyone, or at least a shade of it. Start by identifying your current skill set (i.e. writing and communications, laboratory benchwork), and the areas of interest that you want to bolster (i.e. refining your current skills, or pushing yourself to take on new tasks and challenges).

2. Identify the perimeter of your comfort zone. Are you comfortable with working overseas where you do not speak the local language and have no access to flushing toilets? Or do you see yourself working in a city focusing on public policy? Do you see yourself working alone or in a team? And most importantly, how much mentorship (personal, one-on-one, via email) would you be comfortable with? Be aware of who you are, not how your CV currently sounds.

3. Find an organization that fits your interest and desired level of mentorship Now it is time to finally move from looking inwards to looking outwards. With your friend Google, on-campus group listings, and word of mouth, start the search to find the organization that shares your values and goals. Check to see whether the organization currently has projects available for students, or if that could be a possibility in the future. Who is working on the project now? Who will be part of the team? (Is it just you and your supervisor or are others involved?). And most importantly, who will continue the project once you’ve finished? What phase of the project do you belong to and how will it transition to you and from you?

4. Find funding – search for scholarships, bursaries, project funds or part-time work The reality is that most organizations are happy to take on students but do not provide funding due to budget constraints or fundraising accountability. Unless you can afford the flight and have the means to live safely in the community you are working in, you will be breaking the bank.

5. Work hard, teach harder. Really, try to teach as much as possible since learning is a given. Tying this all back to the priceless value of knowledge and the shortage of health care workers, it is important to work hard on your own but it is more important that you also work hard alongside others. Although you will contribute an important step to a project, it is also your responsibility to ask how those steps will align after you move on, in order to keep the project moving forward so that your efforts are truly worthwhile. As a newcomer to the team, you can also bring fresh eyes to routine tasks. Being on a new project, we often learn much more than what we are able to contribute to the community regardless Spring2011 | Juxtaposition 13


of how hard we work. If we are in another country, we learn their traditions, their customs, some of their language, their systems, and their ingenuity. We often get caught up in the learning and give back very little, especially if the time period is short. Go into your project wanting to both learn and teach as you work alongside others. Being mindful of this dynamic will also affect how you interact with your colleagues and new environment. Even knowing how to use Excel for accounting and teaching a new colleague (who may never have used a computer before) can be an eye-opening learning experience that facilitates better organizational skills for his or her daily work. This approach is by no means written in stone, but it encompasses key questions that will facilitate both personal growth and field learning. Searching your memory for ideas or a touch of inspiration? Start with an internet search or talk amongst friends or campus groups. Not sure which organization you want to work with? If you come across a student funding opportunity that does not require that you apply with a partner organization, go for it first and you will find it much easier to find a suitable organization if you already have your own funding to cover your expenses once you decide that you’re committed to fulfilling the terms of the funding to avoid taking this opportunity away from other students. Nonetheless, the more you recognize why you are undertaking a project in global or local health, the more you will learn from and contribute to your experience. The reality is, the longer you can commit to the project, the more you will see it progress through both its successes and obstacles. As for a future career in global health, once you get involved and continue to develop your skill set, you will have more to share as you continue to learn from others and teach what you can in a bilateral exchange of ideas and practices. The decision to work overseas is a very personal one but regardless of whether you decide 14 Juxtaposition | Spring2011

to stay for months or years or decades, the more you learn, teach, and engage in this collegial dialogue of ideas, practices and common goals, the greater likelihood that you will have a lasting impact on a project and truly practice medicine with a global state of mind. In fall 2008, I started medical school at the University of Toronto and became interested in HIV/AIDS. I knew that I had some medical knowledge and was comfortable with relocating almost anywhere but was not well-versed in the current approaches to addressing HIV in the community nor all its socio-politicaleconomic nuances. After stumbling across the Medical Alumni Association scholarship, I was pointed towards Dignitas International with their HIV work in Malawi. Their values on communitybased health care delivery aligned with my own. Dignitas is a medical humanitarian organization that aims to save lives and reduce the suffering caused by HIV/AIDS and related global diseases. After being cofounded by Dr. James Orbinski and James Fraser, both formerly integral members of Médecins Sans Frontières (MSF/Doctors Without Borders) in 2003, the organization began its work in 2004. Dignitas focuses its efforts on addressing the HIV/AIDS pandemic in Malawi as an entry point for strengthening health systems and related global health issues. Dignitas’ approach of strengthening health systems is what sparked my interest in their work. Suddenly, the broad objective of addressing the HIV/ AIDS epidemic had a focus, a niche, a tangible goal that encompassed HIV but not at the exclusion of other factors. More notably, collaboration with the Malawian Ministry of Health and Malawian health care workers emphasizes their roles as the future of the country’s health care system. Working alongside as colleagues, Dignitas provides training to front-line health workers and health managers and has

implemented initiatives that facilitate the reallocation of work-related tasks in order to effectively respond to Malawi’s ongoing crisis in human resources for health. With approximately 70 percent of all health care posts in Malawi currently vacant, there is a shift of administrative and lower-level tasks to health surveillance assistants and expert patients (patients who help guide newly diagnosed HIV individuals through the health care system while providing emotional support) to reduce the work burden on nurses, clinical officers and health managers. By developing and sharing cost-effective solutions for HIVrelated treatment and prevention as well as conducting research to improve programs and inform health policy and practice, Dignitas tackles the HIV epidemic not through raw emotions or charity, but by working alongside current health providers and policy makers to contribute to a locallydriven system of research, evaluation and ongoing improvement of patient care. As I passed through the stream of pedestrians, Moses Macdonald, my neighbour in the village, smiled at me as he sat in the passenger seat. “Good job!” he said. Earlier that week, I had mentioned that I would have liked to be able to drive standard so that I could better visit the various villages in the region. As a driver himself, he offered to teach me. After a few hours of practicing, I was able to drive on my own, a skill that proved to be incredibly useful for my summer and the years to come as it has allowed me to do my work, and travel to locations without having to inconvenience others’ schedules. With a bit of teaching and sharing, everyone can develop the capacity to go a long way.

References: 1. Jane Philpott, “Training for a Global State of Mind,” Virtual Mentor. 12 (2010): 231-236. 2. Clare Nullis-Kapp, “Health worker shortage could derail development goals,” Bulletin World Health Organization, 83 (2005): 5-6. 3. Adamson Muula, “Case for Clinical Officers and Medical Assistants in Malawi,” Croat Med J., 50 (2009): 77–78.


Feature

Virus in the Desert:

A Photo Essay on the HIV/AIDS Epidemic in Namibia

Charlotte Hunter1 1

Department of Human Biology: Global Health, University of Toronto, Toronto, ON, Canada

The inner workings of the Communicable Disease Clinic (CDC), a site that provides HIV/AIDS treatment in Oshakati, Namibia, are revealed through photographs taken during a summer internship. The importance of adherence to antiretroviral drugs is a problem among CDC patients and is emphasized. Possible barriers to antiretroviral adherence are discussed based on surveys given to CDC staff members. These barriers include structural problems (e.g. lack of access to transportation), social issues (e.g. HIV/AIDS stigma), and economic factors. It is evident that in Namibia, as in many parts of the world, the HIV/AIDS epidemic is caused by a complex web of poverty-related factors that penetrate all levels of society. Months after returning from Namibia, I am still struggling to understand the intricate web of social, political, cultural, economic, and epidemiological factors that have contributed to a seemingly unrelenting HIV/AIDS epidemic in that country. In the two months that I spent working at an HIV/AIDS clinic in Oshakati, a town near

the Angolan border, I learned firsthand about diverse topics such as gender relations in southern Africa, the side effects of antiretroviral drugs, and the complexities of the global HIV/AIDS pandemic. Namibia is just north of South Africa, wedged neatly between the Atlantic Ocean and the Kalahari Desert, and has

a population of about 2 million people. Namibians are some of the friendliest, most welcoming people you will meet in your life. Tragically, 15.3% of adult Namibians are also living with HIV.1 In the Oshana region where I lived and worked, this prevalence was believed to be even higher.

1. The entrance to the hospital where I worked in Oshakati, Namibia. The Oshakati hospital has a catchment population of almost 200,000 people and serves as a referral hospital for several other regions in the north of the country.

Winter2011 | Juxtaposition 15


2. The waiting room of the HIV/AIDS clinic that I worked at, known as the Communicable Disease Clinic (CDC). The CDC was established in 2003 with funding from PEPFAR (the United States President’s Emergency Plan for AIDS Relief). The clinic employs six doctors, who work with a team of nurses, pharmacists, community counsellors, data clerks, and volunteers, to provide a variety of HIV-related services for their patients. The CDC has over 17,000 patients, over 16,000 of whom are on antiretroviral drugs (ARVs).

3. The counselling room where patients were taught about the side effects of ARVs, the importance of safe sex, and the reasons why they needed to take their medication every day without fail. ARVs suppress HIV effectively only if patients take their medication in the correct dosage every day, a measurement known as adherence. Many patients came to the clinic to receive a new month’s supply of pills, yet their old bottles were still filled with leftover pills. Others arrived several months late to refill their prescription. This put them at risk of becoming resistant to the same medication that was necessary in saving their lives.

16 Juxtaposition | Winter2011


4. One of many local bars in the Oshakati area, known as “shebeens”. CDC staff believed that one of the major reasons people exhibited poor adherence was that they missed doses of their medication when intoxicated. Structural and economic barriers also prevent people from adhering to their ARV regimen. Some patients lived in isolated villages and didn’t have access to transportation to come in for their new prescription on time, or couldn’t afford the transit fares. Others refused to take the harsh medication on an empty stomach, a chronic condition in a food insecure and poverty-stricken region. In addition, the social stigma of HIV may have prevented patients from taking pills in front of their family members or co-workers.

5. CDC nurses working in the blood room. Here, samples were taken from patients for CD4 counts, viral load tests, and tests measuring other biochemical markers related to organ function. Although the CDC staff wished that they could offer individualised counselling to more people, the undeniable truth was that the CDC was visited by over 300 patients each day and the overworked staff were unable to devote more than a few minutes to each patient. While understandable, this situation was incredibly frustrating. What good are the millions of pills donated by USAID if people don’t have the support needed to take them correctly?

Winter2011 | Juxtaposition 17


6. Left: An informal settlement called Oneshila. The crippling prevalence of HIV in Namibia seemed to be both caused by and a cause of the pervasive conditions of poverty in the country. This settlement floods three months of the year, displacing its residents.

7. Right: Oneshila children practise the dance routines taught to them by Miss Doris, a local dance teacher. These children were very talented dancers. They also lived in an extremely impoverished community. Many of them were AIDS orphans; others were HIV-positive themselves. 8. Background: The Namib Desert. Namibia is not just the site of a devastating HIV/AIDS epidemic; it is also home to some of the most devastatingly beautiful landscapes in the world.

18 Juxtaposition | Winter2011


I sincerely hope that hospitals like the one in Oshakati are eventually provided with the resources to provide their patients with the adherence support that they need, and that the Namibian government works with the global community to address some of the structural and social barriers that prevent people from taking their lifesaving ARVs consistently. Most of all, I hope that we can all remember the humanity of each individual living with and fighting against

HIV, no matter how far away they live or how different their culture, as this is an important step towards giving this global health disaster the urgent attention it deserves. Charlotte Hunter was in Namibia from June to August, 2010 for a University of Toronto HIV/AIDS internship. For the past 12 years, this program has sent U of T students from different academic backgrounds to conduct HIV-related service learning

placements at various agencies, NGOs, and clinics, in partnership with the University of Namibia. The discussion of barriers to antiretroviral adherence in this essay is based on the results of surveys distributed to CDC staff members as part of a Human Biology Program research project.

References 1. UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance. Epidemiological fact sheet on HIV and AIDS: Core data on epidemiology and response: Namibia. Geneva: 2009.

Winter2011 | Juxtaposition 19


Feature

2010 Conferences in Review: The Ontario Model World Health Organization and The Canadian Undergraduate Conference on Health.

During the weekend of November 12th-14th 2010, two conferences took place: the first Ontario Model World Health Organization (OMWHO), held at the University of Toronto in Toronto, ON, and the sixth annual Canadian Undergraduate Conference on Healthcare (CUCOH), hosted at Queen’s University in Kingston, ON. Both conferences were organized by university student groups and were tailored to the undergraduate population. Both conferences highlighted the importance of promoting health care awareness both in Canada and globally.

OMWHO The Ontario Model World Health Organization Jillian Murray Department of Human Biology, University of Toronto, Ontario

OMWHO was comprised of student delegates from a variety of universities who wanted to gain practical experience in the field of public health policy. The delegates who participated in mock WHO general assembly meetings actively engaged in debates and discussions and were able to pass resolutions regarding the impact of the financial crisis on the state of global health. These future public health leaders had their learning experience enhanced through interactive lectures with two current leaders in the field of global health; Drs. Obidimma Ezezika and Solomon Benatar, colleagues at the McLaughlin-Rotman Centre for Global Health in Toronto. The first Ontario Model World Health Organization (OMWHO) was held over the weekend of November 12-14 in the Sutton Place Hotel in Toronto. It was organized by the University of Toronto International Health Program (UTIHP) in order to provide a practical learning experience for students interested in pursuing careers in the field of international health. The theme of the conference was “Effects of the Financial Crisis on Global Health�; a pragmatic topic for future public health leaders. Similar to its predecessor 20 Juxtaposition | Spring2011

Model UN, OMWHO consisted of student delegates who represented the various member countries of the WHO General Assembly. The delegate sessions began on the Friday with a discussion of the provision of foreign assistance in times of financial crisis. This developed into a critical look at the idea of financial aid and its necessity for alleviating global economic disparity. The second delegate session built upon the issues raised in the discussion on foreign aid, but required the participants to develop frameworks for health care

budgeting and strengthening health systems during the economic crisis. The subsequent delegate sessions evolved from one another and the weekend of committee sessions successfully ended with the passing of three resolutions regarding these topics. The emphasis on discussing international health problems in the context of current world events increased the applicability of this conference to current challenges public health leaders are facing and issues that will be relevant in the future. The learning experience was enhanced by two guest speakers who are prominent in the field of global health. Both colleagues at the McLaughlin-Rotman Centre for Global Health, Drs. Obidimma Ezezika and Solomon Benatar brought to light some of the ethical and moral dilemmas inherent to working in the field of global health. Dr. Benatar focused on the global economy and the detrimental impact of this sector on health. He emphasized that our value system has allowed health care to become a market-driven sector in which money takes precedence over quality of health care; a venture that has dangerous consequences for the health of impoverished individuals and countries. With new paradigms of thinking, better health for all may be a more realistic goal. Dr. Ezezika focused on discussing the foundations for a


model of trust building in order to drive collaboration and innovation in global health partnerships. These global health ventures need investment capital to create successful partnerships, which necessitates the incorporation of the wealthy private sector. Facilitating trust between the public and private sector companies can work to alleviate conflicts which could threaten the outcomes of a particular partnership. The first OMWHO was a successful

conference that provided an opportunity for future public health leaders to develop skills necessary for debating world health issues. This weekend was interspersed with social events that allowed for networking and the opportunity for delegates to interact and learn from one another’s experiences. Overall, this conference proved to be a valuable opportunity for prospective public health leaders and will no doubt help foster the development of their potential in this field.

CUCOH The Canadian Undergraduate Conference on Healthcare Lucy Duan Department of Laboratory Medicine and Pathobiolgy, University of Toronto, Ontario

CUCOH gathered over three hundred undergraduate students from ten Canadian Universities and provided an opportunity for participants to engage in discussion about current interdisciplinary health care issues. Over the three-day period, delegates had the opportunity to participate in engaging seminars and attend talks given by distinguished speakers including Ms. Francesca Grosso, co-author of “Navigating Canada’s Health Care: A User Guide to Getting the Care You Need”, and Dr. Philip Hebert, professor of bioethics at the University of Toronto and author of “Doing Right”.

The sixth annual Canadian Undergraduate Conference on Healthcare (CUCOH) was held from November 12th-14th, 2010 at Queen’s University in Kingston, Ontario. Organized by a group of dedicated undergraduate students, its mandate was to provide insight into the current state of Canadian health care and engage delegates in discussion and debate about interdisciplinary clinical and research issues. Each year, CUCOH gathers over three hundred proactive students from over ten Canadian Universities, inspiring them to think holistically and globally. Over the three day period, delegates had the opportunity to attend motivating

speeches given by four distinguished keynote speakers. They also had the chance to participate in three seminars covering a wide range of health care issues such as: enabling technologies for children with disabilities, medical practice in the 21st century, and progress in oncolytic virotherapy. In addition , some delegates presented their research in a poster competition held on the third day. The competition covered a wide range of both clinical and basic science research topics. The first keynote speaker was Ms. Francesca Grosso, an expert in health policy and Co-author of the book “Navigating Canada’s Health Care: A User

Guide to Getting the Care You Need”. She spoke passionately about the need for collaboration between health care professionals to ensure that patient needs are met, and emphasized the importance of patients having a personal advocate, such as a family member, to ensure timely access to proper care. Dr. Philip Hebert, a prominent figure in Medical bioethics and author of “Doing Right: A Practical Guide to Ethics for Physicians and Medical Trainees”, shed light on real-life ethical dilemmas and the thought processes behind decision making. Dr. Peter Lin, a family physician from Scarborough, voice of the health columnist on CBS Radio, and long-time CUCOH supporter, gave an inspirational and humorous speech focusing on the necessity of thinking outside the box in shaping the future of the health care system. Finally, Dr. Michael Evans, a practicing family doctor, professor, and researcher at the University of Toronto, highlighted how creativity in patient engagement can improve patient satisfaction and outcome. He has developed the Health Design Lab, which helps patients navigate health problems through interactive video, comic books, and peer to peer advice. His talk articulated the collective voice of the 2010 conference; which was one focused on a future with interdisciplinary teams of health care professionals in patient management, tailored health care delivery, and patient engagement in the improvement of their health. CUCOH provides a unique opportunity for students aspiring to make a difference in the health care field. It allows delegates develop a broad understanding of the Canadian health care system from experts. It also allows students to discuss their opinions with like-minded individuals from diverse universities, and engages them in critical thought about the advancements and also the difficulties in providing efficient health care services. For more information becoming a University of Toronto CUCOH 2011 delegate, please visit www.cucoh.ca. Spring2011 | Juxtaposition 21


Opinion

Lessening the Cost of Our Secrets: What we spend on mental diseases without acknowledging them, and what we can do about it. Athena Hau

Department of Human Biology, University of Toronto, Toronto, ON, Canada

Mental disorders are fairly common, and can cost upwards of billions of dollars in treatment costs and lost workplace productivity. Yet, little support is offered to those who suffer from mental illness to ameliorate this problem. The most critical issue is the stigma attached to being mentally ill; this is one of the primary factors keeping patients from seeking help and professional care. Reducing the economic drain of mental illness and increasing treatment and mental health research requires more than just simple short-term educational programs; long-term, permanent plans to combat the disorders must be developed and implemented. To do so, the various types of stigma surrounding mental disorders must be taken apart, so that both society and the patients themselves are better equipped to face these illnesses in a more accepting light. The World Health Organization (WHO) estimates that over 450 million people suffer from mental disorders.1 Those affected by a mental illness are commonly held to be different from others, and treated in a “negative, stereotyped manner”.2 This negative value that society places on undesirable traits results in a stigma, or discrimination, and it is manifested in many different forms, both public and personal. The stigma attached to those who bear a diagnosis contributes to the cost of having a mental illness, in addition to the economic burden of these diseases on individuals. In order to lessen the price affected individuals pay, the discrimination must be dealt with in conjunction to the research of new treatments. Mental illnesses can manifest themselves differently in individuals and symptoms can appear on a continuum of severity. One of the frequently used systems is the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, which is now in its fourth edition. Another commonly used guide is the International Classification of Diseases-10 (ICD-10) Chapter V: Mental 22 Juxtaposition | Spring2011

and Behavioural Disorders, which is part of the WHO’s International Classification of Diseases. These two systems strive to coordinate their diagnoses. For instance, major depression is identified by both as primarily low mood accompanied by low self-esteem and a loss of interest or pleasure in otherwise enjoyable activities for a prolonged period of time.3

In the US alone, [depression] was estimated to have cost $83.1 billion in the form of treatments, suicide, and workplace losses, amongst other factors. In 2000, major depression was the fourth-leading contributor to the global burden of disease.4 In the US alone, it was estimated to have cost $83.1 billion in the form of treatments, suicide, and workplace losses, amongst other factors.5 By 2006, more than 27 work-loss days a year were associated with depression, an

overwhelming percentage of those due to reduced productivity.6 Projections have indicated that by 2020, depression will be the second-biggest contributor to global disease.4 Though the prevalence of depression is on the rise, statistics provided by WHO in the Mental Health Atlas 2005 show that the median of psychologists working in mental health ranges from 0.05 to 3.10 per 100, 000 people in WHO’s member states. A median of only 0.05 to 1.5 social workers per 100,000 to support the patients exacerbates the problem and contributes to poor social integration.7 In addition to this lack of aid, the stigma associated with mental illness increases the problems many affected individuals face. Public discrimination takes form in disadvantages in housing, employment, medical care and social relationships, as well as collateral effects on relatives and friends.8 Revealing a disorder can be a daunting task, particularly for fear of repercussions in the aforementioned areas. Professor James T. Jones, of University of Louisville’s law department, decided to reveal his bipolar disorder only after over thirty years of personal debate, even though he had a highly respectable career in academia and professional practice.9 Even after the revelation, he had added, “I always counsel people who contact me to think long and hard before they go public lest stigma make their work experiences difficult and even cost them promotions or their job.”9 “Stigma erodes confidence that mental health disorders are valid, treatable health conditions,” wrote Dr. David Satcher, a former US Surgeon General, in his 1999 report on mental health. “It appears as prejudice and discrimination, fear, distrust, and stereotyping,” he continues. Satchel further discussed the barriers in finance, institutional structure, and attitudes that mentally ill patients face when seeking treatment and recovery options, such as the prohibitive costs for treatments and the lack of proper clinical support once diagnosed.10 Clearly, treatment should be a priority,


Opinion as well as research into the cause of mental illnesses. However, for a patient to receive treatment and agree to participate in research, first they must choose to address the problem. Understandably, they would be less willing to do so when facing impending discrimination.

Stigma erodes confidence that mental health disorders are valid, treatable health conditions. The magnitude of stigma’s impact in mitigating progress in treating mental illnesses can be found in India. India faces a critical lack of trained personnel to deal with its burgeoning number of people living with mental illnesses.11 Despite its internationally renowned output of world-class medical staff, little prestige is attributed to psychiatry. Although the Indian society and the government have encouraged the acceptance of mental health issues and have begun improving treatments, psychiatric hospitals largely remain places of horror and many still instinctively turn to faith healers when facing mental health issues. Common folk treatments include trance induction, curse dispersion, and even physical abuse. The secrecy and the lack of mental health professionals only perpetuate this vicious feedback cycle. More alarming, perhaps, is the personal stigma that the patients associate with themselves. People tend to internalize the values of the society in which they live and grow up; therefore it is not surprising that they may discriminate against themselves upon a positive diagnosis. Label avoidance is rampant, especially in a society like India that encourages secrecy when dealing with matters of the mind. In addition, a study in Hong Kong revealed that over 50% of sampled schizophrenic patients concealed their diagnosis

from loved ones and colleagues in anticipation of negative feedback, which affected their self-perceptions and decisions to obtain treatment.12 Currently, many of the programs in Australia, Canada, US, and UK that target the eradication of stigma are largely focused on public stigma, which is just one type of prejudice.13 Tackling only the public side of discrimination is not the complete solution – support and attention must be given to the values that the patients internalize as well.

The shame and the silence shrouding mental illness must be eliminated.

Action must be taken to address both public and personal stigma. As with all forms of problem solving, the first steps are education and advocacy. Each culture must have its own unique approach, as each culture has its own type of stigma and sets of stereotypes to overcome.14 Boyd has found that those who have had contact with mentally ill patients have a less negative perception of strangers with mental illnesses; thus, a less ostracising and critical attitude.15 This indicates that exposure and experience with the people suffering from mental illnesses will help reduce both personal stigmatisation and discrimination against others. The shame and the silence shrouding mental illness must be eliminated, and that can only be completed by educational campaigns and increased awareness about the presence of these illnesses in our society.11 In order to fully deal with the discrimination, though, there must be long-term, permanent plans set into place alongside health and social services,14, 16 such as establishing programs that regularly confront the public about reforming and uprooting said stigmas on a regular basis. Mental illnesses are a critical problem

in both the economy and in the lives of the individuals affected by these diseases. Mental health problems are costly, cause distress, and are misunderstood both by those who do not and by those who do suffer from them. Although better treatment plans are indeed important for the improved handling of mental diseases, that kind of simple, implicit acknowledgement is not enough. The most critical step to take is to reorient the perspectives that the society and individuals have developed towards mental disorders so that the negativity is harnessed into a more positive energy – energy which will lead to acceptance and tolerance of these disorders and progress in searching for new treatments and therapeutic strategies.

References 1. World Health Organization. “Mental Health – Strengthening Our Response”. Accessed 2010 November 8. <http://www.who.int/ mediacentre/factsheets/fs220/en/index.html> 2. Mental Health Works. “Stigma and mental illness”. Accessed 2010 November 09. <http://www.mentalhealthworks.ca/facts/sheets/ stigma.asp> 3. Gruenberg AM, Goldstein RD, & Pincus HA. (2008) Classification of Depression: Research and Diagnostic Criteria: DSM-IV and ICD-10, in Biology of Depression: From Novel Insights to Therapeutic Strategies (eds J. Licinio and M.-L. Wong), Wiley-VCH Verlag GmbH, Weinheim, Germany. doi: 10.1002/9783527619672.ch1 4. World Health Organization. “Depression”. Accessed 2010 November 8. <http://www.who.int/mental_health/management/depression/ definition/en/> 5. Greenberg PE, Kessler RC, Birnbaum HG, et al. “The economic burden of depression in the United States: how did it change between 1990 and 2000?”. J Clin Psychiatry, 64 (2003): 1465-75. 6. Kessler RC, Akiskal HS, Ames M, et al. “Prevalence and effects of mood disorders on work performance in a nationally representative sample of U.S. workers”. Am J Psychiatry,163 (2006): 1561-8. 7. World Health Organization. Mental Health Atlas 2005. Geneva: WHO Press. 2005 8. James, Owen. “HEALTH: Social stigma about mental illness - still.” Tri-City News [Port Coquitlam, British Columbia] 1 Oct. 2010: 33. CPI.Q (Canadian Periodicals). Web. 26 Oct. 2010. Document URL: <http://find.galegroup.com.myaccess.library.utoronto.ca/gtx/infomark. do?&contentSet=IAC-Documents&type=retrieve&tabID=T004&pro dId=CPI&docId=CJ238420389&source=gale&srcprod=CPI&userGr oupName=utoronto_main&version=1.0> 9. Andors, Alice. “Dispel the Stigma of Mental Illness”. HRMagazine, Alexandria: Oct 2010. Vol. 55, Iss. 10; pg. 83, 3 pgs. 10. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. (1999) 11. Mohiuddin, Yasmeen. “Taboo hides India’s millions of mentally ill”. The Age. [Melbourne, Australia] 2009 June 10. Accessed 2010 October 24. <http://news.theage.com.au/breaking-news-world/taboo-hidesindias-millions-of-mentally-ill-20090610-c3db.html> 12. Lee, S., Lee, M. T. Y., Chiu, M. Y. L., & Kleinman, A. Experience of social stigma by people with schizophrenia in Hong Kong. British Journal of Psychiatry, 186 (2005): 153–157. 13. Corrigan PW & Shapiro JR. “Measuring the impact of programs that challenge the public stigma of mental illness”. Clinical Psychology Review, 30 (2010): 907–922. 14. Yang, L. H., Kleinman, A., Link, B. G., Phelan, J. C., Lee, S., & Good, B. Culture and stigma: Adding moral experience to stigma theory. Social Science and Medicine, 64 (7) (2007), 1524−1535. Doi: 10.1016/j. cpr.2010.06.004 15. Boyd JE, Katz EP, Link BG & Phelan JC. The relationship of multiple aspects of stigma and personal contact with someone hospitalized for mental illness, in a nationally representative sample. Soc Psychiat Epidemiol, 45 (2010): 1063–1070. Doi: 10.1007/s00127-009-0147-9 16. Sartorius N. (2010). Short-lived campaigns are not enough. Nature 468: 163-165.

Spring2011 | Juxtaposition 23


Opinion

Note to Self: Stop Breathing William Fung

Department of Laboratory Medicine and Pathobiology, University of Toronto, ON, Canada

The pervasive health effects of pollution currently remains largely unexplored and unknown. Pollution can cause respiratory and cardiovascular problems, especially in the young and the elderly, and can even spread to other organs in the body. Pollution impacts lives all across the globe, but governments are slow in their efforts to combat it. Rather than waiting for government intervention, we should take action to both lower pollution levels, and to protect ourselves from unnecessary exposure.

China Factory Pollution. Flickr: Green Way, Micro Guganoni (2008).

Breathing is important: someone performing CPR checks for breathing; we hold our breaths when we swim; characters squeeze out famous words with their dying breaths. And yet, despite its importance, the act of breathing rarely itself crosses anyone’s mind: very few people stop to consider what it is that they are letting into their bodies when they inhale. Unfortunately, what we breathe is a lot more than just oxygen, and probably a lot worse. The impact of the environment upon global health goes largely unknown and its advocates’ voices unheard. Of these environmental factors, one of the greatest and most pervasive is air pollution. 24 Juxtaposition | Spring2011

A recent article in Bloomberg magazine brought to light the fact that recent projections by the School of Public Health at the University of Hong Kong show that, in the coming year, air pollution in Hong Kong may cause the deaths of over double the number of people who died as a result of the Severe Acute Respiratory Syndrome (SARS) epidemic. The most vulnerable are the young and the elderly, but regardless of age group, pollution has been shown to lead to respiratory disease, cardiac problems and even cancer.1 Exposure to chemicals is particularly harmful in the respiratory system because lungs bring large quantities of air into

contact with the blood circulating throughout the body. This allows inspired chemicals to travel to even very distant organs. However, lung tissue is especially sensitive, and can be damaged by coming into contact with pollutants such as ozone, metals or free radicals.2 What makes these chemicals particularly dangerous though, is the possibility of secondary lung damage. This refers to the process by which chemicals are metabolized by enzymes in airway tissues, releasing dangerous metabolites that can then dissolve into the blood and be carried elsewhere. The presence of these toxic substances also causes the lungs to respond by releasing chemical mediators that can travel to other organs, such as the heart, and impact them negatively.2 An example of such a substance is hyaluronic acid, which has a role in regulating lung injury and repair.3 This chemical, when degraded, has been shown to induce metastatic properties in tumours as well as promoting their growth through angiogenesis.4

…in the coming year, air pollution in Hong Kong may cause the deaths of over double the number of people who died as a result of the SARS epidemic… The issue of pollution-related deaths is particularly distressing given that Hong Kong is not alone in its suffering. Health Canada quotes a recent study that measures the impact of pollutants upon health from an economic perspective, such as in terms of increased burden upon the healthcare system. What this study found is that by simply introducing cleaner vehicles and fuels in Canada, the government would be able to save $24 billion over the course of 24 years.2 Since this figure is an estimate of the benefits of reduced (and not eliminated) pollution, it is easy to appreciate that


Opinion pollution-related health problems are as substantial an issue here in Canada as they are anywhere else in the world. In the United States of America, it is estimated that air pollution causes the deaths of 70,000 Americans a year, which is greater than the deaths caused by breast and prostate cancers combined.5 A study headed by Douglas Dockery, chair of the Harvard School of Public Health Department of Environmental Health, demonstrated that individuals living in highly polluted areas lived four years less, on average, than those living in less polluted areas.6 In Europe, pollution has left its mark on history on numerous occasions, including the 1952 “fog” in London which left 4,000 people dead. Although such incidents raised much concern and forced governments to take action, a recent survey by the European Environment Agency showed that 70 to 80% of 105 European cities surveyed continued to exceed air quality standards set by the World Health Organization (WHO) for at least one pollutant.7 The industrialization of developing countries has seen an increase in urban air pollution as a result of booming populations, and the increased use of vehicles. In some megacities such as Beijing, Delhi, Jakarta and Mexico City, pollution levels are quickly approaching the dangerous levels present during the London Fog. In these cities, air quality has been known to exceed the WHO standards by a factor of three or more; in fact, certain major cities in China show pollution levels six times the WHO guidelines. The World Bank estimates that 2 to 5% of all deaths in urban areas in the developing world arise as a result of pollution levels that have exceeded WHO standards.7 Despite the severity and pervasiveness of the issue, governments around the world seem shockingly complacent. In Hong Kong, air quality objectives have not been updated since 1987, and their current goals do not even meet WHO guidelines.

There is also little optimism in regards to this problem: “[T]he government is high on rhetoric and low on action in this area,” said Stephen Vines, political commentator and author of “Hong Kong: China’s New Colony”.1

In some megacities … air quality has been known to exceed the WHO standards by a factor of three or more… In the United States, guidelines are roughly similar to those of WHO, but these too are not being met: an estimated 80 million people live in areas that do not meet these air quality standards.7 These examples underline the fact that there is still not enough being done to lower pollution levels. While awareness of diseases like cancer is high, knowledge about the impact of pollution remain largely hidden from the public eye. The ineffectiveness of government interventions in handling pollution levels, as mentioned above, is only an additional source of worry. Breathing is important. We do it every single day, taking in the cloud of chemicals around us as we try to fill our lungs with oxygen. Although environmental movements and governmental platforms continue a long battle against rising pollution levels, it does not seem like the situation will be improving significantly in the short run. There will be a day when pollution levels become a priority, and when solid action will be taken to force them down, but that day is probably far into the future. Rather than waiting for the governments of the world to take action, we should try to take measures ourselves, not only to combat the threat of pollution, but also to protect ourselves against it. One of the simplest things that we can do is to keep an eye on the forecast: there are usually warnings on days with high pollution levels, and it is best to avoid going outside

on such days as much as possible. Avoiding smoke is also a simple measure that can be taken; this is true both for active smokers and for those who might be subject to second-hand smoke. Of course, one of the best ways to cut down on pollution is to reduce automobile usage. There are many alternatives, such as public transportation, biking or maybe even walking.8 Also, although the exact mechanism is not yet well understood, research has shown that supplementation with omega-3 fatty acids or soy supplements can reduce the damage that the cardiovascular system suffers as a result of exposure to pollutants.9 Regardless of the method that you choose, the issue stands that we cannot wait for our governments to take action for us. In addition to supporting government initiatives aimed toward reducing pollution, we need to take matters into our own hands and proactively safeguard our health. We need to be aware that we are responsible for the quality of the environment in which we live in. Above all, we simply cannot afford to wait with bated breath because, by the time someone has done something for us, there may no longer be any clean air left to fill our lungs.

References 1. Duce, John. “Hong Kong Air Kills More Than SARS, Pressuring Tsang.” Bloomberg, October 7, 2010. http://www.bloomberg.com/ news/2010-10-07/hong-kong-pollution-killing-more-than-sars-astsang-prepares-policy-speech.html (accessed October 25, 2010). 2. Health Canada. “Health Effects of Air Pollution.” Health Canada. www.hc-sc.gc.ca/ewh-semt/air/out-ext/effe/ health_effects-effets_ sante-eng.php. (accessed October 25, 2010). 3. Jiang, D. et al. “Regulation of lung injury and repair by Toll-like receptors and hyaluronan.” Nature Medicine 11, no. 11 (2005): 1173-9. 4. Phillips, Glyn O., Peter A. Williams, John F. Kennedy, and Vince C. Hascall. “Is hyaluronan degradation an angiogenic/metastatic switch?.” In Hyaluronan . Cambridge, England: Woodhead Pub., 2002. 166. 5. Harvard School of Public Health. “Air Pollution Deadlier Than Previously Thought.” Harvard School of Public Health. http://www. hsph.harvard.edu/news/press-releases/archives/2000-releases/ press03022000.html (accessed October 25, 2010). 6. Harvard School of Public Health. “Hot Topics Series: Boston Air Pollution.” Harvard School of Public Health - HSPH. http://www. hsph.harvard.edu/now-archive/20070831/pollution.html (accessed October 25, 2010). 7. World Resources Institute. “Rising energy use: Health effects of air pollution.” World Resources Institute. http://www.wri.org/publication/ content/8463 (accessed October 25, 2010). 8. Rubi, Rubina. “Health measures against air pollution.” Fashion & Masti. http://www.fashionmasti.co.cc/fashion-home/health-measuresagainst-air-pollution (accessed January 5, 2011). 9. Romieu, Isabelle , Raquel Garcia-Esteban, Jordi Sunyer, Camilo Rios, Mireya Alcaraz-Zubeldia, Silvia Ruiz Velasco, and Fernando Holguin. “The Effect of Supplementation with Omega-3 Polyunsaturated Fatty Acids on Markers of Oxidative Stress in Elderly Exposed to PM2.5.” Environmental Health Perspectives 116, no. 9 (2008): 1237-1242.

Spring2011 | Juxtaposition 25


Opinion

American and Canadian Health Care Reform A Need for Proactive Health Care Policy Kathleen Nelligan1, William To2 1 2

Department of Human Biology, The University of Toronto, Toronto, ON, Canada M.Sc. Candidate, Department of Physiology, The University of Toronto, Toronto, ON, Canada

Both the inequity in the American health care system as well as a deepening national deficit have made health care reform a primary focus of Barack Obama’s presidential term. Current changes to health care legislation stand out from previous American attempts to improve access to health care for all Americans. Regardless of any advancements this new legislation may make, considerable improvements can still be made in the realm of preventive medicine. Using eHealth Ontario as an example, information management is explored as an escape from the fetters of a budget constrained by steep primary care expenses. For countries with less government involvement in health care than Canada, like the United States, investment in preventive medicine through information management systems or online health communities may improve the health of those who are not traditionally covered by federally subsidized health care.

For many Americans, the US health care system leaves something to be desired. With millions uninsured and millions more underinsured, access to health care comes at a cost. The road to a more equitable scheme, however, has been hindered by worry over the potential short-comings of a centralized policy and disagreement over its cost-effectiveness. Fortunately, Barack Obama’s presidential period in office has provided an impetus for the significant scrutiny of the health care system. An overhaul of the health care system, though contentious, was signed into legislation on March 23, 2010. The policies, slated to be phased in over a five-year period, marked the inception of the most drastic reform of US health care seen in 40 years.1 The impetus for such progressive legislation stemmed from the vast inequity of the American health care system. Without universal, subsidized health care coverage, private health insurance became the sole way to afford health care for the majority of Americans. Although most Americans received such coverage through their employers, the many that remained 26 Juxtaposition | Spring2011

uninsured were forced to pay individually for coverage or to front the entire cost of their treatment.1 The US Census Bureau approximated in 2008 that 15%, or a staggering 46.3 million Americans, paid out of pocket for medical services.1

…the new laws place the right of the American populace to health care above the demands of the insurance industry.

Thus, the changes, originally proposed by the Democrats with the intention of making health care more affordable and equitable, are a step in the right direction. The two new laws, the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act, mandate insurance coverage and bar insurers from denying insurance to clients who develop new illnesses.2 These laws strive to increase universality and affordability of health care through regulations directed at the insurance industry while also reducing the

US deficit by $100 billion over the next decade through improved accountability and efficiency in the industry.1 Despite these advances, uncertainty still remains as to whether or not the new legislation alone will be sufficient for long-term improvement of patient health care.

Changing the focus Importantly, the new laws place the right of the American populace to health care above the demands of the insurance industry. According to Toba Bryant, Assistant Professor of Sociology at York University, the US has historically allowed the private sector to control health care policy discussions.3 Nonetheless, even with the public voice reflected in the Democrats’ proposal, the root of the health care inequity problem is still unresolved. Take, for example, the legislation’s plan to increase access to community medicine in low-income and marginalized innercity groups.2 While these measures are necessary, they are not sustainable without simultaneous improvements in inequities in education, income and housing.3


Opinion A potentially more attainable though, admittedly, incomplete reformation of health care would focus on preventive medicine as a means of ensuring the health and wellbeing of the American populace instead of the present concentration on primary care, which tends to neglect the social determinants of health.3

until cost-effectiveness becomes a priority of health care policy makers.

Cost-effectiveness: a chore worth undertaking

Although, many are quick to protest cuts to social services, the reign that health care enjoys over the budget cannot go unquestioned. Social service funding is a complex issue, with broad political motives as well as perpetual competition with industry for limited financial resources. Instead of only focusing on where the money will come from, a consideration of how to redistribute funds within the budget can help reduce the burden of chronic preventable diseases on the health care system. In Ontario, aid for one such disease, diabetes mellitus, arrived in the form of eHealth Ontario. The eHealth strategy of amassing health records and information into a centralized electronic system was used to ensure that individuals with diabetes were receiving the proper laboratory tests to manage their health, and saved the $300 million that would have been incurred solely through emergency visits.9

Despite any improvements, cost remains a significant problem in American health care, with its price of care amongst the highest in the world.4 The US Department of Health and Human Services estimated that the National Health expenditure was $2.3 trillion in 2008, including rising costs for Medicare and Medicaid.5 For those without coverage, the high premiums for medical care contributed to 62% of personal bankruptcies in the US in 2007.6 Thus, rising health care costs in the US are one of the largest contributing factors to the steepening deficit and national debt. Part of this problem is that preventive medicine is not always covered by health insurance plans. The changes made to US health care legislation state that insurers must cover preventive care in addition to primary care by 2018.2 It remains to be seen whether or not this will suffice. Even in countries with fully subsidized universal health care, overspending is a significant issue. According to Don Tapscott and Anthony Williams, organizational strategy and innovation consultants and the authors of Wikinomics, health care spending has doubled from $95 billion to $192 billion in the past ten years, largely due to the rise in chronic yet preventable diseases.7 Necessity of access to affordable health care notwithstanding, Americans and Canadians alike are heading down the road to ruin unless they invest in preventive medicine. Current estimates project that Canadian health care spending will encompass 50% of provincial budgets by 2015.8 These numbers will continue to rise

Canadians alike are heading down the road to ruin unless they invest in preventive medicine.

Putting health in the hands of patients The potential of eHealth to reduce the burden of chronic diseases through information collection and management has spurred a movement of health care networking online. Health care communities like MedHelp.com and PatientsLikeMe.com allow users to track symptoms and treatments of many medical conditions, both chronic and temporary.7 The power of online health communities lies in the placement of a patients’ health in their own hands, effectively relocating health care from the realm of hospitals to that of lifestyle choices.7 Tapscott and

Williams rightly point out that without government support, these resources will never reach their full potential in terms of lives and resources saved.7 Fortunately, the eHealth priority in managing diabetes though patient registries and information databases can be extended to the management of many other chronic diseases which face significant budgetary burdens.9

...without government support, these resources will never reach their full potential in terms of lives and resources saved.

In terms of American health care, investment in health campaigns and registries of chronic diseases could greatly reduce spending in the long term. Changes to health care legislation must also address the seemingly inconsequential or unrelated issues of diet, exercise, drug use, environmental welfare and social security. The more these problems are discussed, the more evident it will become that health is not just a budgetary burden or a business, but a human right that is tied into all areas of government and society.

References 1. BBC News. “Q&A: US health care reform.” Accessed December 1, 2010. http://news.bbc.co.uk/2/hi/8160058.stm. 2. Irfan Dhalla. “US Health Reform.” Accessed December 1, 2010. http://www.canadiandoctorsformedicare.ca/us-health-care-reform. html. 3. Toba Bryant, “Introducing Health Policy and Policy Studies” in An Introduction to Health Policy (Toronto: Canadian Scholars Press Inc, 2009), 1-20. 4. World Health Organization. “World Health Statistics 2009.” Accessed December 25, 2010. http://www.who.int/whosis/whostat/ EN_WHS09_Full.pdf. 5. Centers for Medicare and Medicaid Services. “NHE Fact Sheet National Health Expenditure Data.” Accessed December 1, 2010. https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_ Sheet.asp. 6. David U. Himmelstein, Deborah Thorne, Elizabeth Warren, and Steffie Woolhandler, “Medical Bankruptcy in the United States, 2007: Results of a National Study,” American Journal of Medicine 122, no. 8 (2009): 741-746. 7. Don Tapscott, Anthony D. Williams. “Better health care at the click of a mouse.” Globe and Mail, December 29, 2010. 8. Adam Radwanski. “How the major storylines of 2010 played out in Ontario.” Globe and Mail, December 31, 2010. Accessed January 9, 2011. http://www.theglobeandmail.com/news/politics/adamradwanski/how-the-major-storylines-of-2010-played-out-in-ontario/ article1854906/. 9. eHealth Ontario. “Ontario’s eHealth Strategy 2009-2012.” Last modifiedMarch 19, 2010. http://www.ehealthontario.on.ca/pdfs/ About/eHealthStrategy.pdf.

Spring2011 | Juxtaposition 27


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 MRC is an academic centre at the University Health Network and University of Toronto. We        work  at  the  nexus  of  translational  research,  the  developing  world  and  entrepreneurship.  We  use       At the heart of the availability of innovative health technologies is the problem of the uncertain path  scholarly research to help move technologies from the lab to the village.        and unacceptable time lag from discovery and development to commercialization and delivery of      appropriate and affordable products to people in the developing world.  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.      At the heart of the availability of innovative health technologies is the problem of the uncertain path     The MRC is an academic centre at the University Health Network and University of Toronto. We        and unacceptable time lag from discovery and development to commercialization and delivery of  work  at  the  nexus  of  translational  research,  the  developing  world  and  entrepreneurship.  We  use  Our Vision is to illuminate the path towards a world where everyone benefits from new diagnostics,      appropriate and affordable products to people in the developing world.  scholarly research to help move technologies from the lab to the village.  vaccines, drugs and other life science solutions.            Our Mission is to conduct translational research in global health and help researchers and companies  The MRC is an academic centre at the University Health Network and University of Toronto. We        at  the    get their life sciences technologies to those who need them in the developing world.  work  nexus  of  translational  research,  the  developing  world  and  entrepreneurship.  We  use  Visit us at:       scholarly research to help move technologies from the lab to the village.  Website: www.mrcglobal.org      Our Vision is to illuminate the path towards a world where everyone benefits from new diagnostics,  Facebook: www.facebook.com/globalhealthengage    vaccines, drugs and other life science solutions.  Our Mission is to conduct translational research in global health and help researchers and companies  Twitter: http://twitter.com/mrcglobal        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,  Visit us at:  vaccines, drugs and other life science solutions.  Website: www.mrcglobal.org    Facebook: www.facebook.com/globalhealthengage  Twitter: http://twitter.com/mrcglobal    Visit us at:  Website: www.mrcglobal.org  Facebook: www.facebook.com/globalhealthengage  Twitter: http://twitter.com/mrcglobal   

Juxtaposition 4.1  

Movers and Shakers - Recounting Experiences Abroad, Juxtaposition Issue 4.1, Spring 2011

Juxtaposition 4.1  

Movers and Shakers - Recounting Experiences Abroad, Juxtaposition Issue 4.1, Spring 2011

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