VOLUME 9 ISSUE 1 - 2016 |
Letter from the Editors
Global Health Snapshots
Dying Early Behind Bars Nothing "natural" about deaths in Canadian prisons
Liminal Spaces W ithin The Universal
Lead Poisoning Race, Class and the Environment
& Sudipta Saha
Access to Anti-fungals
Marginalization within the sexual rights discourse
The cases of Flint and Grassy Narrows
When the invisible hand does not hand out drugs Lena Faust
The Trans-Pacific Partnership Implications for Canadian Public Health
The Sight of Sight for All A quest to provide affordable eye-care
Rowena Symss & Sudipta Saha
Conceiving Justice Examining India's evolving reproductive health policies
LETTER FROM THE EDITORS ?Juxtaposition? That?s an interesting name for a global health magazine?? is probably one of the most common responses people have upon learning of this magazine?s existence. We both have slightly personalized and flexible versions of an explanation memorized. Mention ?multidisciplinary perspective?, a current global health topic, how the inquirer?s field of study has a role to play, and sprinkle buzzwords as necessary - the editors? trick to recruit new members and keep the magazine running as we graduate We too fell for it back in the day... (2 years ago). Underlying these off-the-cuff responses that are requisites at events, is a strong sense of purpose that has guided this magazine since its inception. At a time when health is often viewed exclusively through a biomedical lens, we have acted as a platform for students to engage in a multitude of alternative narratives - socio-cultural, legal, economic and political. Students "juxtapose", if you will, these against health. Run exclusively by students volunteering their time, the magazine, while staying true to its mission, changes flavor as people come and go. Juxtaposition has spent the last few years transitioning into the digital realm. What started as a bi-annual publication has now transformed into a continuously publishing website with one annual print issue. We entered our term as Co-Editors-in-Chief wondering how to further expand our magazine. Juxtaposition had always fostered an enthusiastic readership within the University of Toronto, but we wanted to broaden that engagement. Throughout this year, we made many notable achievements. Our online pieces garnered the highest readership numbers since the conception of juxtamagazine.org. We covered current issues as they came up in popular discourse, as well as ones that did not: the Flint water crisis, global mental health and health in prison populations. Issue 9.1 includes some of the best articles published during the year, as well as pieces written especially for publication. Our articles gained a lot of traction through social media, collecting shares, likes and retweets on all our platforms. Of course, we also shared notable events in global health, through news and commentaries, and trained our own unique lens on major news stories. From the Zika virus outbreak, to the refugee crisis, we provided a platform to discuss the health implications of such events. In this issue, take a look at some of these in the Global Health Snapshots. Additionally, for the first time ever, our Toronto Thinks Global Health Case Competition became a Canada-wide conference. We were thrilled to receive more than 200 applications! Delegates spent a weekend creating multidisciplinary solutions to a current global health issue, and presented them to a panel of judges. You can find the winning team?s solution featured in this issue. We were pleased to have an active readership and a strong interest from students and future leaders. None of this would have been possible without our brilliant team (the largest in our history), our sponsors, and you, the reader. We hope you enjoy this issue.
Editor-in-Chief Executive Division 2015-16
Editor-in-Chief Editorial Division 2015-16
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GLOBAL HEALTH CANADA'S INTERIM FEDERAL HEALTH PROGRAM REINSTATED In 2012, the Harper government cut back the Interim Federal Health Program (IFHP) in order to save an estimated $20 million annually. This prompted strong public pressure, particularly by a group called Doctors for Refugee Care, to reinstate sufficient healthcare coverage for refugees. The Federal Court of Canada ruled these IFHP cuts unconstitutional in 2014. The refugee healthcare benefits have been fully restored to pre-2012 levels, with additional coverage for refugees before their departure for Canada. Restoring refugee healthcare coverage, although not perfect, has lowered costs for provinces and territories, will save refugee sponsors money, and allows for proactive treatment of conditions, cutting costs to the emergency room. Now, refugees have health coverage analogous to Canadians on social assistance, which involves vision care, prescription drugs, and urgent dental care. The estimated cost of the reinstated IFHP is an annual $5.9 million.
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CHANGES TO CANADA'S BLOOD DONATION POLICIES
Men who have sex with men (MSM) are now able to donate blood to the Canadian Blood Services (CBS) and Héma-Québec if they abstain from sex with other men for at least one year. The policy formally came into effect on August 15, and is meant to protect the blood supply from contamination by HIV and other transmissible pathogens. The decision to enact a one-year deferral period is the most recent change in a long series of donation policy reforms. CBS and Héma-Québec, which took over blood donation services from Red Cross in 1998, originally had a lifetime ban for MSM, preventing men who had sexual contact with other
men since 1977 from giving blood. In 2013, the two organizations reduced this ban to a five-year deferral period, noting that they would conduct further research on a more appropriate time period. Although this change was generally celebrated as a step in the right direction for blood donation policies, some groups are advocating for further reform. For example, the Liberal party noted that the deferral period for MSM ignores those who are in safe and monogamous relationships. They promised to end the ban entirely during the 2015 election.
ZIKA VIRUS OUTBREAK IN THE AMERICAS While the Zika virus had a few outbreaks in Pacific islands prior to 2015, the outbreak in Brazil was the first large-scale one. It was likely brought in with a traveller from the Pacific islands, but the origin of the outbreak remains unknown. As a result of its novelty, very little is known about the virus. Its ability to cause defects in the fetuses of pregnant women (microcephaly) has only now come to light. In most cases, the virus causes no symptoms, or mild flu-like symptoms. Thus far, there have been over 1.5 million people infected and over 3, 500 reported cases of microcephaly. It has continued to spread to most countries in the Americas and has gone as far north as southern United States. The World Health Organization has declared the Zika Virus outbreak a ?Public Health Emergency of International Concern? (PHEIC). Efforts to control the epidemic have mostly centered around mosquito population control, since the virus is spread primarily through mosquitoes (although it can be sexually transmitted as well). There were concerns that the Olympics in Rio would exacerbate the spread of Zika, but evidence seems to show that these concerns have not materialised. To complicate matters, most of the cases are being seen in
SNAPSHOTS countries with strict laws regarding abortion and access to contraception. This has led to drastic recommendations in some countries asking women to delay pregnancy by months or years.
WORLDW IDE DISPLACEMENT AT AN ALL-TIME HIGH The number of displaced people worldwide hit an all-time high in 2015 and has steadily increased since then. Sixty-five million people, or one in every 113 people, are currently displaced ? half of them children. While the Syrian conflict has been the largest source of refugees, displacement has also increased in other places, including the Central African Republic, Yemen, Ukraine and Myanmar. In such regions, health systems are often strained due to casualties and deliberate targeting of health facilities. In addition to the violent conflict and precarious methods of travel, especially across the Mediterranean, refugees face multiple barriers to accessing healthcare once in other countries. In general, political and health systems of host countries have tended to restrict healthcare access to refugees even though they are particularly vulnerable to disease and mental health issues. For example, Jordan repealed free health care for refugees in 2014, and some OECD countries charge fees for non-emergency healthcare. Moreover, theoretical availability of healthcare often does not translate to delivery in practice due to cultural, language and knowledge barriers. A high level UN Summit in September adopted commitments to enhance protection for refugees, although its effects remains to be seen.
EBOLA OUTBREAK ENDS The Ebola outbreak that started in 2014 in West Africa, finally ended in 2016, although flare ups are expected in the region. It was the most widespread
outbreak of Ebola since the virus was discovered in 1976. As of May 2016, the World Health Organization believes that at least 11, 325 deaths have occurred. The response was commendable from a local perspective; dedicated volunteers and affected communities attempted to stave the outbreak. However, the lethargic response of international agencies, such as WHO, drew scalding criticism. WHO officially announced the outbreak as a public health emergency only in August, despite its awareness of the issue since the past spring. Following the H1N1 pandemic, in 2011, the International Health Regulations Review Committee provided recommendations to WHO in its management of outbreaks. WHO simply did not adhere to these recommendations and responded by cutting funds and resources from its surveillance and response teams, the exact opposite of what was advised. Incompetent and understaffed surveillance and response exacerbated the inadequacy of the response. The international community overall also had a poor response to the crisis, the most outrageous being the travel restrictions imposed based on unscientific rationale. A lack of rules and norms regarding research of potential drugs during an emergency also hindered development of treatments. A systemic neglect of such diseases meant a lack of understanding of the disease and potential treatments. A number of steps have been recommended following the crisis to reform WHO's practices. This includes measures to incentivize early reporting, setting up an outbreak response team and an independent accountability commission. Moreover, funding mechansims and research ethics norms should be in place to allow swift reaction in the case of an outbreak with regards to developing treatments. Contributions by Jerico Espinas, GaĂŤlle Groux, Sudipta Saha, Simran Dhunna and Ruth Nathaniel.
CONTRIBUTORS ALINA YU Alina is a global health and international relations student at the University of Toronto, St. George. IMOGEN SIRLUCK-SCHROEDER Imogen studied Microbiology and Health & Disease at U of T, and was Case Guide Co-Director for the 2015 Toronto Thinks case guide competition. She has a particular interest in mental health and aboriginal health. ABTIN PARNIA Abtin is a graduate from the Masters of Public Health degree at the University of Toronto. His current research is in social and environmental epidemiology. AYLIN MANDURIC Aylin is completing her fourth and final year of undergraduate study in the International Relations and Peace, Conflict, and Justice programs. SUDIPTA SAHA Sudipta recently graduated from University of Toronto where he studied Microbiology, Global Health and English. He is interested in topics relating to the political economy of health. LENA FAUST Lena is pursuing a Masters in Health Science at uOttawa, focusing on infectious disease and health inequality, after graduating from U of Toronto.
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SENJUTI SAHA After completing her PhD in Molecular Genetics, Senjuti now works in Bangladesh. She aims to bridge the gap between molecular biology and its implementation in resource-poor countries to advance health equity. ROW ENA SYMSS Rowena graduated from the U of T after having studied global health, anthropology, and classic civilizations. She hopes to pursue a career in education policy and project management. Cover page and all full-page illustrations by SARAH CRAW LEY. In-text ones by JULIAN BATTERSBY MORRIS.
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TEAM Editors-in-Chief Sudipta Saha Apirrami Thavalinkham Managing Editors Imogen Sirluck-Schroeder Simran Dhunna Sarah Bibby Idil Alcinkaya Associate Editors Waleed Ahmed Aylin Manduric WanXian Koh Julia Robson Sara Al Mouaswas Aceel Hawa Jessica Scott Staff Writers Mikayla Plishka Senjuti Saha Alina Yu Lena Faust Reporters Elizaveta Mironova Publicity Director Nicole Gumapac Events Director Navitha Jayakumari Events Associates Rosana Tharmaratnam Soaad Hossain Social Networker Rashi Gupta Abtin Parnia
I am invisible, understand, simply because people refuse to see me. - Ralph Ellison, The Invisible Man
OUT OF SIGHT, OUT OF MIND There are shadows amongst us. Shadows of people rendered invisible through laws, categorization and a lack of public recognition and depiction. They are often excluded from policies and laws that are ostensibly universal. These two articles take a look at different invisible populations - Canadian prisoners, and those excluded from the discourse of reproductive and sexual rights. Deemed deviants in some form or another, their treatment remains systematically different from those considered ?normal?.
DYING EARLY BEHIND BARS NOTHING "NATURAL" ABOUT DEATHS IN CANADIAN PRISONS ALINA YU
Most deat hs in Canadian prisons are labelled as being at t ribut able to "nat ural causes", lending t hem t he veneer of inevit abilit y. They are anyt hing but .
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Between 2004 and 2014, 899 prisoners died while in custody in Canadian prisons - a rate several times higher than in the general population. As an institution that is near-explicitly dedicated to disempowerment and deprivation, the prison system is perhaps as pure an antithesis to a healthy setting as possible. Yet - and it should go without saying - the institution responsible for incarceration and rehabilitation also has a duty to provide care to inmates and respect their human rights. While the state should always aim to uphold the human right to life and health, it holds a special burden of responsibility when the persons in question are directly and explicitly in the state?s care. Whether the Correctional Service of Canada (CSC) has properly upheld these responsibilities is subject to debate. Practices that are liberally employed in federal prisons - double-bunking, solitary confinement, overcrowding, disproportionate incarceration of and use of force against Aboriginal persons - have earned Canada significant criticism from international bodies and human rights committees. However, the disregard for prisoner well-being and rights may manifest in more insidious ways; deaths from ?natural causes?, for example, occur at much higher rates in prison populations compared to non-prison ones.
Natural-cause deaths are ones attributed by the CSC to terminal diagnoses, complications during medical procedures, or cardiac arrest. These account for about 70% of all inmate deaths - more than deaths by suicide, overdose, murder, and unknown causes combined. The average age at death from such "natural" causes is about 60, which is more than 20 years less than the national life expectancy. Even at face value, such statistics bring up a number of questions - are these deaths comparable to ?normal? mortality rates? Are they somehow preventable or premature? Can we truly call these deaths ?natural?? In 2013, a Canadian prison watchdog called the Office of the Correctional Investigator assembled a report on 50 inmate deaths that were labelled ?natural?. The report found that 35 of the 50 deaths were flagged as
?expected? because they concerned individuals with terminal diagnoses. Yet, of these 35, only 31 received palliative care. Additionally, a concerning discrepancy in terminal diagnoses exists between inmates and the general population. The first two leading causes of death among inmates - cancer and cardiovascular disease ? matched national mortality rates. However, the third, pneumococcal or flu infections, caused 10% of the deaths in prisons as opposed to the 3% in the general population. Among inmates, the heightened risk of AIDS, hepatitis, sepsis, influenza, and pneumonia is a cause for concern and a diagnosis with any one of these conditions alone is by no means sufficient to define a death as ?expected?. Indeed, it seems as if these deaths are at least in some part preventable and premature, although they are not labeled as such. Even if the deaths are entirely inevitable following infection, the underlying infections most likely are not. Public health measures and legislature to minimize infections in prisons are poor, and have been criticized for missing opportunities for improvement at best, and grossly inadequate at worst. Considering the higher-than-average infection rates in populations entering prisons, and the inherent higher risk of infection in prison settings, control and prevention measures in prisons should be a public health priority. The high-risk conditions maintained in Canadian federal prisons ? such as crowding, solitary confinement, double-bunking, and cells as small as five meters squared - both promote the spread of infections and exacerbate their outcomes. Within a compromised population, such continued structural negligence can be actively harmful. The failure to properly address this issue is a symptom of continued neglect - there is little ?natural? about the rate and prevalence of deaths attributed to preventable infections. Better policies do not have to be adopted solely for the benefit of inmates - improved measures against the spread of preventable, infectious disease would not only lower the prevalence of these infections in inmates,
but also reduce risk of spread to correctional employees, visitors, and the general public. In addition to the nature of the deaths themselves, the Correctional Investigator also raised concerns on the accountability, transparency, and justice of the investigations into these deaths. The CSC is legally bound to investigate any instance of inmate death or serious injury. This includes suicides, murders, assaults, overdoses, and natural-cause deaths. However, since 2005, ?natural? deaths have been investigated through a different process called a streamlined Mortality Review Process (MRP). None of the MRPs had been independently or expertly reviewed until the Office of the Correctional Investigator prepared its 2013 report. The report involved the review of fifteen natural death cases by a physician consultant. Of these, all but one were flagged as ?expected? by the CSC. Investigating the same charts and patient information available to the CSC, the independent medical practitioner raised concerns over ?questionable diagnostic practices, incomplete documentation, quality and content of information, delays and lack of follow-ups on treatment recommendations?, with some combination of concerns present in all fifteen cases. Additionally, an investigation of the quality of the MRP itself found that it was ?not carried out in a timely or rigorous manner, and it [failed] to meet basic investigative standards [of] independence, thoroughness, and credibility.? The significant shortfalls in standard of care, accountability, transparency and investigation, with regard to ?normal? and ?expected? deaths in prisons would be considered unjustifiable in a public health system. But sadly, these shortfalls endure in the corrections system ? where the norms governing quality of care is perhaps condoned by the workings of the prison itself.
In addition to ethical obligations, the Corrections and Conditional Release Act legally binds the CSC to ensure ?reasonable access to health care with professionally accepted standards of practice?. Yet health issues are the most-reported concerns from inmates. Since the existing protocol cannot keep up with modifications to provide adequate care on a case-by-case basis, fundamental changes to the way the CSC treats prison health is crucial. Such a systemic change should be determined by the demographics and characteristics of the inmate population to best serve all inmates. This population is characterized by a few noteworthy trends - it is increasing, immune-compromised, diverse, and aging. From 2003 to 2013, the rate of incarceration grew by 17%, in spite of the general population only growing by 6% and the crime rate dropping year-to-year. Racialization is clear, with a quarter of the incarcerated population in 2013 having aboriginal ancestry. In women?s prisons, more than one in three inmates is Aboriginal (use of "Aboriginal" is guided by categorical statistics collected by CSC). For Aboriginal and Black populations, rate of incarceration in the past decade has increased by 46% and 90% respectively, whereas a 3% decline in the incarceration of white inmates was seen over the same period. This growth in the inmate population mirrors larger patterns of demographic change in Canadian society - increasingly complex, ethnically diverse, and culturally pluralistic. But the growth cannot solely be attributed to overall population diversity. The rate of incarceration for black Canadians was 9%; nearly three times their representation in general society. Such trends warrant a look at the discrimination in both policing and the social capital and opportunity afforded to racialized populations. Poverty and income are powerful predictors of crime, addiction, and incarceration. The conditions that produce
Solit ary Confinement
Double bunking is defined as a form of confinement where two inmates are housed in a cell that was designed with the intention of housing only one. From 2009 to 2014, double bunking increased 90% and averaged at 20% at the end of the period. Double-bunking can lead to increased risk of violence between inmates. In 2013, the then Commissioner of the Correctional Service of Canada deleted the principles that ?single occupancy accommodation is the most desirable and correctionally appropriate method of housing offenders? and ?double bunking is inappropriate as a permanent accommodation measure within the context of corrections.?
Solitary confinement is defined as a form of confinement where prisoners spend 22 to 24 hours a day alone in their cell. It also describes regimes where prisoners do not have contact with one another, other than during an outdoor exercise period. In Canadian federal prisons, inmates under ?administrative segregation? spend 23 hours a day alone in their cells, eat all meals alone, and is only allowed one hour of exercise outdoors. Such confinement has been associated with insomnia, confusion, feelings of hopelessness and despair, distorted perceptions and hallucinations. (From ?A Sourcebook on Solitary Confinement?, by Dr. Sharon Shalev)
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and reproduce poverty, income disparity, and unmet health needs are partially mediated through a lack of social capital. Studies have shown a powerful link between social and economic inequality, and violent crime - crime is a manifestation of unmet social needs. From a social determinants of crime perspective, the statistics of inmate demographics seem unsurprising. The majority of incoming inmates have a history of underemployment, addiction, and substance abuse. The average level of education received before admission is Grade 8. In women?s prisons, nearly 70% report a history of sexual abuse and 86% report a history of physical abuse.
current prison health crisis. The ?tough on crime? era of the Canadian federal Conservative government - which is still very much in place - will likely generate a prison crisis for the Canada of tomorrow. Sentencing and parole policies have been modified such that inmates are staying longer before first release, federal security levels are higher, and the practice of solitary confinement is up. This translates into a larger inmate population, longer sentences, and more inmates contracting and dying from chronic and acute diseases behind bars. Laws concerning health care provision to these inmates need to change accordingly.
The population entering prisons is therefore already vulnerable, and marginalized - they are predisposed to poorer health even before exposure to the unhealthy environments inside prisons. Moreover, the inmate population is aging - one in five inmates is 50 or older, another one in five is between 40-49, and 23% of the inmate population is incarcerated for life or with an indeterminate sentence. Not surprisingly, prison populations have a disproportionately high prevalence of non-communicable diseases. More and more inmates are living with age-associated illnesses that may require very specialized and/ or expensive care - including palliative care - before their sentence is over. These changes in prisoner demographics result in a higher number of inmates who will contract and die from chronic and acute diseases in federal custody ? deaths that may have been prevented if they were not imprisoned.
Balancing justice and humanitarian concerns for inmates is difficult, but must be actively considered given the high health-risk nature of the prison environment, the vulnerability and complexity of entering inmate demographics, and the system?s capacity for negligence. Suffice it to say that the cumulative effects of demographics, conditions, and policies are becoming evident in an aging population with increasing complaints, diagnoses, and deaths attributed to ?natural? chronic conditions. Though the challenge of creating healthy prisons for an increasingly complex population is not a small one, it is ethically necessary - a criminal sentence should not mean a shortened life expectancy. It has been 40 years since Canada abolished the death penalty, a development celebrated as a great human rights achievement for the nation. Yet a prison sentence today could result in a ?natural? death behind bars with little natural about it.
The demographics linked to poor health access and outcomes, unmet social needs, incarceration, and elevated stress, are one and the same. The conditions of incarceration are undoubtedly intensely stressful and unsurprisingly, inmates report high rates of stress-related illness. The entering inmate population already has disproportionately high rates of trauma, mental illness, and sexual abuse. All three of these have been linked with accelerated psychological and biological aging. The cumulative effects of these stresses manifest in a population that presents as much as ten years biologically older than their chronological age. While Stats Canada defines an elderly person as anyone over 65, many jurisdictions define an elderly inmate as anyone over 50. A number of changes in federal policy in sentencing and parole will also undoubtedly contribute to the
LIMINAL SPACES WITHIN THE UNIVERSAL DYING EARLY BEHIND BARS
MARGINALIZATION WITHIN THE SEXUAL RIGHTS DISCOURSE IMOGEN SIRLUCKSCHROEDER
The human right s discourse has progressed to incorporate sexual and reproduct ive ident it ies and healt h. However, an uncrit ical accept ance risks overlooking inherent issues of exclusion.
Amazing strides have been made over the past 30 years in the recognition of sexual and reproductive rights within global power structures such as the World Health Organization (WHO) and the United Nations (UN). This is in no small part due to the tireless efforts of activists from gender, sexual and romantic minority groups in the wake of the HIV/AIDS crisis. The forms of marginalization and structural violence that these groups already faced were reproduced in discourses of blame, limited access to health care, and a lack of societal protection for the affected. Such oppression was also implicit in the disempowering ?intervention research? characterized by top-down responses aimed specifically at groups that occupy some ?targeted? space - that dominated the response to HIV/AIDS in the 1980?s and 1990?s. These marginalized groups championed debates that led to the inclusion of sexual and reproductive identities and health as important topics within discourses of global governance, where they were primarily framed as human rights issues. This process in some ways culminated in a 2004 statement by the United Nations Special Rapporteur on the Right to Health at the UN Human Rights Commission, which framed sexuality as a universal characteristic of humanity, and thus theoretically protected sexual rights as human rights under the umbrella of the UN?s human rights principles. This framing has created a very necessary space for advocacy and the pursuit of justice. However, an uncritical acceptance of the encompassment of sexuality and reproduction within this discourse, without vigilance with regard to steep power imbalances at play in the administration of the global human rights apparatus, would be a mistake. Many scholars have put forward critiques of the Western, liberal views of personhood and citizenship that are implicit in the current global human rights discourse, and have discussed the problems posed by such a human rights-based structure of legality and rights provision. One
of these was the Italian philosopher Giorgio Agamben, who explores the relationship between sovereign power (as present in the hierarchical structures of governance that currently control most access to health), law, and societal membership. For Agamben, making and applying laws is a process that inherently excludes certain groups, because laws are created by first establishing the definition of ?person? that they apply to. Structural violence is therefore implicit in Agamben?s conception of lawmaking, and the sovereign power responsible for lawmaking is also the power to determine which groups are excluded from the legal system. Legal exemption can be applied both to the sovereign body itself, where a sovereign who retains power cannot truly break the law, and to marginalized people, whose state of societal exclusion is created through the exercise of sovereign power. Agamben?s lens is extremely useful for deconstructing issues of access to the benefits of so-called ?universal? sexual and reproductive rights within the global human rights framework. This is because human rights are very much constructed as laws ? codified rules dictating the protections that should be extended to given groups in given situations. The current human rights discourse is rooted in the idea of a universalized human nature that stems from the European Enlightenment period ? a concept that is central to classical liberal philosophy, and that, in a distorted form, continues to inform contemporary neoliberal thought. The historically liberal human rights discourse thus constructs the human being as being defined by a set of universals. Probably the most famous of these is ?enlightened self-interest,? particularly with regard to social interactions. That self-interest is often constructed in this discourse within a capitalist framework that defines self-interest in terms of economic gain, dynasty-building and cohesion in a capitalist society. This bias within the human rights discourse becomes nefarious when considered with the fact that the
universal, or ?natural? laws that are said to govern human behaviour form the basis upon which the legitimization of the universal ?natural rights? are advocated for. A subtextual problem emerges, then, where in order to secure access to universal rights, one must embody ?natural? laws and emulate the ?natural? human being. When the ?universals? that supposedly define humans were largely defined through a highly Eurocentric, male, and heterosexually-oriented body of research, the structure of this discourse risks delegitimizing atypical or culturally-specific identities and practices. This leaves significant space for the endurance of existing forms of structural violence and for new violence against marginalized people, and limits the access of these people to the ?resources, recognition and representation? that are often contingent upon embodiment of sexual norms.
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The origins of the human rights discourse, and the continued influence of economic identity on concepts of freedom and personhood, also continue to influence how all agendas that are placed under the umbrella of human rights are pursued. The Programme of Action of the International Conference on Population and Development makes an overt call ?to redouble efforts to promote development through strengthened reproductive health and human rights,? tying the socio-economic phenomenon of development to reproductive health in a way that ultimately makes reproductive health goals secondary to economic interests. This tendency to represent human rights as servants to the development narrative, which is often hailed as the ultimate rational pursuit within a liberal conception of human progress, is a widely observed phenomenon within the rhetoric of the UN and WHO. Specifically, this suggests that the negative impacts of economic development policies with regard to non-economic human rights, such as sexual and reproductive rights, can often be under-appreciated. Indeed, some international development initiatives have frayed support systems in the regions that they targeted, creating or allowing human rights abuses that go ignored.
This opportunity for marginalization is reinforced by another feature that Agamben identifies within laws that are based on notions of the ?universal? ? namely that they primarily exist as symbolic structures rather than as a binding contracts in reference to each individual case. The global human rights discourse currently lacks a functional system to enforce legal protections of human rights. But the framework is not questioned and deconstructed every time that it fails to protect ? typically failing to protect the most globally marginalized. The sum result of this is that non-dominant bodies do not have the capacity to claim the benefits of their ?universal? human rights, while the globally powerful are provided with moral
high ground and a basis to cherry-pick the instances in which they choose to pursue any real embodiment of rights. The question arises as to how people are relegated to liminal spaces with regard to their access to ?universal? sexual rights, and thus are, through sovereign structural violence, denied access to sexual and reproductive health care and resources. One way of categorizing the people put in these spaces is to put them into two groups. The first would include those who, due to their citizenship status, are excluded broadly from the human rights framework. The history of the Western human rights discourse shows that it is very strongly rooted in nationalist notions of citizenship, and that citizenship is an essential feature of access to rights. Indeed, many of the groups that continue to experience severe limitations in their access to sexual and reproductive health and rights fit into this category. These include migrants in transit, undocumented immigrants, refugees, displaced people, people whose sovereign government is compromised by civil war or conflict, political prisoners and prisoners of war, and others whose legal status as a resident citizen is somehow compromised. Although there are mechanisms in place within structures of global governance to address this severe limitation in the human rights framework, through humanitarian aid and other channels, the degree to which sexual and reproductive rights violations continue to go unchecked within these populations is a testament to their functional marginalization. The other category of people who are particularly vulnerable within the human rights apparatus include those who have their political citizenship intact, but do not meet the ideological criteria for
personhood that are implicit within the liberal, capitalist framework that houses the global human rights discourse. Deviation from norms of ?rational? sexual conduct, implying a tacit rejection of the logic of the human rights discourse, comes with a nuanced loss of moral status within the ideology governing the human rights framework. Through these mechanisms, people's sexual health status (as reflecting their past sexual behaviour), and their decisions with regard to sex and sexual health, can be used to place them in liminal spaces, where they lose the definition of the "rational" liberal being that is the recipient of rights. This can manifest in stigmatization and infantilization, if not fully dehumanization, of people who do not accept and reflect Western liberal models of logic and personhood. Paradoxes arise when the rules and norms that are being enforced within the ?universal?global human rights apparatus don't reflect the realities that individual bodies within it experience. Sex work is a rich territory for the exploration of how marginalization occurs in the world of sexual and reproductive rights. A central category of people who do not reflect the restrictive characteristics of ?rational? liberal personhood includes those who breach the social norms of ?safe sex,? which is often painted as monogamous, informed of a partner?s sexual history, and involving the consistent use of barrier methods: all choices that sex workers may not make or may not be able to make. Both legal prescriptions and moral stigma combine to place the sex worker within a liminal space with regard to the social legitimacy to advocate for sexual and reproductive rights.
Interestingly, debates about the legitimacy of sex work often center around the identity of the sex worker as a free economic agent, which legitimizes the practice within a capitalist framework of self-commodification in the name of economic self-interest. There are indeed perceived differences in health service needs between sex workers and an idealized general public in the United States. This has led to a call for clinics that cater specifically to sex workers, at the expense of efforts to diversify services and practices at existing clinics. In an already strained health care system, funding for new, sex worker-specific clinics is very predictably underprivileged compared to funding for non-specialized clinics. Segregation and marginalization based on sexual identity is evident in this example, where the right to sexual and reproductive health was unequally protected across different groups, due to the creation of a hierarchy of rights claimants within a single category of rights. The erasure of rights claims can also occur due to the creation of hierarchies between different categories of rights by powerful bodies or institutions. Part of the rhetoric justifying the United States? military invasion of Iraq was based upon importing new human rights and freedoms into a despotic region. Within this presentation, the invading body framed itself as a champion of the ?Western? human rights discourse, and this rhetoric used the moral weight of the entire collection of rights within this discourse to support their military campaign. However, even though the discourse now encompasses women?s rights, and sexual and reproductive rights, women?s health and safety was very evidently deprioritized. As one example, subjection of female Iraqi sex workers to violence and instability rose markedly after the U.S. invasion, with little or no effort to address these issues. It is certainly overwhelming to contemplate the oversights, manipulations, and downright abuses that continue to plague people who are supposedly protected under the expanding umbrella of the human rights discourse. Polarized reactions to the legitimacy of this discourse are likely. But one does not in any way have to delegitimize the human rights discourse, or to argue for its abandonment, to promote enduring vigilance toward the abuses that are possible within this necessary framework. It is imperative that rather than leaving these rights on their finally-achieved pedestals within the ruling discourse and closing the door on continued inquiry, we, as Agamben argues, forever scrutinize laws, with an understanding of their relationship to power and marginalization.
THE POISONS AROUND US Following the Industrial Revolution, heavy metal pollution soared. Although recent policies have helped reduce their impact at a population level, poor and racialized communities continue to be affected disproportionately. Due to impacts on neurodevelopment, children often bear the brunt. These articles take a look at the cases of Flint and Grassy Narrows, and the history of lead poisoning.
LEAD POISONING: A REVIEW ABTIN PARNIA
Lead w as once ubiquitous - present in paint s, fuel and pipes. Since t hen, intervent ions varying in design and scope have reduced human exposure.
The crisis in Flint, Michigan, has brought lead poisoning to the forefront of North American public health discourse. However, as one of the oldest hazards known to public health, lead has been studied extensively, and numerous policies have been implemented to reduce exposure to lead. This heavy metal has been implicated in many adverse health outcomes including neurodevelopmental effects, anemia and kidney diseases. The damage can be permanent in young children, and it causes a variety of learning disabilities and cognitive problems depending on the level of exposure. The objective of lead reduction programs and policies has been to reduce human contact with sources of lead. These interventions are shaped by how the population of interest is conceptualized. For instance, programs that focus on reducing exposures for young children or those that attempt to monitor products that may contain lead represents two different approaches to public health interventions. This article reviews the epidemiology of lead exposure and discusses the conceptualizations that have led to the several public health policies and programs for lead exposure reduction. BACKGROUND Lead was a ubiquitous metal during the industrial revolution until the 21st century. While it was known from early observations that high levels of exposure to lead results in lead poisoning, the effects of sub-clinical exposure (i.e. without showing symptoms) were only investigated in the last 50 years. Until 2012, the Centre for Disease Control and Prevention (CDC) labelled blood lead levels above 10 ug/ dL in young children as the "level of concern". However, there is evidence of harmful effects of lead at lower blood levels, even below 5 ug/ dL; thus, experts now use that as the reference level. Lead can be absorbed through inhalation, and oral and dermal exposure. Although historically the use of leaded gasoline resulted in exposure through inhalation, with its phasing out, other sources, such as drinking water, food,
and products like lead paint have become the major contributors to exposure in Canada. For young children, due to their interaction with the environment and their frequent hand-mouth contact, the exposure could come through non-food items, such as lead paint and contaminated dirt or dust. In Canada and US, the children likely to be at risk live in old houses with lead paint that may require renovation. Moreover, industrial activities are still significant sources of lead exposure throughout the world. The epidemiology of lead poisoning reflects a distribution shaped by socio-economic status and marginalized identities, reflecting the history of environmental racism in policies. In Canada, since 1971, the blood lead levels have decreased by 70%. However, low income, immigrant, and racial groups who reside in old housing are at greater risk of lead poisoning and have higher blood lead levels compared to other Canadians. A similar pattern of skewed distribution is visible in the US. Unfortunately, there are no nationally representative surveys of lead concentrations based on gender, ethnicity, and immigration status in Canada to describe the extent of health inequities between different groups. Globally, the burden of lead poisoning persists, and it accounts for 0.6% of the global burden of disease. The 2010 case of lead poisoning in northern Nigeria illustrates that severe lead poisoning is still a global issue, and public health interventions are needed. According to Medecins Sans FrontiĂŠres, unsafe mining practices resulted in numerous cases of lead poisoning. The average blood lead level was 127 ug/ dL, contributing to the mortality rate of 43% seen in one of the villages. This case highlights the need for strong public health action in all countries and global regulations on lead-containing products and industrial uses. TARGET FOR INTERVENTIONS The primary goal of public health interventions on lead exposure is to remove it from the human environment.
Policies and programs in public health have been designed to achieve this in numerous ways. For example, policies on regulating mining and smelting, banning of lead in gasoline, paint, cans, pipes, and food and other products were designed to protect the whole population from exposure to lead. Other public health interventions focus on specific high-risk groups. High-risk groups can be conceptualized in two different ways. It can either be understood as age-groups that are more at risk of exposure to and harmful outcomes of lead poisoning, or as individuals having blood lead concentration above a certain threshold that is deemed dangerous. Young children below the age of 5 are considered a high-risk group and are often the target for interventions. In the US, the CDC also recommends children of families who are the recipient of Medicaid to be tested for lead, a narrow definition representing low-income families. However, less than 25% of the eligible children receive the test. For secondary prevention interventions, the high-risk group is often defined as children whose blood lead levels are above a certain threshold. While both these conceptualizations of high-risk groups followed a set of justifications, they have disadvantages associated with them.
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The conceptualization of high-risk as being above a certain threshold of blood lead levels has been the dominant public health approach. Interestingly, the threshold changed dramatically as the understanding of the effects of lead improved. The threshold for blood lead levels - described as the level of concern - was at 60 ? g/ dL in 1960. This was changed to 40 ? g/ dL in 1971, 30 in 1975, 25 in 1985, and settled at 10 ? g/ dL since
Medial blood lead level data from NHANES, compiled by EPA
1991. However, no concentration of lead seems to be safe, and there is evidence of harmful effects of lead in levels as low as 1 ? g/ dL. In the case of Flint, Michigan, the recent study on lead exposure in children defined elevated blood lead levels as results above 5 ? g/ dL - this is now used as a "reference level". From blood lead levels below 10 ? g/ dL to 150 ? g/ dL, there are a range of health effects. The historical trend of changing this threshold demonstrates that focusing on only this definition of high-risk will not result in eliminating lead from the environment and and thus not have a population health benefit. This conceptualization of high-risk groups can be attributed to pressures from industries and marginalization of affected communities. The second conceptualization of high-risk is to focus on specific age groups. The reason to target young children is that due to a higher rate of gastrointestinal absorption and less effective renal excretion, combined with the increased risk of ingesting contaminated matter, children are more likely to accumulate lead compared to adults. Furthermore, the bulk of literature on the harmful effects of lead poisoning pertains to the detrimental effects on neurodevelopment. These effects are particularly damaging to children, and the consequences are considered to be irreversible. One of the challenges of focusing on children is the transfer of lead from mother to child. Due to the mobilization of lead from the bone, the mother can transfer lead to the fetus or later onto the infant via breast milk. Therefore, focusing on only children and removing lead from their environments specifically may not minimize the harm from lead exposure. Furthermore,
high blood lead concentration does not only have neurodevelopmental effects in children - it is also associated with cardiovascular, renal, neurodegenerative, and reproductive health conditions. These can be particularly damaging in susceptible populations, such as those with kidney diseases, hypertension, or diabetes. Therefore, attention to the removal of lead hazards from the environment can also benefit those not in the young age groups considered to be at high-risk.
control trials on education and dust removal interventions, it was concluded that these interventions are not as effective as other lead-exposure prevention programs. Lastly, tertiary prevention concerns individuals with highly elevated blood lead levels. The current recommendation by the CDC for blood levels above 45 ug/ dL is the provision of chelation therapy, but its efficacy in reversing the harmful effects of lead poisoning is not clear.
NOTHING"NATURAL"ABOUTDEATHSINCANADIANPRISONS INTERVENTIONS The public health interventions for lead exposure have been well researched in the past 50 years. Interventions exist for primary, secondary, and tertiary prevention, and target both whole populations and specific high-risk groups. For primary prevention, methods to limit known sources of exposure is well understood and during the past 5 decades, policies have been implemented in many countries. However, these measures have not been adopted universally; for example, while harmful effects of leaded gasoline were known since the early 20th century, the US only started phasing it out in 1977. According to the data from National Health and Nutrition Examination Survey (NHANES II), the blood concentration of lead and phasing out of gasoline are associated with one another, demonstrating the importance of policies that remove lead from the environment. Following the implementation of such policies, primary prevention can focus on enforcement as well as removal of lead from the environment. For example, removal of lead paints from old homes and identifying homes in need of such services can be part of strategies. Since this approach can be costly, secondary prevention can focus on households that have high blood lead levels in children. However, this approach has been criticized for not adequately preventing the irreversible impact of early lead exposure. Other examples include removal of lead from drinking water, nutritional intervention to improve iron and calcium levels in the body to reduce uptake and enhance removal of lead, public health educational campaigns, and dust removal. Secondary interventions differ from primary prevention through the use of a screening procedure. Blood lead screening is focused on groups that are defined as high-risk. In this conceptualization, children at risk are defined as those above a certain threshold of blood lead(>10 ? g/ dL since 1991) who live in old housing, and have a certain behavioral history or a history of lead exposure in their household. Following identification, the interventions are often education, dust removal, cleaning, or lead abatement strategies. However, according to a recent meta-analysis of randomized
While each of these strategies may be appropriate for certain populations, the context of lead exposure is important to consider. The current body of evidence demonstrates that policies banning specific types of lead products have shifted the distribution of blood lead concentrations to lower levels. Therefore, if countries currently lack such policies, they need to prioritize their implementation to shift the distribution at a population level. However, phasing out previously used products, (i.e. changing lead pipes, removing lead paint, etc.) is a significant challenge. While primary prevention like this requires significant funding and resources, the case for cost-effectiveness of undertaking such initiatives can be made. As discussed in the conceptualization of high-risk groups, the benefit of interventions with screening processes to find high-risk individuals can be limited in scope. The case for the population-based approach, as opposed to screening, can be argued based on the broad range of health consequences that exposure to lead can have on individuals, leading to high costs on the health care system. Screening, while valuable in generating evidence, needs to be used in conjunction with population-based interventions. Furthermore, lack of effectiveness of individual or family-oriented interventions such as education and dust cleaning emphasizes the need for primary prevention on a population level. CONCLUSION With the industrial revolution and an increase in resource extraction, there was increased use of lead in different products, a higher concentrations of lead in the environment and consequently in humans. In the past century, many public health interventions have been implemented in different countries that have considerably reduced blood lead levels in humans. The most successful policies recognize that the impact of lead is spectral; the ensuing harmful effects exist at virtually all concentrations in humans and as such, there is the need for policies and interventions that will lower blood lead levels among the whole population. The case of Flint demonstrates the need for officials in municipalities and public health departments to be vigilant about the sources of environmental hazards and maintain the infrastructure required to curb the lead?s impact.
RACE, CLASS AND THE ENVIRONMENT THE CASES OF FLINT AND GRASSY NARROWS AYLIN MANDURIC, SUDIPTA SAHA
The cases of Flint and Grassy Narrow s exemplify t he manifest at ions of environment al racism and injust ice in Nort h America.
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In the past year, the water crisis in Flint, Michigan involving lead contamination has garnered extensive media coverage due to its causes, spread and woeful mishandling. While coverage and attention has dwindled since its initial discovery, its effects will leave a stamp for decades as children, who are the most vulnerable to lead poisoning, have been some of the hardest-hit victims. Moreover, the case of Flint, which is majority African-American and incredibly poor, is not a rare exception. Poor and racialized minority communities have consistently been subjected to neglect and detrimental environmental policies not just in the United States, but also in Canada. Environmental injustice and racism have manifested in numerous crises and in daily life.
The crisis began when the city of Flint began to source its water from the Flint River in May of 2014, in spite of evaluations that questioned the water quality. In fact, an assessment in 2004 placed the river?s water in the highest category of susceptibility to contamination. The switch to this riskier source was driven by the small city?s financial difficulties, and was intended to be a ?temporary move? until the town?s new water authority could construct a water pipeline to Lake Huron, due to be completed at the end of 2016. This meant, however, that residents relied on potentially unsafe water for months, ultimately leading to exposure to toxic levels of lead. Residents began raising concerns about the new water source almost immediately after the switch to Flint River. Their reports of murky water, rashes, hair loss, and vomiting were often outright ignored by
public officials. Contaminated water flowed through Flint households for over a year before public pressure intensified and the conditions attracted national and international media attention. The public health consequences were dire: comparison of blood tests conducted in 2013 and 2015 revealed that the number of children with elevated serum levels of lead had doubled after the city switched water sources. The core of the problem with Flint?s water lies in the fact that the river has naturally high levels of corrosive chlorides. In addition, according to the Michigan Department of Environmental Quality (MDEQ), supplementary iron-chloride had to be added to remove high levels of solid contaminants. Indeed, Flint?s water supply contained three times the accepted level of chlorides under public health
guidelines. In spite of the high chloride levels, MDEQ had been allowing the corrosive Flint River water to be piped into homes without necessary anti-corrosive treatment. The water was so corrosive that in October of 2014, General Motors discontinued its use of Flint River water for the manufacture of auto parts - yet it was deemed by the city to be suitable for human use. Other issues with water treatment led to wave after wave of biological contamination and the generation of carcinogenic by-products, trihalomethanes, in unsafe concentrations. When this water flowed through pipes in old buildings, an even greater threat was generated: the corrosive water caused metals, including lead, to leach out of pipes, contaminating the drinking water. There is evidence to believe that many residents of Flint were exposed to dangerously high levels of lead. While the Centers for Disease Control and Prevention (CDC) maintains that there is no such thing as a safe level of lead exposure, the Environmental Protection Agency (EPA), requires action at 15 micrograms per liter or 15 parts per billion (ppb). Between June and December 2014, 2 percent of tap water samples from Flint homes contained a lead level higher than 15 ppb, with 10 percent of homes containing a lead concentration higher than 6 ppb. This is disturbing, given that several researchers agree that lead levels of 5 ppb is already a cause for public health concern. By early 2015, researchers found that 30 water samples collected from Flint homes had lead levels ranging between 200 and 13,200 ppb. At lead concentrations of 5000 ppb, the EPA considers the water akin to hazardous waste. The Flint water crisis is not an isolated incident. Though this crisis was triggered by a change in water sourcing, similar outcomes have been seen in communities
situated within the vicinity of polluting industrial complexes. Often, as in the case of Flint, these communities fight an invisible and silent battle. Sometimes the significant consequences become a topic of interest for national media, bringing public attention to and hopefully prodding governmental action on such injustice. The act of subjecting communities to environmental harms and the subsequent silence and inaction can often be associated with racial and economic factors. Indeed, facilities responsible for the heaviest pollution tend to be located close to low-income and minority communities. Environmental justice and environmental racism are terms used to express the intersections between racialized discrimination, economic and political disempowerment, and unequal burdens of environmental pollution. Although there are many historical examples of environmental injustice and racism, these terms only originated in the 1980s with protests against toxic waste disposal in African-American majority areas in the Southeastern United States. Poor and minority neighbourhoods were disproportionately home to hazardous sites, municipal landfills, incinerators and coal power plants. Unfortunately, although environmental racism has been most widely recognized in the US, egregious examples of this type of discrimination also exist across the border in Canada.
Perhaps one of the most outrageous examples of environmental racism in recent decades has been the dumping of 10 tonnes of mercury into the Abigoon-English River system between 1962 and 1970 by a now-defunct pulp and paper mill near Kenora in northern Ontario. This water system provides for the communities of Asubpeeschoseewagong and Wabaseemoong First Nations, also known as Grassy Narrows and Whitedog respectively. As with lead, the harmful effects of environmental mercury exposure is well known. An infamous incident in Minamata, Japan in the late 1950s was the first case of wide-scale mercury poisoning that was documented and researched. The symptoms - numbness in the extremities, muscle weakness, lack of muscle coordination, and developmental disorders in children of exposed mothers were defined as Minamata disease. In Grassy Narrows, which was directly downstream of the mill, it was not until 1970 that the government finally conducted testing among residents despite clear signs of mercury poisoning. The tests revealed extremely high levels of mercury in hair and blood samples. Dr. Masazumi Harada, who led the research efforts in Minamata, came to Grassy Narrows in 1975 to investigate, and since then, his team has done more comprehensive research than the provincial and federal governments of Canada.
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In 1975, Harada?s team reported the presence of Minamata disease in Grassy Narrows. However, it wasn?t until 1986 that government officials set up a disability board to award compensation to those who suffer from symptoms of mercury poisoning, based on a severity score assigned by doctors. Since then, neither the compensation nor the scoring-criteria have been updated to meet inflation and changing scientific standards. Moreover, the government refuses to explicitly admit that those suffering have Minamata disease - the board insists that the policy is in place to relieve ?residents who suffer from various health issues in the mercury pollution district?.
Although Harada?s team conducted field studies in 2002, 2004 and 2010, there has been no systematic investigation or monitoring by Canadian health authorities to uncover the full extent of mercury poisoning in this area. One long-term study undertaken by Health Canada has been plagued by complaints of withholding information from study subjects. Between 1978 and 1992, researchers collected data on mercury levels in umbilical cord blood, which provides a measure of fetal exposure to mercury. Follow-up studies looked at potential neurodevelopmental effects and measured mercury in hair. At least 143 children were exposed to concerningly high levels during pregnancy. Yet Health Canada never contacted their parents, or incorporated these findings into
the compensation board?s diagnostic criteria - they were, and still are, being deprived of potential measures that could help alleviate future development of symptoms. Perhaps most concerning is that the 2010 investigation by Harada?s team found evidence of a surprisingly high rate of mercury poisoning symptoms in younger generations. In addition, an ecological study has found increasing mercury levels in the area. Both levels of government have consistently not only ignored the plight of the victims, but have also been negligent in cleaning up the river system. Recent investigations by the Toronto Star have revealed that for months the provincial government ignored information from a former worker at the factory who recently disclosed the location of a potentially unsafe mercury dumping ground that could still be leaking. Back in 1984, the province also ignored a minister?s recommendation to clean up the river system, instead opting for ?natural? recovery. There has been no such recovery. The residents of the area, victims of environmental racism, continue to suffer from the effects of poisoning and will likely continue to be affected for at least a generation. The local economy, based on fishing and fishing tourism, was destroyed. Some victims complain of numbness in their fingers, making regular household tasks incredibly hard. Others, including children born after the initial dumping, suffer from degenerative muscular diseases, and some have died. Psychiatric symptoms of poisoning like depression and self-injury have also taken lives. In the absence of a systematic study, assigning a number to the toll is impossible. The stories of Flint and Grassy Narrows are just two instances where a confluence of factors, including the severity of the crisis, the magnitude of negligence, and the vagaries of the news cycle, have resulted in broad public awareness. Yet, environmental racism and injustice is a pervasive phenomenon. First Nations homes across Canada are 90 times more likely to be without safe drinking water than Canadian homes. African American neighborhoods are constantly used as sites of toxic industries and plants. Communities deprived of political power, either due to race or their financial situation, are subject to unfavorable environmental policies, raising questions about the value that is put on the lives of poor minority citizens. The EPA only began seriously engaging with federal authorities on the issue of environmental discrimination in 2012, but progress has been slow. No such equivalent exists in Canada yet. Until every level of government starts equally respecting the lives of all residents, after the news cycle moves on cases like Flint and Grassy Narrows risk becoming nothing more than water under the bridge. Kara Grace Hounsell helped in editing this article.
W HEN HEALTH IS NOT FOR ALL
In the past 60 years, unbridled globalization and spread of neoliberalism has resulted in "economic growth" at the cost of profound inequalities. W hile markets and people across the globe are more connected than ever, essential medicines can remain out of reach for those who most need it. It can take decades before a drug used in North America reaches a low-income country. These articles take a look at the ominous signs of the Trans Pacific Partnership, and an innovative approach to provide short-term relief for access to specific drugs.
ACCESS TO ANTI-FUNGALS WHEN THE INVISIBLE HAND DOES NOT HAND OUT DRUGS
The global drug market fails to provide medicines to t hose most in need. Research and Advanced Market Commit ment s offer hope for access to ant ifungals in Sub-Saharan Africa.
Today?s capitalist global economy has created and perpetuated serious disparities in healthcare delivery between the rich and the poor. Within this economic system, market forces are a greater determinant of medical resource distribution than actual health needs. This imbalance represents a significant barrier to the provision of equitable access to medicines, which remains one of the greatest global health concerns.
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Despite many medications having come off-patent in recent years, and there being a greater push for development of generic drugs, there remains a distinct inequality in access to medicine within developing countries. This is particularly true for antifungals in Sub-Saharan Africa, where inadequate monitoring of fungal infections such as cryptococcal meningitis (CM), coupled with the high cost of antifungal drugs, has resulted in market failure for even the most basic medications for these diseases. This is all the more concerning in light of the fact that many common antifungal compounds were introduced to markets in developed-countries over 50 years ago.
Effective treatment of CM usually involves a combination of the antifungals amphotericin B and flucytosine. Unfortunately, significant barriers exist to the widespread use of both drugs in developing countries. Amphotericin B is significantly more expensive than other antifungals, and treated patients require extensive monitoring for potentially severe side effects, making it unfeasible to administer in low-resource settings. Flucytosine, associated with very positive recovery outcomes in CM patients, is not available in many parts of Africa, leaving a cheaper but less effective alternative, fluconazole, as the only treatment option. THE POW ER OF PREVALENCE DATA The unavailability of flucytosine in African markets
is believed to be due to an underestimation of the severity of CM and a lack of precise data on its contribution to the region?s total disease burden. This has created an apparent lack of demand, resulting in market failure of the drug. Considering these economic and systemic barriers to drug access, market-based solutions to global health problems have attracted increasing interest, as they provide opportunities to intervene in markets that otherwise cater disproportionately to the high-income minority and widen disparities in access to medicine. In the case of antifungals in Sub-Saharan Africa, as a viable market cannot emerge via ?natural? market forces, the availability of these drugs must be more actively facilitated through solutions such as need-based preferential pricing negotiations and advanced market commitments (AMCs).
AMCs usually involve the presentation of disease prevalence data to governments and non-governmental organizations, in order to determine their interest in providing up-front funding for drug distribution. Depending on anticipated demand and the amount of pledged funds, an AMC proposal and preferential pricing scales can be presented to manufacturers, who may in turn agree to supply the drug at a set price. This ensures the affordability of the drugs for developing-country markets, whilst the manufacturer?s profit gap is bridged by donors. This model has proven successful in previous initiatives, such as the Pneumococcal AMC Program carried out by the Gavi Vaccine Alliance to facilitate pneumococcal vaccine availability. The lessons learned from this program, such as the need to make pricing schemes adjustable to accommodate the fluctuations of a new market, can be applied to increase the likelihood of success of a similar program in the case of flucytosine.
Projected AMC model and implications for addressing CM. KT = Know ledge Translation. (Adapted from GAVI )
Unfortunately, although the prevalence of CM in Sub-Saharan Africa is estimated to be high, precise data on its prevalence in particular regions, and on community-specific health and resource needs are lacking. This lack of accurate epidemiological data - which forms the basis of AMC funding and pricing - has limited negotiations for AMCs for CM drugs. PILOTING DATA COLLECTION: INITIAL CROSS-SECTIONAL STUDIES OF CM IN SUB-SAHARAN AFRICA Given the absence of accurate, comprehensive and geographically specific disease prevalence data, conducting a cross-sectional study
of the current prevalence of CM in a Sub-Saharan country is a crucial first step. This would not only provide relevant disease-burden data in the country itself, but also act as a pilot for similar initiatives in other countries in the region. Moreover, since ineffective distribution is another major barrier, precise, community-specific data on the occurrence of disease would allow more coordinated distribution of the antifungals once available. Ultimately, this would enable evidence-based negotiations with drug manufacturers to secure AMCs, making the required antifungals available and affordable where they are most needed. A relevant initial target site for such data collection is Tanzania, as there is a lack of previous studies of CM prevalence in the country, and flucytosine remains both unregistered and unavailable in Tanzanian markets. Little attention has been paid to preventing the development of cryptococcal infections into severe CM, which could be achieved through increasing the availability and appropriate distribution of flucytosine. Moreover, considering the strong comorbidity of CM with HIV, Tanzania?s relatively high HIV prevalence (5.6%) makes it a pertinent study location. In terms of measuring CM prevalence, the use of the Lateral Flow Immunoassay (LFA) ? a recently approved diagnostic test for CM ? is a promising approach. It has been shown to be cost-effective and capable of detecting CM-specific antigen in both serum and urine samples. Urine sampling is a safer and simpler process in low-resource settings where sterile equipment may be limited. LFA also provides results in under 10 minutes, and is stable at room temperature, not requiring expensive or complex storage facilities.
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Pharmaceutical companies develop original drugs that are sold as brand-name drugs following clinical trials and approval by regulatory authorities. Generic drugs are ones that are equivalent to a brand-name product in dosage, strength, route of administration, performance and use - in other words, it is biologically equivalent to the original brand-name one. Generics are drastically cheaper (80-85% on average) than brand-name drugs since they do not incur the same research and marketing costs.
THE IMPORTANCE OF KNOW LEDGE TRANSLATION AND INTERDISCIPLINARITY As the unavailability of antifungals in Sub-Saharan Africa highlights, substantial progress towards universal access to medicines cannot be made through a purely epidemiological approach. Filling existing research gaps must be accompanied by effective knowledge translation strategies. As the translation of health benefits into commercial gains is arguably necessary for sustaining research and development (R&D) and the availability of medical resources, interdisciplinary approaches like evidence-based AMCs can help ensure access to medicines. The viability of market-based solutions notwithstanding, programs implementing alternative, non-market-based approaches to increasing access to medicines are also gaining impetus. One such program is the Drugs for Neglected Diseases Initiative (DNDi): in its mandate, it places significant emphasis on capacity-building of local disease-specific research facilities to enable more rapid adaptation of medical technologies and the distribution of medications from local sources directly to patients, consequently lowering prices. It also has research networks that work to develop drugs without a profit-motive. Regardless of the intervention approach, it is crucial to consider that while the treatment of health concerns may remain a scientific challenge, barriers to effective and equitable distribution of health resources incorporate political, economic and social factors beyond the purview of the medical and biological sciences, thus highlighting the need for ongoing interdisciplinary efforts to address global health concerns.
Moreover, they face competition in the market from other generic producers. Brand-name producers receive a period of patent-exclusivity during which time generic production and marketing is not allowed. Following expiration of that period, any number of generic manufacturers may enter the market and thus driving down costs. Brand-name companies lobby and advocate for longer patent-exclusivity periods. Proponents of greater access to medicines and lower health care costs want the opposite.
THE TRANS-PACIFIC PARTNERSHIP IMPLICATIONS FOR CANADIAN PUBLIC HEALTH LENA FAUST
The Canadian government is decidedly pro-t rade. However, t he Trans Pacific Part nership t rade deal t hreatens to hinder healt hcare, drug regulat ion and pharmacare.
On October 5, 2015, twelve Pacific Rim countries, representing almost 40 percent of the global GDP, reached an agreement on the highly controversial Trans-Pacific Partnership (TPP). Although proponents predict that the TPP will lead to economic growth in its member countries through the increased economic integration of markets in the Asia-Pacific region and the elimination of tariffs, health policy researchers anticipate that other provisions, such as the extension of patent terms on pharmaceuticals, will have profoundly adverse consequences for health globally. In Canada, with the new Liberal majority government being decidedly pro-trade and largely in favour of the TPP, the deal?s implications for Canadian healthcare, especially equitable access to medicines, seem unpromising. LIMITING ACCESS TO HINDERING HEALTHCARE
A key concern of health researchers is that the TPP imposes restrictions on data sharing for biologics. Compared to non-biologics, which consist of chemically synthesized small molecule drugs, these are treatments derived from biological sources and include vaccines, antibodies and antitoxins. The proposed 5-8 year data-sharing restrictions on such biologics will hinder access to medicines in multiple ways. Biosimilars, the equivalent of generics for biologics, can be registered and released on market without any clinical trials because manufacturers can rely on the data from clinical trials of the original drug. With these restrictions, they will be unable to do so, thus delaying the availability these much cheaper alternatives. Thus, data exclusivity can translate to effective market exclusivity, driving up drug prices, sustaining high prices for longer, and rendering many
crucial treatments unaffordable. Moreover, biologics are increasingly becoming the focus of research on the development of more effective treatments for chronic non-communicable diseases (NCDs) such as rheumatoid arthritis and cancer. With the burden of NCDs increasing globally, tighter controls on biologics would undermine current advances in health outcomes. Canada?s single-payer healthcare system can also come under stress due to such increasing costs. CLOSING THE DOOR ON PHARMACARE 2020? Much like past trade agreements such as the World Trade Organization?s Agreement on Trade-Related Aspects of International Property Rights (TRIPS), the TPP has direct implications for access to affordable medications, in both developing and developed countries. Article 18.48 of the agreement is of particular concern, as the patent term extensions proposed in it threaten to significantly limit the availability of generic drugs. In Canada specifically, this could significantly undermine efforts towards establishing universal drug coverage. Although Canada prides itself on its publicly-funded single-payer healthcare system, it falls behind other countries that provide adequate coverage for prescription drugs. While there has been intense lobbying to establish publicly-funded prescription drug coverage (termed ?Pharmacare?), the implementation, however, would be difficult under the TPP. The treaty significantly strengthens the influence of industry and the private sector in the marketing and control of
pharmaceuticals, consequently jeopardizing the financial and regulatory feasibility of Pharmacare.
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Specifically, the TPP not only extends the length of patent terms, but also gives pharmaceutical companies the authority to demand compensation for long patent processing times. This would significantly increase the influence of the pharmaceutical industry on the healthcare system, and has the potential to become a critical barrier to the adoption of Pharmacare. Moreover, in light of the marketing of drugs that offer little or no therapeutic advantages and in some cases can even be harmful, Pharmacare would ideally involve increased monitoring of the prescription and marketing. Alarmingly, the TPP includes a clause stating that signatories ?may adopt or maintain procedures that expedite the examination of marketing approval applications.? Expedited approvals could compromise drug safety, and new, highly priced (and not necessarily higher-quality) products could more easily find their way into Canadian markets. Taken together, these provisions mean that if drug reviews are carried out as rigorously as they should be, manufacturers will have the authority to request longer patent terms, keeping affordable generics off the market for longer periods. The TPP therefore jeopardizes Health Canada?s regulatory capabilities, as well as Pharmacare?s proposed future efforts towards stricter regulatory measures and consumer protection.
Most importantly, the higher drug prices resulting from the TPP would make the implementation of Pharmacare financially challenging. It would likely result in a recourse to a hybrid system that covers only certain drugs and treatments, whilst others remain out of reach for those who cannot afford them. These barriers to implementing Pharmacare are particularly concerning in light of Canada?s present failure to secure low drug prices for generics, which could be achieved by concentrating purchasing power in a single payer. Pharmacare?s suggested single-payer system therefore holds the potential to drastically reduce the cost of pharmaceuticals, and is urgently needed considering that Canada?s system of drug coverage is one of the most unsuccessful in comparison to those in other OECD countries. Under the TPP however, Pharmacare, and the improvements it offers, are unlikely to become a reality. THE NEW GOVERNMENT: DOES PRO-TRADE MEAN PRO-TPP? In an official statement on the TPP, Prime Minister Justin Trudeau highlighted the Liberal party?s support for free trade, but emphasized that the terms of the deal will be extensively discussed in parliament in the form of a public debate, creating a platform for informing and involving Canadians in the decision-making process. In
comparison, New Democratic Party (NDP) leader Thomas Mulcair voiced unambiguous opposition to the TPP, stating that the deal would cost 20,000 Canadian jobs. With the NDP falling to third, however, its ability to meaningfully oppose the TPP in parliament is weak. Prime Minister Trudeau?s strong emphasis on the pro-trade nature of the Liberal Party and the agreement?s attractive trade advantages, such as reduced tariffs and increased access to global markets, suggest a push towards approving the TPP. Although the Minister of Health, Dr. Jane Philpott has not officially commented on her position regarding the TPP, she has an ambitious agenda for Canadian Healthcare: a renewed federal health accord providing Canada?s provinces with long-term healthcare funding. Moreover, Dr. Philpott has expressed her concerns with the fragmented nature of provincially-regulated healthcare, calling it ?a game of Jenga?, and has consequently emphasized the importance of national Pharmacare in improving Canadian healthcare delivery and access. With TPP approval still hanging in the balance, Dr. Philpott?s appointment provides a much-needed voice for Canadian public health in parliament. Unfortunately, she has recently indicated that implementing Pharmacare is not part of her mandate. THE CHOICE BETW EEN EXPORTER PROFITS AND PUBLIC HEALTH Regardless of the willingness of the Trudeau cabinet to negotiate a more public welfare-oriented TPP agreement, the question that remains is whether it is practically equipped to do so. The agreement has been signed, but it has to ratified by parliament within two years to come into effect. Theoretically the government could renegotiate all or part of the deal, but it is unlikely that the other 11 countries would agree to reopen negotiations. Moreover, the relevant provisions, including the data-exclusivity terms, are strongly backed by the US. Canada could altogether refuse to implement the TPP, but this seems unlikely given that the government has been staunchly pro-trade and the economic consequences of forgoing participation in a multilateral trade deal, particularly one that includes the US, could be severe. Negotiations concerning the TPP were far from transparent, and only the final agreement was made public. In its current form, the TPP prioritizes commercial interests over public health, and the protection of profits over the needs of the poor and the ill. We are anxious to see what, if anything, Canada?s 42nd parliament will do to mitigate the threat the TPP poses to Canadian healthcare and universal drug coverage. Acknowledgements: The author would like to acknowledge Dr. Joel Lexchin at York University for his suggestions of source material.
W hile equitable and just health for all remains a long way off, there have been countless successes. The first article here looks at a brilliant success story in India. The second analyzes recent and potentially positive changes to India's family planning program. Building systems for health is relentlessly challenging and progress is almost always incremental.
THE SIGHT OF SIGHT FOR ALL A QUEST TO PROVIDE AFFORDABLE EYE CARE
Around 12 million people in India suffer from curable or prevent able blindness. Aravind Eye Hospit al has been working since 1976 to bring affordable eyecare to communit ies.
?Intelligence and capability are not enough. There must also be the joy of doing something beautiful. Being of service to God and humanity means going well beyond the sophistication of the best technology, to the humble demonstration of courtesy and compassion to each patient.?- Dr. G. Venkataswamy
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For one who is poor, for one who lives under $2/ day, for one who has to work every day to feed the family, blindness equals death. In India, as in other developing countries, average life expectancy after blindness is 2-3 years. What makes this more striking is that 80% percent of all blindness in India (12 million) is needless ? they can either be prevented or be cured. What stands in the way is access to care.
With several competing priorities, there is a severe lack of facilities to treat the poorest of the poor for blindness at an affordable price. Even if there is such a facility, how does a poor blind mother of three get treated without dipping into the already diminished family income? Overcoming these hurdles is not an easy task because the problem is multifaceted. However, it is not impossible either ? and the Aravind Eye Hospital of India exemplifies this. In 1976, Dr Venkateswamy, at the age of 58, decided to give up all his life savings, mortgage his house, take bank loans and dedicate the rest of his life to eradicate unnecessary blindness. To him, the problem was easy to solve. He wanted to devise a method to provide eye care like the way McDonald?s devised a way to deliver burgers all over the world (albeit with different motives and health outcomes). ?Supposing I can produce eye care and make it available in every corner, the problem of blindness is gone,? he said. He founded the Aravind Eye Hospital in Madurai that year with 11 beds to provide care for blind patients, regardless of ability to pay. Aravind is like no other facility ? in fact, it has been the subject of numerous case studies. In the 36 years since its
birth, Aravind has built 5 hospitals with 4000 beds in 5 cities ? all with one mission: to ?eliminate curable blindness.? It is the largest and most productive eye care facility in the world with 1.4 million patients every year and 200 000 sight restoring surgeries, most of which are done for no charge. The working model of Aravind is quite unique: every patient who comes to Aravind has an option of not paying for the services, regardless of the patient?s financial background. Each patient who pays for the service (market price), pays for at least two patients who cannot pay. There is absolutely no difference in the quality of care received between the paying and non-paying patients. The only difference is in accommodation. Interestingly, most people who can afford to pay do pay the full cost. Studies have shown that not only is the quality of surgeries performed in Aravind comparable to those of in the UK, Aravind does them at less than 1% of the cost. Every aspect of Aravind has been maximized for service, not profit. The biggest culprit causing unnecessary blindness is cataract. Up to 46% of all people are affected by cataract in the USA and up to 82% in India. Although the cure involves only a simple one-time surgery, cataracts still lead to 50% of the world?s blindness, mostly in developing nations where patients cannot either afford or access care. Although this is the barrier that Aravind is breaking, a major challenge faced initially was the rising costs and availability of intraocular lenses required for eye surgeries. In the early 1990s, each lens cost about USD 100, threatening Aravind?s model. To overcome this massive roadblock, in 1992, Aravind started Aurolab, an on-site lens-manufacturing set-up. Its mission was to deliver ophthalmic products of world-class quality at affordable prices. As of 2012, Aurolab produces nearly 1.8 million lenses annually at a price of $2 each, exports them to 120 countries and holds 10% of the global market. Ten million people in the world see through lenses made by Aurolab.
The mission of Aravind is not only to provide care to patients who can make it to the hospital, but also to take eye-care to the doorsteps of patients who cannot. It has an extensive community outreach program that sets up eye screening camps by engaging with communities in the villages. These camps are run by nurses who screen patients, provide basic eye care like eye exams and glasses, and decide which patients need further care. The patients who need surgery are transported to the hospitals. There they receive food, lodging, surgery, care and get transported back home. Between April 2011 and March 2012, 2831 camps were conducted; more than 1 million patients were screened, and around 85 000 patients underwent surgery in hospitals. However, Aravind?s quest to provide eye-care to all is constantly evolving as it keeps up with rapidly developing technology. In 2004, Aravind started setting up primary eye clinics in villages, providing people with the opportunity to access care as soon as they need it, instead of having to waiting until an eye camp was set up in the village. The vision centers use tele-consultations; nurses run these with real-time video consultation with hospital-based doctors. The centers are completely paperless, and maintain all records on a centralized database. Each patient pays less than 50 cents for three visits. By 2011, these centers were receiving 160, 000 patients every year. The unwavering growth of Aravind tells stories of one mission, of collective optimism and of several successes. As of 2012, Aravind has provided care to 32 million patients and performed 4 million surgeries ? the numbers are high but they have only been able to target less than 10% of the 200 million people who need eye care in India. Dr. Aravind, grandson of Dr. Venkateswamy, says that while they may have reached 40-50% of what they are capable of doing, there is still a lot more to do. As one knows more and more about Aravind ? one asks ? how can an organization do so well and be so selfless and give away most of its services for free? Mehta and Shenoy, authors of the book Infinite Vision, say ?the framing of that question tends to limit the
scope of the answer. Aravind is an unconventional model that came into being ? not despite, but because of ? the deep-seated compassion at its core.? Emanuel Nazareth and Laura Spencer, of Seva Foundation Canada, who just visited Aravind Eye Hospital in Tamil Nadu, say that they were struck by how ?every person involved in Aravind, starting from the one who holds the door to the surgeon has the same mission, the same dream. It is the culture that is cultivated there.? Dr. Thulasiraj Ravilla of Aravind says that it is perhaps the building blocks set in place by Dr. Venkateswamy - the value system, efficient delivery process and fostering the culture of innovation. Aravind?s success has begun to spill over beyond its boundaries, and if curable blindness is to indeed to be eliminated, Aravind cannot be the only example. The organization systematically promotes similar practices and in addition to helping neighboring hospitals, they have reached out to 270 hospitals worldwide. All over the world, millions die of preventable diseases like pneumonia, malaria, AIDS perhaps we can pledge that Aravind will not be the only example. It is, however, possible that Aravind was only able to be successful because of the nature of the problem it tackled. The issue of cataract surgeries is a well-defined clinical problem that can be cured using a well-established clinical procedure. While the path to Aravind?s current success had numerous roadblocks, other healthcare problems might have even more. Regardless, for many problems and processes within the health system, the model of Aravind may be applicable. The idea of offering free care to those in need based on income generated from those who can afford care is conceptually simple and applicable to developing country markets that need accessible and affordable healthcare. The most important component of Aravind, however, is the compassion and the care afforded to all. Perhaps all we need to do to solve some problems is own the problem, be compassionate and care. How tough can that be?
CONCEIVING JUSTICE EXAMINING INDIA'S EVOLVING REPRODUCTIVE HEALTH POLICIES ROW ENA SYMSS, SUDIPTA SAHA
Follow ing numerous deat hs and injuries, India's sterilizat ions camps have finally been banned. The government is now int roducing inject able cont racept ives. Crit ics, however, remain w ary.
The first census of independent India, carried out in 1951, was accompanied by a remarkably gloomy and ominous analysis. R.A. Gopalaswami, the then Census Commissioner, termed child-births occurring to a mother who has already given birth to three or more children of
declared a State of Emergency, she and her party forced a political wave across India that uprooted the field of family planning. The federal party drew on established sterilization initiatives and on the Malthusian sentiments articulated by Gopalaswami in order to present population
The occurrence of improvident maternity should evoke social disapproval, as any other form of anti-social self-indulgence.
- R.A. Gopalaswami,
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Registrar General and Census Commissioner of India, in the 1951 Report on the Census of India
whom at least one is alive as ?improvident maternity?; he called it ?a form of anti-social self-indulgence? that would have catastrophic outcomes since agricultural output would not be able sustain the population. While this Malthusian catastrophe never came to pass despite population increases beyond his predictions, the echoes of his call for mass sterilization haunts India to this day. The deaths of 13 women in Chhattisgarh in 2014 following botched sterilization attempts was the latest tragedy in the long history of coercion, misinformation, and botched procedures in India?s sterilization program. That history, however, might be coming to an end. A recent Supreme Court directive to halt mass sterilization camps and the government?s decision to introduce an injectable long-acting contraceptive are potentially positive developments. However, much depends on ensuring that the actors involved in implementing these policies are aware of, and actively move away from, the appalling historical context. In 1975, when Prime Minister Indira Gandhi
control as part of a solution to India?s poverty. With civil liberties suspended the federal government encouraged states to use compulsory measures to meet targets; millions of Indians, mostly poor men, were sterilized within two years. In addition, a system of incentives and disincentives was created in the state-run sterilization program - those who were sterilized were formally offered money, loans, and/ or land while practitioners and outreach workers received compensation per patient, while those opting out often found themselves cut off from loans, allowances, and work-leaves. All this resulted in a massive proliferation of mass-sterilization camps. Separate from services available at permanent health care centres, these camps are temporary and mobile units that solely focus on performing as many sterilizations as ?efficiently? as possible. With the end of ?The Emergency?, the centrally-sanctioned forced sterilizations to meet outrageous targets stopped. However, despite controversy, the rest of the program still exists today with the only significant changes being a shift in focus from poor men and women to almost exclusively poor women, and a mellowing of the incentive/ disincentive system. However, even now, reports of coercion are not uncommon. In theory, this should not have been the case. Following the 1994 International Conference on Population and Development in Cairo, India officially adopted new approaches that were free of targets and emphasized reproductive health and informed consent over population control. Moreover, following a Public Interest Litigation (Rai v. Union of India), in 2005 the Supreme Court ordered states to follow more stringent guidelines. Yet in practice, not much has changed ? while a ?basket? of
Because of this, in September 2016, a second Public Interest Litigation (Biswas v. Union of India) resulted in the Supreme Court ordering the shutdown of all sterilization camps within 3 years. Moreover, it blamed the federal government for passing on much of its responsibility to the states and not adequately monitoring the program. Although such camps will no longer be conducted, sterilization will continue to be part of the ?basket of contraceptives? available to women. Coincidentally, the court ruling came just as another option was being added to that basket - the government announced the introduction of the much debated Depo-Provera. Depot medroxyprogesterone acetate (DMPA), known by its brand-name Depo-Provera, is a long-acting reversible injectable form of birth control that prevents pregnancy for 3 months following injection. DMPA has been in use in the Indian private sector for over two decades, and is recommended for use by the World Health Organization (WHO). A major factor for maternal and child mortality is short intervals between consecutive pregnancies; contraceptives like DMPA help women to space out pregnancies without having to undergo permanent sterilization. Pilot programs will mostly be run in urban centers through local hospitals and if plans proceed well, the program will be scaled up to reach non-urban populations. Given the pre-existing context of birth control in India, it is no surprise that there are numerous critics. A major apprehension is with regards to the communication between patients and physicians. Many critics do not believe that the existing evidence base supports the safe use of DMPA or that the associated health risks and side effects, which include irregular bleeding and bone density loss, will be shared
Over the decades, the programme has undergone transformation in terms of policy and actual programme implementation and [is] currently being repositioned to not only achieve population stabilization goals but also promote reproductive health and reduce maternal, infant & child mortality and morbidity.
- Excerpt from the National Health Mission website contraceptives, including IUDs, oral contraceptives and condoms, are available, healthcare workers are often focussed on sterilization. Women are sometimes told it is their only option, and the incentives and disincentives remain in place at state levels. In Chhattisgarh, for example, the doctor responsible for the botched procedures was under pressure to meet targets; he performed an astounding 83 surgeries in 6 hours.
with patients. In the absence of measures to ensure that patients are aware of the risks and infrastructure to track symptoms, patients could be unknowingly jeopardizing their health. Of course, this context presents a significant threat to the informational aspect of informed consent. Critics are particularly concerned about the nature of informed consent of poor and marginalized women. Informed consent relies on both access to information
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and a level of individual agency or autonomy to actually give consent. Alternately phrased, patients should have access to information and should meet a socially acceptable standard for their ability to make decisions without the influence of distorting forces. The concepts of standards for what constitutes autonomy and what is considered distorting forces are highly subjective. Should poverty be considered a distorting force that would threaten the value of a patient?s consent? Would these women opt for this birth control if they were financially stable or generally had more visible power to choose from a broader array of options? If these women are being influenced by distorting factors, should we deny them access to certain reproductive care services? The idea of limiting the DMPA program to protect poor women from harm may seem logical especially in light of the patient abuse witnessed in the sterilization camps. However, the DMPA program is markedly safer for women at a population level. Assuming the absence of blatantly distorting forces like monetary incentives are phased out along with sterilization camps, expanding the options available to women is a major step forward. Moreover, despite the cases of coercion and lack of regulation, when carried out properly the sterilization camps do in fact serve the family planning needs of millions of poor rural women; DMPA has the potential to fill the gap that will be left by the phasing out of the camps.
In theory at least then, DMPA introduction, combined with the end of mass sterilization camps, has the potential to finally shift India?s approach to respecting reproductive health and rights. Yet, whether this happens in practice will depend on implementation. Sterilization will still remain an option in the ?basket of contraceptives?, and whether poor and marginalized women are made aware of all the choices and associated risks, including those of DMPA, will depend on how the programs are adjusted. Previous experience has shown that government approaches on paper translate to vastly different
practices in the field. Worrying signs include the fact that the federal health system has given even more autonomy to the states, encouraging involvement of more private actors, and that a possible link between DMPA and increased risk of HIV infection is now being investigated by the WHO. In addition, although the central government has no official targets, international funding from the global partnership of Family Planning 2020 has targets for access to contraceptives; whether the delineation between access and utilization will be made on the ground during implementation remains to be seen. With much fanfare behind the introduction of DMPA, there has to be strict regulation to ensure that misinformation and incentive-systems are not implemented at lower levels to inflate numbers of users to portray the program as a success. Thus, while adamant opposition to the very inclusion of DMPA may be unwarranted, skepticism about its rollout and implementation should be heeded and addressed.
A W inning St rategy for Tackling Drug-Resist ant Tuberculosis in Conflict-ridden Donbass, Ukraine NEHA MALHOTRA, MATTHEW YAU, PADMAJA SREERAM, RAMACHANDIRAN SETHURAMAN The authors of this article placed first at the 3rd annual Toronto Thinks Global Health Case Competition. Toronto Thinks is a nation-wide case competition that simulates real-life global health issues and challenges delegates to work in a multidisciplinary team. The 2015 Challenge was for participants to design a hypothetical monitoring strategy for a TB outbreak in war-torn Ukraine
Tuberculosis (TB) disproportionately burdens low-income countries and has a propensity to thrive in communities with inaccessible health care, unsanitary living conditions, and insufficient food?places like Donbass, Ukraine. The armed conflict in the Donbass region, spurred by Russia?s annexation of Crimea, displaced about 1.4 million Ukrainians and created optimal conditions for the spread of TB. Many unregistered internally displaced persons (IDPs) lacking required documentation fall outside the Ukranian government?s jurisdiction and are unable to access government health care due to fear of persecution. As a result, incidence of MDR-TB has been steadily rising, making both first-line and second-line TB drugs such as rifampicin, isoniazid, and fluoroquinolones ineffective means of disease control due to antimicrobial resistance. To effectively manage a TB outbreak, prevalence and incidence must be appropriately monitored. However, designing a monitoring strategy for a polarized population in a conflict region presents complex challenges. It is especially difficult to develop a sustainable strategy that complements existing infrastructure. With this in mind, we centered our proposal around 3 primary themes: building capacity, implementing surveillance systems, and using novel Information Communication Technology (ICT) tools to improve delivery of care. Building capacity involves maintaining neutrality and establishing nonpartisan partnerships with Russian and Ukrainian government officials, community leaders, and medical personnel to gain access to their respective populations and infrastructure?uniting opponents against a common enemy, TB.
Gathering comprehensive surveillance data regarding TB incidence requires access to citizens on both sides of the conflict. We proposed the introduction of mobile clinics in high-traffic locations, such as schools and churches, to screen and treat unregistered IDPs. We suggested converting existing clinics into polyclinics, which, along with hospitals, will serve as multipurpose centers where patients are screened for TB and concomitant diseases (HIV) in Russian-controlled areas. Polyclinics will be also introduced in IDP internment camps to screen and treat registered IDPs. Mobile clinics and polyclinics will be equipped with emergency aid supplies to address a broad range of health needs and incentivize people of the Donbass region to access care. Individuals visiting clinics will receive a card containing a QR code for storing and updating their medical information. Using QR codes to store patient information regardless of government status helps vulnerable, unregistered IDPs remain discrete. One major benefit of QR codes is that they can be used to integrate surveillance data regarding TB incidence and prevalence into a pre-existing national database while still being relatively affordable in a low-resource setting. The TB crisis in the Donbass region cannot be ignored. This is an opportunity to demonstrate that it?s possible to deliver health care in a nuanced, efficient, and nonpartisan way despite the complexities of the setting. The proposed strategy is also designed to work synergistically with current best practices in TB treatment. Our strategy is customized for each demographic and leverages QR technology to facilitate surveillance in the Donbass region.
Manulife/IpsosReidHealthandWealth Study2015 As a provider of group benefits and retirement savings programs for many Canadian companies, Manulife has developed a unique perspective of the health and wealth challenges that employees face. Our group benefits team noticed an increase in disability claims associated with mental health issues. Additionally, our group retirement area was becoming increasingly concerned about what appeared to be a lack of retirement preparedness. W ith the help of research firm Ipsos-Reid, we investigated these trends to gain a deeper understanding of their relationship and their repercussions for employees across Canada. An online survey was conducted with 2,000 Canadians from across the country. Respondents were selected from all regions across Canada, fell within the age group of 25 to 65 years of age, worked a minimum of 20 hours a week, and were at varying income levels. Our study revealed that the financially unprepared face many day-to-day financial challenges, and either can?t or don?t know how to overcome them, implying that financial wellness is a struggle. They felt uncomfortable about the state of their finances since they don?t have a clear picture of their financial futures, nor what it takes to become financially prepared. Many of them were unable, or less likely to plan for common large financial contributions that Canadians make. For example, compared to respondents who had better maintained their finances, the financially unprepared felt that they were less likely to create budgets or plans to pay off debt and less likely to save for things such as a child?s education, an emergency fund or retirement. Even life insurance was a luxury that many respondents were less likely to have. Our study drew a clear connection between participants?health and wealth, revealing that
approximately 33 per cent of all workplace disability claims were related to mental illness and 90 per cent of employers identified stress as the most significant reason for these claims. Our study revealed 45 per cent of employees identified personal finances as the leading cause of their stress. For the financially unprepared, financial problems were the leading cause of stress followed by work-life balance and job security. The impacts of this kind of financial stress extends into many different parts of the respondents?lives. They worried about supporting their loved ones if something happened to them, being unable to pay back their financial debts or simply a sense of embarrassment around their finances. Aside from the effects that financial worry invoked on the respondent?s mental health, the study showed a considerable impact on physical well-being as well. For many participants, the financial concerns manifested as delaying or not obtaining various services aimed to improve their health due to money constraints. In comparison, the financially prepared revealed that they were more than twice as likely to actively manage and maintain their health. Our results suggest financial wellness is a multi-faceted problem that?s complex and evokes strong feelings within the respondents. But clearly, the financially unprepared need real solutions to their financial challenges and can benefit from knowing help is available. Look to Manulife for health and wealth solutions. We continue to commission ground-breaking research to help influence how we design our products and services to fit the needs of working Canadians. To view the entire study, please visit us at www.manulifehealthandwealth.ca. *The article was edited by Juxtaposition for clarity and brevity
Juxtaposition Volume 9, Issue 1