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Letter from the Editors
Global Health Tidbits
Ali Vedadi, Naushin Ali, and Ravneet Padda
Mental Health in East Jerusalem
Physically Active Youth
Laura Dekroon and Lindsay McCabe
10 Partners for an Educated Future
Jennifer Siu & Maggie Siu
15 Books in Review
16 Events in Review 21 Ethical Considerations of Food Advertising and Childhood Obesity
Juxtaposition Global Health Magazine
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Letter from the Editors
Dear Juxta Readers, Thank you for your continued comments, perspectives and support over the past seven years. As University of Toronto’s premier global health magazine, we’ve had an exceptional opportunity over the years to interview a variety of inspirational leaders, analyze salient health policy issues and their implications, as well as tackle a myriad of controversial issues impacting the health of populations. In achieving our mission to generate advocacy and awareness, we are also sincerely grateful for the long-term partnerships we’ve cultivated with the Department of Postgraduate Medicine, UTSU, Trinity College, the McLaughlin Rotman Centre and the Human Biology Department. As we enter this new year, we have reached an interesting turning point in the realm of global health – a point where researchers, policy makers and ground-level workers have begun to not only acknowledge the deficiencies in the polices and programs of years past, but are now taking active measures to develop strategies that can effectively address these limitations. Two particularly salient themes emerging from this discussion include the development of meaningful partnerships as well as practical policies to achieve this. As we welcome you back to another academic year, we felt it imperative that Juxtaposition explore these critical topics through a variety of lenses and contexts. This eighth issue, entitled Partners for an Educated Future: Strengthening Health Systems through Sustainable Partnerships, draws our initial attention to the Toronto Addis Ababa Academic Collaboration (TAAAC) – a partnership between the University of Toronto and Addis Ababa University (Ethiopia). TAAAC has received widespread recognition as a model of success in strengthening the Ethiopian health system by improving medical education through a strong, sustainable partnership. Juxtaposition writers, Jennifer Siu and Maggie Siu, sit down with various key players from TAAAC and offer a compelling series of interviews that illuminate their experiences and lessons learned. While the development of such partnerships is often ignited from a benevolent desire to assist countries and organizations, TAAAC reinforces the importance of working within the capacity and desire of governments and their representative health systems. We then shift to celebrate the over ten-year partnership between the University of Toronto and the University of Namibia through our photo essay documented by Laura Dekroon and Lindsay McCabe. Here, they feature the important work of Physically Active Youth, a Namibian NGO dedicated to improving the healthy behaviour and well-being of Namibian youth through sport. To highlight the importance of healthy policy-making in providing services easily accessible to marginalized populations, Kathleen Nelligan first takes us to the Middle East where she illuminates the mental health implications of the Israeli-Palestinian conflict on refugee and non-refugee Palestinians, and stresses the importance of increasing pyscho-social services at the community level. We then end this discussion with an interesting take on the ethical dimensions of the on-going obesity debate as Kevin Kobylak exposes us to the ethical considerations underpinning food advertising and its links to childhood obesity. Through these varying perspectives, we are able to gain an appreciation for the complexity inherent in strengthening health systems, and how various interests and conflicting agendas can have profound consequences on policy development and service provision. As we recognize the importance of student engagement on campus, we end this issue with a reflection on last year’s campus activities, including our own inaugural ‘JuxtaTalks,’ which explored the ethics of international volunteerism and research, and the inaugural TedxUTIHP that brought together a variety of stimulating global health advocates to address the theme of “the human experience.” Furthermore, given the significance of the Millennium Development Goals in achieving stronger health systems, students are also introduced to UTIHP’s Millennium Project, which aims to foster a greater discussion on existing constraints in reaching these goals. As always, we welcome you to contact us, engage in initiatives and get connected with others driven by the same resolve. We hope this issue generates on-going dialogue about the critical elements still needed to strengthen health systems and the particularly important role that partnerships, and healthy and realistic policies bear on this effort. Sincerely,
Kadia Petricca & Maggie Siu
Editors-in-Chief, Editorial and Executive Divisions
Global Health Tidbits by: Ali Vedadi, Naushin Ali, and Ravneet Padda
Over 500 Die from Encephalitis in India’s Most Populous State While the rest of India is basking in religious celebrations, Gorakhpur is still soaking in despair from its annual encephalitis outbreak, courtesy of the monsoon season. Stagnant water from heavy rains provides a breeding ground for mosquitoes – a transmitter of Japanese encephalitis. Encephalitis is characterized by brain inflammation, which can arise from a viral or bacterial infection. This year alone, there have been over 500 related deaths in the Gorakhpur district, an increase from 215 the year before. The majority of them are children, with roughly 2-3 dying every day according to K.P. Kushwaha, Chief Paediatrician at BRD Medical College. Although Japanese encephalitis has been combatted through immunization programs throughout the Uttar Pradesh state, many recent cases are being blamed on contaminated water. This new viral strain is tougher to control and calls for a major improvement in drinking water supply and sanitation. “We can reduce the deaths by 50 if people follow basic hygiene and then take their child to the nearest hospital quickly”, says the city’s top administrator, Sanjay Kumar. However, many villages lack health-care facilities and the nearest hospital may be hours away. Even Gorakphur’s main hospital is under strain, lacking not only space, but also enough doctors. While efforts are underway, more continue to die in this outbreak.
Photo: Esther Havens
Ultra Rice: the super-food that’ll combat malnutrition?
Photo: John Lok/Seattle Times/MCT
Millions of people worldwide suffer from micronutrient deficiency. According to UNICEF and the Micronutrient Initiative, vitamin A deficiency is responsible for about a million deaths since 1998. Furthermore, zinc deficiency affects more than a third of the global population, which can affect children’s immunity and growth. For the past several years, PATH, an international non-profit organization, has been working to fortify the staple food of more than half the world’s population: rice. Their new technology, Ultra Rice, involves mixing rice flour with micronutrients that can be shaped to appear like normal rice. When mixed with normal rice in a 1 to 100 ratio, the taste and smell is virtually no different from the unfortified variety. This is a potentially powerful way to address the micronutrient deficiency since not only is it cost-effective and sustainable, it doesn’t require a change in cooking habits. Paul Macek, World Vision’s senior director for nutrition programs agrees, saying that “using Ultra Rice to address global hunger is important because so much of the world already depends on rice as a staple food”. Thus far, PATH has introduced Ultra Rice in India and Brazil through government-sponsored meal programs for schoolchildren – in 2009, 60 000 children in India received the fortified rice, and the number is expected to rise to 185 000, says PATH project director, Dipika Matthias. Furthermore, in 2010, PATH began plans to work with Federal Way to introduce Ultra Rice in Africa, beginning with 15 000 schoolchildren in Burundi. If this trial is successful, PATH hopes to expand its reach in Africa, where millions of children are malnourished. Fall 2011 | Juxtaposition
It’s a familiar experience when people steer clear of an individual with the seasonal flu. Yet, how familiar is an experience where an individual’s blood test is used to determine his/her eligibility for a job? This is the reality of present-day China, whereby companies require job applicants to take part in mandatory blood screening for hepatitis. The practice originated in the late twentieth century following hepatitis B outbreaks in Shanghai and Nanjing. Hepatitis B transmission generally occurs through interaction with blood or bodily fluids. However, the outbreak established fear among the Chinese population and caused them to become misinformed. Many individuals in China believe that hepatitis B is easily spreadable and therefore, wish to avoid hiring infected individuals. However, despite the ban on hepatitis screening last year, this practice has continued in other sectors, including schools. In a number of cases, children have been rejected from prestigious schools as a result of a positive test. How the blood-based discrimination will be brought to an end is unclear. But given the present circumstances, individuals have resorted to falsifying their blood reports. Many infected job applicants hire hepatitis-negative individuals to take the blood test for them, and may pay between $125 to $300 for these services. With the continuation of hepatitis screening practices, relationships between employers and staff are bound to become based on distrust and fear. Employers will fear infection among workers while infected workers will fear being exposed. Considering these implications, it is essential that accurate knowledge of the disease is promoted among the Chinese population through educational sessions at the workplace and in school.
Photo: FMH - http://www.fmh.org/body.cfm?id=598
Blood Built for the Job
Measles Outbreak in Africa
Photo: Reuters/Jean Pierre Aime Harerimana
Juxtaposition | Fall 2011
The United Nations declared a measles outbreak in the horn of Africa in September 2011, affecting thousands of people in Ethiopia, Kenya, and Somalia. The World Health Organization (WHO) reports more than 1000 cases, most of them involving children, and 31 related deaths. The measles, similar to the common cold, is spread through droplets sprayed out when an infected individual sneezes or coughs. Moreover, the measles virus can remain airborne for up to two hours, contributing to the spread of this virus. Last year 64 000 people were diagnosed with measles, prompting the WHO and the UN Children’s Fund to start an emergency vaccination campaign in southern Somalia and other affected regions. UNICEF has now sent over 700 000 doses of measles vaccines to Mogadishu, the capital of Somalia, with the overall goal of immunizing 2.5 million children. This makes for a formidable task given that most affected areas are overcrowded refugee camps that lack proper sanitation, providing the perfect conditions for the spread of measles. The recent measles outbreak is a major setback for this region, which has seen improvements over the past decade in preventing the spread of disease through the use of vaccinations and enhanced sanitation.
TAX THE FAT! The mid-1990s were the epitome of the trans-fat era, with the average trans-fat consumption reaching 8.4g/day in Canada. But initiatives beginning in the late twentieth to early twenty-first century brought a wave of changed attitudes. Denmark had previously inspired positive change for healthy practices by becoming the first nation to ban trans-fats in their food products in 2003. Now, the Nordic country brings about a new approach to tackle the obesity endemic – a tax on fat. The tax on saturated fats is applicable to the sales of both raw ingredients and prepared foods, with a 12-cent tax on chips and a 50-cent tax on butter. This new tax expects to reduce the incidence of obesity and associated cardiovascular disease by enforcing change on two segments of society: the consumer and the producer. The expectation is that the high price of fatty foods will encourage the Danish public to redirect their eating habits to lower fat foods. At the level of the industry, it is anticipated that producers will aim to reduce the cost of their food by reducing the levels of saturated fats in their products. With such a remarkable approach to public health, one can be optimistic that these measures will soon extend to other obesity stricken nations, including Canada and the United States.
Should you Bank your Baby’s Stem Cells? Over the past decade, interest and investment in stem cell research has grown considerably as its potential to cure a myriad of diseases has grown. Stem cells are cells found in all organisms and can divide and differentiate into more specialized cell types. In particular, these cells have been shown to hold great promise in treating, and in some cases curing such diseases as Multiple Sclerosis, Parkinson’s, Alzheimer’s, and cancers such as Leukemia. As the umbilical cord offers the richest supply of these cells, the number of expecting parents interested in banking their child’s stem cells has increased. The fundamental concept behind stem cell research is that if you have these cells in every tissue, why can’t we simply recruit them to repair damaged tissue? While this research is still in its infancy, it is not without controversy. Does it fulfill the promise of protecting a child from potentially deadly diseases? The answer is both yes and no. Stem cells have the ability to cure diseases and repair damaged organs. However, the clinical application of these “master cells” may be a few years away as complete stem cell trials have yet to be conducted. Moreover, in some cases it may be ineffective to treat a child with his or her own cord blood as some diseases may be carried genetically; meaning one would reintroduce the same potentially defective cells that were trying to be eliminated. While many couples have begun to consider this harvesting of cells as a serious option, the high price associated make it considerably unrealistic for many. Private companies can charge anywhere from $1,000-4,000. For now, banking your baby’s stem cells may be a risky investment in the future of science, but with risk there is sometimes reward – in this case, the life of one’s child.
Should you bank your baby’s stem cells?
Photo: 123dan321, SXC.hu, HAAP Media Ltd.
Fall 2011 | Juxtaposition
Photo: Simeon, SXC.hu, HAAP Media Ltd.
Mental Health in East Jerusalem Political versus psychological perspectives by: Kathleen Nelligan
Residents of the Occupied Palestinian Territories have been the subjects of fluctuating sovereignty, territory, and identity since the establishment of the Israeli state. East Jerusalem, for instance, has been populated by Palestinian refugees who continue to live in a state of residential ambiguity with little idea as to when and if they will be repatriated. Such persistent threats to life and security faced by Palestinian refugees and non-refugees alike have fostered lasting and detrimental psychological effects. While life as a refugee within an occupied territory causes significant anxiety over safety and security, these challenges also constitute major stresses for non-refugee Palestinians. Unfortunately, the coping mechanisms and social service provisions which help manage the effects of trauma exposure and affronts to personal safety related to the Occupation are often times overwhelmed by the long-lasting conflict, leaving the Palestinian population without essential psychosocial care. It is well established in the literature that exposure to trauma can have lasting effects on mental health and wellbeing both over the short-term, such as in acute stress disorder, and over the long term, as in post-traumatic stress disorder (PTSD)
Juxtaposition | Fall 2011
(1). In the case of PTSD, events that result in a sudden and severe injury or assault lead to psychological repercussions that manifest and sustain themselves over an extended time period (1). In particular, this has been recognized with respect to military and political conflict, such as that which continues to afflict the territories contested by Israel and Palestine (1, 2).
While life as a refugee within an occupied territory causes significant anxiety over safety and security, these challenges also constitute major stresses for non-refugee Palestinians. In the case of the Israeli-Palestinian conflict, a number of studies have identified the mental health of Palestinian civilians and refugees to be adversely affected by Israeli sanctions that restrict their personal freedom (3, 4). These investigations have centred on the significance of indirect and direct physical threats to the psychosocial and physical wellbeing of Palestinians.
Needless to say, the looming threat of property loss by encroaching settlements, air-bombing to civilian areas, imposed curfews, checkpoints and physical barriers have prevented Palestinians from achieving a sense of normalcy in their daily lives â€“ thus fostering the development of chronic stress for civilians (4). Within the Israel-Palestine conflict, several documentations have been made of adult, adolescent and child manifestations of psychological stress and military-associated trauma, including coping mechanisms and their benefits (1, 5). An investigation of the mental health of Palestinian adolescents exposed to trauma and violence in the West Bank found that a startling 80% of the group had seen shooting and over one third of the sample had witnessed someone killed. It appeared that greater exposure to such brutality occurred in refugee camps and urban areas than in rural townships (5). Although the authors anticipated that collective exposures to trauma would have a less negative impact on the mental health of adolescents than individual exposure, this was not the case (5). This suggests that the social safety net of solidarity, a proven coping mechanism, was not actively helping (5). In addition, prolonged presence
of violent political conflict may also undermine the social service system through the diminished mental health of social workers and social service providers (6). By extension, this would inherently impact the availability and quality of services received by refugees. Most importantly, it shows that social support – both organized services and community solidarity – is compromised in these states, depriving victims of trauma a potential coping mechanism. One of the significant consequences of this lingering conflict has been the multi-generational psychosocial impacts evidenced by intergenerational sharing and interaction (1). One study investigated the mental health of children to examine the burden of psychological trauma carried through three generations of Palestinians (1). Although the authors acknowledged the manifestation of trauma as highly individualized, they reveal that serious trauma does have a heavy impact on the efficacy of coping mechanisms, particularly social solidarity and collective identity. In this study, the community was seen by Palestinian
While an end to this conflict may be a long way off, social service implementation can ameliorate symptoms of the problem in the mean time.
Photo: CathyK, SXC.hu, HAAP Media Ltd.
children as a resource for psychological support, which is consistent with the notion that Palestinian identity is highly influenced by the community (1). In general, the collective is thought to enhance psychological wellbeing by fostering a sense of belonging and identity. Despite this, it is uncertain whether social support persists through psychosocial trauma that spans multiple generations (5). In fact, although community-centered coping approaches have been suggested as more effective than individual therapy, “recovery is rooted in the attainment of justice and... peace,” (5) While an end to this conflict may be a long way off, social service implementation can ameliorate symptoms of the problem in the mean time. However, the Israeli government appears to limit social service provision and resources to Palestinians refugees living under their jurisdiction. Furthermore, it is clear that many threats to mental health are actively facilitated or advocated by the Israeli government, such as settlements that encroach on Palestinian owned land. Presently, most of the social services in the area are managed by the Palestinian National Authority or nongovernmental organizations (NGOs), both locally and internationally funded (6). For instance, since 1995, school counsellors have been employed by the Palestinian Authority in all schools within the Occupied Territories (6). However, the conditions of the political conflict, such
as checkpoints which delay travel and cause fear and humiliation, create logistic and psychological barriers to service delivery to Palestinians (6). Thus, although service provision has the capacity to lessen the psychological burden of conflict, there remain clear impediments to this process. The long-lasting Israeli-Palestinian conflict has caused persistent, detrimental psycho-social effects on Palestinian civilians and refugees. Israeli-sanctioned activities such as bombings, shootings, physical barriers to travel and public humiliation at checkpoints, amongst a myriad others, serve as threats to the mental health of Palestinians. In particular, sudden direct threats, or trauma, cause psychological manifestations that can endure for years, while indirect threats serve as chronic stressors, which aggravate existing anxieties. The situation of Palestinians is further worsened by the extent of the conflict and the damage it has inflicted on coping mechanisms, especially community solidarity, which is a potentially significant resource. Unfortunately, evidence suggests that the social collective safety net may be impaired due to compounded psychological trauma across generations. To make matters worse, the violent political conditions create physical and psychological barriers to social service delivery. Unfortunately, it appears that minimal improvement to assisting those in need of services will be had until peace between Israel and the Palestinian population is realized (5). References
1. Effects of Political and Military Traumas on Children: The Palestinian Case. Baker, Ahmad and ShalhoubKevorkian, Nadera. 8, 1999, Clinical Psychology Review, Vol. 19, pp. 935-950. 2. The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: A review. Johnson, Howard and Thompson, Andrew. 2008, Clinical Psychology Review, Vol. 28, pp. 36-47. 3. Palestinian refugees in the West bank and Gaza strip: Health = Development. Husseini, Abdullatif S. 2, 1996, Medicine, Conflict and Survival, Vol. 12, pp. 131-137. 4. Health as human security in the occupied Palestinian territory. Batniji, Rajaie, et al. 2009, Lancet, Vol. 373, pp. 1133-1143. 5. Individual and collective exposure to political violence: Palestinian adolescents coping with conflict. Giacaman, Rita, et al. 4, 2006, European Journal of Public Health, Vol. 17, pp. 361-368. 6. The Impact of Political Conflict on Social Work: Experiences from Northern Ireland, Israel and Palestine. Ramon, Shulamit, et al. 2006, British Journal of Social Work, Vol. 36, pp. 435-450.
Fall 2011 | Juxtaposition
Physically Active Youth Awareness Through Sport by: Laura
Dekroon and Lindsay McCabe
Physically Active Youth (PAY) is a registered nongovernmental organization founded in 2003, and focuses on providing youth from low-income areas in Windhoek, Namibia with the tools necessary to succeed in confidence building and life skills. The program incorporates a holistic approach to child development by combining academic tutoring, physical activity and sport, as well as a series of life skills sessions. The main objective of the program is to ultimately empower young Namibians to become leaders in their communities and nuture their active participation in society. The photos displayed here highlight some PAY activity sessions held daily from Monday to Thursday. The program encourages its members to engage in physical activity in a safe space, which is particularly important since physical education is not currently a mandatory component of the Namibian academic curriculum. Yet, its incorporation into education and daily practice has significant implications on an individual’s health and development.
Another key aspect of their physical activity sessions is the weekly Kicking AIDS Out workshops. This program involves educating participants on issues surrounding HIV/ AIDS through a variety of cooperative games. Currently 15% of the population in Namibia are living with HIV/AIDS, and many of the PAY youth are directly affected by the epidemic. These interactive sessions not only educate participants on HIV/ AIDS, but also provide an opportunity for youth to openly ask questions on issues related to prevention and transmission of HIV/AIDS. Studies continue to support that providing younger generations with HIV/AIDS education is still an effective preventative measure that has shown to decrease the number of newly infected individuals over the years. References
1. World Health Organization, UNAIDS, and Unicef. (September 2008) Epidemiological Fact Sheet on HIV and AIDS-Core data on epidemiology and response. Namibia. 2. Republic of Namibia Ministry of Health and Social. (April 2006 – March 2007) Services United Nations General Assembly Special Session (UNGASS) Country Report Reporting Period
Picture 1 - This is a picture of the participants of PAY playing a game called Cat and Mouse, where the object of the game is to help the mouse escape from the cat. In HIV/AIDS scenarios the cat became the virus and the mouse was any potential individual. During these scenarios we would emphasize certain strategies that could help the individual “escape” HIV. Knowledge about condoms, monogamous partners, the effect of alcohol and drugs were all apart of the discussion.
Juxtaposition | Fall 2011
Picture 2 - This is a game we played with the participants that emphasized teamwork and communication. Alot of the activities we did involved this because PAY works to promote a safe and inclusive environment where the participants could build strong relationships with their peers, as well as the volunteers at PAY. This is an important aspect when dissing such topics as HIV/ AIDS.
Picture 3 - This picture was taken during a workshop, where we had a local lady come in and lead a session for our Lifeskills component of PAY. Here the participants are playing a game called Doctor, Doctor, where they are tangled in a knot, and working together as a team they have to untangle themselves without letting go of each others hands.
Picture 4 - During the same workshop, the participants had to make their way across the area using only the tools they were given, and they could not touch the ground at any time. This emphasizes teamwork again, but also being aware of the tools you have and being able to use them to your advantage, which can be translated into everyday life, as well when discussing HIV/AIDS.
Fall 2011 | Juxtaposition
PartnersInterviews for anwith Educated Future the leaders of the
Toronto-Addis Ababa Academic Collaboration (TAAAC)
by: Jennifer Siu and Maggie Siu
Ethiopia, a country of over 82 million inhabitants is the second most populous nation in Africa. According to a recent study published by Edward Mills, chair of the Global Health Department at the University of Ottawa (1), Ethiopia is one of the sub-Saharan African countries affected by the “brain drain” – the mass migration of skilled professionals to developed countries. This phenomenon has significant economic consequences, and also impacts on an already stressed health care system, which is attempting to deal with challenging population health conditions, limited health services, and a lack of health human resources. However, Ethiopians have a strong determination to lift their country out of these circumstances into becoming a middle-income country within the next short while. In 2008, the Ethiopian government initiated an ambitious and exciting plan to build the training capacity of medical professionals and academics including engineering in order to strengthen and expand the sustainability of post graduate programs and health services across the country. This has included the development of 6 new medical schools and over 20 new universities. It was
Juxtaposition | Fall 2011
within this strategy that the Toronto Addis Ababa Academic Collaboration (TAAAC) arose. TAAAC was formed in 2008 as an educational partnership between various faculties within University of Toronto (UofT) and Addis Ababa University (AAU) in Ethiopia. Under TAAAC, partnerships are developed in order to strengthen specific postgraduate training programs in medicine, engineering, nursing, pharmacy and beyond. This involves a partner-leader at both universities who work to identify the specific needs of the post graduate program. The Toronto partner organizes small groups of volunteer faculty teachers and a senior student to travel for a month to AAU where they teach, co-teach, mentor, and collaborate closely with corresponding Ethiopian faculty. The ultimate goal is to assist AAU to develop capacity and sustainability within all graduate and post-graduate programming identified as able to benefit from the partnership. Currently, TAAAC partnerships include Anaesthesia, Emergency Medicine, Engineering, Family Medicine, Internal Medicine, Library Sciences, Medical Imaging, Nursing, Pharmacy, Psychiatry, and Rehabilitation Medicine/
OT, with the following in negotiation: Dentistry, Surgery, Pediatrics, Obstetrics and Gynecology. As global health projects continue to rely heavily on international collaborations, the opportunity to learn from effective partnerships is paramount. In order to understand the challenges, strengths and complexities of such a global partnership, Juxtaposition spoke with some of the key players involved since TAAAC’s inception.
Dr. Milliard Derbew
Former Dean of Medicine, Addis Ababa University
What are your goals for the medical profession and training in Ethiopia and how does a collaboration such as TAAAC help you achieve them?
When I was a Dean of Medicine at AAU from 2007 – 2010, higher education and health were given due attention by the Ethiopian Government. So there was dual responsibility and opportunity between our faculty and the government to work on these salient issues. We therefore engaged in a planning phase
with colleagues to assess what could be achieved within our capacity, and what would be needed from our partner institutions. The University of Toronto was the first on my list. Over the years, we have received unreserved support from UofT Faculty and Management – we were able to equip our skills lab and many UofT faculty have been able to offer assistance in almost all our programs at their own expense, which hasn’t impacted our institution financially. There were many hands of support, and then the idea of TAAAC emerged – primarily to coordinate the support and to deliver it in a more organized way. Now I am confident that our partnership will continue for generations. The impact UofT has brought to our institution is profound.
establishing an Emergency Medicine training program and in improving the Emergency Services in Ethiopia wouldn’t have been successful without the support of TAAAC. We are also now in full capacity to kick off the family medicine program as specialty training in Ethiopia with our Canadian counterparts. I would like to acknowledge Dr. Jane Philpott and the groups for their unlimited support.
In your opinion, what have been some of the key features of the TAAAC partnerships that you feel have contributed to the success of the collaboration?
How did the educational partnership between the University of Toronto and the University of Addis Ababa emerge?
The main advantage is the commitment and positive attitude of the faculties between the two sister institutions [Addis Ababa University and University of Toronto]. The partnership is genuine. It is only helping, with no other strings attached. The commitment, transparency and the confidence we build with each other are the secrets to our success in my opinion. The contribution of selfless people like Dr. Clare Pain is an iron bond for our partnership. What successes have been achieved thus far?
There are palpable results so far with our partnership, including the psychiatry program, the Toronto Addis Ababa Psychiatry Program (TAAPP), which increased the number of psychiatrists in Ethiopia from11 to 44. The collaboration to strengthen the library, the initiation of the first Emergency residency training program, department of Surgery, Anesthesiology, Radiology, Nursing, Pediatrics, OB/GYN and more are heading forward with the same momentum. I am also a beneficiary of the collaboration. I spent a year in the Wilson Center and Sick Kids Hospital in Toronto during my sabbatical, which has brought a paradigm shift in my career. The recent achievement in
Dr. Clare Pain
Psychiatrist & Co-ordinator of TAAAC
We started in 2003 with an educational partnership between the Departments of Psychiatry at UofT and AAU, and agreed to partner for 3 years and then reassess. In those years we provided 9 one-month educational trips and it went very well culminating in the graduation of the first 6 Ethiopian trained psychiatrists. Since then we have renegotiated our partnership every 3 years and are now on our fourth agreement and have completed our 21st trip. One of the successes of TAAPP is that AAU identified it as their preferred model of partnering with western universities and have modified their trainings to accommodate visiting faculty from other universities for month long stays. In light of this, in 2008 the Government of Ethiopia developed an educational plan to have 5,000 PhD and 10,000 Masters graduate in 10 years. It is a brilliant and challenging undertaking to increase the number of trained professionals to address the country’s problems such as poverty, food insecurity, deforestation, health and technology. TAAAC came about as a result of this long-term vision and we have most of our programs in health-related faculties because health remains a critical issue on many fronts. That our colleagues in Engineering are also a part of TAAAC is a great bonus and is very encouraging since the development of a manufacturing base,
and improved technology and industry will rely heavily on the expansion of the engineering trainings. As well medicine and engineering make natural partners in development and I believe we can look forward to some creative and exciting collaborations as a result. What have been some of the key features of TAAAC that have contributed to its success?
Ultimately, it’s a partnership that was requested by the Ethiopian faculty at AAU, which is a great honour and a reason for us to feel proud of our work and attention to the quality of our relationships with our Ethiopian colleagues. TAAAC is built on a model that was derived and tested in Ethiopia through TAAPP, so both sides in the TAAAC partnership have been exposed to building, problem solving and implementation of AAU-UofT department partnerships. Of course each partnership is unique within TAAAC, so a rigid adherence to the TAAPP template would not work and our TAAAC partnership leaders have been able to adjust the TAAPP model to better suit their objectives. The leadership of individual program partnerships is another key component. Having the TAAAC partner-leader accompany their outgoing training groups for a week provides each of them with the chance to gain a deeper knowledge and experience of the country and context. It increases and strengthens their relationship with their opposite number at AAU and ensures that the outgoing teaching group whom they accompany finds their way quickly into the system, and are optimally ready to teach and supervise. We try and keep the teaching groups small – 2 faculty members, a senior resident/student, and sometimes an accompanying nurse trainer, since big groups of external teachers disrupt rather than strengthen the usual structures at AAU and tend to relate more to each other rather than to their Ethiopian colleagues and learners. It is also extremely important that we go for at least a month in residency and fellowship programs (it can be shorter in academic programs at the discretion of the partnership leaders). It is difficult to imagine effective teaching and Fall 2011 | Juxtaposition
supervision if your stay is so short you don’t get to know the students’ names, their strengths, and struggles. Ultimately, it is imperative that we share common objectives and communicate often. We are fortunate to have superbly committed Ethiopian colleagues who inspire us with their dedication and competence, this attracts excellent UofT faculty and senior students who find the project aims and objectives in line with their own ideas about development, and who enjoy and pursue their roles in achieving the longterm success of the partnership.
There is an imminent need for physicians trained in Emergency Medicine in Ethiopia, a country where the incidence of road traffic fatalities is among the highest in the world (2). Dr. James Maskalyk co-director of the TAAAC-EM Task Force shares some of his thoughts and experiences in helping develop the first Emergency Medicine Residency program in Ethiopia at the Black Lion Hospital.
Dr. James Maskalyk Emergency Physician
What did emergency medicine look like in Ethiopia before TAAAC got involved?
Although there is no doubt good emergency care was being practiced in some clinics and hospitals, Emergency Rooms and emergency residency training did not formally exist. Therefore attention to the first critical hour post emergency was not generally implemented. How do you go about starting an emergency medicine program in Ethiopia?
We were and are guided by our Ethiopian colleagues. For instance, right now our colleagues are building an Emergency Room and we have been sending emails back and forth, discussing its redesign. The resource differences between our contexts are significant, so introducing concepts that are possible to implement here
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in a high tech situation are not yet helpful in Ethiopia. Instead we discuss universal concepts that are not contextdependent. As things continue to develop in Ethiopia it may become possible to introduce other paradigms that require a more technological environment. How do you think the TAAAC program will help Ethiopia in the future?
The program has already attracted a number of young, capable, and knowledgeable residents, so our next step is to help them transition into having a long career. They are going to be the stewards of this program; they are going to be the advocates of emergency medicine in Africa – not just in Ethiopia, but the whole continent. Already some emergency medicine exists in other parts of Africa, including South Africa and Kenya, but I can imagine this program growing to a point where the Addis Ababa University Black Lion Hospital, is the center of excellence in emergency medicine in lower resource settings. This kind of meaningful education and research has the potential to affect 80% of the world. Currently most of the publications, educational curricula and research are in more developed countries like Canada, but that relationship needs to change and become more equal. How will you keep the TAAACtrained physicians in the country and prevent them from going elsewhere where they can be paid more after they finish their residency?
You have to inspire them through this relationship. This is something I enjoy doing because that’s how I’m inspired. For me, it’s not all about the money. If you are able to provide a
reasonable life for your children and the people you care about, do you really need a big house in the hills? Rather, you have a chance to contribute to the development of your country and to change the world! – That’s my message, and I don’t know if I’ll influence them all, but hopefully some people will identify with that. Our shared ideal is to create a situation where emergency medicine can thrive in this setting. I would argue that strengthening this TAAAC program is investing in a cost-effective project that will ultimately save many lives. How does the program differ between Canada and Ethiopia?
In North America the residency program for Emergency Medicine is 5 years, or you can do a 1-year certificate program after a 2-year Family Medicine Residency. The Emergency Residency program we will set up in Ethiopia will last 3 years, and will focus on emergency training from the beginning. Another difference is that we have emergency medicine teachers here in Canada, but specialized emergency physicians have not yet graduated from our program at AAU. This was the situation in Canada up until 20 years ago. Further, the current emergency task force at AAU is comprised of physicians from various specialties who also have other clinical obligations, so although emergency is a focus, it’s not their only one, which is a challenge. Nevertheless the faculty members on the task force are remarkable physicians, and their enthusiasm and dedication shows us what commitment is. That’s why we’re all really excited about the idea of getting as many people as possible well trained as quickly as possible, and of giving them the responsibility to continue to expand
this in new directions. Are there any cultural barriers or language barriers that you’ve encountered?
The language is a difficult one for me. You want to make people feel comfortable and make them laugh and it’s difficult. It’s worthwhile learning Amharic [Ethiopia’s official language] though, just because it thrills people whenever you can say anything. I work with translators a lot, unfortunately, and it has a different set of challenges. For example, the doctor-patient space is partly predicated on privacy and genuine connections so it’s a bit challenging. However, in Ethiopia with TAAAC, my relationship is less with the patients and more with the doctors and nurses who can speak excellent English. How do you see the TAAAC program growing in the future?
I think a long-term relationship will exist between these two countries and I’m very proud of it. Canada and Ethiopia are wonderful partners in this endeavor. As the program grows, it will require a group of capable and empowered individuals, and it is the Ethiopians who will continue to push this forward. Eventually I want to be able to replace myself with an Ethiopian who is an expert in emergency medicine, able improve the health and wellbeing of his fellow citizens. Are there any lessons that you’ve learned from the Ethiopians that you think can be applied back here in our system?
I’m humbled by their attention to this – it’s miraculous. They really care about the idea of medicine and the importance of higher education. There are now so many more students in the medical undergraduate enrolment that they don’t have enough teachers, so now teachers come in on Saturdays to teach. That’s what inspires me as a physician – the deep conviction that they have. In that way medicine is more than a job or a career and I think that’s really been an important thing for me to recognize in them as partners. Secondly, I think that a relationship built on genuine affection, mutual respect and understanding, and a common set of ideals like this one will last. It’s not
like someone assigned us 5 years to this program and we’re doing it in between things. It’s on our minds every day.
Similarly, no Family Medicine program currently exists in Ethiopia. Dr. Jane Philpott offers insights into her experience in helping to set-up a model of health care that has not previously existed within this context.
Dr. Jane Philpott Family Physician
What was the rationale for establishing a Family Medicine program in Ethiopia?
The challenges for health delivery are profound in Ethiopia. According to the Ethiopian Ministry of Health, most of the country’s health problems are caused by preventable communicable diseases. Yet currently, there is no Department of Family Medicine that specializes in primary care to address many of these illnesses through prevention and treatment methods. Instead Ethiopia’s model of primary health care is comprised of nurses, health officers, and health extension workers. There is evidence from other countries that higher-level primary care workers such as family physicians make a real difference on health outcomes, and thus our Ethiopian colleagues were very keen on adopting this model. What is the University of Toronto’s role in the TAAAC Family Medicine program?
Our role is as consultants and advisors and so we can share from our understanding through needs assessments, program development, evaluation plans, developing examinations, and accreditation. Much of the teaching will be conducted by the very skilled Ethiopian teachers there. We will be standing back and helping with the organizational things and didactic teaching as necessary. So we act as partners jumping in whenever necessary. The curriculum itself has
been written and is pending approval at Addis. We hope that the training will start in 2012. We expect to have about 10-12 students in our first year. The AAU leaders intend to start the program with a small number of residents with a plan to scale up at the appropriate time. How does the Family Medicine curriculum differ in Ethiopia compared to Canada?
We have tried to be proactive in ensuring that the curriculum is appropriate geographically. We have a Needs Assessment Study that addresses the concerns of stakeholders, getting a sense of what kind of care will need to be conducted by the physicians. Family medicine, more than any other specialty needs to be designed for the place that it is delivered. For instance – family doctors in Canada don’t do C-sections, appendectomies, etc… but most family physicians in Ethiopia will have to do these. So there will be a difference in injury management and emergency surgical skills that would be different from the family medicine curriculum in Canada. So in essence, they will have even more to learn than a typical North American family medicine resident. That is why the residency is 3 years instead of 2, because you can’t possibly address the whole comprehensive spectrum of job requirement without the proper training. We will follow the TAAAC model fairly closely, but we will provide more support in order to get the program started. Unlike TAAAP where there was assistance from existing psychiatrists within the country, we will need more UofT faculty within the first years – as much as is needed – then eventually move to a model where we teach there for maybe one month 4 times a year. Do you think the TAAAC model will be expanded to other places?
I think this is a great model. Certainly other universities in Ethiopia other than AAU have already benefitted from this model. However, it does depend on a lot of generosity from UofT. Not all universities will find that they have many volunteers who will be able to give up their time to volunteer for this. Not everyone has time to do this. We do it because we all love it and we are Fall 2011 | Juxtaposition
totally committed to it. [The success of this program] depends on good will and the amount of teaching experience people have. Working within the public infrastructure to support higher education is one of the best things that people can do and I think it is a fantastic model, probably one of the best ways that Canadian physicians and other professionals should be contributing. How do you recruit University of Toronto Faculty to volunteer for TAAAC?
We don’t have much trouble recruiting people to help out. The Department of Family Medicine is huge and we have over a thousand faculty members. Within that there is a lot of interest and excitement. However, given this excitement, we also have to adjust people’s expectations to realize that we have to go at the right time. I am very conscious that even in our good will we don’t sometimes overwhelm our Ethiopian colleagues. Even sometimes just being there can cause a lot of work for them, including accommodating us, or taking care of us when we are lost. It has to be the right kind of people who get involved. Most of us have had international experience before. How has the program been accepted by the university and the local population?
Most of the contact is with the faculty partners there, and TAAAC has a very good reputation at the University. I’ve had a chance to meet both the past and current Presidents of the university who have been very supportive of the program. After 30 years having different experiences working in about 10 countries in Africa – I feel like the TAAAC project is probably the most sustainable use of my contributions and the best thing that a Canadian physician can do to contribute to improved health outcomes in another setting.
The TAAAC model is also being applied outside of medical specialties through a collaboration between the Faculty of Applied Science and Engineering at UofT and the Addis Ababa Institute of Technology (AAiT) at AAU. The goal is to help AAiT expand its PhD program through the introduction of sustainable graduate courses and
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the co-supervision of PhD candidates. Currently, collaborations have been established across three different engineering disciplines: Electrical and Computer Engineering, Mechanical and Industrial Engineering, and Chemical Engineering. Professor Yu-Ling Cheng from the University of Toronto leads this effort, and describes the unique challenges faced.
Prof. YuLing Cheng Professor of Chemical Engineering
What are some of the challenges that the TAAAC Engineering Program has encountered?
The PhD program is a very different model, because the main part of the program is the completion of a thesis. Interest in co-supervision of PhD candidates, where one faculty member is from AAiT and the other is from UofT, is the main challenge, at it requires a 4 to 5-year commitment and continuity by faculty here, whereas the residency training programs in the medical specialties don’t involve a thesis. Even if we get a project set up, it will be difficult to supervise from a distance. We will have to work through this challenge when we get to that point, but it is very interesting to be engaged in this kind of pursuit. We are still not at the point of a model of co-supervision, which is what Addis Ababa University proposed originally, and it may take some years before we get to that stage. What has your approach been thus far?
We have found that we can contribute by teaching a graduate level course during a reasonable one month time frame. Then if we can do this multiple times, we can work with the faculty more and develop the trust and the relationships. Then we can work together to co-develop projects in the local context in terms of national context and importance. Overall though, I have learned to approach this with patience. When I first went to Ethiopia, I came back very
inspired. I was naïve then as to how universities function in other parts of the world, but now I have a different attitude. I feel wiser, more experienced and have learned the importance of patience. We’re working with very intelligent people there, with many constraints and demands, factors in environment that I can’t even imagine. We have to let them take the lead. I must also acknowledge Professors Johnathan Rose and Tony Sinclair, who have each spent one month teaching there; their work has been invaluable in deepening our relationships with Addis Ababa.
In recognizing the importance of building sustainable partnerships, it is necessary for us to reflect on the features that have contributed to the success of this initiative. The present achievements of TAAAC appear to hinge on a working relationship cultivated on the principles of respect, patience, sincerity and humility. Dr. Maskalyk said it best when describing his reasons for dedicating his life to international endeavors: “If you get into this work because you think it’s going to make you look great, then you’re a loser basically. You’re being disingenuous. Some people do it [volunteer abroad] once or twice for one or two years. They bring back some great stories or photos, but then they fade out. People need to come in from a perspective that is ultimately going to serve the purposes of the people they’re planning to or wanting to help.” By focusing on a long-term relationship, the main goal of TAAAC is not to simply intervene, but to support the caliber of academic scholars that already exists within the country. The TAAAC partnership inspires us at UofT and supports colleagues in Ethiopia to form a strong foundation for the development of higher education and for the growth of their health system. For more information on TAAAC, visit www.taaac.com.
1. Mills, E., S. Kanters, A. Hagopian, N. Bansback, J. Nachega, and M. Alberton. 2011. “The Financial cost of doctors emigrating from subSaharan Africa: human capital analysis.” British Medical Journal 343. 2. Persson, A. 2008. “Road traffic accidents in Ethiopia: magnitude, causes and possible interventions.” Advances in Transportation Studies 15: 5-16.
Books in Review by: India Burton
The Bite of the Mango Mariatu Kamara with Susan McClelland Annick Press, 2008
The Bite of the Mango presents the moving story of Mariatu Kamara, a UNICEF Special Representative for Children and Armed Conflict, who lost both of her hands when her village in Sierra Leone was attacked by rebel forces. Told in her own words, the book details Mariatu’s arduous journey as she fled her homeland in Western Africa, eventually taking up residence in Canada. Simply and honestly written, her story is one of hardship and suffering, but also of triumph in the face of a brutal civil war. As articulated by fellow Sierra Leonean Ishmael Beah, “Mariatu’s story gives that necessary human context to what it means to be both a victim and a survivor, to transform your life and continue to love with vigor.” This is a wonderful articulation of the power of the human spirit in light of interminable conflict and emotional desolation.
28 Stories of AIDS in Africa Stephanie Nolen
Vintage Canada (a division of Random House Canada), 2007
A finalist for the Governor General’s Award for Non-Fiction in 2007, 28 Stories of AIDS in Africa is an anthology of accounts told to and compiled by author Stephanie Nolen as she traveled through Africa investigating the continent’s AIDS pandemic. In an elegant and respectful manner, Nolen gives a voice to 28 individuals whose lives have been touched by HIV as they shed light on issues such as stigmatization and inadequate access to care and medications. Each story in the compilation is presented candidly and without judgment or prejudice, resulting in a body of work that is both heartbreaking and hugely motivational. In the words of humanitarian activist Dr. James Orbinski, “Nolen shows that the struggle of one to live with dignity must be the struggle of all. Read. Weep. Rage. And above all else – like those people described in this brilliant book – find the courage to do.” A must-read for anyone interested in understanding the realities and complexities of the individual’s experience with HIV.
Fall 2011 | Juxtaposition
2011 Events in Review TEDxUTIHP by: Andy Tran
In the spirit of “ideas worth spreading,” over the years the Technology Entertainment Design (TED) Talks, has spurred the onset of a series of locally driven TEDx talks. Through these talks, local movers and shakers convene for what are often extremely motivating and enlightening speeches. Inspired by the success of TEDx Toronto, the inaugural TEDxUTIHP drew from previous TED Talks videos and brought together a series of inspiring speakers to generate deep discussion and reflection among our University of Toronto community. The theme of this inaugural talk was “The Human Experience.” These days we are often inundated with news of global disasters and other international crises. But, who are the faces behind these stories? What are their stories? And how are people impacted at an individual level? Through this event, TEDxUTIHP sought to generate ideas around these questions and motivate participants to think about these issues at a deeper level. Over 100 students from the University of Toronto and beyond gathered at Innis Town Hall on September 17, 2011. Speakers included: Dr. Jon Kim
Andrus, Deputy Director at the Pan American Health Organization; Dr. Nava Ashraf, Associate Professor of Business Administration at Harvard Business School; Leo Johnson, Founder of Empowerment Squared; Aaron Vincent Elkaim, a Toronto-based photojournalist; Dr. Catherine O’Brien, an educator on sustainable happiness from Cape Breton University; Peter Rosenblum, Human Rights Professor at Columbia Law School; Dr. Kerry Bowman, Bioethicist at the University of Toronto and Dr. Onil Bhattacharyya, a Clinician Scientistat St. Michael’s Hospital. Upon the cessation of the event, participants, organizers and speakers departed with new connections, a sense of purpose, innovative ideas, and enlightened perspectives on issues in human rights, humanitarianism and global health. We welcome you to check out our website on the event, which provides more detailed information on the event and event summaries: http:// www.tedxutihp.com/ Given the success of this inaugural TEDxUTIHP, we look forward to continuing this tradition of sharing ideas focused on global health issues within UofT.
“The Ethics of Global Health Volunteerism and Research”
by: Kadia Petricca
Back in early February 2011, columnist Catherine Porter wrote a fairly bold article in the Toronto Star that headlined “Don’t Go to Haiti to Volunteer.” Briefly, she outlined her concern that short-term volunteer placements have become the new ecotourism. She contended that while going to Haiti will likely open one’s eyes to many stark realizations and possibly incite an overwhelming sense of social responsibility, spending a short period of time in such a context would likely not change the life of
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a Haitian. Or would it? As humans, many of us have this profound desire to help others in need. But what are the parameters of this assistance and when may it become counter-productive or potentially unethical? On the evening of February 15th, 2011, Juxtaposition hosted its first speaker event focused on the ‘Ethics of Global Health Volunteerism and Research’. The talk aimed to unite faculty, researchers, and students to address the myriad of complex and ethical challenges as the field of global health expands, on campus and beyond. The panel was comprised
of experienced faculty and students from the University of Toronto who have been engaged in a variety of global health initiatives; Dr. Stephanie Nixon (Assistant Professor in the Department of Physical Therapy and Academic Director for the International Centre for Disability and Rehabilitation); Michael Beeler (Masters student and Executive Director for Students for International Development); Dr. Barry Pakes (Program Director for the Global Health Education Institute, Centre for International Health and Adjunct Professor, Dalla Lana School of Public Health); Bing
Wang (undergraduate science student and Unite for Sight volunteer); and Sarah Steele (Doctoral candidate and HIV/ AIDS epidemiologist). The panel led an impassioned and insightful discussion on the concept of ethics in global health work through an interactive question period, a discussion of ethical principles and descriptions of practice in the field. While each offered unique insights, many commonalities emerged having implications on both volunteer-related projects and academic research. Such themes included thinking critically about the concept of ‘helping’ others where stark power differentials exist, striving to work on sustainable projects aligned with local needs, respecting cultural and religious differences, and upholding humility as one engages in partnerships and collaborations. Thinking Critically About ‘Helping’ As suggested by Ms. Porter, individuals must think critically about where and how they channel their efforts. During the panel discussion, Dr. Nixon was the first to emphasize that in appreciation of our passion to help and our desire for altruism, we must think critically about our expectations of helping. She contended that often, the first few times we travel to a new country or community, whether to volunteer or conduct research, we will typically leave more enriched by the experience then it leaves the community. This is not meant to negate the potentially positive short-term impacts left on local communities and individuals. It is however, meant to force those working with under-resourced populations to reflect on the consequences of their presence and the outcome of their work; particularly with respect to the longterm consequences of their potentially ‘short-term’ presence. Dr. Nixon emphasized that individuals should think critically about: (i) the goal of their mission, (ii) the organizations to which they are affiliated and, (iii) the scope and longevity of the projects they intend to work. Efforts should be made on the part of both volunteers and researchers to ensure that projects are aligned with the needs of communities
and that mechanisms have been established to ensure that institutional memory of their work will be upheld upon the cessation of the project. Lack of such critical reflection could potentially bear profound consequences on the dynamics and rapport of partnerships and collaborations. For instance, in recent years, a burgeoning sense of foreigner fatigue has emerged across many lowincome countries, often fostering an environment of frustration among local workers and communities having to cope with the continuous influx of
foreigners for various projects. It is not uncommon to hear of accounts from fellow researchers detailing such concerns from their local counterparts, such as “Are you one of those foreigners who will take what you want and then leave?” Thus, we have a responsibility to our colleagues to ensure effective modes of communication and ensuring that projects are both warranted and desired. To guide one’s thinking around these salient concerns, Sarah Steele, an experienced global health researcher, further emphasized the importance of being self-reflective before one
commences a volunteer work placement or research project. She suggested questions to include: 1) what skills do I have?; 2) what do I hope to gain out of the experience?; 3) who else may be able to do the job or work I intend to do?; and 4) how can I ensure sustainability of my efforts? This reflection is crucial as it frames the process and outputs of one’s experience and the likelihood of establishing future collaborations within that setting. Aligned with this critical thought is the question of when do we do more harm than good? Dr. Pakes, public health specialist and primary care physician, focused much of his discussion on what he referred to as ‘global health decision-making.’ Here, he emphasized a responsibility among those involved in global health work to make complex decisions that may sometimes conflict with ones own values and beliefs. An example was given of a vaccination program where the re-use of needles, in an effort to conserve resources, could potentially lead to a host of other infections. Thus, in this scenario, how do we balance the harm that may arise from the good intentions of our actions or interventions? These are contentious issues that individuals will have to critically question and potentially confront, as power differentials will inherently weigh into partnership dynamics. The Importance of Social Responsibility While individual responsibility plays heavily into this process, organizations and universities also have a key role to play when developing programs structures, enforcing ethical standards for research and when sending students abroad. Bing Wang, an undergraduate volunteer for Unite for Sight stressed that organizations should adequately prepare students to ensure that ethical behaviour and practices are upheld. An example was given where medical students will engage in practices beyond the scope of their medical training in an effort to gain practice and exposure. Such practices become highly unethical as it compromises quality of care for those in impoverished settings and simultaneously puts students at risk Fall 2011 | Juxtaposition
for the repercussions of their actions. It then becomes a question of whether the individual or the institution to which they are affiliated is at fault. As overseas programs expand and more students are able to travel and work and volunteer abroad, training and de-briefing sessions with an overarching emphasis on ethics should be emphasized to avoid frustration amongst local partners and ensure that those volunteering are aware of community needs and boundaries related to the scope of their practice. Cultural Sensitivity and Sustainability While some may not classify cultural sensitivity and respecting local values under an ethical umbrella, Executive Director of Students for International Development, Michael Beeler, stressed the implications of not treating it as an ethical concern. He drew from his Kenyan experiences of building health infrastructure and discussed the importance of not only respecting the local culture, but also working alongside governments and communities for long-term sustainable change. He suggested that the difficulty in working abroad isn’t necessarily rooted in Westerners imposing their own views and philosophies, but rather may be driven by an inability to acknowledge the differences across communities and respect and work within government policies and practices. This is particularly significant when working on projects that are intended for long-term impact
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and require both community and government buy-in. Ultimately, as echoed among all speakers, it is extremely important that all global health work be aligned with local health needs, and there is a large responsibility among ‘Northern’* volunteers and researchers to ensure that this is upheld in practice. Dr. Nixon further reinforced this concept by stressing that prior to departure one should be cognizant of what contributions have already been made to the host community and how efforts to minimize duplication and ensure sustainability can be maintained. The Importance of Humility A final theme that emerged from the panel was that of humility. Through her interactive question period with the audience, Dr. Nixon posed the question, “Is the most important personal value for a student working or volunteering in a poor country is humility?” While audience and panel members were divided on whether it was the most important value per se, there was an overall consensus that students and researchers must be in a position to learn from their partners and should embrace this opportunity for learning. When working in global health, individuals should recognize that overarching power differentials will always present a trade-off between being an independent volunteer, worker or researcher and working as a team player. The importance of recognizing
the utility of our collaborations and working in a true partnership is paramount to what can be considered a form of ‘ethical sustainability.’ Ultimately, a global health experience can have a profound impact on an individual’s personal growth and career. The challenges discussed above describe some of the common complexities and realities of working in global health. Both individuals and institutions play a pivotal role in ensuring ethical standards are upheld in practice. As university programs and curricula tailored to global health continue to expand and the number of volunteer and research opportunities also increase, universities have a great responsibility to ensure that global health ethics be incorporated accordingly into education and debriefing efforts. Perhaps the University of Toronto launch of Dr. Solomon Benatar and Dr. Gillian Brock’s much anticipated book, Global Health and Global Health Ethics may provide both the momentum needed to call attention to existing practices as well as provide a framework on how to attend to such concerns. Of course, while going to Haiti may not change the life of a Haitian in the short term, there is much to be gleaned from global partnerships that cannot be underestimated. Yet, it is imperative that students and researchers enter these partnerships with a sound understanding of the ethical implications for their work on the communities and systems they ultimately intend to support.
UTIHP’s Millennium Project 2010-2011 The Millennium Development Goals:
Progress, Critique and a Challenge for Students
by: Brigid Burke, Nymisha Chilukuri, Jeffrey Cook, Abinesha Elanko,
Victoria Leung, Amy (Jiahe) Li and Mona Younis
The development of the Millennium Development Goals On September 6-8, 2000, 168 world leaders (Heads of State and Government) gathered at the Millennium Summit of the United Nations to review the successes and challenges of the UN, and to determine its role in the 21st century. In response, four key challenges were highlighted: (1) the eradication of poverty, (2) freedom of people from war, (3) the pursuit of environmental sustainability and (4) the establishment of the United Nations as a key stakeholder in addressing these issues. Emerging from these talks were specific targets defined by the Millennium Development Goals (MDGs). Rooted in the primary values of “freedom, equality, solidarity, tolerance, respect for nature, and shared responsibility,” these aimed to translate commitments into concrete objectives for action. As a result of the initial slow progress,
The 8 Millennium Development Goals
In 2010, the University of Toronto’s International Health Program (UTIHP) founded the Millennium Project. As a committee, we started the year with eagerness, excited to engage students in questioning and evaluating the Millennium Development Goals and model, as well as in investigating issues of accountability in social and health development. Countless times, throughout our initiatives, we were met with many blank stares from students and faculty alike regarding the MDGs as the main development model that is shaping our world. This had a profound impact on our committee and through this article, we hope to share our knowledge about the MDGs, highlight progress in the health and political agendas cultivated thus far, and emphasize the need for student activism towards achieving MDGs locally, nationally and globally.
ERADICATE EXTREME POVERTY AND HUNGER
2 ACHIEVE UNIVERSAL PRIMARY EDUCATION
3 PROMOTE GENDER EQUALITY AND EMPOWER WOMEN
4 REDUCE CHILD MORTALITY
6 COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES
IMPROVE MATERNAL HEALTH
7 ENSURE ENVIRONMENTAL SUSTAINABILITY
in 2005, economist and professor, Jeffrey Sachs, led an independent group of advisors, consisting of researchers and scientists, policymakers, representatives of NGOs, UN agencies, the World Bank, IMF and private sector, to review challenges towards achieving the MDGs and outlined three recommendations: (1)
8 GLOBAL PARTNERSHIP FOR DEVELOPMENT
to aim for a 2015 deadline, (2) to approach the MDGs as only minimum targets to be met, and (3) to encourage developed countries to support those that were less developed in achieving these goals. Since the publication of his report, several supporting non-profit organizations and UN-commissioned Fall 2011 | Juxtaposition
projects have emerged, dedicated to achieving at least one of the MDGs. Two prime examples are The Millennium Promise and the Millennium Villages project. The Millennium Promise was established in 2005 by Jeffrey Sachs and philanthropist Ray Chambers focusing on eradicating extreme poverty. The Millennium Villages project was launched in 2006 by the mandate of the Earth Institute at Columbia University. With the help of local community leaders, the organization aims to assist African rural communities through 14 designated villages in ten different countries. Each village has its own strategy for “productivity, health, education, business development and access to markets” tailored to its specific ecological zone. In September 2010, the UN-MDG Summit was held to assess the successes, challenges and next steps to achieve the MDGs by 2015. While commending the success of the work towards eradicating poverty, improving education and health for children, expanding access of HIV medicines and clean water, the Summit report also critiqued the slow progress made towards improving “maternal and reproductive health,” and especially, “maternal mortality”. In 2005 alone, more than 500,000 women died from child birth, 99% of whom were from the developing world. Yet according to the Millennium Development Goals website, many of these were preventable and treatable if proper health care and medication had been given. It was therefore emphasized that underlying all goals was the importance of strengthening gender equality and empowerment of women. To also decrease maternal mortality rates, the UN also recognized that ‘strengthening the national health systems’ was imperative. Thus, focusing on building communication and partnerships between local government, international organizations and the private sector. Political Challenges and Critiques Deliberations on the progress of the MDGs revolve not solely around health, but also on political debates. Various scholars, activists and government officials have expressed concern about the nature of the goals themselves as well
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as how they are executed, specifically significant because they represent a regarding accountability and how the global shift in thinking. They go beyond MDGs are to be measured. economics to recognize the importance of health, education, and social justice. Yet, some critics argue that this is not This brings us to the enough. While the MDGs recognize question of accountability: the importance of global partnerships, if countries are unable to they frequently end up being uneven: projects are all too often topreach the MDG targets MDG down, acting for but not with partners then who should be held in resource-poor nations. These critiques are not meant to responsible? challenge the validity or importance of the MDGs. The MDGs are to date the With respect to maternal health most holistic, influential and globally for instance, the MDG framework recognized development goals. While measures success in this area based on calling for improvements in areas such as the achievement of two key goals: reduce accountability, equity and participation, by three quarters the maternal mortality we must also call on developed nations ratio and achieve universal access to to live up to their commitments. In 1970 reproductive health . Scholars like Amir the United Nations passed a resolution Attaran , argue that data used to measure stating that economically advanced the progress of the MDGs are unreliable countries should contribute 0.7% of because in resource-poor countries their gross national product to assisting census data, like birth and death rates developing countries. Sadly, a 2008 report used to calculate maternal mortality, are by the Global Forum for Health Research often not collected, or, collected without found that out of all the countries party “systematic and scientific sampling to the resolution (DACs), only 5 met and methodology.” For example, the 2006 even surpassed their commitment. None Millennium Development Goals Report of the G7 countries, including Canada cautions readers that adequate data contributing 0.28% only, came close. for many countries are unavailable to accurately calculate progress . Our role in moving them forward Thus, if progress being made cannot As students interested in global health, be validated, how do we justify investing it is our responsibility to stay informed billions of dollars in the MDGs as and inform others about important worthwhile? issues such as the MDGs. As we have Some might argue that the MDGs highlighted, these goals are far from are not about financial outcomes, but perfect, but they represent the current rather human outcomes and therefore model for development and cultivate that the question is irrelevant. In that a climate for progress. Through this case, human outcomes should at least group, we feel it is our responsibility show signs of progress. Yet, in 2005, as student activists, to think critically, the Millennium Project reported that challenge criticisms of “student apathy,” for the previous 15 years prior to the and put our creativity to use through MDGs, levels of maternal mortality the development of innovative ways to seem relatively unchanged . address the challenges in achieving the This brings us to the question of MDGs. accountability: if countries are unable to It is important to recognize that reach the MDG targets then who should students from all disciplines have a be held responsible? Clemens et al. (2007) role to play, beyond the fields of health argue that the nature of the MDGs makes and life sciences, but extending to it impossible to assign the blame on business, engineering, social sciences one particular cause . An untargeted and humanities. cause means shirking of political Contact us should you be interested responsibility. The fact that statistics to get involved at http://www.utihp. for measuring progress are unreliable ca/committees/engage/mproj ect/ further allows for deniability. involvemproject Fundamentally, the MDGs are
Ethical Considerations of Food Advertising and Childhood Obesity by: Kevin Kobylak
Nova Southeastern University, Fort Lauderdale, Florida, USA
“According to the CDC, childhood obesity has more than tripled in the past 30 years, thus becoming a global concern as a result of impending health complications...”
Childhood obesity is an increasing health issue in the United States. The Centers for Disease Control and Prevention (CDC) define childhood obesity as having a Body Mass Index (BMI) at or above the 95th percentile for children of the same age and gender (1) and most often results from the imbalance between calories consumed and calories expended. According to the CDC, childhood obesity has more than tripled in the past 30 years (2), thus becoming a global concern as a result of impending health complications like high cholesterol, diabetes, high blood pressure, and orthopedic problems. According to Wang & Dietz (2002), the annual cost for hospital expenses associated with obesity has also increased from 35 million to 127 million between 1979 and 1999 (3). A question then becomes, what factors continue to contribute to this ever-growing issue? Nowadays, many children are consuming outside meals and snacks, deemed “unhealthy” due to their high caloric content and low nutritional value, as a result of their low cost and convenience. In addition to being convenient, such unhealthy foods are commonly the center of widespread marketing campaigns, which has led scientists and policymakers to argue that unethical marketing strategies are a potential contributor to childhood obesity.
Breach of Ethical Theories and Principles Due to the visible damage caused by unhealthy food choices, the marketing of these products has been acknowledged as a potentially unethical practice. Protecting children from being influenced by marketing strategies correlates with virtue based ethics, which emphasizes a person’s moral character as a guide to make correct decisions, as it underscores values of honesty and responsibility. When companies market unhealthy foods to children, they are more profit driven and less focused on curbing the negative health effects of their products on society. Furthermore, these advertisements conflict with duty-based ethics, that is based on doing the right thing no matter what the consequences are, as food companies play a risky balancing act between their rights to market and the rights of children to live healthy lifestyles. Ultimately, unethical business practices can be described as a form of ethical egoism as they are acting on motives that benefit their own interests. “Food marketers are interested in youth as consumers because of their spending power, purchasing influence, and as future adult consumers” (4). Most Affected Populations and Underlying Causes Future generations have the greatest interest in the outcomes Fall 2011 | Juxtaposition
of current unethical marketing strategies. As populations’ are educating their children about advertisements that mature and continue to propagate unhealthy eating practices promote eating unhealthy foods, there has been an increasing among their children, poor health issues and increasing amount of educational material developed to assist parents in health expenditures will continue to result. According to educating their children on the principles of healthy eating the American Physiological Society, susceptibility to obesity habits. For example, the Children’s Nutrition Research Center begins in childhood, especially among children that live an at Baylor College of Medicine and the Rudd Center for Food inactive lifestyle and indulge in unhealthy choices. This is Policy offers an extensive array of free printed and online particularly concerning since obese children are often more material on this topic. Nevertheless, some parents may still likely to become obese adults. (5) choose to provide unhealthy meals to their children due to Inherent in this trend is the influence that ones social and their convenience and low cost. cultural environment play in shaping the current childhood obesity epidemic. Cultural influences for instance, involve the Opposing Opinions ethnic background and the social environment children are While the aforementioned claims appear sound and exposed to and in turn, the impact on culinary practices. For justifiable, some research studies have proven inconclusive example, Japan has the world’s longest life expectancy, which regarding the effect of the media in childhood obesity. is attributed to their healthy eating habits consisting mainly The Institute of Medicine for one, has emphasized that the of fish and soy (6). In addition to this, family interaction and latest studies do not show a clear relationship between structure can yield profound impacts. Research conducted environmental and individual influences and the eating habits by Huffman, Kanikireddy, and Patel (2010) concluded, of children and their consequences (11). And a report by the “children of single-parent households were significantly Henry J. Kaiser Family Foundation discusses that although more overweight than children of dual-parent households” studies may point out that watching TV and being overweight (7). Some contributing factors are that family members in are related, they do not prove that watching TV caused the single-parent homes are less likely to eat together at the table, weight gain (12). and children are more likely to be allowed to watch television In their defense, companies have argued that it is and play during meal times (8). With parents spread thin in unethical to ban their ability to market their food products these contexts, education and implementation of healthy toward children as it infringes on their direct right to fair food options are deferred to a lower priority. advertisement and freedom of speech. Pomeranz (2010) Additional underlying factors that further perpetuate contends, “speech uttered for profit, however, can be regulated” the development of childhood obesity are that some family (13). Moreover, companies argue that they now offer a much environments do not foster atmospheres of socializing, broader, more holistic menu that includes healthier options. learning, and a structure that offers social support, which For example, some restaurants now offer alternative options can generate sedentary behavior to French fries, which include salads and increased food consumption. Inherent in this trend is the and apple slices. Nowadays, in our increasing In light of this however, some technologically driven society, influence that ones social and companies may argue that the cultural environment play in purchasing authority lies in the many advances are also significantly contributing to childhood obesity. shaping the current childhood parents’ hands and that there is The US Department of Health enough public information to help obesity epidemic. and Human Services states that decide what are healthier food children spend a large amount of choices; thus concluding that it is time watching television, using the computer, and playing the responsibility of parents and not that of the food industry video games, which have a detrimental effect on the amount to regulate their children’s food intake. of physical activity they engage in (9). Consequently, television and internet advertising campaigns are some Healthy Policies of the preferred methods by companies to target children, Currently, some policies have been developed to override and food marketing campaigns are getting more tactical by the marketing of unhealthy foods to impressionable youth incorporating advertising schemes into video games and on groups. These initiatives include policies that ban the use of social networking sites. television marketing campaigns targeted toward children Parental interaction therefore plays a critical role in during certain hours of the day, like the Children’s Television the prevention of childhood obesity as parents can establish Act of 1990 enacted by the US Congress (14). Additional and instill a long-term framework of healthy eating habits efforts involve taskforces developed to ensure nutritional and more active lifestyles. According to Perryman (2011), information is not misleading, and banning marketing to “parents act as decision makers for their children in the areas children who are under a certain age. of nutrition and activity because children do not yet possess However, these policies have not proven to be totally the maturity and capacity needed to make health-related effective. For example, Harris & Graff state that the Children’s choices. This is an ethical issue because parents are acting Food and Beverage Advertising Initiative (CFBAI) is comprised on the child’s behalf while having a vested interest in the of food companies pledging on advertising healthier food outcome of those choices” (10). options towards children. However, these companies have Although there is little evidence to suggest that parents developed their own definition of healthier foods, which are
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Moving Forward Ultimately, the perpetuation of childhood obesity is caused by multiple social and cultural factors. The inclusion of marketing techniques targeting children and youth populations has been considered by some unethical as it Proposed Solutions and Existing Strategies sustains and contributes to this devastating health problem. While multiple policies have been developed to decrease Although some studies do not prove a relationship between food advertisements to children, childhood obesity has food marketing and childhood obesity, researchers do not continued to increase (16). deny that obese children spend Presently, according to the However, these companies have more time exposed to marketing Kaiser Family Foundation, only campaigns via a variety of channels developed their own definition previously discussed. In order to 31 states in the United States have implemented laws and policies eliminate marketing campaigns of healthier foods, which are that address childhood obesity unethical, governments often subsequently labeled as considered (17), including the Healthy School and health systems will need to unhealthy by dietitians. Acts of 2009 which establishes create immediate and influential healthy nutritional standards for changes in policy and legislation school-provided food (18). Globally, various countries like the such as banning misleading and false advertisements. United Kingdom and France have also implemented healthIn the mean time, parents and family members will need promoting policies to limit advertisements to children. But to become the foundation for not only educating children on despite these attempts, the World Health Organization states healthy eating, but perhaps on the harms of highly influential that in Europe rates of obesity among children are estimated marketing campaigns that youth should be cognizant of. to have tripled during the last 20 years (19). Another strategy has been the banning of toys among fast References “Overweight and Obesity.” Centers for Disease Control and Prevention. Last modifood restaurants in the state of California. Yet, the impact of 1. fied April 26, 2011. http://www.cdc.gov/obesity/childhood/basics.html. such strategies has yet to conclusively deduce its effectiveness 2. “Adolescent and School Health.” Centers for Disease Control and Prevention. Last modified September 15 2011. http://www.cdc.gov/healthyyouth/obesity/facts.htm. on curtailing the consumption of unhealthier foods. (20) Wang, Guijing, and William H. Dietz. “Economic Burden of Obesity in Youths Aged A reflection on global polices and strategies thus far reveals 3. 7 to 17 Years: 1979–1999.” Pediatrics 109, no. 5 (2002): E81. that to date, minimal success has been seen in hindering 4. Story, Mary, and Simone French. “Food Advertising and Marketing Directed at and Adolescents in the US.” International Journal of Behavioral Nutrition unhealthy marketing. An alternate approach may therefore Children and Physical Activity 1, no. 3 (2004): 1-17. be required, such as directly educating children about food 5. “Obesity.” The American Physiological Society. Last modified 2008. http://www. marketing explicitly. It can also be argued that parents have the-aps.org/press/disease/womb.htm. 6. Jason. “Aging 150 Year Old Japanese in Abundance – Health Secrets and Populaan ethical obligation to further educate their children on tion Issues.” Global Sherpa. Last modified 2010. http://www.globalsherpa.org/150year-old-japanese-in-abundance. marketing techniques. 7. Huffman, Fatma G, Sankarabharan Kanikireddy, and Manthan Patel Huffman. There are current initiatives that focus on this approach. “Parenthood - A Contributing Factor to Childhood Obesity.” International Journal of The Children’s Nutrition Research Center at Baylor College Environmental Research and Public Health 7, no. 7 (2010): 2800–2810. 8. “Childhood Obesity.” United States Department of Health and Human Services. of Medicine has designed a website that offers an abundance Accessed October 16, 2011. http://aspe.hhs.gov/health/reports/child_obesity/. of educational materials for families that include interactive 9. Perryman, Mandy. “Ethical family interventions for childhood obesity.” Preventing Chronic Disease 8, no. 5 (2011): 1-3. nutrition calculators, a family friendly newsletter and 10. Institute of Medicine. Food Marketing to Children and Youth: Threat or Opportumagazine, kid friendly posters, and commercials targeted nity? Washington, DC: The National Academies Press, 2006. The Henry J. Kaiser Family Foundation. “The Role of Media in Childhood Obetoward children that teach them healthy eating habits. This 11. sity.” Issue Brief (2004): 1-12. website also includes a six-step video series that teaches 12. Pomeranz, Jennifer. “Television Food Marketing to Children Revisited: The FedTrade Commission Has the Constitutional and Statutory Authority to Regulate.” families goal-setting and parenting tips based on the latest eral Journal of Law, Medicine & Ethics 38, no. 1 (2010): 98-116. nutritional research and have multiple links to educational 13. “Children’s Educational Television.” Federal Communications Commission. Accessed October 16, 2011. http://www.fcc.gov/guides/childrens-educational-television. games for kids. Harris, Jennifer, and Samantha Graff. “Protecting Children from Harmful Food Another example includes the Rudd Center for Food 14. Marketing: Options for Local Government to Make a Difference.” Preventing Chronic Policy and Obesity at Yale University which has recently Disease 8, no. 5 (2011): 1-7. “Frequently Asked Questions About Childhood Obesity and Advocacy.” National launched a new website titled ruddspark.org that teaches 15. Initiative for Children’s Healthcare Quality. Last modified 2010. http://www.nichq.org/ parents fundamentals on becoming advocates in their advocacy/obesity_resources/obesity_facts.html. “United States: State Laws Addressing Childhood Obesity, 2010.” Kaiser community in relation to childhood and school nutrition. 16. Family Foundation. Accessed October 19, 2011. http://shfonew.kff.org/profileind. This is an excellent place for parents who want to acquire jsp?rgn=1&cat=2&ind=52. “Archived Bills Enacted into Law.” Yale Rudd Center for Food Policy and Obesity. information on wellness policies, the school lunch program, 17. Last modified 2011. http://www.yaleruddcenter.org/legislation/archive/enacted_bills. as well as foods sold in vending machines and at various aspx. “Nutrition Facts and Figures.” World Health Organization / European Region. school functions. Also linked to the centers main website 18. Accessed October 19, 2011. http://www.euro.who.int/en/what-we-do/health-topics/ is a blog where parents can post kid friendly cookbooks, disease-prevention/nutrition/facts-and-figures. CBSNews. “Happy Meal Toy Ban Faces Vote in Calif. County.” CBSNews multiple resources that rank fast food kids meals and cereals 19. Healthwatch, June 23, 2010. http://www.cbsnews.com/stories/2010/04/27/health/ by nutritional value, and an abundance of parent-friendly main6436917.shtml. CBSNews, “Happy Meal Toy Ban Faces Vote in Calif. County,” CBSNews nutritional tools and educational materials on marketing 20. Healthwatch, June 23, 2010, http://www.cbsnews.com/stories/2010/04/27/health/ main6436917.shtml. techniques used to target children. often subsequently labeled as unhealthy by dietitians (15).As a result of such discrepancies, national and local governments should generate consensus on food classifications in order to regulate marketing.
Fall 2011 | Juxtaposition
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