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CONTENTS Volume 6.1 Issue Highlights

3 Global Health Tidbits Naijin Li, Julianne Lee, Joanne Lee

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4 Improving Systems of Mental Health Treatment in Southeast Asia

Tears are Best Dried with Your Own Hands

Kaleem Hawa

6 Health and Empowerment through Sustainability

How a Ghanaian grassroots NGO is empowering women and children aected by HIV/AIDS

Catherine Szymczyk

8 Events in Review India Burton

9 Tears are Best Dried with Your Own Hands Sarindi Aryasinghe

15 More than a School: the Nkanyezi Stimulation Centre

Issue Highlights

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Jingwei Chen

17 Surburbia and Human Health

Suburbia and Human Health

Erik Bracciodieta

Cri cal analysis of the impacts of living in suburbia on community health within the Greater Toronto Area

19 What Counting the Dead can Teach Us Vipal Jain

STAFF Executive Division Editor in Chief Strategic Advisor UTSC Directors

Sarindi Aryasinghe Kadia Petricca Sara Siddiqui Aidan McNeill Administrative Director Molly McGillis Michelle Lee Production Editor Production Associates Cornelia Baptista Ivee Molina Raissa Chua Sponsorship Director Sponsorship Associate Marize Bakhet Abtin Parnia Publicity Director Michelle Volpe Publicity Associates Amna Iqbal Danielle Klein Social Networker Ivee Molina & Cover By Michelle Volpe Michelle Lee Cover Photo

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Editorial Division India Burton Editor in Chief Managing Editor Jingwei Chen Athena Hau Section Editors Yunjeong Lee Jacqueline Parrish Vipal Jain Tahsin Khan Jessica Oh Melissa Patania Victoria Scrubb Julianne Lee Staff Writers Naijin Li Joanne Lee

This Issue is Sponsored By: University of Toronto International Health Program Human Biology Department Postgraduate Medical Education Contact Us: 610-21 Sussex Avenue, University of Toronto Toronto, Ontario, M5S 1J6 juxtaposition.ezine@utoronto.ca juxtapositionglobalhealthmagazine.wordpress.com @juxtamagazine facebook.com/juxtapositionghmagazine This issue is available online: issuu.com/juxtaposition

Juxtaposition | Winter 2013


DEAR JUXTA READERS This issue marks a major milestone for our magazine—it has now been a decade since Juxtaposi on was founded by two University of Toronto students seeking to create a forum for discussion of global health issues. We have come a long way as a student publica on, having been able to reach readers beyond Canada and accept contribu ons from individuals on almost every con nent. We have also sought to expand our readership within the University of Toronto community through the establishment of a chapter at the university’s Scarborough campus. Addi onally, we held an informa ve student speaker series en tled “Greatness from Small Beginnings” in collabora on with Millennium Development Project of the University of Toronto Interna onal Health Program, which focused on student ini a ves targe ng the fulfillment of the Millennium Development Goals. Having grown to appreciate the power of community through connec on with our readers both at home and abroad, we’ve chosen to dedicate our Winter 2013 issue to discussing the importance of collec ve ac on in achieving health equity. Be it at the local, na onal or interna onal level, the ar cles presented in this issue highlight the ability of a community to enact posi ve, las ng change and improve health outcomes. We begin this issue with Kaleem Hawa’s ar cle, which outlines the barriers to treatment of mental health condi ons that exist within the Southeast Asian medical system while discussing solu ons that have been proposed by the global community to narrow this gap in treatment. We con nue our feature piece, a photo essay by Sarindi Aryasinghe showcasing the work of the Kaleo Area Women Development Associa on (KAWDA), a Ghanaian grassroots group which serves to support women and children affected by HIV/AIDS. Pictures highlight various projects being undertaken by KAWDA including educa on ini a ves, free tes ng centers, and a jewellery project which aims to provide both income and skills to women in need. Next, Jingwei Chen takes us inside the walls of the Nkanyezi S mula on Centre, a school for children living with disabili es in Soweto, South Africa. While highligh ng the amazing work being done at this facility every day, this piece also serves to iterate the struggles being faced by staff on a daily basis to keep the doors open. We follow up with Erik Bracciodieta’s ar cle discussing the poten al increase in adverse health outcomes that may result from living in suburban environments within the Greater Toronto Area, while also ar cula ng how changes in urban planning and design may serve to curb these effects. Our final piece, an interview with epidemiologist Dr. Prabhat Jha, comes from Vipal Jain. This ques on and answer session provides insight into Dr. Jha’s current project, the Million Death Study, while detailing how it may serve to provide evidence as to major risk factors for mortality both in India and worldwide. We hope that this issue provides you with a comprehensive look at the intricacies involved in achieving good health within a community. Despite these complexi es, each ar cle provides poten al solu ons, proving that change is possible should individuals take the ini a ve to strive towards it. Sincerely,

Sarindi Aryasinghe Editor in Chief, 2012-2013 Execu ve Division Juxtaposition | Winter 2013

India Burton Editor in Chief, 2012-2013 Editorial Division 2


GLOBAL HEALTH TIDBITS Julianne Lee, Naijin Li, Joanne Lee

Reaching and Succeeding: The first bioartificial organ An accomplishment by Dr. Macchiarini at the Karolinska Ins tute in Stockholm in October has changed the percep on of our internal organs’ finiteness. A er seeing a pa ent (Mr. Beyene) with a tumor growing in his windpipe, Dr. Macchiarini resolved to implant a “bioar ficial” organ made of plas c and the pa ent’s own cells. His method of ssue engineering and organ synthesis is lauded to be an innova ve strategy, as it allows for the construc on of organs with living cells, nerves and blood vessels. The process closely resembles a natural repair mechanism, which contrasts against the previously conceived no on of ar ficial organ transplanta on as being the introduc on of highly developed “machines” into the body. Working toward the goal of producing more complex implantable bioar ficial organs with the smallest degree of rejec on possible, researchers are now examining stem cells and “scaffolds” which can act as moulds to recruit cells for ssue repair. Despite these experiments being costly and without guaranteed results, the increase in relevant research being conducted and stories of successful cases (such as Mr. Beyene’s) make researchers hopeful that producing a complex bioar ficial organ is now an a ainable goal.1 1. Henry, F. (2012, October 23). A First: Organs Tailor-Made With Body’s Own Cells. New York Times. Retrieved from h p://www. ny mes.com/2012/09/16/health/research/scien sts-make-progress-in-tailor-made-organs.html?_r=1&. ons in UK secondary schools,” The Bri sh Journal of Psychiatry, (2001): 75-107.

Transmission Model to Save the World from Malaria

image: http://topnews.in/health/files/malaria-Africa5451.jpg

According to WHO reports, in 2011 malaria deaths declined by a staggering 33% in Africa, with this number expected to con nually decrease as the popularity of cell phones on the con nent grows.1 With 600 million Africans currently using cell phones2, Kenyan scien sts decided to take advantage of these devices’ technological capabili es to track the movement of malaria using popula on maps for reference. U lizing principles of probability, they produced a “transmission model” for malaria in Kenya, which provided valuable informa on regarding popular transmission routes and highlighted areas where resources would be best invested.3 Despite the fact that this project is costly, it is an excellent example of how maximizing posi ve health outcomes using minimal resources can be both a worthwhile and effec ve approach when tackling a major global health issue.4

1.Amy Wesolowski, Nathn Eagle, Andrew J. Tatem, David L. Smith, Abdisalan M. Noor, Robert W. Snow, and Caroline O. Buckee, “Quan fying the Impact of Human Mobility on Malaria.” Science 6104th ser. 338 (2012): 267-70. Science. AAAS, 12 Oct. 2012. Web. 27 Oct. 2012, www.sciencemag.org/content/338/6104/267.abstract?sid=c35122ea-caaf4653-ba22-6e9713f9ab7c 2.Donna Hesterman, “In Africa, 15M Cell Phones Map Malaria,” Futurity, 18 Oct. 2012. Web. 13 Nov. 2012, www.futurity.org/top-stories/in-africa-15m-cell-phonesmap-malaria/. 3. Dr. Tim Kelly, “Mobile Applica ons: Crea ng Sustainable Businesses in the Knowledge Economy,” InfoDev, Web. 26 Oct. 2012, h p://www.infodev.org/en/Project.116.html. 4. Greenwood, F. (2012, October 19). Researchers use cell phones to track the movement of malaria in Africa. GlobalPost. Retrieved from www.globalpost.com/ dispatch/news/regions/africa/121019/researchers-use-cell-phones-track-the-movement-malaria- africa

Home-Testing Kit for HIV an Effective Screening Tool? The OraQuick Advance Rapid HIV test – a home-tes ng kit that individuals can use to determine their HIV status privately – has recently become available on the United States market at a cost of $40. Some experts claim that this inven on may be useful in screening one’s sexual partners and could poten ally reduce the 50,000 new HIV infec ons in the US each year. Advocates of this home-tes ng kit have a point; studies have shown that a significant number of people with HIV hide this truth from their partners. Although OraSure Technologies, the manufacturer of this product, does not support the idea of using the test for screening purposes, 70% of the 4,000 people who work for the company do. However, some are of the opinion that $40 is too expensive if the kit is being used to test mul ple partners, while others claim that they would feel uncomfortable asking their partner to take such a test. Some assert that a nega ve test could result in the abandonment of condoms; without use of these contracep ves, protec on against infec on with HIV and other sexually-transmi ed diseases would be compromised significantly. Despite poten al benefits, the OraQuick test s ll needs improvement. It is only 93% accurate and can therefore indicate that a person does not have HIV when they actually do, simply because he or she does not produce the an bodies that the test screens for. However, it seems that this product has the poten al to become very successful in the market provided all kinks can be worked out.1 1. McNeil Jr., D.G. (2012, October 5). Another Use for Rapid Home H.I.V. Test: Screening Sexual Partners. New York Times. Retrieved from h p://www.ny mes.com/2012/10/06/ health/another-use-for-home-hiv-test-screening-partners.html?pagewanted=all&_r=1&.

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Juxtaposition | Winter 2013


IMPROVING SYSTEMS OF MENTAL HEALTH TREATMENT IN SOUTH EAST ASIA obstacles and proposed solutions Kaleem Hawa

Image: Mart1n / sxc.hu

insular world of the asylums. These Improving systems of treatment the circumstances have led to obsolete systems of care that remain widely, and one step at a time ineffec vely, used today. 2

With a popula on exceeding 500 million people, Southeast Asia is one of the most diverse and poli cally complex regions of the world. With cons tuent na ons including Cambodia, Laos, Thailand, Vietnam and Malaysia, there exist a variety of medical systems that each operate with differing levels of effec veness and with their own oversights as to who cons tutes a “righ ul recipient of care.” This means that certain groups iden fied by the World Health Organiza on (WHO) for concerted efforts toward medical support have been ignored. No such group is as s gma zed and overlooked in the aforemen oned Southeast Asian medical systems as those with mental illnesses such as schizophrenia as well as mood, personality and anxiety disorders. This ar cle will explore the reasons for the gap in treatment of the mentally ill in Southeast Asia while commen ng on the Juxtaposition | Winter 2013

difficul es of developing stronger systems of care and assessing some possible solu ons that have been proposed by the global community.

Roots of the problem The roots of the problem faced by the mentally ill in Southeast Asia can be traced back to historical treatment mechanisms and societal prejudices. According to a study by Deva Meshvara in World Psychiatry, old colonial systems of mental health treatment o en took place in isolated asylums located far from most generalized hospitals and the rest of society1. This contributed to a lack of medical supervision in the treatment process and led to the adop on of community-based healing that focused on mental illness as something to be cured. As a result, any major advances to mental health that might have proliferated in the medical community rarely reached

Furthermore, societal prejudices towards the mentally ill underscore this stagnancy by refu ng the importance of their treatment; it is clear that societal bias towards the mentally ill has contributed to a secondary – and poten ally more damaging – harm. The systems of governance that exist in these Southeast Asian na ons are unlikely to priori ze equitable healthcare for the mentally ill given the s gma associated with discussion of the topic in the public realm. For example, a study by Christoph Lauber in the InternaƟonal Review of Psychiatry concluded that, “the pathway to care is o en shaped by skep cism towards mental health services and the treatments offered. S gma experienced from family members is pervasive [and] moreover, social […] devalua on of families with mentally ill individuals are an important concern.”3 Clearly, li le progress can be made in 4


Kaleem Hawa

IMPROVING SYSTEMS OF MENTAL HEALTH TREATMENT IN SOUTH EAST ASIA obstacles and proposed solutions defending the rights of the mentally ill if the s gma and poli cal deadlock surrounding them aren’t relieved.

Structural difficulties Besides the major founda onal impediments to the development of be er systems of care for the mentally ill, there also exist structural difficul es inherent to the system. These include, but are not limited to, the process of educa ng medical students and the staffing of mental healthcare departments in the region. Psychiatric educa on in Southeast Asian medical schools has been cited numerous mes as being severely lacking; according to a WHO Report, most medical schools in Asia do not have formalized psychiatric teaching and the ability to diagnose mental health illness is not required in order to become a doctor.4 Not only are there few physicians qualified to treat mental illness, but those who are adequately trained rarely prac ce in this field of medicine for very long. The report goes on to cite ra os of less than 1.5 psychiatrists per 100,000 people in many Southeast Asian countries.5 This chronic understaffing of such an integral health sector is a severe structural barrier to las ng change.

the primary healthcare level. Not only will this help to normalize the prac ce of mental health inspec ons, it will also allow for early iden fica on of illness in young pa ents and their families.6 Another possible solu on that changes the fundamental systems of care is the transi oning and reintegra on of asylum pa ents into general hospital treatment centres.7 This, coupled with a phasing out of the isola onist prac ces of the past, will help ensure more supervision in the treatment process. However, it is uncertain as to whether any of these reforms are possible under systems where mental health remains s gma zed. The WHO proposes that educa on programs be targeted specifically to the general populace and schools, with the hope being to use media and educa on to change the percep on of mental health to something for which communi es bear a responsibility in trea ng and helping. A study by Vanessa Pinfold in the BriƟsh Journal of Psychiatry showed that similar educa on programs in Britain have been effec ve in driving up mean posi ve a tude scores towards the mentally ill.8 That being said, the efficacy of such an endeavour may differ within the Southeast Asian context.

www.bangkokpost.com

Mental health is o en an issue that exists outside the public’s mind. In Southeast Many solu ons have been proposed Asia, systems of care have fallen apart in order to address the issues faced by due to societal s gmas, historical Southeast Asian medical systems. One of treatment mechanisms and structural the most powerful proposals currently deficits in educa on and training. It will being considered is the integra on of not be an easy process to undo years of mental health services into general health stagna on on the issue of mental health, services. This would entail screening for but it is a cause that warrants change and mental and behavioural disorders during is not outside our ability to reform. general check-ups and, in par cular, at

Proposed solutions

1, 2. Deva Meshvara, “Mental health in the developing countries of the Asia Pacific region,” Asia Pacific Journal of Public Health, 11 (1999): 57–59. 3. Christoph Lauber, “S gma towards people with mental illness in developing countries in Asia,” Interna onal Review of Psychiatry, 19 (2007): 157-178. 4, 5. Rangaswamy Srinivasa Murthy, “The World Health Report 2001 - Mental health: new understanding, new hope,” World Health Organiza on, (2001): 75-107. 6-8. Vanessa Pinfold, “Reducing psychiatric s gma and discrimina on: evalua on of educa onal interven ons in UK secondary schools,” The Bri sh Journal of Psychiatry, (2001): 75-107.

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Juxtaposition | Winter 2013


HEALTH AND EMPOWERMENT THROUGH SUSTAINABILITY Northern Ghana’s disability clinic Catherine Szymczyk

Enhancement of Community Health in Sandema Although all socie es include individuals living with physical and mental disabili es, the treatment of these individuals is what makes a holis c community, and community is a significant contributor in fostering health.1 This past summer I spent some me volunteering in Ghana, where I worked in several hospitals and clinics throughout the country. Through this experience I had the opportunity to work with passionate individuals who sought to create an environment promo ng posi ve change, empowerment and equity through enhanced healthcare at the community level. In Sandema, a small northern city, I met one such individual named Gilbert Asekabta, who founded and manages a clinic which aims to assist individuals living with disabili es.

Juxtaposition | Winter 2013

Gilbert was afflicted with polio as a child, a circumstance which imparted upon him a permanent physical disability. He has dealt with the repercussions of this unfortunate situa on for many years and has now made it his mission to fight for the rights of individuals with disabili es in hopes of sparing them from the hardships he has faced. He also promotes self-sustenance for these individuals by training them to develop skills that can allow them to generate income and become financially independent. The Persons with Disability Act in Ghana dictates that individuals with disabili es have equal rights to employment, educa on, health care and more, but was not enacted un l 2006.2 The introduc on of this legislature was of paramount importance to improving the overall health of individuals living with disabili es, given that many had previously struggled both socially and psychologically due to a lack of legal rights; according to Gilbert3, many of these individuals had received no formal educa on, were unable to a ain a job to sustain themselves and lacked access to adequate housing, all of which

led to unhealthy lifestyles. The rights outlined in this act have had a tremendous impact in changing these individuals’ circumstances, making a healthier lifestyle possible for the first me, thanks to an increase in available resources. Gilbert, garnering strength and inspira on from the disadvantages he had faced, became a significant part of the movement for disabled individuals’ rights in rural Northern Ghana. With assistance from both local and interna onal volunteers, he built the Sandema Disability Clinic on land given to him by the previous chief of the community. The centre has since become a mee ng place and refuge for individuals with disabili es seeking both social and psychological assistance. Recently, the clinic has expanded its focus to aid individuals with mental disabili es. To assist patrons in the development of marketable skills, Gilbert has set up sessions with volunteer teachers who live at the centre for three to four months and teach cra s such as key-soap making and cot weaving. Each student’s training is based on his or her individual capabili es and provides an opportunity to generate

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NORTHERN GHANA Catherine Szymczyk

Gilbert Asekabta, founder of the Disability Clinic Juxtaposition | Fall 2012 in Sandema, Ghana

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HEALTH AND EMPOWERMENT THROUGH SUSTAINABILITY Northern Ghana’s disability clinic income by selling their wares.and provides them with the opportunity to generate income by selling their wares. The centre relies mostly on donor funding, despite the provision in the Persons with Disability Act outlining that the Ministry of Health will provide appropriate training to disabled individuals2; unfortunately, despite Gilbert’s efforts, the government has provided no funding, which limits the ideal frequency of classes.

and cra supplies. Unfortunately there is no kitchen, nor are there bathrooms or lodging facili es; pa ents sleep on mats on the floor wherever there is space. Food is provided only when possible.

Gilbert has diligently advocated for more support from the General Assembly, which has since granted him funding for half the cost of a new facility. However, though engineers and contractors have developed plans and preliminary es mates Despite the lack of financial resources, many for the building, private funding has other forms of social and psychological fallen through. Gilbert has yet to give assistance con nue running. Gilbert up and is s ll looking for donors to fund maintains the building independently, and the remaining half of the construc on, which is set at 20, 000 GHC (Ghana Cedis) is constantly available to talk with visitors. or approximately $10, 000 CAD. His The building within which he facilitates con nued advocacy and perseverance are all of these support services only has one two major assets that will hopefully help small room with a side office - there is to achieve the goal for a new facility. barely enough room to store equipment

The disability clinic in Sandema is oneof-a-kind in Northern Ghana; it provides many benefits with few resources. It has significantly changed the lives of many individuals by enhancing health, encouraging self-esteem and promo ng sustainable, healthy lifestyles for all, and it will con nue to do so with the help of other advocates. Numerous individuals living with disabili es travel from Northern and Central Ghana seeking the centre’s assistance and support, however in order to survive as a primary health facility, it must be supported at na onal and interna onal levels by individuals, communi es and governments. The author would like to thank Gilbert Asekabta for his generous contribuƟon, Ɵme and passion in assisƟng the author in the informaƟon uƟlized in this arƟcle while in Sandema, Ghana.

1. Stamler, Lyne e Leeseberg, and Yiu, Lucia. Community Health Nursing. Toronto, Ontario: Pearson Canada Inc., 2012 2. “Ghana: Persons with Disability Act 715,” HumanRightsIni a ve.com. Last modified August 11, 2006. h p://www.humanrightsini a ve.org/publica ons/ ghana/disability_rights_in_ghana.pdf 3. Gilbert, Asekabta (Disability Centre Manager) in discussion with the author, June 2012.

EVENTS IN REVIEW India Burton

Seeking to provide a forum for students involved in various development ini a ves abroad to discuss their ini a ves, this past November Juxtaposi on held a speaker event en tled “Greatness from Small Beginnings” in collabora on with the University of Toronto Interna onal Health Program’s Millennium Development Project. Julie Caron (CWEF Tanzania), Kelly Hadfield (Ghana Medical Help), Taha Tabish (G-Roots), Derek Chan (Ntugi Group) and Jennifer Naidoo & Paul McGoey (LetsStopAIDS) spoke in turn about the challenges each has faced while working with their respec ve NGOs to enact posi ve change, while also highligh ng successes big and small that have been achieved along the way. Though the focal areas varied between groups, commonali es emerged as the presenta ons con nued. All speakers men oned the importance of understanding and evalua ng local needs before implemen ng any programs. Poten al for capacity building also emerged as a crucial factor in ensuring interven on success and sustainability. These shared themes formed the basis of a panel discussion, which was moderated by University of Toronto professor Dr. Paul Adjei. Ques ons posed to the group by Dr. Adjei allowed for the informa on presented by each speaker to be further analyzed and disseminated, proving to be a valuable, enjoyable and informa ve learning experience for all those who a ended. If you would like to see some video highlights from Greatness from Small Beginnings and learn more about our speakers, please visit JuxtaposiƟon’s Facebook page (facebook.com/juxtaposiƟonghmagazine) Juxtaposition | Winter 2013

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TEARS ARE BEST DRIED WITH YOUR OWN HANDS Sarindi Aryasinghe

How a Ghanaian grassroots organization is empowering women to become their own advocates in the fight against HIV/AIDS

W

omen are becoming infected by HIV/ AIDS at dispropor onal rates around the world. They o en face many social and cultural barriers which affect their access to HIV tes ng, support and ARV medica on. This past summer, I volunteered with a Ghanaian grassroots organiza on called Kaleo Area Women Development Associa on (KAWDA) which serves to provide counselling, care and support for women and children affected by the HIV epidemic. KAWDA partners with local hospitals in the Bekwai and Obuasi districts of Ghana to help provide this holis c care for individuals affected by HIV/AIDS.


I got the chance to visit some of these women in their homes and learn first-hand how HIV/ AIDS has impacted them and their families. Many had kept their HIV-posi ve status a secret from their communi es to avoid being discriminated against and ostracized; what I learned behind these closed doors was that living with HIV/AIDS is a mul -faceted issue.


KAWDA was founded by Albert Annadie (on the right) in 2000 with an ini al membership of 21 women. The organiza on has grown considerably over the years— they now conduct regular HIV awareness campaigns in schools in and around Kumasi, provide free counselling and have established partnerships with neighbouring hospitals and HIV clinics. Another crucial ini a ve that KAWDA is currently trying to implement is their microcredit loan ini a ve. Those who have received loans have been able to start their own businesses and have thus been provided with a source of income. These loans help empower the women, giving them a sense of financial independence.

While volunteering with KAWDA, I led several school presenta ons addressing HIV preven on and transmission. The presenta ons were very simple; we used a flipbook with pictures and performed skits. We also discussed the importance of reducing s gma and discrimina on with regards to HIV infec on, encouraging students to be more accep ng of those aected by the pandemic, and also answered any ques ons they had. Interes ngly, the younger students tended to have more knowledge and exper se regarding the subject of HIV than did those in the older grades. When presen ng to older students, we used more explicit examples to be er inform them as to HIV transmission and preven on methods. Given the increased likelihood of sexual ac vity among these senior students, it was par cularly important to present our informa on in an engaging and informa ve manner.


In an a empt to decrease the prevalence of HIV in the country, Ghana Health Services has been offering both free tes ng and counselling as part of a preven on campaign. Public health clinics, with the aid of grassroots organiza ons like KAWDA, are playing an important role in reaching out to local communi es and discussing the reali es of HIV. By talking more about the disease and encouraging tes ng, the en re popula on (but women in par cular) have a be er chance of remaining infec on-free. To make treatment more accessible, the government is also subsidizing the price of ARV drugs; a month’s supply now costs roughly 5 cedis, or $3 CAD. In many of the candid discussions I had with members of KAWDA, a common concern was lack of income – women o en ar culated the struggle they faced in choosing between pu ng food on the table and buying their ARV medica on. To help combat this issue, I assisted KAWDA in star ng a simple, income-genera ng beading project. Not only did we want all the women of KAWDA to have access to some money, but we also sought to give them an opportunity to start their own businesses, empowering themselves and future genera ons through mentorship while promo ng women’s rights.


With money fundraised by several Canadian volunteers, we were able to hire a local female ar san, buy beads and organize a training session for selected KAWDA members. In October, fi een women were trained by the organiza on and have since started to make various bracelets, necklaces and earrings. They are the pioneers in this project, and will be organizing training sessions within their own communi es and villages in order to provide more women with this skill set. All the jewellery made through this ini a ve will be brought to North America and Europe by KAWDA’s interna onal volunteers, where the pieces will be sold to raise funds for KAWDA’s women while also increasing awareness as to the plights of those aected by HIV.


MORE THAN A SCHOOL: THE NKANYEZI STIMULATION CENTRE and why it may have to (but must not) close Jingwei Chen

Every day, children at the Nkanyezi S mula on Centre move through four classrooms, each staffed by two expert carers. The staff in S mula on Room 1 coach their “shining stars” in communica on, basic body movements and using the five senses; ac vi es the children enjoy in this Room are singing and playing in the garden. The learning goals of children in S mula on Room 2 include prac sing their ves bular and propriocep ve senses, which refer to the body’s balance and the movement of muscles, respec vely, and depending on their unique circumstances, the children are helped to learn to stand or walk. The third room is called the Early Interven on Room, where the staff recap lessons from S mula on Room 1, in addi on to helping the children refine their motor

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skills as well as those useful for dayto-day ac vi es such as coun ng and naming the days of the week. The fourth room, dubbed the Flower Room, contains mul ple areas to s mulate the children’s senses: the feather-adorned area, for instance, s mulates the sense of touch. And twice during the day, the children are served delicious home-cooked meals using ingredients grown from the Centre’s own garden or donated by staff and the children’s families.1 But to call the Nkanyezi S mula on Centre a school would be to call a diamond a rock. For children living with disabili es in Soweto, a township in Northeastern South Africa, it is not only a “safe place to interact, play, learn, and grow,” with carers who are commi ed

to providing for the children’s “physical, educa onal and emo onal needs”2 it is the only place. One of the carers, Nonhlanhla, notes that, “It is the only [place] in Soweto for children like ours and they can learn things here [and] not just be a day-care like many other centres.” Recent fiscal cutbacks by the South African government have put considerable strain on the Nkanyezi S mula on Centre. Yet, no government representa ve has offered insights as to why these cutbacks are necessary. Because lack of state funding has become a ubiquitous problem experienced by many non-governmental organiza ons (NGOs), these groups are now ever more reliant on the support of external donors

Juxtaposition | Winter 2013


to help them achieve their aims and goals. Juxtaposi on takes an in-depth look at the exemplary work of the Nkanyezi S mula on Centre and addresses why helping to keep it ac ve is impera ve.

instance, their efforts in the Centre’s garden allow them to feed both their children and the rest of the families as well as fundraise for the Centre by selling whatever extra produce is available.6 All tasks are performed collabora vely This holis c Centre was created in by a community united in their fight to memory of Nkanyezi Tshabalala (1989ensure that children with disabili es in 2000), whose daily companions were Soweto are given love and support and cerebral palsy, a wheelchair and the love encouragement – no number of glowing and support of his mother, (his father adjec ves seems adequate to describe abandoned the family, calling his son “the everyone’s effort and devo on. devil’s child”, Tracy, a Centre volunteer, confides to me). In September 1998, To date, the Nkanyezi S mula on Centre when Nkanyezi was nine years old, he has received funding from several encouraged his mother (and current sources. First, there are voluntary manager of the Centre), Thembekile donors who contribute financially. Prisca Tshabalala, to establish a local Second, there are donors who contribute support network of families who had items – anything from tools to clothes, loved ones living with disabili es. This tapes to cra supplies – which are network grew and developed, eventually then sold in regular, increasingly busy spurring the crea on of the Nkanyezi jumble sales. Third, the South African S mula on Centre.3 government provides a monthly subsidy to this government-registered, nonprofit organiza on to pay eight of the Since the Centre’s incep on, much has thirteen staff members the Centre needs progressed. Previously, the care staff to employ to conform to government began their work at the Centre a er having received brief training in the form regula ons.7 Unfortunately, recent cuts of government-sponsored courses. Now, mean that the payout for this subsidy the carers are so experienced that the has delayed indefinitely; this year alone, Department of Social Welfare relies on the Centre has only received three of them to give hands-on training to the the five subsidies it is owed. Efforts by students it sends to the Centre, and with this author to contact the South African good reason, too.4 One such carer, Prisca government for their side of the story (whose dedica on and devo on exceed went unanswered. her level of training) began working with Thato Makhanya, a student welcomed to Thankfully, the Centre has managed to Centre in July of 2009 as a wheelchairkeep its proverbial head above water, bound three-year-old; under Prisca’s thanks to the volunteers’ reless efforts unwavering care, within eight months of to raise funds and awareness, Prisca’s a endance, Thato succeeded in learning generosity in sharing her meagre pension, to use a standing frame and eventually and the carers’ willingness to work in the achieved the ability to walk and run and face of an uncertain – and much belated play hide-and-seek, her favourite game.5 – pay date. Busi, another carer, speaks for all her colleagues when she says, “I In fact, this is what Winne (a fellow carer) stay here because I love my job and I considers the most sa sfying part of her love the children.” It really isn’t about job, the joy of, “working with the children the money. It’s about the children and and watching them achieve milestones.” the gross detriment to their well-being if the Nkanyezi S mula on Centre were to And many of the children’s parents cease to exist. are also involved with the Centre, as volunteers or other contributors. For

Acknowledgements The author wishes to thank Kadia Petricca for alerƟng her to the issue, as well as Tracy Hammond, a Centre volunteer, and Irene Mboweni, the Centre Administrator, for their long, detailed responses to the author’s quesƟons. Progress update: The Twi er campaign has been hugely successful: the South African government was bombarded with more than 360 000 tweets, and all six months’ worth of outstanding subsidies were paid in full. The Centre’s precarious posi on has much improved, but the struggle is not yet over. Five staff members’ salary as well as equipment costs rely solely on fundraising efforts. Please send a tweet or send a dollar – or both. If you would like to learn more about the Nkanyezi S mula on Centre or donate, please visit their website at h p://www.nkanyezi. com. The Centre is also on Facebook and Twi er @NkanyeziCentre.

1, 2, 4. Nkanyezi S mula on Centre. “About us.” Accessed May 10, 2012. h p://www.nkanyezi.com/about-us.php 3, 6. Nkanyezi S mula on Centre. “Home.” Accessed May 10, 2012. h p://www.nkanyezi.com/ 5. Nkanyezi S mula on Centre. “Our Shining Stars – Big and Small.” Accessed May 10, 2012. h p://www.nkanyezi.com/our-shining-stars---big-and-small.php 7. Nkanyezi S mula on Centre. “Be a Star Supporter – How to Help.” Accessed May 10, 2012. h p://www.nkanyezi.com/be-a-star-supporter---how-to-help.php

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SURBURBIA AND HUMAN HEALTH a Toronto-centric foray into our built environment Erik Bracciodieta

Image: IDuke, 2005 h p://kyleanderson.us/wp-content/uploads/2011/05/Markham-suburbs_aerial-edit2.jpg

A er World War Two, North America embraced a new urban design challenging tradi onal city life. The la er was vilified as crowded, diseased, dirty, impersonal and unhealthy, especially for children.1 New housing and industrial development on the city’s edge promised larger homes surrounded by green lawns, clean air, plenty of parkland, welcoming neighbours, large parking lots and transporta on networks designed for the automobile. The majority of the people of the Greater Toronto Area (GTA) now live in these suburbs; Brampton, Mississauga, York Region, Oakville, Etobicoke and Scarborough are almost completely sub-urban. For the purposes of this ar cle, suburban areas are characterized as being ‘low density, auto dependent land development[s] taking place on the edges of urban centres

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ac vity imparts significant health benefits. Physical ac vity can be u litarian or recrea onal: the former is done to accomplish everyday tasks and the la er requires conscious effort and planning. The nature and rela ve importance of either differs in varying urban se ngs. The suburbs brought home U litarian ac vity such as ownership to the public, but has walking or biking is performed their promise of be er living because it is both necessary been fulfilled? Does living in the and convenient.3 Studies have suburbs equate to a healthier shown that such moderate life with friendly neighbours? exercise, (e.g. walking for 40 This ar cle will examine the minutes per day in informal impact of the aforemen oned bursts), is just as beneficial suburban design on two aspects as short episodes of vigorous of human health: physical exercise at a gym.4 Thus, in ac vity and mental health. order to improve health in the long run, it is best to increase moderate u litarian ac vity. Physical Activity of

land use mix.5 Suburban areas are dominated by low density residen al sectors, leaving few des na ons close to home which offer (o en inadequate) sidewalks or bicycle paths. In terms of design, curvilinear streets made to deflect automo ve traffic onto arterial roads leave few direct paths to des na ons. Furthermore, the streetscape of the suburbs is bland, reducing the appeal of walking. Pa erns of land use factor heavily as well; commercial, residen al, industrial and ins tu onal areas are isolated from each other due to distance, busy roads and parking lots. This discourages walking and promotes automobile use.6

Suburbanites: Give Me a Bike and a Lane to Ride Her In

Mental Health in the Suburbs: Sick in the concrete (and lawned) jungle

. . . [which serve] to transform open, undeveloped land into single family residen al subdivisions and campus-style commercial office parks … [with] diffuse retail uses.’2 This suburbaniza on was, and s ll is, the predominant form of urban expansion in North America.

There is no doubt that physical

There are three interlinked factors to be considered when assessing whether an urban area is conducive to physical ac vity: density, design and

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Marke ng the suburbs in their early years of existence was not a difficult task. It was widely believed that ci es were unhealthy places; industry fouled the air and residents were crowded into dilapidated tenements with cold and unfriendly people.7 In contrast, the suburbs offered open green spaces for children and a vibrant social life with like-minded families. However, these ideals do not reflect the suburban reality. In fact, social capital, or sense of community, is o en less pronounced in the suburbs compared to dense downtown areas.8 This has significant consequences on mental health. In efforts to quan fy these effects, social capital researchers have asked ci zens to what degree they feel a sense of belonging, confidence in public ins tu ons, trust in others and op mism other turnout, newspaper

Juxtaposition | Winter 2013

readership, and the magnitude of volunteer ini a ves have also been measured.9 Results have indicated that the long commutes of suburbanites leave them too red, depleted and irritable to engage with the community.10 With few people walking and a dearth of common spaces, there are no opportuni es for spontaneous, informal social interac on. In the suburbs, greater emphasis is placed on the individual with larger homes and private cars. This reduces people’s enthusiasm for local government and public ini a ves. Feelings of loneliness, listlessness and exhaus on are the result.11

living spaces, contribu ng to the high residen al turnover rate. This further reduces social capital because people cannot develop stable and meaningful connec ons with others.12 Life is made even more difficult for seniors in the suburbs because they o en lose the ability to drive. This means they spend more me at home alone and are thus at a higher risk of being depressed, because they are denied physical ac vity, social interac on and chances to view nature.13

Automobile dependence and the decline of social capital are par cularly harmful for the elderly. The suburbs lack a variety of housing op ons; most units are large single-family houses. When seniors downsize their suburban living space, they are o en forced leave the community due to the lack of smaller and more manageable

People recognize that sprawl is unhealthy. This is reflected in the increase of residents and property values in Toronto’s downtown area; denser, less car-dependent urban areas are becoming expensive to live in.14 This leaves outlying areas to be occupied by those with lower incomes. The Three Ci es report by the University

On the Edge: Sprawl and the Growing Income Gap

of Toronto’s Ci es Centre observed those who made 20% or more below the average income were concentrated in Northern Etobicoke and Scarborough, once enclaves of the middle class.15 These peripheral areas of the city are also home to a significant por on of Toronto’s immigrant popula on, exposing these vulnerable groups to the nega ve health outcomes of sprawl; a study from the Ins tute for Clinical Evalua ve Studies in Toronto found that the incidence of diabetes is higher in the suburbs than in urban areas.16 Although poor ea ng habits associated with lower income do play a strong role, the high dependence on car travel must also be considered. The financial burden of car ownership is most onerous on the poor, reinforcing a downward economic spiral; a car is o en needed in order to find and secure employment but having one reduces income to spend on healthier foods or extracurricular ac vi es for

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Solving Sprawl: A Healthier Urban Environment for All

image: www.yrt.ca

children.17 Though public transit is an op on, it is of insufficient reliability and convenience for naviga ng the automobiledominated design of Toronto’s suburbs. Crime rates are higher in these areas as well, reducing the residents’ percep on of safety for outdoor ac vi es, and thus reducing social capital.18 This in turn leaves low income residents at a higher risk of chronic health condi ons. This situa on can be remedied with intensifying exis ng urban areas in Toronto’s core. More available living space means units can be more affordable, even for those with

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low incomes. It is unfortunate that residents in these dense areas resist these efforts, but Toronto’s long term prosperity depends on all ci zens having access to healthy living areas. Life in intensified urban areas would help relieve the financial pressures faced by individuals with low incomes: all automobile related expenses can be avoided as modes of transporta on diversify into walking, biking and using frequent public transit. In fact, public transit becomes a more reliable and convenient op on with increased density because of sufficient funding from ridership.

Adding density and transit is a basic requirement for urbaniza on. Pre-World War Two neighbourhoods defined by their grid-line streets were built to house more people, a ract commerce, develop efficient public transit and have the capacity to change over me.19 The early twen ethcentury ‘streetcar suburbs’ of New Toronto, Mimico, and The Beach once consisted of singleunit houses with convenient public transport. Over me, this grid street pa ern encouraged denser housing resul ng in the desirable communi es of today.20 The design of postWorld War Two suburbs, however, inhibits this tradi onal evolu onary process. By designing urban areas for cars, streets are not arranged in grids but in indirect curvilinear paths with many dead ends. This o en makes reaching des na ons inconvenient and me-consuming with the personal automobile as the de facto mode of transporta on.21 To overcome the design flaws of modern suburbs, three concepts must be applied: walkability, des na ons and intensifica on. People are healthier when they walk to run errands, which means municipali es should be maintaining sidewalks and slowing cars down. Changing land use pa erns to increase the number of des na ons to homes can be accomplished

by legalizing mobile vendors and permi ng home-based businesses. Intensifica on can occur naturally; immigrant popula ons o en have extended families living in one house or ren ng out por ons of their living space.22 Municipali es can relax stringent land use by-laws to allow more des na ons to develop in residen al zones while ac vely encouraging healthier modes of transport. The Ontario government has taken ac on to curb sprawl. The Greenbelt was ins tu onalized in 2005, protec ng 1.8 million acres of rural landscape around the GTA from development.23 This places a geographic limit on how far sprawl can extend in the GTA. Ontario’s Places to Grow Act outlines general principles to ensure sustainable development in the Golden Horseshoe: revitalizing downtown centres, ensuring a mix of residen al op ons, protec ng green space and improving public transit.24 However, land use and rural

image: www.ala.org

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SURBURBIA AND HUMAN HEALTH a Toronto-centric foray intoour built environment development are s ll the responsibility of municipal governments. Sprawl has been a profitable enterprise for municipali es; large swaths of land are sold to developers who have strong lobbying efforts.25 The provincial government subsidizes new infrastructure, ar ficially reducing the price of newly built houses.26 However, a confluence of factors, both environmental and economic, is propelling governments in new direc ons. In Mississauga, where all land in its boundary is developed, concerns over longterm costs of infrastructure and sustainability have driven plans to intensify the area around the Square One shopping mall.27 High rise residen al towers and a new ‘main street’ will transform this area into a walkable neighbourhood. York Region plans to convert

segments of Highway 7 and Yonge Street into avenues, aiming to bring efficient public transit and small shops to tradi onally car-dominated spaces.28 The design for the new Mount Pleasant Village neighbourhood in Northwest Brampton shows that public transit and density are closely linked. It includes townhomes (instead of tradi onal singleunit houses), small shops and a public square adjacent to a GO train sta on.29 Hopefully this urbanist theme will linger with suburban poli cians and enhance the livability of exis ng suburban environments. The history of humanity is a story of se lement. The development of agriculture led to fixed se lements, and these led to great civiliza ons. The form of a human habitat

provides a window into the par cular quality of life and values harbored in socie es. What do the suburbs reflect of North American life? The desire to own property, especially houses? An unhealthy dependence on automobiles? A rejec on of social life? The health issues of sprawl described in this ar cle are only a few examples. Concerns over air quality and traffic injuries are further important concerns for suburban areas. In fact, these two issues are interlinked with physical ac vity and demonstrate how the built environment impacts the health of popula ons.

for a new model of building communi es, one that emphasizes walking over driving and focuses on community rather than isola on. A great challenge for the 21st century is to make current suburbs more livable—the health of future genera ons depends on it.

The environmental and health concerns of the suburbs are well-known. Both ac on from governments and consumer demand are paving the way

1. Frank L, Frumkin H, Jackson R. Urban Sprawl and Public Health. Washington DC: Island Press, 2004. pg 5. 2. Frank et al. pg 2. 3. Frank et al. pgs 92-3. 4. Gardner S. ‘The Impact of Sprawl on the Environment and Human Health.’ Urban Sprawl: A Comprehensive Reference Guide. Ed. David Soule. Westport Conn.: Greenwood Press, 2006. pg 252. 5. Frank et al. pgs 97-99. 6. Frank et al. pg 93. 7. Frank et al. pg 5. 8. Frank et al. pg 102. 9. Frank et al. pg 164. 10. Carter M, Foley D, Gurin D, Petrie S. Understanding Sprawl: A Ci zen’s Guide. Vancouver: The David Suzuki Founda on, 2003. pg 16. 11. Carter et al. pg 19. 12. Carter et al. pg 18. 13. Berke EM, Go lieb LM, Moudron AV, Larson EB. Protec ve associa on between neighbourhood walkability and depression in older men. Journal of the American Geriatrics Society 2007; 55(4):526-33. 14. Pigg S. “Toronto vs Vancouver: Which will have the highest house prices in a decade?,” Toronto Star, May 11, 2012, GTA3. 15. Hulchanski, D. The Three Ci es Within Toronto: Income Polariza on Among Toronto’s Neighbourhoods, 1970-2005. Ci es Centre Research Bulle n 41, December 2007. 16. Creatore MI, Booth GL, Glazier RH and Gozdyra P. Pa erns of Diabetes Prevalence, Complica ons and Risk Factors. In: Glazier RH,Booth GL, Gozdyra P, Creatore MI, Tynan, M, editors. Neighbourhood Environments and Resources for Healthy Living—A Focus on Diabetes in Toronto: ICES Atlas. Toronto: Ins tute for Clinical Evalua ve Sciences; 2007. 17. Reid D. ‘Suburban Evolu on,’ Spacing, Summer/Fall 2009, pg 23. 18. Frank et al. pg 182. 19. Reid. pg 24. 20. Carter et al. pg 3. 21. Reid. pg 24. 22. Reid. pg 23. 23. Growth Plan for the Greater Golden Horseshoe, 2006. Ontario Ministry of Infrastructure. h ps://www.placestogrow.ca/index.php op on=com_content. Accessed Dec 8, 2010. 24. Growth Plan for the Greater Golden Horseshoe, 2006. Ontario Ministry of Infrastructure. h ps://www.placestogrow.ca/index.php op on=com_content. Accessed Dec 8, 2010. 25. Carter et al. pg 4. 26. Carter et al. pg 5. 27. Grewal S. ‘Growing Up: Curvy Towers help Mississauga turn a hayfield into a downtown,’ Toronto Star, Nov 12, 2012. GTA2. 28. York Region Rapid Transit Corpora on. “Vivanext: Rapidways,” www.vivanext.com/rapidways. Accessed Jan 9, 2013. 29. City of Brampton. “Mount Pleasant Village.” www.brampton.ca/en/Business/planning-development/projects-studies/Pages/Mount-Pleasant-Village.aspx. Accessed Jan 9, 2013.

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WHAT COUNTING THE DEAD CAN TEACH US Vipal Jain

Studying the dead has the potential to save millions of lives Studying the dead may not seem related to saving lives but, as one Toronto epidemiologist has shown, it has the poten al to save millions. As a strong proponent of this no on, Dr. Prabhat Jha is leading a study of 14 million Indians called the Million Death Study (MDS), which began over a decade ago. Jha’s study indicates that collec ng data on the dead can alter the way public health is addressed in developing countries such as India. Jha, a Rhodes Scholar, is a founding director of the Centre for Global Health Research at St. Michael’s Hospital, which is affiliated with the University of Toronto. Jha studied epidemiology and public health at Oxford University, which eventually landed him a posi on at the World Health Organiza on in the 1990s. He has published widely on topics such as HIV/AIDS and malaria; he is also the author of a groundbreaking publica on on tobacco control, which has been signed by over 160 countries. Juxtaposi on was able to interview Dr. Jha regarding his work with Million Death Study and how it contributes to understanding the healthcare system in India as well as applying the lesson learned in other health systems around the world.

What is the Million Death Study? PJ: The Million Death Study (MDS) is one of the largest

studies of premature mortality in the world. It’s an ongoing inves ga on that is being conducted in India, where, like most low- and middleincome countries, the majority of deaths occur at home and without medical a en on. As a result, most deaths do not have a cer fied cause.

deaths from infec ous diseases and consider the growing burden from chronic disease and it’s clear that India provides a beau ful living laboratory. Plus, India has always led on sta s cs – the world can thank Indian scholars for inven ng the “zero”, or we’d s ll be stuck with XXXVIII etc…

Dr. Prabhat Jha

How do you follow the Has the Indian public lives of millions in India? health system failed PJ: In collabora on with the its population?

influenced health priori es worldwide. Results have also shown that HIV/AIDS kills about Registrar General of India, MDS PJ: Yes and no. Child and 100,000 in India annually, rather has been monitoring nearly maternal survival in India than the 400,000 es mated eight million people in over one has improved substan ally, by the UN, providing direct million na onally representa ve especially in recent years, evidence as to the mortality households in India since 1998, due in part to modest health and will con nue to do so un l investments by the public health rate associated with a major 2014. Any deaths that occur in system. HIV infec on has fallen disease and risk factor. Through these examples, it becomes these households during this and malaria transmission has clear that coun ng the dead period are assigned a probable likely also decreased, but we cause, which is determined by a are less sure if deaths have also is one of the best possible investments in global health. method called verbal autopsy. decreased. The key challenge Our team of 800 field staff is to apply simple, widespread What advice do you collects informa on on deaths in remedies for adult mortality these homes and those records that can achieve the kind of have for students are then converted to electronic successes seen in child survival. interested in global form. These reports are sent health research? to two doctors trained by us What implications PJ: Be quan ta ve and serious to code the cause of death. about global health. Understand do the results of It’s a simple system being the transforma ve power of this study hold? u lized on a na onal scale. ideas and research, and don’t PJ: The results for the leading

Why is India the centre of focus for this study? PJ: As goes India, so goes global health. India’s popula on alone suffers approximately nine million of the 56 million deaths per year globally. It also accounts for nearly two million child deaths annually – about a quarter of the world’s total. Add these numbers to those of

causes of death in India have been provided to governments, research agencies and media as they become available so that these bodies can take ac on against preventable deaths. MDS findings, such as es ma ng one million deaths a year from smoking in India and 200,000 deaths from malaria (versus the 15,000 es mated by the WHO in India), have already directly

be too confused by the “social distrac ons” of health. Big gains from tackling major diseases and risk factors are possible, and don’t require general improvements in poverty or governance. Understand the differences between charity (what NGOs do well) and research (what universi es do best).

1. Prabhat Jha, personal interview with epidemiologist, September 27, 2012. 2. Prabhat Jha, Centre for Global Research h p://www.cghr.org/index.php/researchers/cghr-toronto/#PJha

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Juxtaposition | Winter 2013


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Juxtaposition 6.1  

It Takes a Village: Improving community health outcomes at home and abroad

Juxtaposition 6.1  

It Takes a Village: Improving community health outcomes at home and abroad

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