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Volume 10 Issue 1  |  2017  |  ISSN 1918-7653

Contributors Maitri Gupta Maitri specialized in Mental Health Studies and majored in Neuroscience from the University of Toronto Scarborough Campus. Roohie Parmar Roohie graduated with a Master of Science in Global Health from McMaster University. Her current research interests are in the intersections between health disparities, medical education and mental health. Aylin Manduric Aylin recently completed her undergraduate studies in International Relations at the University of Toronto, and is currently a law student at UofT. She is interested in how civil society influences law and policy. She is now working towards a JD at University of Toronto’s Faculty of Law. Simran Dhunna Simran is a recent graduate from the University of Toronto, and is currently a research/policy fellow on precarious work at Access Alliance Multicultural Health and Community Services. She is interested in health equity, mixed methods research, and women’s health. JASMINE SPENCE Jasmine Spence is a 3rd year undergraduate student at the University of Toronto. Her areas of focus are economics, geography, and Indigenous studies. Julia Robson Julia is a 4th year undergraduate student at U of T, completing a major in Health Studies. She is particularly interested in the effects of climate change on health. Benjamin Levy Ben is a third-year student at the University of Toronto studying Global Health, Philosophy, and Statistics. Ben is interested in writing about the intersection between health, economics, politics, and conflict. Jessica Chan Jessica is a recent graduate of the University of Toronto Scarborough, where she studied International Development & Anthropology. She is currently a medical student at the University of McMaster and likes to read fiction when she isn’t thinking about or discussing the kidney (and other organs). Angela Salomon Angie is a soon to be graduate of the Master of Public Health program at the University of Toronto. She is interested in the epidemiology of global health, maternal health, and infectious diseases. Sarah Crawley: Artist for the cover page and all illustrations.

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TEAM Editors-in-Chief: Simran Dhunna Aylin Manduric Editorial Team: Benjamin Levy Julia Robson Jessica Scott Aceel Hawa Christopher Tait Amy Chen Maitri Gupta Rajeeha Siddiqui Fatin Tawfig Fakeha Jamil Shaan Bhambra Sarah Allarakhia Communications: Selena Hussain Yael Ihejirika Abigail Wiggin Urbee Mahmood Toronto Thinks Director: Nessikha Karsenti

Table of Contents Letter from the editors Global Health Snapshots Uprooting Colonialism

4 5 9

An Inquiry Will Not Suffice: 10 Violence Against Indigenous Sex Workers Mending the Broken Hoop: 13 Indigenous Health and the Dis-ease of Disconnection

Environmental JUSTICE


Climate Change: 16 New Extremes A Manifestation of Agrarian Distress: 17 Farmers’ Suicides in Punjab, india

FRom Ideology to Power


In Freefall: 23 Scarcity in Venezuela Odd Couples: 25 Health Advocates and their industry Partners what my grandmother taught me: 28 towards equitable end-of-life care Demographic Dividend or demographic disaster 29 for nigeria

Toronto Thinks 2016-17

Juxtaposition |  Table of Contents



LetteR from the editors Welcome to the 10th volume of Juxtaposition, University of Toronto’s foremost global health magazine! We’re an interdisciplinary, student-run organization operating at the nexus of health, social justice, and politics. Our aim is to take complex global health problems and put them in terms that people from any discipline can understand. Sometimes, we take a small piece of a broader issue and apply a critical lens on it until it becomes large and loud. Sometimes, we’ll turn over old stones and show you what’s been long forgotten underneath. But every time, we are driven by the same sense of purpose that has kept our publication going for nearly a decade. We write what we’re passionate about – that which is as political as it is biomedical – and we try to ignite that passion in our readers. This often takes us out into the community. Our online content this year included new interview pieces with experts from the University of Toronto community and beyond. We have also increased our coverage of conferences, community events, and other live reporting opportunities. Our online pieces will take you across the country and across the globe, showcasing topical and diverse stories along the way. Volume 10.1 is no different. This year, you will find perspectives on Indigenous health; environmental (in)justice and its impacts on health; and pieces that dive deeper into the political pathologies behind present-day public health struggles. But we don’t just write about global health. Every year, Juxtaposition brings academic events and conferences to interested community members here in Toronto. This year, we held an Indigenous Health Symposium which brought together speakers from Anishnawbe Health Toronto, Native Youth Sexual Health Network (NYSHN), and scholars including Deborah McGregor to talk about Indigenous health in an urban setting. We also held an inaugural “fishbowl” panel to launch Juxtaposition Volume 9.1, featuring authors from that edition and notable faculty members, Anne-Emanuelle Birn and Donald Cole. In 2016-17 our flagship event, the Toronto Thinks Global Health Case Competition, entered its fourth year. This year’s case focused on tobacco use among Indonesian children and youth, and the winning team’s pitch can be found as a feature in this issue. Thanks to our organizing committee, spearheaded by Nessikha Karsenti, #TOThinks2017 brought together over 200 students, faculty, guest speakers, experts, and community members. We have also strengthened the magazine’s relationship with the Dalla Lana School of Public Health and laid the foundations for a mutually beneficial partnership. Juxtaposition’s enthusiastic coverage of global health activities on campus, including Dalla Lana events, has opened the door for DLSPH students to play a more active role on the Juxtaposition team. We are pleased to bring you the 10th volume of Juxtaposition, and would like to thank our hard-working editorial and executive teams, our sponsors, and you, our readers, for celebrating the juxtaposition of health and politics with us for another year.

Simran Dhunna

Aylin Manduric

Editor-in-Chief 2016-2017

Editor-in-Chief 2016-2017

Keep in Touch | @juxtamagazine | 4

Juxtaposition |  Letter from the Editors

Global Health snapshots

Global health snapshots Fentanyl: the not-so-silent killer in the opioid epidemic Maitri Gupta Today’s opioid epidemic has killed more people than did the AIDS epidemic during its peak years in the 1980s and 90s. It is estimated that between 26.4 million to 36 million people worldwide are abusing opioids, a group of medications generally used to help patients manage pain. In Canada, 4,000 opioidrelated deaths were projected by the end of 2017, compared to 2,861 in 2016. Second to Americans, Canadians are the highest per-capita consumers of opioid-based medication in the world. Opioids are susceptible to abuse because they induce intense feelings of pleasure, known as euphoria. As patients develop physical and psychological tolerance to the drug, higher doses are needed to produce the same euphoric effects or relief from pain. Overdosing occurs primarily when individuals self-administer the drug, particularly by crushing, snorting or injecting it to obtain a faster and stronger effect. Accessed illicitly or by prescription, fentanyl is currently one of the strongest opioids on the market: 50 to a 100 times stronger than morphine. A significant portion of illicit fentanyl makes its way to Canada from Chinese pharmaceutical companies that manufacture it at alarming rates, with its transport across our borders made easier by online access. The current crisis is linked primarily to illicit, and often unexpected, doses of fentanyl mixed into other street drugs. Effects of the drug are similar to heroin and include euphoria, drowsiness, and sedation, although fentanyl is far more effective. So potent is the drug that paramedics and police officers have overdosed from skin-based contact with the drug. Emergency drug kits with naloxone, an opioid receptor antagonist, are being distributed by harm reduction community advocates to users and in neighborhoods where there is known to be high drug use.


The previous era of drug addiction treatments favoured abstinencebased rehabilitation. But harm reduction, which facilitates safer use of such drugs and offers detox options, has gained some traction in recent years. In addition, structural neglect, stereotypes around drug addiction, and the pathologization of drug users prevent these approaches from becoming standard policy. Calls for decriminalization of drugs are even more challenging to bring to fruition. Meanwhile, at the frontlines, advocates and communities are working tirelessly to frame the opioid crisis as a public health issue, rather than just a criminal one. There has been a concerted effort to provide safe injection sites, such as the Moss Park pop-up site in Toronto, despite a sluggish response by municipal and public health agencies. As Canada slowly wades into public discourse on systemic responses to the opioid crisis, the voices of frontline harm reduction advocates who have witnessed overdose deaths in our communities are more important than ever.

Interpret This: Improving Physician-Interpreter Communication for Newcomers ROohie Parmar Language barriers pose a significant challenge to effective healthcare. A study in 2013 revealed that 2.5% of the Ontario population could not communicate in either English or French. Meanwhile, only 3.8% of physicians are able to speak the most popular unofficial languages: Punjabi, Chinese, Italian, Portuguese and Spanish. With increasing numbers of newcomers to Canada, communication between newcomers and health providers is a crucial healthcare issue. The need for interpreters is significant, particularly for refugee families. Last year, 39,671 refugees were resettled but “the demand for interpreters outstrip[ped] their numbers”. Due to such language barriers, newcomers often have difficulty understanding information communicated by health providers, resulting in a lack of “health literacy”. Without being able to navigate the

Juxtaposition |  Global Health Snapshots

healthcare system, newcomer patients’ health outcomes are negatively impacted: misdiagnoses, decreased compliance concerning treatment and consultations, decreased patient satisfaction, and lower rates of screening for oncological, gynecological, and other preventative tests. In some cases, language barriers may lead patients to forgo seeking medical attention altogether. Health communication is further complicated for non-English-speaking patients in search of culturally similar physicians, or for those relying on family members to act as translators. In the latter case, family translators may impact how information is communicated (eg. cultural norms concerning elderly respect which prevent younger generations from asking invasive questions) and may elicit bias from patients who may not feel comfortable disclosing medical history to said ‘translator’ due to privacy concerns. Medical facilities across the Greater Toronto Area (GTA) have provided interpretation services in an attempt to address these barriers to care. However, these services can be expensive to maintain depending on the type of service (in-person, phone call, specialized equipment, etc.), and underused by physicians and medical residents in particular. Due to the nature of medical training and standards of practice, physicians can be conflicted with how to provide care to individuals who do not speak english. According to one study, doctors either ‘got help’ from interpretation services or ‘got by’ by using their own judgement in lieu of interpretive services. This depended on how much time was available during the patient appointment, the “acuity of the clinical situation,” and how easy it is to use available interpretive services. Doctors reported a sense of anxiety about relying on their own judgement, admitting it to be less than ideal. It is essential to promote two-way communication between interpreters and physicians using the common language of patient-centered care. If successful, this would help foster trust and maintain engagement in intrahospital communication. Some clinics are already acting on this: Crossroads Clinic at Women’s College Hospital in Toronto is offering hundreds of languages via interpreter services, helping newcomer populations of all stripes, especially recently arrived refugees.

The state of indigenous health Aylin manduric The peoples indigenous to this land – First Nations, Inuit, and Métis – are facing deep and troubling inequities in the determinants of health and access to services. In 2015, the Truth and Reconciliation Commission (TRC) called on “the federal, provincial, territorial, and Aboriginal governments” to acknowledge the role of Canadian government policies in creating the current health gaps, and to work to close them. In consultation with Aboriginal* peoples, the TRC called on the federal government to, create benchmarks for reducing disparities in health outcomes; to recognize health needs distinct to Indigenous peoples; to collaborate with traditional healers; to mandate that medical and nursing schools require their students to study Aboriginal health issues; to increase the number and retention of Aboriginal professionals working in health care; and to sustainably fund Aboriginal healing centres.

Juxtaposition |  Global Health Snapshots

Two years on, the TRC’s 94 Calls to Action, which include the above recommendations, still serve as a key measuring stick by which the Canadian government’s progress on indigenous issues is assessed. While the process of “reconciliation” – a contested term among some Indigenous advocates – will undeniably be a long one, the government has taken steps to signal good faith, though with mixed results. For example, changes to the Canadian citizenship oath will ensure that newcomers acknowledge treaty relationships upon being welcomed into the country. Meanwhile, little action has been taken to address indigenous over-representation in prisons. More recently, a new oversight body to monitor progress on reconciliation was discussed. This is how a government tells us that it is “trying”. But what does this mean for the state of indigenous health? Acknowledgements, monitoring mechanisms, and commissions all play an important role in reconciliation, but they cannot produce reconciliation on their own. Many health issues, such as the mercury poisoning in Grassy Narrows, are illustrative: the government long failed to even acknowledge the problem, and once it did, action came slowly, leaving generations of people sick. In January of this year, the government also allocated $380 million to implement the “Jordan Principle”, which aims to ensure that Indigenous children receive healthcare without disruption or delay due to jurisdictional conflicts over who should pay for the costs. Notably, this has been in the works for a decade: parliament voted to adopt the Jordan principle in 2007 but was found to be failing in this area as recently as May of 2017, when the Canadian Human Rights Tribunal found that failure to implement it may have contributed to multiple child suicides. This was after the Wapekeka First Nation’s request for suicide prevention funding was denied, apparently because the request came at an “awkward time” for Health Canada. According to a recent statement from Indigenous Services Minister Jane Philpott, things have changed significantly in the past few months, with the government now approving more requests for funding, and clarifying expected response times for requests.

How can we accept that a routine treatment in an urban centre becomes financially infeasible on a reserve? That is not an acceptable grounding for Canadian health policy. The solutions, which vary for each Indigenous community, lie in equitable expectations regarding health standards. Dr. Alika Lafontaine, a physician of Cree and Anishnaabe heritage and chair of the Indigenous Health Alliance, emphasizes the role of expectations in improving indigenous health. In other words, creating effective indigenous health systems begins with an expectation that the problems that exist are possible to fix. The rest is a question of will. *The term “Aboriginal” is used in the context of the Truth and Reconciliation Commission’s use of the word within its Calls to Action.


The pipeline Predicament Aylin manduric Pipeline proponents are facing a predicament in British Columbia. We have all seen it on the news: John Horgan, BC’s premier (New Democratic Party), has refused to allow the Trans Mountain pipeline to be extended through his province unless he is assured that the risk of spillage can be mitigated. Horgan’s choice to fight the pipeline was met with a mixed reaction. The move was welcomed by environmentallyconscious BC residents, but attracted the ire of Alberta’s premier, Rachel Notley. Outraged at the potential for lost revenue associated with a safer pipeline, Notley initiated an Alberta-wide ban on BC wines, and encouraged BC residents to join the boycott. Her outrage is based on the fact that the federal government has already approved the project, which is expected to triple the amount of diluted bitumen moving across BC and lead to a seven-fold increase in oil tanker traffic along the coast. This hasn’t stopped BC from continuing to fight back. Large pipeline projects that cross provincial boundaries constitutionally fall within federal jurisdiction: in other words, once the Liberal government approved the pipeline project, it became a lot harder for BC to prevent Trans Mountain from moving forward. The National Energy Board (NEB), the federal office in charge of approving large energy projects, has proceeded to leverage its jurisdiction over the matter to try to crush local efforts to resist the construction of the pipeline. This has resulted in predictable frictions at the local level. For instance, the City of Burnaby’s bylaws would ordinarily require a pipeline project like Trans Mountain to obtain tree-cutting permits and certain zoning approvals before proceeding. The NEB, however, legally relieved Trans Mountain of those obligations. BC has since considered regulating what kind of bitumen might be allowed to move through the pipelines, but even this is vulnerable to challenge. The Canadian government has the power to set aside provincial regulations that interfere with an interprovincial project that has already been federally approved. Moving forward, the BC government has the option to keep passing more regulations (and then having them set aside) until Kinder Morgan, the company responsible for the Trans Mountain project, decides that it’s not worth it anymore and gives up. Another route is to change policies at the federal level so that it becomes harder for projects to be approved before we can properly understand their impacts on health and the environment. Bill C-69 is one piece of legislation ostensibly geared towards this purpose, though it has been criticized by the leader of the Green Party for doing too little to restore environmental protections to what they were before Harper-era cuts. Environmental priorities, it seems, trickle slowly through the legislative process. Meanwhile, scholars and journalists, environmental groups, and First Nations in BC are giving no indication that they plan to lie down and take the pipeline as it comes. This is a hopeful sign, though they should be prepared for a long fight that won’t end with Trans Mountain.


Canada’s Gender-based Violence Strategy and the MMIW Inquiry Simran dhunna The Canadian Liberal government unveiled its Strategy to Prevent and Address Gender-Based Violence (GBV) in July of 2017. Of the $101 million earmarked for implementing the strategy, $77.5 million will go to Status of Women Canada’s Center of Excellence over five years for further research into GBV. As part of a “whole-of-government” approach, minor components of this funding will go to government agencies such as the Public Health Agency of Canada, the Royal Canadian Mounted Police (RCMP), and Immigration, Refugees, and Citizenship Canada, to name a few. Given the vulnerabilities that women in rural areas, refugee and newcomer populations, and Indigenous communities face regarding GBV, it’s not entirely clear that the funding has been allocated on a needs basis. There is no dearth of scholarship on the root causes of GBV, yet the funding allocation may just be reinventing the research wheel by trying to understand, as Status of Women Minister Maryam Monsef puts it, “why gender-based violence happens in the first place”. A small proportion ($2.4 million) of the GBV strategy funding is going to the RCMP for cultural competency training. While little funding is going towards program implementation and systems-level change, critics may also question whether training RCMP officers on “cultural competency” would reliably render their treatment of Indigenous women less violent. Indigenous women are implicated as the victims and survivors of violence at the hands of the RCMP, both historically and currently. The RCMP has also been involved in the investigation of Missing and Murdered Indigenous Women (MMIW), in a manner that has been disappointing to many Indigenous community members during the ongoing federal inquiry process. The National Inquiry into the more than 1,200 missing and murdered Indigenous women and girls has itself been fraught with challenges, giving little to no comfort to affected Indigenous communities. Amongst a chain of resignations by Inquiry commissioners over time, the Inquiry lost its executive director in January, 2018. The MMIW Inquiry is marked by bureaucratic inefficiency, structural inadequacies, and, one could argue, a fundamental lack of adherence to principles of reconciliation as outlined by the Truth and Reconciliation Commission.

Mired by one political quagmire after another, the inquiry has also failed to undertake key actions such as pursuing a critical review of police agencies and their case records. The Inquiry into MMIW has until November 2018 to produce a final report, but with possibilities of extension and not much to show since its inception, Indigenous families are justified in forsaking any confidence in its outcomes.

Juxtaposition |  Global Health Snapshots

Uprooting Colonialism

The brutalizing forces and health impacts of settler colonialism implore us to consider what is required to uproot the continuities of such a system of oppression. These articles examine violence against Indigenous sex workers during a time when state platitudes and formal inquiries are insufficient, and the importance of addressing the colonial dis-ease of disconnection through Ininew (Cree) Indigenous healing practices. Undergirding both is a powerful call to center the healing and safety of Indigenous communities who have been deracinated by colonialism, but who continue to resist.

An Inquiry Will Not Suffice: Violence Against Indigenous Sex Workers SImran Dhunna We are Aboriginal women. Givers of life. We are mothers, sisters, daughters, aunties and grandmothers. Not just prostitutes and drug addicts. Not welfare cheats. We stand on our mother earth and we demand respect. We are not there to be beaten, abused, murdered, ignored. - As cited by Scholar Dara Culhane, from a flyer at Downtown Eastside Women’s Memorial March, February 14, 2001, Vancouver, British Columbia, Canada.

hile the 2016 Census shows that Indigenous peoples (First Nations, Inuit, and Métis) make up only 4.6% of Canada’s total population, Indigenous women are overrepresented amongst victims of sexual violence, domestic abuse, and human trafficking – often perpetrated by Caucasian men. Vancouver’s Downtown Eastside (DTES), along with metropolitan regions in Alberta and Manitoba, are home to an incredibly high number of Indigenous women who engage in sex work, often to survive.


Several social, political and historical factors have aggregately pushed Indigenous women to occupy urban inner-city spaces and to resort to survival sex work. Colonial policies like the Indian Act have systematically disenfranchised Indigenous women, made worse by a history of conflating Indigenous women’s femininity with the Victorianera ‘whore’. Further, the neoliberal restructuring of cities has resulted in greater economic marginalization, especially for Indigenous women. Because Indigenous women navigate multiple intersecting systems of oppression – patriarchy, colonialism, and capitalist neoliberalism – they are uniquely vulnerable to violence, especially within sex work. While various socially constructed representations, policies, and sociocultural attitudes justify this violence, any form of systemic change should focus on decolonizing our legal and social service systems in order to prioritize the safety of Indigenous women.

Settler Colonialism and its Lasting Effects The historical and political context of settler colonialism has shaped dominant settler representations of Indigenous women over time.


The early stereotype of the ‘Indian princess’ – a version of the ‘noble savage’ with virginal sexual status – originated from a colonial mentality informed by Victorian ideals of sexuality and Christian patriarchal dogma. Such a representation was promoted in a context where Indigenoussettler relations were conducive to colonial economic pursuits, and white women had yet to arrive on Turtle Island.

Later came depictions of Indigenous women as the morally inferior ‘squaw’, marked by sexual deviance, savagery, lasciviousness, contagion, and disposability. Native scholar, Andrea Smith, suggests that these colonial representations were essential to justifying violence against Indigenous women, who were seen as “inherently violable” and equated to the land, thus acting as objects of property and violent conquest. At the same time, colonial authorities introduced legislation and administrative policies that encouraged the criminalization of Indigenous women, often conflated with “prostitutes”. The highly gendered Indian Act with sections predicated on women’s “good moral behaviour”, the pass system which restricted Indigenous women’s mobility from reserves to towns, 1892 amendments to the Criminal Code that made it easier to convict Indigenous women as prostitutes, and the abduction of Indigenous children for Indian Residential Schools and the ‘Sixties Scoop, all made it easier for settlers to inflict sexualized violence upon Indigenous women. Economic disenfranchisement and intergenerational trauma are legacies of these policies.

Juxtaposition |  Uprooting Colonialism

In addition to navigating these legacies of colonialism, Indigenous sex workers must contend with racialized “classes” within sex work itself. The “high-class hooker” or escort is deemed non-threatening and “clean”, while the “street sex worker” is morally corrupt, a public nuisance, and contagious. Meanwhile, the “trafficked prostitute”, according to human rights discourse, is a passive victim who has been economically and sexually exploited, while other classes of prostitutes have been demonized as criminals. Indigenous women in areas such as the DTES are most often survival street sex workers. One study estimated that of the street sex workers working in the lowest-paying and most stigmatized parts of Vancouver’s DTES, 70% were Indigenous women under 26 years of age.

funding and political support to Indigenous community groups, but also did little to implement its own recommendations. Nevertheless, the DTES community and other groups across Canada come together on Valentine’s Day every year to honor missing and murdered women, resist systemic oppression, and support the communities affected. The media spectacle over the DTES’ sex trade, crime, drugs, and violence has created what anthropologist, Dara Culhane, calls a “regime of disappearance” that selectively erases categories of people (and their forms of resistance). Pathologized and normalized representations of the inner city contribute to a simultaneous overexposure and marginalization of racialized and gendered groups of people, particularly Indigenous women. The media also tends to objectify and reduce Indigenous women to the singular category of the “prostitute”, as if their lived realities do not extend into the daylight and transcend the streets of the Downtown Eastside. As such, Indigenous women are concurrently confined to narratives of victimhood and deviance.

The media tends to objectify and reduce Indigenous women to the singular category of the “prostitute”, as if their lived realities do not extend into the daylight and transcend the streets of the Downtown Eastside.

Missing and Murdered Indigenous Women And Girls While comprehensive data on the number of missing and murdered indigenous women and girls is still lacking, the overall count may be higher than 4,000. Vancouver’s DTES has proven to be an especially precarious site for Indigenous sex workers. During the 1980s, inaction from police and authorities allowed notorious serial killer Robert Pickton to murder half a dozen Indigenous women, while the media sensationalized their disappearances. The Liberal provincial government responded with an official commission of inquiry in 2010 into the disappearances of Indigenous women in the DTES, compelled by the Pickton Case and the Amnesty International Stolen Sisters report. This inquiry and its resultant report not only failed to provide legal

Juxtaposition |  Uprooting Colonialism

Indigenous organizations have differing opinions on how best to politically tackle the issue of violence against Indigenous women, particularly within sex work discourse. Scholars like Sherene Razack argue that sex work can be a form of violence because it “relies on the notion that consent makes the violence permissible”, particularly if the conditions under which a sexual bargain is made are coercive – a view supported by Indigenous scholars such as Robyn Bourgeois and organizations like the Aboriginal Women’s Action Network (AWAN). Razack makes a case for this approach by pointing out that many Indigenous sex workers are underage, engage in survival street sex work, and are often coerced into trafficking rings because of the power and gender hierarchy that defines their work. This position is however staunchly polarizing, as other organizations such as the Native Youth Sexual Health Network and Kwakwaka’wakw scholar Sarah Hunt argue for harm reduction and protective approaches based on the premise that sex work is a legitimate source of labour.


Violence against Indigenous Sex Workers in an Urban, Neoliberal Context Within both European and Canadian history, reformers have sought to “cleanse the city” of what they termed the “social evil” of prostitution. At the same time, a discourse of incommensurability between Indigenous people and urban spaces has often informed policies on urbanization. Historical, and even contemporary, views that Indigenous people are somehow meant to remain contained in reserves or allocated tracts of land, away from ‘modernity’, are illustrated within the Indian Act and the pass system that demobilized Indigenous women. Today, nearly 60% of Indigenous people who migrate to urban areas are women. The pathway to metropolitan spaces is risky, but instead of finding ways to make Indigenous women more safe and mobile, the BC provincial government uses billboards along the Highway of Tears to prevent hitchhiking as a contentious and risky form of mobility. Thus, the city is a relatively new space for understanding Indigenous-settler relations and their impact on violence against Indigenous women. Meanwhile, Indigenous women within Vancouver face discursive enclosure within the city’s poor, or “unclean”, marginalized spaces. Representations of missing women link them specifically within the “small two-bloc radius of the DTES” as opposed to the entirety of Vancouver city. Even Tourism BC has carefully dissociated Vancouver

from the Missing Women, instead making explicit the representation of violence as DTES-specific, thus eliding the city’s responsibility for violence against Indigenous women. Scholar Shawna Ferris calls this an urbanization process in which the dead sex worker’s body is no longer associated with the “city proper”, but is instead just another zone that the city officials have marginalized through municipal policies, and the media through its sensationalized headlines. Indigenous women’s existence, like the value of any people in a neoliberal society, is valued with reference to their role in economic growth and development, as shown by the 2010 Vancouver Organizing Committee’s lobbies to legalize brothels during the Olympic games. When the federal Conservative government rejected the Vancouver Organizing Committee’s bid for legal exemption of brothels, it lent its support to the unionization of sex trade workers. AWAN opposed this on the grounds that it failed to dismantle the systems that encourage violence against Indigenous sex workers, and merely converted illicit,


violent, and oppressive practices into legal ones that could serve as profit engines for the privileged. Neoliberal policies and nationbuilding activities such as the Olympics demonstrate that policies on trafficking or sex work are not congruent with concerns for Indigenous women’s welfare. Further, neoliberal governance models place the onus for protection and welfare management on individual women, as opposed to social security systems that continue to be defunded. Most Indigenous advocates would agree that the safety of Indigenous sex workers must be our collective priority. This can be realized through policies that decriminalize sex work. Sex workers ought not to be treated as threats to public safety. Rather, sex workers should be treated as workers, as having a right to safe working conditions, free from criminalization and policing. Naomi Sayers, a First Nations activist currently completing her articles to become a lawyer, suggests that “Canada needs to recognize violence beyond violence from “pimps” and “johns”, since violence also comes from police and civilians (i.e. non-sex workers)”. For Indigenous sex workers, a history of violence perpetrated by law enforcement authorities, exemplified by the sexual and physical abuse carried out by Quebec police against Indigenous women in Val D’Or, cannot be omitted from policy discourse. In navigating multiple systems of oppression, Indigenous women are disproportionately overpoliced but underprotected. By engaging in sex work, they also face the thorny issue of sex work stigmatization. Decriminalization of sex work paves the way to respecting the selfdetermination of Indigenous sex workers as people.

Canada needs to recognize violence beyond violence from “pimps” and “johns”, since violence also comes from police and civilians (i.e. non-sex workers) - Naomi Sayers, First Nations Activist Our history, and indeed the facts, tell us that Indigenous women are disproportionately vulnerable to violence. The current social and political climate that Indigenous sex workers navigate enables their invisibility in the streets of inner cities such as the Downtown Eastside of Vancouver. Current understandings of and conditions surrounding sex work normalize violence and trafficking against Indigenous women. Urban centres in particular need policy change that prioritizes the safety of Indigenous women and respects the needs of Indigenous sex workers. Only then can colonially-rooted violence against Indigenous sex workers be eliminated.

Juxtaposition |  Uprooting Colonialism

Mending the Broken Hoop:

Indigenous Health and the Dis-ease of Disconnection Jasmine Spence


n 2015, Canada’s Truth and Reconciliation Commission (TRC) identified significant gaps in health outcomes between Indigenous and non-Indigenous communities. These pervasive gaps are evidenced by numerous indicators, including infant mortality, maternal health, suicide rates, incidence of mental illness, addictions, chronic diseases, and accessibility to appropriate health services. For Indigenous people, this has been a painful lived reality for generations, but Canada is only slowly beginning to recognize the impact of a history of violent policies on Indigenous health. Canada’s Indigenous policies, including the Indian Act, disconnected people from their land, identities, and families; facilitated forced assimilation, and physical, emotional, and sexual abuse; and outlawed Indigenous medicine and ceremony. Two of the TRC Calls to Action address the need for Indigenous healing practices within the Canadian healthcare system, as well as the need for Indigenous healing centres to support those who’ve been physically, mentally, emotionally, and spiritually harmed by residential schools. Promoting the practice of Indigenous healing is not only essential for the wellbeing of patients, it is also a critical part of ensuring that the body of Indigenous medicinal knowledge survives, develops, and flourishes.

What is Indigenous medicine?

Health extends beyond the patient and into relationships with other people, with animals, plants, rocks, water, stars, and ancestors.

Indigenous healing practices vary from region to region, and from Nation to Nation. However, the concept that wellness encompasses mind, body, heart, spirit, and connection to land, is common to many Indigenous cultures. From this perspective, the physical, mental, emotional, and spiritual components of the natural world are all equally important. Health extends beyond the patient and into relationships with other people, with animals, plants, rocks, water, stars, and ancestors. The role of a healer in my Ininew (Cree) culture is to assist the patient in restoring good relationships and increasing their awareness of the desired state of equilibrium. Practices that help us understand and achieve equilibrium may be physical (eg. ingesting a plant), mental (eg. assessing our needs and communicating them), emotional (eg. social relationships or taking appropriate measures to grieve), and spiritual (eg. understanding all these interactions, which may involve dreaming or praying). Many of our Ininew ceremonies facilitate all four types of healing at once. The way we pray, for instance, is usually accompanied by a physical experience, such as burning a plant medicine, entering a sweat lodge, smoking a sacred pipe, piercing our skin, or sounding a drum.

Juxtaposition |  Uprooting Colonialism


The relationship between the material and spiritual realms is intricate and deep. We need to spend physical time on the land to learn which plants to use, when to use them, and how to prepare them. Much knowledge is also stored in the wisdom of our family and community members. We have to learn the landscape and its rhythms like the back of our hand in order to gain medicinal knowledge. The way other animals, plants, seasons, and planets interact informs our healing practices. We have to watch them for a long time. There is a subtle enlightenment and inspiration which results from long-term exposure to the intricacy and interdependence that shapes the material world. This inspiration is spiritual in nature.

The way other animals, plants, seasons, and planets interact informs our healing practices. We have to watch them for a long time. There is a subtle enlightenment and inspiration which results from long-term exposure to the intricacy and interdependence that shapes the material world. This inspiration is spiritual in nature. It is simpler to explain spiritual inspiration as a byproduct of physical experience, but physical experience is also a byproduct of spiritual inspiration. Neither comes before the other. This is one of several fundamental concepts of Indigenous health that can be expressed in hoop symbolism. The hoop as a conceptual framework is popularly represented by the Medicine Wheel image. The Medicine Wheel is a circle with a centre and lines extending in all four cardinal directions. The four directions also represent the four aspects of being (body, mind, heart, spirit). When we look out at life from the centre of our circle, we acknowledge the way in which we are situated relative to other people, to our environment, to the past and to the future. Understanding and respect for those relationships brings us to equilibrium.

In 1875, my nation, Pimicikamak, signed a treaty with the British Crown. Thereafter, the physical, intellectual, and religious influence of the settler people grew until it overpowered our traditional healing ways. This was often accomplished by force. Indian Agents were hired to monitor compliance with new Canadian (foreign) policies across Ininew territory. The landbased spirituality of our ancestors was banned and we underwent a systematic process of Christian conversion. Children were placed in an education system which removed them from their families and from the land. They were penalized, sometimes brutally, for speaking their language. Our language holds a wealth of information that is necessary for Ininew wellbeing. The intricate relationships I have described are embedded in it and

cannot be expressed in English. The plants, meats and fats that once precisely regulated our physical systems were replaced by rations of refined flours and sugars. We fried bread, wrote, read, and drank until we largely forgot who we once were. When our identity was stolen, we became sick with ailments that had never afflicted us before, such as cancer, diabetes, alcohol addiction and suicide. We were given medicines that had no life, no roots, no leaves. We were given clothing we did not need to make ourselves. We were given food that we did not need to harvest ourselves. We did not need to know what creature gave its life for it, and what ecological systems support that creature. We were shown European ‘civilization’ and had little choice but to embrace its psychology and technology. As our relationships to land and family continue to be systematically severed through policy, economic imperialism, and environmental destruction, we lose touch with our ancient understanding of health. This greatly inhibits our ability to heal ourselves. Sickness in Canada’s Indigenous communities can be described as a disconnection. But this disconnection has affected non-Indigenous society as well, and for much longer. It has been there for so long that it is scarcely recognized in the Canadian health care system. Allowing, including, and promoting Indigenous healing practices is essential for re-establishing connection and wellness in Indigenous patients. But it can also help to inform the direction of inevitable change as we enter a time of great instability in our global health and environmental systems.


Juxtaposition |  Uprooting Colonialism

Environmental justice

A changing global climate, and the concomitant political climate, demands of us a more refined and equitable approach to environmental justice. These articles consider the implications of extremes in the environment, and an environment of extremes. The first addresses the disproportionate health impacts of climate change-associated extreme heat events on low- and middle-income countries. The second shifts gears, asking the reader to delve into the acutely complex political economy of an agrarian suicide crisis in Punjab, India.

Climate change: New extremes Julia Robson


requent, severe, and prolonged extreme weather events lie ahead of us as our climate continues to change. Extreme weather events, including droughts, floods, forest fires, and extreme heat, are often accompanied by serious effects on human health, and should act as catalysts for meaningful climate action. Climate change-associated extreme heat is expected to have significant impacts on human health, but unlike other types of natural disasters we have relatively little experience with it. Furthermore, many of those who face the impacts of extreme heat contributed little to its causes, and often struggle to exert the political pressure needed to mitigate the damage. Although all countries should engage in climate change mitigation and adaptation, low and middleincome countries (LMICs) require the most attention and resources if they are to avert a humanitarian catastrophe in the decades to come. In many cases, the brunt of the negative effects of climate change fall on the backs of the most marginalized, vulnerable, or politically impuissant groups of people.

Fortunately, many cities in high-income countries have cooling centres and other community buildings that can offer a respite from the heat to those without air conditioning. Other measures, such as green roofs, reflective surfaces, and ‘smart’ structures that can adjust according to the heat may also be useful, but they evidently do not relieve the need for extensive measures to combat climate change at all levels.

There is no universally accepted definition for an extreme heat event, known colloquially as a “heat wave.” This is partly because it’s a relative term, and average temperatures and local weather conditions vary significantly across the globe. For example, humid areas may have a higher ‘threshold’ for declaring a heat wave because humidity index values often remain relatively stable throughout the year. Nonetheless, the relationship between extreme heat and adverse health outcomes is strongly supported by the literature. Extreme heat events are more concerning in cities than in surrounding rural areas due to the urban heat island phenomenon, whereby the physical and geographical characteristics of cities retain more heat than rural areas in the same region. Extreme heat events are associated with various damaging health effects in vulnerable population groups, including heat stroke and electrolyte disorders. As discussed in a 2014 article by Bobb and colleagues, elderly adults can be especially vulnerable to heat events due to age-related decline in the body’s ability to thermoregulate, as well as frailty and other factors. Such effects can impair normal functioning, cause or exacerbate illnesses, and even result in death. These risks are unacceptable, and they are avoidable.


The situation is much more concerning in LMICs, many of which do not have sufficient resources to protect the health of their inhabitants during extreme heat events. In this case, the lack of resources in LMICs often includes human resources, financial resources, infrastructure, and support from reliable government institutions. Extreme heat, drought, food insecurity, and related geopolitical climate-related circumstances have been recognized by many scientists and other authorities as a source of current and future regional instability. The vulnerability of populations in LMICs may be compounded by socioeconomic factors such as informal and precarious housing, food insecurity, lack of access to clean water, political conflict, corruption, and other factors. Not only

Juxtaposition |  Environmental Justice

do these factors make surviving extreme heat much more difficult, but they may also lessen citizens’ ability to exert political pressure and demand appropriate environmental policies.

How can humans be expected to live and work in temperatures that exceed 45º or 50ºC? Where can they go if they experience heat stroke or other heat-related illnesses? Are current medical structures and systems capable of serving very large numbers of people during heat waves? Who should be responsible for planning for heat waves? Governments are typically responsible, but few leaders are able or willing to plan and execute potentially expensive prevention measures that will serve to be immensely useful long after the typical four- to eight-year political term. Extreme heat events are significant in an environmental health context because they are an example of the interactions between climate and human health. It is important to take structural and policy steps now to mitigate and adapt to the increasing global threat posed by climate change. For example, policies that improve electricity and disaster management infrastructure, thereby improving community resilience, should be supported in LMICs and high-income countries alike. While high-income countries typically have the capacity to implement cooling centres, for example, LMICs may not. Some LMICs would therefore likely benefit from participatory, targeted outside assistance to increase their capacity.

Fortunately, extreme heat presents opportunities to improve the way systems function on many levels. For instance, changes that make cities less vulnerable to extreme heat, such as planting more trees and encouraging the use of public transportation, also have numerous co-benefits for health. Along with measures to cut greenhouse gas emissions, morbidity and mortality due to extreme heat events can be reduced with proper preparation and mitigation efforts to reduce general vulnerability in at-risk populations such as low-income communities, young children, and the elderly. We already have much of the data and many of the tools necessary to make such changes. Citizens all over the world need to demand sustained action proportionate to the threat of extreme heat events from their local, regional, and national elected officials. Recent action on climate change, including the Paris Agreement and the Kigali amendment to the Montreal Protocol, has been encouraging. Despite these advances in international cooperation on reductions in greenhouse gas emissions, challenges still remain. The political situation in the United States may make climate progress somewhat more challenging, suggesting the need for more binding measures and increased global pressure on states who have yet to fulfil the commitments they made to reduce their own greenhouse gas emissions. As we look for increased political commitment, it is important to understand that the climate has already changed, and will continue to do so. But immediate action on our commitments could help us avert some of the worst outcomes. We must advocate for the sake of our own health, but especially on behalf of those unable to advocate for themselves. Anything less would be unjust.

A Manifestation of Agrarian Distress:

Farmers’ Suicides in Punjab, India

Simran Dhunna


here is little that can match the sheer horror of farmers’ corpses accumulating along the banks of the Bhakra Beas canal in Punjab. Bodies are defiled by wild dogs and float downstream to Khanauri village, where a ‘rest house’ has been set up to support those who come by to identify their fallen family members. Raw footage of this scene was shared by Inderjeet Singh Jaijee, leader of the Movement Against State Repression (MASR), in order to compel the government to recognize the epidemic of farmers’ suicides in Punjab. Jaijee, a human rights activist at the forefront of farmers’ rights advocacy, estimates that 5,000 Punjabi farmers kill themselves per year. He has spent the past three decades meticulously documenting more than 2,375 suicides from 110 villages, particularly from the Sangrur

Juxtaposition |  Environmental Justice

District. Punjab Agricultural University claims that three Punjabi farmers have committed suicide every day over the last 17 years. Multiple secondary investigating bodies, including state-commissioned studies, have enumerated suicide mortalities in particular regions, but those numbers tend to be underestimates. Small and Marginal (SM) farmers are most affected by the suicide epidemic. While the surplus income of rich farmers allows them to repay their loans, SM farmers (constituting 20% and 15% of all Punjabi farmers, respectively) are driven to suicide by overwhelming agricultural debt. Moreover, the number of suicides of landless farm laborers currently exceeds those of land-owning farmers. A disproportionate number – two-thirds – of these suicides are committed by young men.


The work of a farmer, tethered to the vagaries of nature and the market, is marked by volatility. It is also characterized by tragic irony: the majority of farmers consume pesticides such as celphos, while others jump in front of moving trains. Although debt is often the immediate motive for farmer suicides, the roots of the problem are complex, and partly lie in the lack of appropriate infrastructure to buffer the financial insecurity faced by most Punjabi farmers.

The Political Economy of Agrarian Punjab

Once known as the “breadbasket” of South Asia, Punjab’s agricultural story can be divided into five parts.

A Flourishing, Self-sufficient, Agrarian Society before Independence (1947) British colonial rule transformed Punjab’s agrarian system by introducing a canal system to Punjab’s five rivers. The canals allowed for greater irrigation, and by extension arable lands that led to a profound increase in agricultural productivity. Agrarian debt existed then as it does today, but the British Colonial government codified the protection of Punjabi farmers through policy that included institutional and legal safeguards against indebtedness (eg. the Land Alienation Act of 1900). Prominent Punjabi politician Sir Chhotu Ram (1881-1945) played a role in shaping protective laws in the 1930s, which established debt settlement boards, local arbitration societies for legal support, and caps on interest for loans. Today, the oncecelebrated Chhotu Ram laws are no longer in use.

Punjab’s Unstable Relationship with the Central Indian Government The post-independence parliamentary model of the nascent Indian state was strong, while states functioned as relatively weak political units, leading to a long struggle between federalism and statism. The 1960s witnessed the Punjabi Suba (Sikh-majority) movement, which vied for an autonomous Punjabi-speaking state. The water dispute between the Central Indian government (the “Center”) and Punjab significantly shaped contemporary agrarian Punjab. In 1976 the central government constructed the Sutlej-Yamuna canal to divert Punjab’s water to Haryana without compensating the Punjab state, directly affecting water availability for Punjabi farmers. This (unresolved) water conflict was the fuel to the fire, causing a militancy period that lives in the consciousness of Punjabis today and has severely damaged Punjab-Center government relations.

An era of violent conflict In the 1970s and ‘80s, Sikhs, including farmers, demanded greater autonomy through protests. In 1984, farmers and the Sikh political party, Akali Dal, blocked the transportation of wheat out of Punjab (i.e. Rasta Roko) and withheld taxes from the Center. What was rooted in an agrarian conflict became a religio-political one through the government’s attempts to suppress Punjab’s demands. In

Punjab community members express fear of violence, and farmers’ unions recall memories of forceful crackdowns that now hinder agrarian organizing amongst farmers. There is a palpable power differential between Punjab and the Central Indian government, both of which Jaijee says “downplay agrarian distress across the country” since suicides arose in the 1980s.


response to Rasta Roko, the Indian Army sent 100,000 army troops to the Sikh Golden Temple, massacring thousands of Sikhs. A 9-year long violent period, from 1984-93, ended when Sikh bodyguards assassinated Prime Minister Indira Gandhi, and militancy in Punjab was, at the time, quashed by 1994.

Juxtaposition |  Environmental Justice

An Unsolicited Experiment: the Green Revolution Colonial changes to the canal system and violent clashes with the Center put agrarian Punjab in a precarious position. At the same time, ravaged by droughts in the 1960s, India was under immense international pressure (namely by the US and Western international agencies) to adopt an agricultural development plan. This came in the form of the Green Revolution (GR). Whereas post-independence India passed several pro-peasant reforms that invested in rural infrastructure, the GR of the 1970s and 1980s turned agriculture into an individualistic and mechanized enterprise.

In other words, a water-intensive Western agricultural model was being imposed on Punjab during a time when the Central government had diverted water to Haryana, leaving it in a position to eventually fail under the strenuous demands of the Green Revolution. Eventually, farmers became disillusioned with the Green Revolution’s initial merits, and found themselves in trapped in debt during a deep economic crisis. The lower-caste, small and marginal farmers suffered the most, resulting in increased rural inequality.

The “Punjab peasant is born in debt, lives in debt and dies in debt”.

The primary elements of the GR included the introduction of high-yield genetically modified seeds that would only be highly productive if farmers used expensive inputs such as fertilizer, pesticides/insecticides and irrigation.

Debt is the leading cause of farmer suicides in Punjab. Punjab farmers experience the highest levels of debt in the country, with marginal farmers experiencing 6 times more debt than large farmers. In a society dictated by strict social norms and reputation, farmers are under enormous pressure to save face in their respective communities. Hence, there is a social dimension to indebtedness, whereby inability to repay is treated with public humiliation, social ostracism and disrespect.

Entrenching an Agricultural Debtscape

Why do farmers and farm labourers end up in a cycle of debt? 1) Natural factors (eg. monsoons, droughts) result in adverse crop outcomes, producing low profit margins due to stagnant crop productivity or crop failure. Crop insurance programs do not currently exist to account for the volatility of farming in Punjab. The added impact of climate change threatens to make Punjab’s farming households more vulnerable, and in fact increases the suicide rate. Given the location of Punjab, the melting of the Himalayan glaciers will result in extreme water flow leading to heavy floods, loss of livestock, and variability in droughts/rains. Furthermore, the GR left Punjab’s farming sector with monocrops of wheat and rice, whose narrow genetic diversity leaves them vulnerable to pests, and for which pesticide is exceedingly expensive.

2) Due to the demands of the agricultural system after the GR, there are greater productive costs for agricultural inputs, requiring small and marginal farmers to take loans from institutional and informal moneylenders. Operations such as tilling and harvesting rice and wheat have been mechanized, so farmers have to pay out in cash for diesel, inputs, and hiring labour. 3) High social expenditure increases household debt (eg. marriage, house construction, expensive healthcare and education, consumption of intoxicants). While the majority of debt (57.4%) is taken for productive agriculture purposes such as farm machinery, land and inputs, non-productive social purposes also account for 43% of debt (maintenance/repair of houses, consumption, health and social ceremonies). 4) Low literacy levels prevent farmers and their families from accessing alternative modes of income generation. Disproportionately low literacy rates have been observed in the regions of Punjab most affected by suicides. Without higher levels of literacy, families without farming income are left with manual labour as their only option.

Juxtaposition |  Environmental Justice


Neoliberal Reforms Exploitative relationships with informal money-lenders Farmers access a mix of institutional and non-institutional loans, though mainly the latter poses significant risks for indebtedness. Due to the easy availability and timeliness, farmers often pursue non-institutional informal money-lenders for loans. Commission agents (arhtiyas) are the most popular source of credit amongst non-institutional sources. Arhtiyas are middlemen for the sale of crops between farmers and buyers, resulting in farmers being highly dependent on them and therefore easily exploited. Although the banking system is highly developed in Punjab, more than 35% of total credit is provided by arhtiyas. Informal moneylenders like arhtiyas remain a problem; they charge interest rates as high as 24-30%, require collateral, engage in land “grabbing”, and operate independently of formal written records or institutional legitimation.

suicide and despondent families left in its wake The story of Gurbaj is one of thousands of Punjabi farmers, differing only by the poison they chose to kill themselves and the family members left behind. Not all are farmers: some are landless labourers, like Karnail Singh of Chural Kalan, a 22-year-old who consumed poison due to a debt of Rs. 40,000. The device you are reading this article on is likely worth more than his debt. Of particular interest, and perhaps limited in the literature, is how these suicides impact the lives of women, children and elderly people. The agrarian farmer suicide crisis is fundamentally gendered. Patriarchal gender dynamics in India place the widowed wives of deceased farmers in a precarious position. They are less likely to be educated than men, and are generally unable to find alternative employment to support their children. Punjabi women have also committed suicide due to the continued harassment from moneylenders to repay their loans. Another way in which women are implicated in farmer suicides is through dowry: post-suicide remuneration cannot be given if debt is dowry-related. Farmer suicides also impact elderly parents who often depend on their son(s) to care for them. They have resulted in streaks of multiple suicides within a family. Family members may end up blaming themselves for


The weaning-away of a social security net due to neoliberal reforms, beginning in the 1970s, served to further push vulnerable farmers to the margins. Afterwards, the 1990s began an era of globalization, involving massive trade liberalization, privatization, and a divestment from rural agricultural development by the Indian government. For instance, the Indian government has attempted to dismantle the Public Distribution System (PDS) through which millions of families have received food assistance. Under the pressure to privatize, in 1997 the PDS became a “Targeted PDS”, limiting the types of citizens eligible for benefits. Such neoliberal policies have shifted the government’s priorities away from subsidized agriculture. Structural Adjustment Programs in 1991 also disrupted the fragile agrarian economy of small and marginal farmers. In addition to limited institutional support, neoliberal individualization of agriculture has deconstructed social support systems, whereby joint families have morphed into nuclear households. Without the communal social relations that buffered the volatile lifestyle of the farmer prior to the GR, the individual farmer must now bear the risks of a de-socialized agrarian life. Further, alienation and the loss of the rural social self in the face of urbanization renders the issue of farmer suicide more complex than mere debt or drought. The Story of Gurbaj Singh Gurbaj Singh was a 32 year old farmer in Guniana (Faridkot District). He committed suicide on April 1st, 2017, by jumping in front of a moving train. A small farmer, he had inherited three acres of land from his father, but gradually sold all of that land due to several losses. His death left behind his wife and three children. Gurbaj’s mother urged the government to give his wife a job, asking “Who will look after us? We neither have land nor anyone to support us.”

suicides and crop failure, particularly when they are unaware of debt. One elder whose son had killed himself expressed a loss of self-esteem: “We are like the living dead”. Farmers’ and labourers’ suicides do not occur in a vacuum. They result in strings of suicides where the widowed wives and young sons feel compelled to meet the same fate. Beyond the family, an entire village suffers from these suicides: a farmer’s livelihood is connected to everyone, from the shopkeeper to the milkman. Without the earnings of a farmer, the shopkeeper ceases to get more customers. Cases of shopkeepers committing suicides have been reported.

advocacy in the face of State Apathy Indian scholar, Aninhalli Vasavi, argues that the rural farmers of India have experienced an “advanced marginality”: persistent state neglect, invisibilization by the popular media, and even an inability to mobilize into cooperatives without catering to the interests of dominant/ upper-caste farmers. When lifelong activist, Jaijee, sent reports to both state and central governments, he received vague responses from government officials, one of whom even told him that all suicides had been committed due to grudges and personal rivalries. The

Juxtaposition |  Environmental Justice

government has outright denied farmer suicides in the past, and any state-commissioned survey of the issue has been unable to elucidate the full extent of the crisis.

in Punjab, the challenge lies in political will, especially in prioritizing the people over a transnational neoliberal agenda. Scholars have done extensive work to identify policies that may prevent Punjabi

Not all are farmers: some are landless labourers, like Karnail Singh of Chural Kalan, a 22-year-old who consumed poison due to a debt of Rs. 40,000. The device on which you are reading this article is likely worth more than his debt. Despite these political roadblocks, advocates like Jaijee have been persistent. For example, Jaijee also founded the Baba Nanak Education Society, an NGO that funds the education of children whose farmer parents committed suicide. As the leader of MASR, he has also petitioned the National Human Rights Commission, and worked with his team over the past few decades to bring forward welldocumented cases to Panchayats (local governance councils). MASR has even prepared a booklet to explain legal protections available to indebted individuals, which has been distributed through gurdwaras (Punjabi temples) and Panchayats. During the 1970s push for Punjabi state autonomy, a Sikh Punjabi political party put forward the “Anandpur Sahib Resolution” to both state and central governments, though it was never accepted. It advocated for a fixed minimum wage in rural society, agricultural diversification, industrialization for alternative livelihoods, and removing excise tax on tractors. Some strides have been made since then, and NGOs such as MASR have worked to advocate on behalf of farmers.

farmers from entering the sphere of indebtedness. These include greater state investment into rural development, crop diversification, crop insurance against climate/ecological change, and a legitimate institutional backbone for financial transactions. Moreover, current state policies like the Agricultural Loan Waiver for farmers should be extended to provide relief to landless farm labourers as well. Two key policy components must be prioritized. Firstly, historical context must address the old canal system of Punjab and the tense relations between the Punjab State and the Central Indian government. Secondly, Punjabi farmers need to have the impetus and resources to mobilize. Cooperatives were supported before independence, and they have demonstrated success in other states such as Maharashtra. Farmer cooperatives that are grassroots, member-owned and participatory can restore some of the social relationships that strengthened farming communities prior to the 1960s agrarian transformation.

Beyond the family, an entire village suffers from these suicides: a farmer’s livelihood is connected to everyone, from the shopkeeper to the milkman. Building a resilient agrarian punjab Farmers today are slightly more cautious not to borrow from informal lenders like Aartiyas, who have strong lobbies. More recently, in 2001, the Punjab government also introduced a rehabilitation program for families of farmers who committed suicide, offering over $50,000 as compensation. However, some consider these to be band-aid solutions. There are myriad policy solutions that can, and should, be implemented by the Indian government. In order to build resilient rural communities

Juxtaposition |  Environmental Justice

A stronger social security net (eg. a robust pension scheme), redistributive policies (eg. prevent rich farmers from reaping free power from the government by way of electricity subsidies), and nonagricultural employment opportunities need to be reinvigorated in rural areas to create diverse income sources. By creating a resilient, institutionally supported, and ecologically sustainable social and ecological rural structure in Punjab, farmers and their families would be less likely to commit suicide due to indebtedness.


From ideology to power

Undeniable is the power of ideology, and indeed the ideology of power, in shaping who gets good health and wealth. These articles look at a breadth of global health issues, with careful attention to how political pathologies play out in public health struggles. From teasing apart the socialist political economy of Venezuela amidst famine, to the politics of who bankrolls patient advocacy organizations, and from a deeply personal window into endof-life care for ethnocultural groups, to how political priorities in Nigeria can help it to realize its demographic dividend – these perspectives are reeling with the weight of power-laden ideological decisions.

In Freefall:

Scarcity in venezuela

Benjamin Levy


he lines begin to stretch around the block well before 5:00 each morning. People wait for hours, hoping that there will be something left by the time they reach the door. They’re waiting for a loaf of bread. These scenes have become commonplace across Venezuela, even in the once prosperous capital city of Caracas. A humanitarian crisis has reached previously unseen levels in this country of over 30 million

ten percent, the WHO’s benchmark for a serious crisis. Protesters march daily on the streets of Caracas to demand early presidential elections, banging together empty pots as a symbol of the food shortages. In response, the government has cracked down, with security forces firing canisters of tear gas, or even live ammunition, at demonstrators. To date, government forces have killed at least 64 people since April of 2017. Like so many other food crises, Venezuela’s is both anthropogenic and preventable. Until recent years, Venezuela was performing well by many standards. It has the largest proven oil reserves in the world and a socialist government dedicated to providing social programs for poverty alleviation. For years under Hugo Chavez, the President from 1998 until his death in 2013, those socialist policies succeeded in reducing poverty from 55% to 34%, helping 1.5 million adults become literate, and delivering healthcare to 70% of the population with Cuban doctors, paid for with oil revenues.

people. There are shortages of basic medicines, goods, and above all else, food. About 85% of medicines are in short supply, maternal mortality and infant mortality are up 65% and 30%, respectively, and mosquito-borne illnesses like Zika virus and malaria are on the rise. Meanwhile, 75% of Venezuelans reported losing 19 pounds on average in 2016, and one in three are eating two meals or less a day. Caritas Internationalis, a religious charity, has measured the Global Acute Malnutrition (GAM) rate – the proportion of children from six months to five years of age suffering acute malnutrition – to be hovering around

Juxtaposition |  From Ideology to Power

In recent years, however, the government became increasingly authoritarian. First under Chavez, then continuing under his successor, Nicolas Maduro, the ruling party gradually consolidated its power. Courts and electoral authorities have been filled with Chavez supporters, known as Chavistas, while press freedom has significantly deteriorated. This past March, the government-controlled Supreme Court tried to dissolve the opposition-controlled National Assembly, although the ruling was later weakened after massive protests broke out. So what is causing the dire crisis in Venezuela? American news outlets such as the Washington Examiner, Fox News, and New York Magazine, have described it as the inevitable collapse of socialism. According to Maduro, the crisis is due to the political opposition collaborating with the United States to bring down the People’s government. As always, the reality is more complicated than both sides make it out to be.


External factors The main causes of the crisis are economic. A significant reason why Venezuela cannot buy food is because the government is out of money. Ninety-six percent of government revenues come from oil, so when the price of crude oil recently plunged to a twelve-year low, the government could no longer afford to pay subsidies to farmers or give food vouchers to the poor. On top of a decrease in national revenues, creditors are pressuring the government to put any limited funds towards paying down debt to avoid restructuring bonds (a term for government debt) rather than feeding people. This has prompted some economists to assign the epithet of “hunger bonds” to Venezuelan bonds. Emerging market

Transparency International, Venezuela ranked 169th out of the 180 countries surveyed for the Corruption Perceptions Index in 2017, and was considered to be the most corrupt in the Americas. Corruption leads to mismanaged nationalized companies, and significant barriers to doing business.

An Inevitable Failure? For right-wing critics, this is a classic case of a populist, socialist government’s inevitable failure. The argument goes: price controls, overspending, and mismanagement are not the exception, but the rule as far as socialism is concerned. The oft-cited whale of Venezuelan mismanagement is Petróleos de Venezuela S. A. (PDVSA), the national oil company. In the 1990s, the board and much of the upper managem-

Even if one believes that Maduro must go, if the cause of Maduro’s fall is a US oil embargo, that only plays further into the government’s narrative that Venezuela’s problems are entirely foreign-caused. Any change in Venezuela must come from within. bonds funds, such as JP Morgan’s EMBI+, have a significant stake in Venezuela, since Venezuelan debt is so risky that it has five-times the rate of return compared with other countries. These funds stand to lose massive profits if Venezuelan debt is restructured, so they are pushing the government to take actions like curbing imports to free up money to service the debt.

Internal factors Volatile oil prices and callous bond traders both fit into the Maduro government’s narrative that Venezuela is a victim of external imperialist forces. However, the government is itself at fault for the consequences of years of mismanagement, corruption, and short-sightedness. When oil prices fell, Venezuela had next to no currency reserves, since it had spent more than all of its oil revenues on social programs. To pay its bills, the government began printing money, which increased the currency supply and drove up inflation. At the same time, the government fixed the exchange rate of Bolivars (Venezuela’s currency) to dollars and mandated that prices for basic goods like bread be kept at low levels. The result was runaway inflation – which is when the value of the currency decreases extremely rapidly – and a massive black market for US dollars and all other goods. Since Bolivars are so plentiful, the bills are hardly worth the paper they are printed on. The situation places farmers, bakers, and shopkeepers in a precarious position. Facing persecution from the government for failing to meet quotas, many produce the bare minimum amount of food and sell it at a loss. They then sell everything else on the black market so they can afford to feed their families. Many farmers have simply left their fields vacant because there is no one to pay them. A high level of corruption means that officials often enrich themselves from Venezuela’s byzantine price control system. According to


ent were replaced by pro-Chavez Bolivarian socialists. The revenues were subsequently redirected to pay for large social programs and not reinvested to develop the company. PDVSA became the government’s chequebook, which it used to buy influence, such as by giving cheap subsidized oil to Cuba in exchange for medical care. In 2002, Chavez responded to a PDVSA strike by firing between 20,000 to 30,000 workers and replacing them with loyalists, which severely reduced the company’s operational efficacy. In 2014, over USD 11 billion was reported stolen from the company. Yet a Venezuelan crisis is hardly the fault of socialist policies alone. One need only look at Venezuela’s neighbour, Bolivia. Both countries are quite similar in having a socialist and natural resource-reliant government. However, Bolivia is not experiencing anything like Venezuela’s crisis. The country has no shortages of basic goods; poverty has reduced from 66% in 2000 to 39% in 2015; and inequality has shrunk. This is mainly due to the fact that while Venezuela spent itself into debt during the Golden Decade of 2003-2014, Bolivia built up its international reserves to USD 15.1 billion by the end of 2014. As a result, Bolivia can afford to feed its people even while government revenues are down. Though Bolivia suffers from many of the same issues Venezuela faces with respect to corruption and free speech, the success it has had with socialist policies paint a different picture from that imagined by some American critics of Venezuela.

Hungry for change On August 4th of 2017, President Maduro inaugurated a brand-new Constitutional Assembly, with near-unlimited power, to rewrite the 1999 constitution and to bypass the opposition-held National Assembly. The 545 members of the assembly were elected in a disputed election on July 30th. The election was boycotted by the opposition and rife with allegations of voter fraud on the part of the government, even coming from Maduro’s attorney-general, Luisa Ortega. As well, there was no option for people to vote against having an assembly; they could only

Juxtaposition |  From Ideology to Power

choose which Maduro loyalists would represent them. Although Maduro claims that the body is independent from him and his government, among the members are Maduro’s wife, his son and his former foreign minister Delcy Rodriguez, who is the assembly’s president. In response to the Maduro government’s actions, US President Donald Trump has undertaken the extreme measure of sanctioning Venezuela’s president, citing the government’s ongoing repression of free speech and civil liberties. Further, the Trump administration has threatened to cease all imports of Venezuelan oil into the United States. This would dramatically worsen the crisis, as the US is the largest buyer of Venezuelan oil by far. Although there are plenty of valid criticisms of Maduro, Slate’s Josh Keating notes Trump’s hypocrisy: he praises leaders like Russia’s Vladimir Putin, the Philippines’ Rodrigo Duterte, and Saudi Arabia’s King Salman, yet singles out Maduro as the only real dictator. This

discrepancy takes on an especially unsavory connotation, as it would be cruel and unjust for the US to plunge Venezuela further into famine, especially given a brutal history of US interventionism against leftist Latin American governments in the name of “democracy”. Even if one believes that Maduro must go, if the cause of Maduro’s fall is a US oil embargo, that only plays further into the government’s narrative that Venezuela’s problems are entirely foreign-caused. Any change in Venezuela must come from within. More recently, Maduro called a snap presidential election, which is taking place in May and is being boycotted by the opposition. Along with the election and the recent announcement of an oil-backed state cryptocurrency, it seems as though the Maduro administration is grasping at straws to stay in power. The question is: how many more will starve as a result of Maduro’s efforts to stay afloat? The answer, as of yet, is far from clear.

Odd couples:

Health Advocates and their Industry Sponsors Aylin Manduric


e all know that health advocacy is easier for the generously resourced, but does it matter where those resources come from?

It’s not always a straightforward matter, though patient advocacy organizations with industry funding have a curious tendency to approach controversial health issues in industry-friendly ways. Wellheeled advocates have greater capacity and resources to bring their perspectives to decision-makers, who don’t always discriminate between the voices backed by industry funding and those whose funds come from elsewhere. This creates a risk of allowing industry-friendly perspectives to achieve a dominant position in policy discussions that should focus primarily on patients’ interests. Perhaps it’s time to take a deeper look into who is advocating for health policy, why, and how. When government grants and other donations are scarce, some organizations welcome any support they can get, regardless of the source. Others refuse industry funding on the grounds that it could compromise their political legitimacy or mission by creating a conflict of interest (COI). Let’s take for example two advocacy groups working to influence medicines policy at the international level: Stichting Health Action International (HAI) and the International Alliance of Patients’ Organizations (IAPO). These two organizations select similar advocacy targets, tactics, and issues, but take divergent positions on patients’

Juxtaposition |  From Ideology to Power

access to information and access to treatment. They also diverge on the question of the importance of financial independence from commercial interests. While HAI rejects any partnership with commercial actors, IAPO depends on industry funding for over ninety percent of its annual budget.

Civil Society as a Marketing Partner Patient advocacy groups are part of a global civil society that has increasingly become involved in decision-making at the national and supra-national levels, particularly when it comes to framing issues and setting agendas. Between the early 1990s to the mid-2000s, healthcare advocate and scholar Sharon Batt noted that government funding for patients’ advocacy organizations was shrinking. Advocates in turn sought support from the private sector, particularly from the pharmaceutical industry. This provided industry with the opportunity to pick and choose only the organizations best suited for marketing partnerships. The groups that did receive industry funding grew their capacity with incredible results: patients’ advocates began to get involved in shaping the funding and direction of medical research, as well as state health decision-making in the UK, Australia, Europe, and North America. If pharmaceutical companies partner with advocates to increase


the visibility of their products and lobby for licensing and pricing agreements, then there is reason to think that such companies would avoid partnering with groups whose missions ran counter to these aims. At the same time, advocacy groups face what has been called “the dilemma of ambitious goals and limited funds”. This dilemma can turn into a serious problem when an advocacy group’s primary purpose – to advocate on behalf of patients and in support of public health – conflicts with secondary goals, like attracting funding. In the absence of non-commercial funding sources, advocates who need resources to accomplish their organization’s primary goals are forced to choose between industry partnerships and financial deficit or dissolution. According to Bernard Lo and and his colleagues, institutional conflicts of interest occur when an institution (or its senior officials) have financial or personal interests that risk creating undue influence over the institution’s primary interest. What makes these conflicts particularly insidious is that they are not always readily visible to observers looking for deliberate co-optation or pressure in an institutional relationship. In other words, corporations need not explicitly demand that advocacy groups promote their agendas at risk of losing sponsorship. Either sponsors will select already-friendly advocacy groups or advocacy groups will find themselves reluctant to jeopardize their funding with a risky position.

So what does this look like in practice? Canadian health advocacy groups who do not rely on industry funds tend to support state regulation of drugs and emphasize safety standards, a ban on direct-to-consumer advertising (DTCA), continuous surveillance of product safety after it reaches the market, and controlling the amount of money government health systems spend on pharmaceuticals.


Those funded by industry tend to challenge the assumption that government regulation properly serves the public interest, and lobby for faster drug approval processes; relaxed DTCA laws; and increased spending on pharmaceuticals. Sharon Batt, along with everyone’s common sense, notes that these demands are “consistent with those of industry”.

Implications of Conflict of Interest for Corporate Power Advocates who take industry-positive positions open the door for industry actors to access avenues of power that were previously in the domain of the advocate alone. By making sure to strategically support advocates whose positions align with their interests, industry actors can use advocacy groups to amplify and echo industry positions in policy discussions. The result is that an apparent plurality of voices are equipped to lobby for industry-friendly positions, while opposing positions that may resonate with a multitude of patients must seek funding from less fertile sources. In other words, businesses can effectively increase their lobbying power by amplifying voices they agree with. This is exacerbated by the specialposition advocacy groups are often afforded in health policy discussions. Health policy and ethics scholar Susannah Rose defines patients’ advocacy organizations (PAOs) as nongovernmental, non-profit organizations that “provide patient- and caregiver-oriented education, advocacy, and support services”. Many PAOs were founded by patients or their close allies, and are often considered to be authentic and legitimate representatives of patients’ voices on those grounds. The special position granted to advocacy groups may take the form of an official status or listing, as facilitated by the World Health Organization (WHO) and the European Medicines Agency (EMA).

Institutions, like the WHO or EMA, who trust advocacy groups, are less likely to restrict advocates’ voices in the same way they restrict blatant industry promotion. Unfortunately, if the distinction between those voices becomes blurred, then there is a risk that corporate ideas will be passed on to institutions under the colour of advocacy, making them more appealing to decision-makers who are ordinarily wary of business involvement in decision-making. Alternatively, the trust decisionmakers place in advocacy organizations could be degraded. Advocates could lose some of their legitimacy, and with it their power to shape the

Juxtaposition |  From Ideology to Power

preferences of policymakers. They might also run the risk of alienating their patients, should it become clear that a COI exists. Alliances between industry and patients’ groups per se create an insidious sort of power, casting the pharmaceutical corporations as a positive force for change in access to medicines. The partnerships legitimate the corporate position to outside observers as well, by virtue of the fact that organizations with patients’ interests at their core are willing to partner with them. This kind of legitimation may thus hide the inherent conflict of interest from both the advocate and from observers. Are these differences in policy position a general trend or an outlier? According to research by Douglas Ball and others, conflict of interest

affects all patient organisations involved in industry partnerships. This raises questions about what might be done to challenge the source of the power corporations have over advocates in the first place: money. Of course, money must come from somewhere, and unless every donor is also a patient, there will always be a gap in common cause between the beneficiaries and the supporters of advocacy groups. Well-intentioned advocates strapped for cash will always have to thoughtfully determine and protect their interests from undue influence. At the same time, decision-makers and policy-setters at all levels must demand transparency from civil society, and be vigilant about the potential implications of COI when they choose to work with conflicted organizations.

HAI and IAPO Health Action International (HAI) was founded in 1981 by medicines policy experts concerned about inappropriate pharmaceutical industry influence on research and policy. It was founded with the support of Consumers International, a noncommercial consumers’ advocacy group that distances itself from business interests. Today, HAI serves as a network connecting thousands of experts conducting research and advocacy activities primarily in the European Union (EU). On the other hand, the International Alliance of Patients’ Organizations (IAPO) was founded in 1999 by representatives of patients’ organizations and with the financial support of Pharmaceutical Partners for Better Healthcare (PPBH), a consortium of 40 pharmaceutical companies that dissolved the same year IAPO was founded. Both HAI and IAPO conduct extensive activities in the EU, and hold “official relations” status with the WHO. Both organizations strive to build partnerships with regulators, and have worked jointly on projects with the European Medicines Agency (EMA). The EMA considers them to have fulfilled its criteria for patients’ organizations, which include “legitimacy… representing patients… and transparency”. The two organizations can thus be described as having comparable access to identical political targets. Despite being similarly structured, having similar relationships with decision-makers, and even using similar advocacy tools and tactics, HAI and IAPO have taken very different standpoints on access to information and access to safe

Juxtaposition |  From Ideology to Power

and affordable treatment in their advocacy activities. These divergences notably echo the disagreements found by Batt in her discussion of Canadian patients’ advocates: the industry-sponsored organization judiciously frames issues in industry’s favour, while the independent organization frames industry profit-seeking as an obstacle to public health. Both IAPO and HAI have published and advocated on the issue of consumers’ access to information about medicines. While both express concern about inadequate access to reliable information, they seem to disagree on what kinds of information patients and their allies should be receiving, and from whom. HAI has long supported bans on all forms of direct-to-consumer advertising (DTCA) by pharmaceutical companies. It urged European officials to avoid passing legislation that allows for companies to circulate “information” to consumers, warning that such legislation could “open the floodgates for ‘creative’ advertisers to put out their promotional messages”. At a conference in 2017, HAI also expressed concern about the reliability and accessibility of industry-sponsored clinical trial data. IAPO, on the other hand, does not challenge the notion that pharmaceutical companies are an excellent source of reliable information about their products. IAPO was amongst several advocacy groups with industry sponsors who lobbied the European Union (EU) to allow DTCA. In 2003, an HAI scholar accused IAPO of camouflaging industry demands for relaxed advertising laws under the guise of patient information. In response, the IAPO chair maintained that “long-term

users of medicines want more and better information, regardless of the source of that information.” Access to medicines is another issue on which IAPO and HAI have taken highly divergent stances. In 2014, IAPO commissioned an issue guide on medical innovation as it relates to the public interest. It elaborates that intellectual property (IP) rights protections, like pharmaceutical patents, may make medicines more expensive for patients, but are nonetheless necessary because “without [them] private investment in high risk biomedical research would be very unlikely to take place .” IAPO’s publications and commissioned studies are full of praise for IP rights and their value in promoting innovation. Per IAPO, if there is a treatment access problem, it is either because patients lack information or because treatment doesn’t exist – a problem linked to underinvestment in privately-funded research. Efforts to cut costs or take advantage of legal flexibilities are downplayed or framed as harmful to patients’ stake in maintaining investor interest in drug development. HAI’s position radically diverges from that of IAPO on this issue. HAI’s primary focus is to enhance equitable access to medicines by encouraging civil society actors to demand more affordable medicines. Overwhelmingly, IAPO focuses on medicines that don’t yet exist, while HAI investigates why existing treatments aren’t reaching the patients who need them the most.


What my grandmother taught me:

towards equitable end-of-life care Jessica Chan


n a hot and humid Saturday afternoon, my grandma and I were lying on her bed. Like many of the afternoons spent together in my hometown of Pingtung city, Taiwan, my grandmother peppered our conversations with explanations about how her hands, the skin thinned by steroids, were easily bruised and injured; how her feet were bloated with water and she had to prop them up; how a barrage of different medicines over the years had ruined her body; and how none of us knew how she felt: trapped like a prisoner in her own body.

mother translated so that I could understand the names of the different dried mushrooms in stock. These happy reminiscences were often interrupted by bouts of coughing. On bad days, my grandmother, frustrated, would stop talking in the middle of a story, compelling us both into silence. Mindful of the poverty that marked most of her generation, I once hesitantly asked her what her dreams had been as a girl, and if she had achieved them. She emitted a noise in response, nestled between a laugh and a scoff. Back then, she explained, we didn’t have dreams. We were just focused on working to have enough to eat and a place to sleep. Still, it was the questions that I didn’t ask her that weighed most heavily on my mind. Coincidentally, my trip to Taiwan had coincided with my reading of Atul Gawande’s Being Mortal: Medicine and What Matters in the End. Gawande struggles with how the medical profession addresses end of life care, particularly for aging patients. Susan Block, a palliative care specialist Gawande consults in the book, describes the difficult conversations she has with patients about end-of-life care. For Block, these conversations help patients and their families to negotiate anxiety about their own mortality, suffering, financial burdens, and an acceptance that medicine is limited in its reach. She offers some insightful questions: if time becomes short, what is important to you? How do you understand your prognosis? What are your concerns about the path before you? What trade-offs are you willing to make? Who will make decisions for you if your health worsens?

On good days, my grandmother would tell me about how she had tenaciously worked to support her family throughout her life. These were her favourite stories to tell. Despite being half-blind, she had ridden around Pingtung county on a bicycle, travelling from home to home to perm womens’ hair. She would hold the locks two inches away from her eyes as she worked, while trying to hide the extent of her nearsightedness from her clients. With my grandfather, she had managed to turn a convenience stand into a small store. She would excitedly list the prices of the inventory to me, pausing when my


When I asked my aunts and mother, my grandmother’s main caregivers, whether we should ask these hard questions, they unanimously answered ‘no’. My mother advised that my grandmother was already afraid that we were hiding the truth of the severity of her illness. Asking these questions would alarm her. She would lose hope of recovery and believe that she was close to death, and this belief would further my grandmother’s depression and diminish her ability to live happily. My grandmother’s fear that information was being withheld from her was not

Juxtaposition |  From Ideology to Power

baseless: doctors in China and Taiwan sometimes default to providing information to the family of frail patients, with the understanding that the family would know how best to deliver, or not deliver, this news to their loved one. Furthermore, death and its associations are taboo subjects in Taiwan. Doing less harm, in the view of some Taiwanese doctors, was to not discuss death directly with patients at all. Having grown up in Canada, this type of thinking and practice unbalanced me. I assumed that my family members knew how best to care for my grandmother. They were enmeshed in the same localized moral world, and understood her values and narratives of illness more deeply than I did. In Taiwan, a history of Confucian philosophy prioritizes family harmony and collective decision-making over individualism. At the same time, death is not only taboo on the island of Taiwan. Many societies find conversations about death and suffering to be difficult.

Should I, as a granddaughter, relinquish the responsibility of discussing death solely because I am told it would cause more harm? I wondered, does asking these questions constitute an act of antiheroism? Anti-heroic acts, as defined by Arthur Kleinman, are those that critique our local worlds “to create a space for alternatives where critical selfreflection can thrive”. If discussing death could ultimately clarify and enhance my grandmother’s wishes and care, surely that would be worth some initial fear and confusion. For many Taiwanese people, particularly among the younger generation, seeking detailed answers from their healthcare providers and family is becoming the norm. At the same time, anti-heroic acts that dislocate the status quo can also be unnecessary disturbances rather than necessary critiques, or even

subtle vehicles for Western ethics and values. To ask my grandmother about her wishes or to remain silent: what is the best way to ensure that she lives her last years in close alignment with her values? As I left Taiwan and returned to Canada, I imagined how my grandmother’s world would have been disrupted by the Canadian healthcare system, and the current standards of end-of-life care for diverse ethnocultural groups in Canada. Would her doctors have respected her desire to bow out of healthcare decision-making, even though she was still mentally able to do so? The need for research focusing on aging ethnic minorities in Canada is increasing with our rising senior population. With this expanding population promising to be increasingly ethnically diverse, policies on senior health care across Canada need to address ethnocultural differences. In addition to healthcare barriers that face ethnocultural groups (such as language barriers, or income disadvantage from lower payouts from the pension system), the Canadian medical system must also re-evaluate how health care institutions will address bioethical differences presented by ethnocultural groups. While Taiwanese doctors may be flexible in managing information flows according to the patient’s wishes, this may be more challenging in Canada. When it comes to creating end-of-life plans that adhere to the values of the patient, sensitivity towards the patient’s belief and knowledge systems and acknowledgement of more family-centered, rather than individual-centered, decision-making becomes important for many elderly Chinese Canadians. On the micro-scale, this could mean that those fundamental questions Susan Block poses can be altered so that the family, not the individual, is at the center of these questions. On a larger scale, this could mean a shifting perspective in how Western biomedicine understands relational autonomy, beneficence, geriatric care, and ethics. Only in doing so can we ensure that ethnocultural groups receive equitable care.

Demographic Dividend or demographic disaster for nigeria Angela Salomon


igeria is a vibrant West African country known globally for its crude oil production, musical and literary legends, and its more contemporary struggle with the Northern terrorist regime known as Boko Haram. It is the origin of peppery and savory Suya and Egusi soup, and home to Nollywood, the second largest film industry in the world. Nigeria is also known for having the largest population of all African

Juxtaposition |  From Ideology to Power

countries (182 million). A high total fertility rate (5.4 children per woman) and improvements in child survival have contributed to a bottomheavy population structure, with over 40% of the population below the age of 15. Despite Nigeria’s bottom-heavy population, the country’s fertility rate has been on the decline, and is expected to drop to 2.27 by the year 2100. This decline will have drastic implications on the population age structure, which can produce subsequent downstream effects on the economy, kickstarting a phenomenon known as the


also highlights two African countries, Botswana and Tunisia, that have made significant improvements in both lowering fertility and increasing income per capita since 1980. Both countries were among the first in Africa to adopt policies to reduce fertility in order to accelerate social and economic development. “demographic dividend” (DD). But this is not inevitable: reaping – and keeping – the demographic dividend requires good governance and careful planning. In general, the demographic dividend refers to the boost in economic development that can be experienced when a country’s population structure shifts from having a high percentage of “dependents”, to having a population dominated by working-age adults (age 15-64), or “providers”. As the working population grows more quickly relative to children and the elderly, dividends can be experienced in the labor supply, personal savings, human capital (including a family’s investment capacity per child), GDP per capita, governmental services, and social and political stability.

. . . But not inevitable Over the past 35 years, Bangladesh’s contraceptive use has increased by 53.5%, enabling fertility to decline from 6.3 to 2.3 children per woman. Although the working age population has now surpassed that of the young and old, Bangladesh risks missing its window of opportunity for the DD because of its inability to absorb and productively employ these workers. By 2040, the population structure will shift again, potentially leaving the country with unprecedented rates of unemployment, and an aged population that heavily burdens both the healthcare and social security systems. Although Nigeria’s population is poised to transition, the resulting economic growth will occur only in the presence of accelerated fertility decline (rapid expansion of access to high quality, voluntary family planning), productive employment opportunities, investments in education and training, good governance, and continued improvements in health, education, and gender equity.

Success is possible . . . In 1962, South Korea began a national family planning initiative that reduced fertility from 6.3 births per woman to 1.2 in the span of 40 years. Coupled with reforms in the policy areas of education, public health, and trade, South Korea experienced a “miraculous” boost to its economy, leading to an increase in per-capita GDP of about 2,200% over this same period. Many other countries in East Asia (China, Japan, and Thailand) have reaped similar benefits, improving the wellbeing of their people and changing the course of their economic trajectories. The Population Reference Bureau

Launching Nigeria’s National Roadmap Longing for Nigeria to follow in the footsteps of the “Asian Tiger” countries, a summit was held in July, 2017, titled “Investing in Youth to Harness Demographic Dividend in Nigeria”. With representation from both the Acting President of Nigeria and the Honorable Minister of Health, Labor and Employment, Budget and National Planning, the summit launched the Nigerian Roadmap to Harnessing the DD, which outlines policy priorities across five pillars: Health, Education, Employment, Governance, and

Evidence Building. It provides guidance on how interventions can align with national and international initiatives (such as Nigeria Vision 2020, the Economic Recovery and Growth Plan, and National HIV Strategy for Adolescents and Young People). It also outlines a responsibility matrix model to hold government, civil society organizations, and NGOs accountable to their commitments.

This is an example of the economic phenomenon known as “Dutch disease”. As one sector grows (services or natural resource extraction), the nation’s currency rises in value in relation to other nations. This appreciation results in the exports from other sectors (agriculture, manufactured products) becoming more expensive globally, making

In his speech at the Summit last July, Professor Yemi Osinbajo, Acting President of Nigeria, poignantly stated that “young people, and not oil, are Nigeria’s most valuable resource”. What could go wrong? Deeply rooted social, political, cultural and religious ideologies and institutions can impede development efforts in Nigeria. Indeed, the country faces some unique challenges to achieving a demographic dividend, particularly in and improving employment prospects, as described below.

Children and large families are valuable According to many Nigerian women (and often, their husbands), large families are a symbol of health and wealth. In line with the country’s patrilineal and male-dominant traditions, men are often the decisionmakers in family planning, and many families will continue to give birth until they have a boy. In cultures where polygamy is permitted, a woman’s status in her family can depend on the number of children she bears. In the 13 states of Nigeria where child marriage is legal, childbearing occurs early in life. Historically, and spilling into modern times, bearing children is a form of economic survival – an addition to the family workforce. Nigerian cultural norms designate children as the primary caregivers of the aging population. This norm is reflected beyond the country’s borders in The African Charter on Human and Peoples’ Rights, which stipulates that children must “maintain [their parents] in case of need”. Given the scarcity of assisted living/retirement homes in Nigeria, children become, by necessity and by constitution, a form of social security. These are complex yet clearly comprehensible reasons for Nigeria’s high fertility rate. So where do campaigns for family planning fit into this framework? The local context calls for an intelligent, culturally appropriate, and evidence-based framing. National goals relating to health and the environment make family planning an important area for government focus, while the impact of very high fertility on educational and career-related achievements make family planning a relevant issue for individual citizens and families, especially women and girls.

their industries ultimately less competitive. Other challenges include the weak integration of small and medium-sized enterprises (SMEs), a lack of entrepreneurial education, and limited effort on the part of the government to stimulate job growth in the public sector. To truly capitalize on the growth of the youth demographic, national and state-level efforts that support youth advancement such as YouWIN (Youth enterprise With Innovation in Nigeria) must be expanded and promoted. Launched in 2011 by the federal government, YouWIN provides equity contributions into start-up businesses of youth entrepreneurs. Nigeria has the opportunity to realize its demographic dividend, but it may also face the real possibility of a demographic disaster. In his speech at the Summit last July, Professor Yemi Osinbajo, Acting President of Nigeria, poignantly stated that “young people, and not oil, are Nigeria’s most valuable resource”.

Nigeria is a country of immense demographic and economic potential – a “sleeping giant” that is ready to wake. Along with its fame for petroleum extraction, spicy foods, and movie stars, Nigeria may yet become globally renowned for its success in harnessing the potential of youth to shift power to more women, improving the health of its people, and obtaining its well-deserved demographic dividends. The following Population Council staff are acknowledged for their insight: Dr. Sylvia Adebajo, Dr. George Eluwa, Dr. Otibho Obianwu, Mr. Segun Sangowawa, Ms. Modasola Balogun (Nigeria); Dr. John Bongaarts (USA).

Jobless growth Despite the growth observed in both Nigeria’s population size and GDP in recent years, this growth is often described as “jobless”. Unemployment has increased from 13.4% in 2004 to 25.1% in 2014. Labor is rapidly shifting towards the services sector (eg. retail and telecommunications), and away from agriculture and manufacturing, which have higher labor absorptive capacity and employment multiplier effects.

Juxtaposition |  From Ideology to Power

What is the Employment Multiplier? The employment multiplier refers to the number of direct, indirect, and induced jobs created within or in support of the industry in question.


Toronto Thinks 2016-17

Curbing Tobacco Use among Children and Youth in Indonesia: from the ground up Aninditee Das, Anna Goshua, Lucy Luo, and Nada Dali

Tobacco use is a risk factor for six of the eight leading causes of death worldwide and is the leading cause of preventable death. In Indonesia, young people are in the throes of a smoking epidemic perpetuated by picking up the habit early and continuing it into adulthood. Targeting children and youth with smoking cessation and prevention campaigns is key to reducing tobacco use and its harmful impacts.

The Challenge Indonesia is the only country that has not ratified the United Nations Framework Convention on Tobacco Control, despite considerable international pressure to do so. Domestic, social, and cultural norms around smoking, as well as relaxed regulations around marketing to youth due to a powerful tobacco lobby, hinder cessation and prevention efforts. Given some of these state-level barriers, we propose an intervention within communities, and lobby for national change at a later stage.

Phase 1 Firstly, we would develop after-school programs in collaboration with local NGOs like Nutty Scientists and Bricks 4 Kidz to offer mental health (eg. stress relief) and leisure activities for children as an alternative to smoking during idle time. We would also seek to develop a partnership with Islamic religious leaders in order to implement context-specific anti-smoking strategies. Nearly ninety percent of Indonesia’s population is Muslim. By working with Islamic leaders to discourage smoking, we can reach a sizeable audience, especially with messaging that distances tobacco use from local culture and Indonesian identity. In particular, Islamic leaders can play a valuable role in reducing the popularity of clove cigarettes called kreteks. Programs of this nature have proved successful in Indonesia’s Aceh province. As such, we are confident that we would be able to achieve similar results by leveraging educational infrastructure, and religious networks to curb smoking among youth. Further, we would also collaborate with awareness groups such as Project Quit Tobacco International to develop culturally appropriate tobacco cessation therapies and to mobilize other community leaders to ensure that interventions reach the population more broadly.

Juxtaposition |  Toronto Thinks 2016-17

Phase 2 In collaboration with the Ministry of Health, we aim to use educational modules developed by Project Quit Tobacco International to train healthcare providers on quitting strategies and the dangers of smoking. This is one way that we plan to build capacity to ensure that our programs are sustainable. At the community level, we would train community health workers to conduct smoking cessation group sessions. In particular, we will focus on ex-smokers acting as role models. In addition to being informed by the Global Youth Tobacco Survey conducted by the World Health Organization, we would strategically partner with the Ministry of Agriculture and Health to monitor consumption of tobacco products and disease outcomes, using funding which we would secure from the Bill and Melinda Gates Foundation.

Phase 3

We plan to leverage the positive outcomes from phase 1 and 2, as well as any increased community-level support, to lobby for policy changes at the national level. Our primary priority would be to increase the current excise tax from 37% to 70%, and to apply it to all tobacco products. We also aim to abolish existing structures which favour tax evasion. These tax changes are expected to generate USD 3.2-6.5 billion in revenue for the Indonesian government as well as more than 250,000 jobs. To mitigate the effects of reduced consumption on local employment numbers, the tax revenue would be used for job training programs for Indonesian tobacco farmers to transition to alternative crops. Revenue can also be used to increase accessibility of healthcare services and tobacco addiction treatment, and to address the barriers of cost and lack of access in rural areas. Finally, we will push for the following policies: a blanket-ban on tobacco-related advertisements; smoke-free zones in places of worship, education, and hospitals; graphic health warnings on packaging; a separation of smoking from norms of masculinity; and healthcare coverage of nicotine replacement therapies and increased accessibility to addiction treatment.


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Juxtaposition 10.1  

Juxtaposition Global Health Magazine Volume 10, Issue 1

Juxtaposition 10.1  

Juxtaposition Global Health Magazine Volume 10, Issue 1