Juxtaposition 11.1

That Which Sustains Us: Animal Agriculture as an Environmental and Public Health Concern Inequality in Global South Cities: A Call for Action

Volume 11 Issue 1

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2018

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ISSN 1918 - 7653

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LETTER FROM THE EDITOR 21 SUSSEX AVENUE, ROOM 610, TORONTO ON M5S 1J6 Dear Juxtaposition Readers, Welcome to Volume 11.1, Juxtaposition Global Health Magazine’s eleventh print edition, produced by our 2017-2018 team of undergraduate and graduate student volunteers at the University of Toronto! Juxtaposition is the University of Toronto’s premier global health magazine. With a special emphasis on topics that affect the vulnerable and marginalized locally and globally, Juxtaposition provides an interactive forum to explore the essential health issues of our time.

This year, our team grew to include more staff writers and graduate students, as well as talented and dedicated events staff. We attended various conferences in Toronto and beyond, sharing our work and learning from others. We were also pleased to be able to expand our partnership with the University of Toronto’s Dalla Lana School of Public Health (DLSPH), and in particular the Office of Global Health Education and Training. On January 27th and 28th 2018, we co-hosted the fifth Toronto Thinks Global Health Case Competition with the DLSPH, welcoming more than 150 students, judges, case advisors, and community members for lively discussions and case solution presentations on air pollution in Toronto.

While we still have much to learn, the myriad links between the environment and human health have never been clearer to researchers. Whether one has access to technological comforts that interrupt this relationship, or lives close to the land, the environment is a key determinant of health. Indeed, it can be argued that it underpins all other determinants of health.

Yet climate change and environmental degradation continue to be key threats to the environment. Both remain relatively unchecked, and L to R: Elizabeth Loftus, Sanah Matadar, Julia Robson, and Aceel Hawa require attention, alarm, and action from the global health community.

By writing about some of these issues, and continuing the conversation far beyond Volume 11.1, the Juxtaposition team hopes to contribute to necessary systems change.

Our team of writers and editors worked hard throughout the school year to bring you thought-provoking articles that highlight important issues and challenge conventional perspectives in global health and the environment. We are excited to share our work with you, and look forward to hearing your feedback.

Thank you to our sponsors and supporters:

Happy reading, Julia Robson Editor-in-Chief 2017-2018 Website: juxtamagazine.org Twitter: @juxtamagazine Facebook.com/juxtamagazine/

2 Our thanks to Kirstyn Koswin for the cover photo, taken in Kigali, Rwanda, in August 2017. All other photographs © Julia Robson.

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Issue 11.1 Authors MICHELLE AMRI Michelle Amri is a PhD Student in Public Health (Global Health Collaborative Specialization) at the University of Toronto, studying cities and health under the supervision of Drs. Arjumand Siddiqi and Theresa Enright. She has a Master of Public Administration and Bachelor of Health Sciences (Honors Specialization in Health Promotion) and has worked for the Ontario Public Service and as a Consultant for the World Health Organization. She enjoys travelling and learning about different cultures, particularly by sampling the unique cuisines.

JOCELYN CATENACCI Jocelyn is a third-year student at the University of Toronto pursuing a degree in Health Studies, Political Science and History. She is also a Senior Editor for Health Perspectives and hopes to study law after she graduates.

ALLISON DANIEL Allison Daniel is a PhD student in the Collaborative Specialization in Global Health. Her research focuses on nutritional and developmental outcomes in children who have been hospitalized with severe acute malnutrition in Malawi.

BENJAMIN LEVY Benjamin Levy is entering his fourth year at the University of Toronto, studying Global Health, Statistics, and Philosophy. Ben is interested in all forms of communication and persuasion, whether it be through debating at Hart House or analyzing news with machine learning. At Juxtaposition, Ben writes on the intersection of health, politics, economics, and conflict. His favourite Star Wars movie is Rogue One (and after that, Episode III: Revenge of the Sith).

ELIZABETH LOFTUS Elizabeth is a fourth-year student in the Heath Studies Specialist and Indigenous Studies Minor programs at U of T. She likes to learn about the forces that impact our health, and the role that media can play in helping or harming our health.

LEAH ROSENKRANTZ Leah is currently a Master’s candidate at Simon Fraser Universitystudying health geography, with a specific focus on global health issues. She has a previous Master’s in Global Health Systems in Africa from Western University. When she is not studying health, she can be found trail running or skiing out west in beautiful BC. KELSEY YANG Kelsey is a third-year undergraduate student at the University of Toronto, where she is studying Global Health and Molecular Genetics.

She is interested in how science and technology enable passionate people to solve global challenges like air pollution.

2017-2018 TEAM Editor-in-Chief Julia Robson EDITORIAL TEAM Managing Editor Aceel Hawa Associate Editors Charlie Jupp-Adams Celina Liu Joanna Liu Fakeha Jamil Staff Writers Michelle Amri Jocelyn Catenacci Benjamin Levy Elizabeth Loftus Marlena Nguyen-Dang Kelsey Yang EVENTS TEAM Events Director Sanah Matadar Events Associate Chika Nwaka

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Table of Contents Juxtaposition Global Health Magazine Issue 11.1 That Which Sustains Us: Animal Agriculture as an Environmental and Public Health Concern p. 5 ELIZABETH LOFTUS Inequality in Global South Cities: A Call for Action p. 8 MICHELLE AMRI The Health Case for a Basic Income in Canada p. 10 BENJAMIN LEVY Viral Zoonotic Diseases and “The Next Big One” p. 14 LEAH ROSENKRANTZ Moyo Means Life: a Photo Essay p. 16 ALLISON DANIEL Air Pollution and Cyber-Protest: Civic Activism in China p. 21 KELSEY YANG The Mountain of Youth: What We Can Learn from Okinawa, Japan p. 25 JOCELYN CATENACCI Toronto Thinks Global Health Case Competition 2018: Winning Solutions p. 31 TORONTO THINKS PARTICIPANTS

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That Which Sustains Us: Animal Agriculture as an Environmental and Public Health Concern ELIZABETH LOFTUS

Diet is one of the most powerful ways in which individuals can help address public health and environmental crises. Globally, the food system is responsible for more than one quarter of all greenhouse gas emissions1, of which up to 80% are associated with animal agriculture2,3.

The environmental impact of our food system is a growing issue, alongside the human population. By 2050, the global population is projected to grow to 9.8 billion4, which will lead to an increased demand for food.

A current challenge to the food system is the rapidly increasing demand for meat and dairy products, which is largely attributable to the increased wealth of consumers in many regions, and especially in countries such as China and India5. This nutrition transition represents a major challenge for the near future, as growing and increasingly wealthy populations adopt Western-style diets, which are associated with chronic disease, and will further exacerbate the global burden of such chronic diseases5,6.

Despite the aforementioned, sustainability should be the ultimate goal of our food system, and current dietary trends and food production methods are becoming increasingly unsustainable. This is to the detriment of both public health and the state of the environment. Those who have the privilege of secure access to and choice over food should take responsibility for their dietary decisions, and seek to consume foods which can be produced in a sustainable manner, in the interest of their personal health, and for the sake of the environment.

The healthiest foods are often the most sustainable foods

Decreasing our reliance on animal agriculture would yield a host of benefits for both human health and the state of the environment.

There is a robust body of research which supports the health benefits of decreased consumption of animal products, especially of red and processed meats and high-fat dairy products.

Diets comprised of predominantly plant-based foods are known to be more healthful than those

However personal our diets may appear to containing high proportions of meat, especialbe, at the aggregate level, the systems of food ly red meat, and dairy products5. Consuming production have effects that are anything but whole, plant-based foods significantly lowers individual. Our dietary decisions have significant one’s risk of chronic diseases such as cardiovasimpacts on both our personal health and on the cular diseases, certain cancers, and Type 2 diabeshared environment, and thus warrant considertes7. ation which honours this relationship.

Researchers at the Oxford Martin School

This is not an argument against the conhave shown that the adoption of diets with fewer sumption and use of all animal products. This animal-sourced foods would significantly reduce article has been written in acknowledgement of the incidence of premature death. They found the fact that this goal is overly simplistic. There that when compared to a reference scenario are vast differences in the production efficiency in line with current dietary patterns, by 2050, and environmental impact of the different kinds the adoption of global ‘recommended’ dietary 5 of meat consumed . Additionally, in some devel- guidelines would result in about 5.1 million oping countries, meat is the only or most conavoided deaths per year, the adoption of the centrated source of some vitamins and minerals, vegetarian diet would result in about 7.3 million and livestock acts as a means of livelihood and avoided deaths per year, and the adoption of transportation5. a vegan diet would result in about 8.1 million avoided deaths per year7.

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Beyond the known benefits of consuming fewer animal products, and more plant-based foods, the unsustainable nature of animal agriculture cannot be ignored. Animalizing protein is a highly inefficient method of securing nutrition – the conversion efficiency of plant into animal matter is around 10%5, meaning that 90% of the total energy involved in the process of animalizing plant matter is lost.

Livestock production is also a major source of greenhouse gas (GHG) emissions, with methane being of particular concern5. Dietary changes towards fewer animal-sourced foods can help to mitigate the expected growth in food-related GHG emissions. In the aforementioned Oxford study, researchers found that when compared to the reference scenario in line with current dietary patterns, by 2050, the adoption of global ‘recommended’ dietary guidelines would result in a 29% reduction compared to the reference (REF) emissions, and the adoption of vegetarian and vegan diets would result in emissions that were 63-70% lower than REF emissions7. Beyond GHG emissions, factory farm-style practices contribute to the loss of biodiversity, soil degradation, water pollution, and the mass deforestation of precious rainforest.

Your dollar is your vote - if you have the choice, you

consumption of animal products, other than the value of the traditions which we have built around certain dishes, which happen to contain animal products. Similarly, there is nothing inherently important to industry groups in the production of beef, pork, other animal products, beyond the profits which are to be made from meeting demand with supply.

The diet-environment-health trilemma6 requires a complex response, as there is no simple solution to sustainably feeding nine billion people. This is especially true because of the increasing wealth-related nutrition-transition5, as well as the personal and cultural connections that people have with food.

It is important, however, that adaptations be made in spite of these difficulties, as the negative impact of animal agriculture exists whether we choose to accept it or not.

In many ways, positive changes are already underway. One such a change is being made here in Canada through evidence-based recommended changes to the Canadian Food Guide. After two years of consulting with both the public and health professionals, the new Food Guide is undergoing final review8. The proposed recommendations emphasize the role of whole plant foods and plant-based sources of protein, and warns against processed foods high in sodium, sugar, and saturated fat8.

should choose to vote wisely

Food is a symbol that represents one’s culture, is an important aspect of social and family gatherings and ceremonies, and in many ways, is an important part of one’s identity. However, there is nothing inherently significant about the

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Most notably, the newly proposed policy recognizes the environmental sustainability of diets as a core concern8, and makes recommendations to encourage eating less meat and replacing dairy products, that are often high in saturated fat, with foods that contain mostly

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unsaturated fats like nuts, seeds, and avocados8.

These new guidelines, proposed by the Standing Senate Committee on Social Affairs, Science and Technology in March of 2016 were made to reflect scientific evidence8, and it is this kind of evidence-based policy change we would do well to support.

Another positive change can be found in novel policy solutions, such as the idea of substituting beans for beef - a simple, yet meaningful way that individuals can reduce their impact on the environment, without necessitating an entire dietary shift9. A study conducted by researchers from Oregon State University, Bard College, and Loma Linda University, found that significant GHG reductions could be made through this simple food substitution10. If the United States adopted this substitution, they could meet up to 74% of the reductions needed to reach the 2020 GHG target for the U.S. as defined in the Paris Accord, and could spare the 42% of US cropland currently used to produce cattle-feed10.

The solution to the consequences of our reliance on animal agriculture will require a combination of consumer-driven changes in demand, evidence-based policymaking, and innovative adaptations.

References 1. Vermeulen, S. J., Campbel, B. M., & Ingram, J. S. I. Climate change and food systems. Annu Rev Environ Resour.

37(1):195–222 (2012) 2. Steinfeld H, et al. (2006) Livestock’s Long Shadow (FAO, Rome).

3. Tubiello, F. N., et al. (2014) Agriculture, Forestry and Other Land Use Emissions by Sources and Removals by Sinks: 1990–2011 Analysis (FAO Statistics Division, Rome).

4. United Nations, Department of Economic and Social Affairs, Population Division (2017). World Population Prospects: The 2017 Revision, Key Findings and Advance Tables. Working Paper No. ESA/P/WP/248.

5. Godfray, C. J. et al. Food security: the challenge of feeding 9 billion people. Science.327, 5967, 812-818; 10.1126/science.1185383 (2010).

6. Tilman, D. & Clark, M. Global diets link environmental sustainability and human health. Nature. 515,7528; 10.1038/nature13959(2014).

7. Springmann, M., Godfray, H. C. J., Rayner, M., & Scarborough, P. Analysis and valuation of the health and climate change cobenefits of dietary change. Proc Natl Acad Sci U S A.113(15), 4146; https://doi.org/10.1073/ pnas.1523119113(2016) 8. Grant, J. D. & Jenkins, D. J. A. Resisting influence from agri-food industries on Canada’s new food guide.CMAJ. 190, 15; 10.1503/cmaj.180037 (2018).

9. Hamblin, J. If everyone ate beans instead of beef.

The Atlantic.(2017). At https://www.theatlantic.com/ health/archive/2017/08/if-everyone-ate-beans-instead-ofbeef/535536/ 10. Harwatt, H., Sabaté, J., Eshel, G., Soret, S., & Ripple, W. Substituting beans for beef as a contribution toward US climate change targets. Clim. Change. 143, 261-270; 10.1007/s10584-017-1969-1

We would do well to discuss, openly and honestly, whose interests our current food system is supporting, and whether we can stomach supporting a system which prioritizes short-term economic gain over public health, food security, and a habitable climate.

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Inequality in Global South Cities: A Call for Action

In 1975, only three cities had ten million or more inhabitants: New York City, Tokyo, and Mexico City. By 2012, there were 271. The world is rapidly urbanizing. By 2050, 66 percent of the world’s population is expected to reside in cities, adding 2.5 billion people to the world’s urban population2. Research in the field of urban studies has shown that a major challenge facing cities is growing levels of income inequality3,4. Further research conducted in mainly high-income contexts has demonstrated that income influences health, both in terms of socioeconomic status (SES)5 and income inequality6.

As such, increasing urbanization may forecast increased disparities in both income and health, but this relationship needs to be further studied, particularly in low- and middle-income countries (LMICs).

Currently, developing regions house 75% of the world’s urban population, which produces an unequal spatial distribution of people8.

But it is only relatively recently that research has focused on studying inequalities in a more systematic manner in LMICs (Houweling & Kunst, 2010). As such, little is known about how income and income inequality are influencing health status in LMIC contexts. Therefore, understanding the influence of SES and income inequality on the health status of individuals living in LMIC cities becomes particularly important. In fact, the Secretary-General of the United Nations (UN) considers “rapid urbalization and its links with

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MICHELLE M. AMRI, MPA poverty, inequality, public health, migration, climate change, and natural disasters to be one of the most pressing concerns of the UN”9.

In seeking to better understand the problem of income inequality plaguing cities of the global south, and the attendant public health concerns, we must return to the fundamentals.

For example, the Fundamental Cause Theory (FCT) may serve us well through its application to this problem. The FCT was first introduced in Link and Phelan’s paper published in 199510.

In this paper, the authors argue that instead of directing attention to risk factors studied in public health (e.g. smoking), further attention should be paid to how these are “contextualized”, or rather, what puts 10 people at “risk of risks” . According to Link and Phelan, what puts individuals at risk of developing these risks, or the “fundamental causes”, is likely to be rooted in social factors, such as social support and SES10. Essentially, these factors allow for increased resources that are used to improve one’s health and well-being. These resources, as defined by Link and Phelan10, include: money, knowledge, power, prestige, and interpersonal (e.g. notions of social support and social networks). These work to shape behaviour through individuals’ knowledge, access, and support, to engage in health-promoting behaviours and more broadly, broader contexts in which they live, such as neighbourhoods, occupations, and social networks12,13. Therefore, societies greatly influence and shape disease11.

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In considering the large role societies play in influencing health and well-being, Phelan et al.14 suggest that the FCT would support the development of public policy that does one of two things: (1) reduce disparities in the resources indicated above, or (2) develop interventions that are more equally distributed across various levels of SES (i.e. anyone can adopt). Both of these approaches work to dissociate public health advancements from SES resources14. Examples of public policies that work in this way include: housing for homeless individuals, income security programs, and parental leave policies14.

Furthermore, because of the strong relationship between SES and health outcomes11, FCT also alludes to the potential for increased inequality – such as those described in the brief summary of the global landscape and literature above. Phelan et al.15 highlight this by indicating that socioeconomic inequalities in mortality may be more pronounced, meaning that those with fewer resources are more prone to die earlier, with the understanding that this may not be true in all instances. This is particularly true for more preventable diseases where the role of resources in improving health is greater, such as diabetes mellitus type 2. With the global scope of inequality coupled with the prediction afforded by Phelan et al.15 above, an argument developed by De Maio becomes increasingly important: that there is value in re-considering the geo-political ‘frame’ of work done in this field, with a move towards a truly global analysis of the health effects of income inequality16. By drawing on global information and applying theories such as the FCT, we will be better equipped to address fundamental causes of poor health across various settings (for example, learning which policies work best to reduce disparities in SES-related resources across numerous settings). This is a call for action to use theories such as FCT, along with other established knowledge, to continue to build our understanding and reorganize action for a more equitable and healthy future.

References 1. Taubenböck, H. et al. Monitoring urbanization in mega cities from space. Remote Sensing of Environment 117, 162-176, doi:http://doi.org/10.1016/j.rse.2011.09.015 (2012).

2. UN DESA. World Urbanization Prospects: The 2014 Revision, Highlights (ST/ESA/SER.A/352). (Population Division, United Nations Department of Economic and Social Affairs, 2014).

3. Barber, B. If Mayors Ruled the World. (Yale University Press, 2013).

4. Florida, R. The New Urban Crisis: How Our Cities Are Increasing Inequality, Deepening Segregation, and Failing the Middle Class and What We Can Do About It 336 (Basic Books, 2017).

5. Elo, I. T. Social Class Differentials in Health and Mortality: Patterns and Explanations in Comparative Perspective.

Annual Review of Sociology 35, 553-572 (2009).

6. Marmot, M. The Health Gap: The Challenge of an Unequal World. (Bloomsbury Publishing, 2015).

7. UN DESA. World Population Prospects: The 2006 Revision. (United Nations Department of Economic and Social Affairs Population Division, 2007).

8. Houweling, T. A. J. & Kunst, A. E. Socio-economic inequalities in childhood mortality in low- and middle-income countries: a review of the international evidence.

British Medical Bulletin 93, 7-26, doi:10.1093/bmb/ldp048 (2010).

9. UN News Centre. Organizational reform moves ahead as Guterres receives proposals on a strengthened UN-Habitat, <http://www.un.org/apps/news/story.asp?NewsID=57305 - .Wc_bHDOZOqA> (2017).

10. Link, B. G. & Phelan, J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior, 80-94 (1995).

11. Link, B. G. & Phelan, J. C. McKeown and the Idea That Social Conditions Are Fundamental Causes of Disease. American Journal of Public Health 92, 730-732 (2002).

12. Phelan, J. C. & Link, B. G. Controlling Disease and Creating Disparities: A Fundamental Cause Perspective. The Journals of Gerontology: Series B 60, S27-S33, doi:10.1093/geronb/60.Special_Issue_2.S27 (2005).

13. Link, B. G. & Phelan, J. C. Understanding sociodemographic differences in health--the role of fundamental social causes. American Journal of Public Health 86, 471473 (1996).

14. Phelan, J. C., Link, B. G. & Tehranifar, P. Social Conditions as Fundamental Causes of Health Inequalities: Theory, Evidence, and Policy Implications. Journal of Health and Social Behavior 51, S28-40 (2010).

15. Phelan, J. C., Link, B. G., Diez-Roux, A., Kawachi, I. & Levin, B. “Fundamental Causes” of Social Inequalities in Mortality: A Test of the Theory. Journal of Health and Social Behavior 45, 265-285 (2004).

16. De Maio, F. Advancing the income inequality – health hypothesis. Critical Public Health 22, 39-46, doi:10.1080/0 9581596.2011.604670 (2012).

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The Health Case for a Basic Income in Canada

The medicine of the future might be mailed to the doors of patients in thin envelopes every month. However, these envelopes wouldn’t contain pills or powders. Rather, they would simply contain cheques. Millions of Canadians suffer from health issues ranging from chronic diseases, mental illness, malnutrition, and more, all of which are caused or worsened by conditions of poverty. This is one of the main reasons why places around the world such as Finland, the Netherlands, Spain, Kenya, the United States, and now Ontario, are all running pilot experiments for giving out unconditional cash transfers, known as a basic income1. Although the idea of a basic income has been around since at least the 15th century, it has only recently begun to gain traction as a social intervention to alleviate some of the worst impacts of poverty2.

What could a basic income look like?

There are many possible versions, ranging from generous to stingy. One version, proposed by University of Chicago economist Milton Friedman, is called a Negative Income Tax3. In this scheme, any individual with an income below a given threshold – say, the poverty line – would pay no taxes and would receive an amount of money that increased the further they were below this threshold. In Friedman’s version, someone with an income $1,000 less than the cutoff would receive 50% of the difference, or $500, whereas a difference of $500 less than the cutoff would merit $250 in aid. This creates an effective floor for anyone’s income and progressively helps poorer people more. A more radical version of a basic income provides unconditional cash stipends to all members of society, which either decrease as they earn more money, or are given at a completely equal level independent of income. In all these versions, the key feature is that basic income is a cash transfer given unconditionally, allowing the recipient the freedom spend the money in any way they choose.

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BENJAMIN LEVY

The medicine of the future

Valerie Tarasuk, a professor at the Dalla Lana School of Public Health, points to the numerous health benefits that could result from a well-planned basic income, mainly mediated through the effect of such an income on food security4. Her research team at the University of Toronto, PROOF, has reported that one out of every six Canadian children are affected by household food insecurity, which becomes even more pronounced in the North, where 60% of children in Nunavut face food insecurity5,6.

Food insecurity brings with it a massive health burden: it increases the likelihood of malnutrition, mental health problems, and chronic illnesses like asthma or diabetes.

These health problems pose a significant economic cost to the Canadian health system, since the overall health ser vices needed by a food-insecure adult are roughly double those of a similar food-secure adult.

Although food banks are important sources of basic food items, they are far outstripped by the sheer number of people who are food insecure, according to Food Banks Canada7.

Even in cases where someone has access to a food bank, the food given out may be unfamiliar or undesirable8. Thus, a better solution may be to simply give food insecure people the money they need to purchase their own food by means of a voucher, such as food stamps. However, conditional cash transfers like food stamps bring with them a whole host of problems. Not all stores accept food stamps, and paying with them can signal to others that an individual is on welfare, which can evoke feelings of shame.

These problems can be avoided entirely by simply giving people an unconditional cash transfer,

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allowing them to buy the food that they want without the stigma of welfare. It is no surprise, therefore, that Food Banks Canada has called for a basic income guarantee by 2019 specifically to target food insecurity9. Substantial evidence already exists to show that an unconditional basic income can lower rates of food insecurity.

In Canada, seniors (65 and older) automatically receive a form of basic income, the Old Age Supplement (OAS), and they may also receive the Guaranteed Income Supplement (GIS) if they have low income10. When low-income individuals turn 65 and begin receiving OAS and GIS, their risk of being food insecure drops significantly11.

Food security is only one of several pathways through which income and other socioeconomic factors can affect health, collectively known as the Social Determinants of Health (SDH). Among these myriad factors, such as education, environmental health, and social inclusion, income is distinct in that it affects nearly all other determinants, prompting Ryan Meili, an MLA in Saskatchewan for the NDP, to call it the â&#x20AC;&#x153;Determinant of Determinantsâ&#x20AC;?12. Another key determinant of health, which is directly linked

to income, is housing. In the course of one year, around 235,000 Canadians need to sleep in a shelter at some point in time, 85% of whom are experiencing temporary homelessness as a response to income shocks11.

In fact, homelessness has been rising significantly across Canada since the 1990s, due to a cocktail of cuts to income support and social housing, alongside skyrocketing housing prices in most of the largest cities. A basic income could provide households with enough money to buy them peace of mind by not having to worry about having enough money to pay rent, and affording them the ability to save or invest any leftover income in lifting themselves out of poverty. is basic income feasible?

From 1974 to 1979, one of the most widely-referenced basic income experiments was conducted in two locations in Manitoba: Winnipeg and a small farming town called Dauphin.

Known as the Mincome experiment, the results of the trial showed that hospitalization rates in

Source: PROOF (2013)

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Dauphin decreased by 8.5% relative to nearby similar communities8. As U of T’s Dr. Danielle Martin put it13, “if we could find a drug that cut all hospitalizations by 8.5%, we’d be putting it in our water supply.” This view of money as a particularly potent kind of drug can be seen in the work of Dr. Gary Bloch at St. Michael’s Hospital, who has prescribed his patients money as a ‘cure’ for all manner of symptoms14.

Of course, there are still significant hurdles to implementing a basic income, chief among which are concerns about how much such a program would cost if it were to be effective.

According to The Economist, a basic income that raised everyone in Canada to at least the poverty line might cost as much as 35-40% of GDP, or roughly $540 billion CAD per year15. A less generous program, such as the hypothetical universal basic income grant studied by Boadway et al., might cost a little under half of that number, providing $20,000 CAD to each adult while cutting tax credits to partially finance the program16. In that study, researchers found that such a basic income grant could substantially decrease inequality and reduce the poverty rate from 9.6% to 3.2%. This potential reduction in poverty could further help offset the costs, seeing as the cost of poverty in Ontario alone is over $30 billion CAD per year17. Still, a basic income program on a national scale would certainly require extra funding in the form of higher income taxes or corporate taxes, at least in the short term before health costs could be recouped.

However, one of the principal concerns raised from the Left is not that basic income would cost too much, but rather that it would cost too little12. That is, when many right-wing economists, such as Milton Friedman, propose basic income as a form of social welfare, they do so with the assumption that the cost of a basic income would be offset by cutting all other social programs and consolidating them into a single cash payment, which would end up reducing the total benefits for the poor. For this reason, it is facetious to claim that there is bipartisan support for basic income, since advocates on the Left want basic income to be only one component of a strong, comprehensive social safety net, rather 12

than an excuse to do away with the safety net entirely.

Another objection to basic income is with respect to how individuals’ behaviours would change18. Namely, if someone receives an unconditional cheque every month, that may reduce their incentive to work or allow them to spend it on so-called ‘temptation goods’, such as alcohol or tobacco. However, decades of empirical research have shown both of these concerns to be unfounded. Regarding work incentives, the Mincome experiment in Manitoba showed very little overall reduction in the hours worked by those receiving basic income8. When the data were more closely examined, it became clear that two specific groups did in fact reduce their working hours: married women and young, unattached males. This was because the women were taking longer maternity leaves than the 4-6 weeks offered in the 70s, whereas the young men were staying in school longer. Thus, even in the small cases in which basic income might lead to a decrease in hours worked, that may actually lead to better health and economic outcomes.

With respect to “temptation goods”, data from the World Bank show that there is little evidence that cash transfers given to poor people go into alcohol or tobacco19. Rather, households tend to spend the money on education, food, and housing. will onTario be The firsT To see a basic income in canada?

The government of Ontario is currently testing a pilot basic income project in Hamilton, Lindsay, and Thunder Bay, similar to the Mincome experiment done in Manitoba in the 70s20.

In this trial, individual participants will receive up to $16,989 and couples will receive $24,027 every year, with benefits decreasing by $0.50 for every dollar the recipient makes in income, meaning that an individual earning roughly $34,000 would receive nothing. The hope is that, after three years, there will be good enough data to demonstrate the benefits of a basic income in a modern context.

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income, but more closely resembles a poverty floor, lifting the incomes of the poorest recipients so that they reach a minimum level of income, while giving nothing to people with higher income. This makes intuitive sense: if resources are limited, then they ought to be prioritized for those with the greatest need. However, some argue that if a basic income program is to survive, it needs to be universally offered to all members of society regardless of their wealth21. This is because if basic income only helps the poor, who tend to hold less political power, whereas the rich receive nothing, the program may not be prioritized by future governments. A good analogy is Medicare: socialized health care is available to all Canadians independent of how much money they make, which may arguably be one of the reasons it is so popular and resilient.

Another lesson from Medicare is the way in which it went from a far-fetched idea to real policy. It began in Saskatchewan and Alberta, and after considerable backlash from doctors, eventually spread to the federal level22. In the same vein, advocates of a Canadian basic income would be wise to push for entire provinces to adopt it as a proof-of-concept, before lobbying the federal government to pass any sort of basic income legislation. Already, momentum is building in PEI, Quebec, and of course, Ontario23.

By 2020, when the initial Ontario basic income trial completes, we should have clearer data on the costs, benefits, and feasibility of basic income in Canada. Based on the wealth of data about the social, economic, and health benefits of basic income, we may soon have confirmation that this policy, if prudently implemented, has the potential to improve the lives of millions of Canadians. For those Canadians living at or below the poverty line, this intervention cannot come soon enough.

References 1. McFarland, K. (2017). Overview of Current Basic Income Related Experiments (October 2017). Basic Income News. Accessed at https://basicincome.org/news/2017/10/ overview-of-current-basic-income-related-experiments-october-2017/.

2. https://basicincome.org/basic-income/history/ 3. Weller, C. (2017). Bill Clinton, Donald Trump, and Jamie Dimon all agree on a little-known tax that pays poor people. Business Insider. Accessed at http://www.businessinsider.com/how-negative-income-tax-earned-income-taxcredit-works-2017-1.

4. Oldfield, J. (2016). Basic Income Can Reduce Food Insecurity and Improve Health. What’s New–Dalla Lana School of Public Health Website.

5. http://proof.utoronto.ca 6. PROOF Lab. (2016). Household Food Insecurity in Canada. Accessed at http://proof.utoronto.ca/food-insecurity/.

7. https://www.foodbankscanada.ca/Hunger-in-Canada/ About-Hunger-in-Canada.aspx 8. Martin, D. (2017). ‘A basic income could improve the health of all Canadians’ from Better Now: Six Big Ideas to Improve Health for All Canadians. (Except from http:// www.thinkupstream.net/one_thing).

9. Pegg, S., & Stapleton, D. (2016). HungerCount 2016.

Food Banks Canada.

10. https://www.canada.ca/en/services/benefits/publicpensions/cpp/old-age-security.html 11. McIntyre, L., Dutton, D., Kwok, C., and Emery, J.C. (2016). Reduction of Food Insecurity among Low-Income Canadian Seniors as a Likely Impact of a Guaranteed Annual Income. Canadian Public Policy. 42(3), 274-286.

12. Himelfarb, A., and Hennessy, T. (Eds.) (2016). Basic Income: Rethinking Social Policy. Canadian Centre for Policy Alternatives.

13. Uechi, J. (Feb 27 2017). Here’s the medicine to make Canada’s healthcare system even stronger, doctor says.

National Observer.

14. Porter, C. (May 23 2015). St. Michael’s Hospital health team offers prescription for poverty. The Toronto Star.

15. The Economist Data Team. (Jun 3 2016). Universal basic income in the OECD. 16. Boadway, R., Cuff, K., and Koebel, K. (2017). Designing a Basic Income Guarantee for Canada. Prepared for the New Frontiers in Public Policy: Federalism and the Welfare State in a Multicultural World conference.

17. Laurie, N. (2008). The Cost of Poverty: An Analysis of the Economic Cost of Poverty in Ontario. https://www. oafb.ca/assets/pdfs/CostofPoverty.pdf 18. Milligan, K. (Apr 27 2017). Ontario’s ‘basic income’ pilot will send the most money to grownup kids who still live with mom and dad. National Post.

19. Evans, D., and Popova, A. (2014). Cash Transfers and Temptation Goods: A Review of Global Evidence. Policy Research Working Paper, The World Bank Africa Region.

20. Alini, E. (Apr 24 2017). What you need to know about Ontario’s basic income plan. Global News.

21. Myerson, J. (2015). The Right to a Dignified Life.

Jacobin Magazine.

22. Dunlop, M. (2015). Health Policy. The Canadian Encyclopedia.

23. Segal, H. (Apr 27 2017). Ontario’s ‘basic income’ pilot helps defuse political anger that stems from economic exclusion. National Post.

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Viral Zoonotic Diseases and “The Next Big One” LEAH ROSENCRANTZ

Between December 9, 2017 and January 17, 2018, the World Health Organization reported a total of twenty new cases of Middle Eastern Respiratory Syndrome, an infectious disease commonly known as MERS, in Saudi Arabia. The symptoms of MERS may include fever, cough, shortness of breath, and pneumonia. The disease is often a deadly one, with this most recent outbreak having a devastating case fatality rate of 45%1.

MERS is caused by a corona virus, which was newly identified in 2012 after an outbreak in the Al-Ahsa region of Saudi Arabia. It belongs to the same viral family and genus as the virus causing Severe Acute Respiratory Syndrome (SARS)—also a relatively new and deadly disease commonly remembered for the 2003 epidemic that took the lives of nearly 800 people in China and elsewhere2.

Both MERS and SARS are examples of zoonotic diseases, or in simpler terms, diseases that spread from animals to humans. What is interesting about these infections is that they seemingly cause no harm in the animals that host them (i.e. the reservoir species), but can result in severe pathology for humans or other species that come in contact with them. For scientific researchers studying a new outbreak, finding the reservoir is an important, albeit complicated, first step towards trying to prevent new infections.

For MERS, the smoking gun seems to point to dromedary camels, a domestic species found throughout the Middle East and North Africa, although researchers are still debating this3,4,5. For SARS, evidence points conclusively now to the horseshoe bat as the primary reservoir species for this virus6.

In both cases, close contact with these animals facilitated the spread of disease first from animal to human, and then subsequently from human to human. It is this first jump though that is crucial to watch for, and as the United Nations 14

Environment Programme reported in 2016, is becoming ever more common as an increasing trend in worldwide zoonotic diseases takes hold.

“Never before have so many animals been kept by so many people—and never before have so many opportunities existed for pathogens to pass from wild and domestic animals through the biophysical environment to affect people causing zoonotic diseases or zoonoses”7.

In part, this increase is due to the boom in the human population over the last half century and our consequent need to feed this growing population. Intensive livestock production, expanding agriculture, and new human settlements encroaching on forest ecosystems or other habitats are all driving this trend. When we start bringing wild animals in closer proximity to humans, or start breeding livestock so intensively that we reduce their genetic variability and thus resilience to new pathogens, we open our population up to these opportunistic infections.

Given that one new infectious disease emerges in humans every four months, it is safe to say we have reason to start worrying about these practices that drive this pattern7.

Yet, looking at the numbers associated with this latest MERS outbreak, it might seem that there is nothing particularly worrisome occurring. Yes, twenty people were infected and nine died—but in comparison to other diseases that affect millions every year, why should we be devoting precious research dollars to such a seemingly small problem? The answer to this question hinges largely on chance.

Zoonotic researchers today are constantly talking about the “Next Big One”– in other words, either a new disease or more potent version of an existing infectious disease that is waiting to take hold in the human population.

While nothing on this scale has happened since the AIDS pandemic that reached its height in the United States in the 1980s, and continues to Juxtaposition

persist globally to this day, scientists are staying vigilant for what many deem an inevitable occurrence.

To explore the likelihood of this occurrence, let’s again revisit the MERS and SARS viruses. Currently, MERS is considered a more fatal infectious disease than SARS. However, it is also less transmissible between humans than SARS, meaning far fewer cases and resultant fatalities. For now, a global pandemic is far-off for something like MERS. Yet, given its viral RNA structure, it is constantly undergoing genetic mutations8. Most of these will be deleterious to the virus’s cause, but some could be advantageous, in terms of either boosting its virulence or, even more alarming, boosting its ability to spread between humans. What this means is that while it is no longer considered a new virus, MERS has the capability to adapt and change as it replicates in its reservoir hosts to become even more deadly and transmissible when it finally makes the jump to humans once again. In other words, it could become the next pandemic. The same could happen for SARS or any other viral zoonotic disease. Ultimately, it is this possibility that makes the study of viral zoonotic diseases so important.

Whether the Next Big One is an entirely new infectious disease or something we have seen before, it is bound to be disastrous if the global community fails to act quickly enough.

Health care facilities should be operating with increased suspicion of an outbreak, whether they are in the Middle East or elsewhere and should also have policies and programs in place for rapid screening and treatment by trained healthcare workers to minimize spread of disease within the population9. While relatively small infectious disease outbreaks like those caused by MERS may seem inconsequential now, their importance must not be overlooked, as they are opportunities for both researchers and healthcare workers alike to glean as much information as possible.

We will no doubt need this knowledge and more to fight back against the Next Big One both effectively and efficiently.

References 1. World Health Organization (WHO). Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia. http://www.who.int/csr/don/26-january-2018-mers-saudiarabia/en/(WHO, 2018).

2. Centers for Disease Control and Prevention (CDC).

SARS, Basics Factsheet.https://www.cdc.gov/sars/about/fssars.html(CDC, 2004).

3. Nowotny, N., & Kolodziejek, J. (2014). Middle East respiratory syndrome coronavirus (MERS-CoV) in dromedary camels, Oman, 2013. Eurosurveillance, 19(16), 20781.

4. Adney, D. R., van Doremalen, N., Brown, V. R., Bushmaker, T., Scott, D., de Wit, E., ... & Munster, V. J. (2014).

Replication and shedding of MERS-CoV in upper respiratory tract of inoculated dromedary camels. Emerging infectious diseases, 20(12), 1999.

5. Mohd, H. A., Al-Tawfiq, J. A., & Memish, Z. A. (2016).

Middle East respiratory syndrome coronavirus (MERS-CoV) origin and animal reservoir. Virology journal, 13(1), 87.

6. Li, W., Shi, Z., Yu, M., Ren, W., Smith, C., Epstein, J. H., ... & Zhang, J. (2005). Bats are natural reservoirs of SARSlike coronaviruses. Science, 310(5748), 676-679.

7. UNEP. UNEP Frontiers 2016 Report: Emerging Issues of Environmental Concern. United Nations Environment Programme,Nairobi, 2016.

8. Zumla, A., Hui, D. S., & Perlman, S. (2015). Middle East respiratory syndrome. The Lancet, 386(9997), 995-1007.

9. Boyd, M. A., Cooper, D. A., Ledgerwood, J. E., Rizzetto, M., Ciancio, A., Thompson, K. M., ... & Cibulskis, R. (2015). MERS—an uncertain future. The Lancet Infectious Diseases, 15(10), 1115-1242.

Whether the Next Big One is an entirely new infectious disease or something we have seen before, it is bound to be disastrous if the global community fails to act quickly enough.

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Moyo Means Life: A Photo Essay ALLISON I. DANIEL

References 1. United Nations Development Programme. Human Development Report 2016: Human Development for Everyone.

(2016).

2. World Health Organization. Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children. (2013).

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PhoTo 1 (lefT): The Southern African country of Malawi is one of the least developed countries in the world. Malawi is ranked 170th out of 188 countries according to the Human Development Index, which is based on a composite score of life expectancy, schooling duration, and per capita income1.

Pictured here is the Queen Elizabeth Central Hospital in Blantyre, Malawi; the largest hospital in the country.

Date and location: August 24, 2016, Queen Elizabeth Central Hospital, Blantyre, Malawi

3. Ashworth, A., Khanum, S., Jackson, A. & Schofield, C. Guidelines for the inpatient treatment of severely malnourished children. (2003).

4.

World Health Organization. WHO Global Health Workforce Statistics: 2016 Update. (2016).

All photographs were taken by Allison I. Daniel in 2016 at the Queen Elizabeth Central Hospital in Blantyre, Malawi with permission from individuals in the photographs.

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The inpatient mortality rate at Moyo is over 20%, with many of these deaths occurring because children are taken to hospital too late, only once they are in critical condition.

PhoTo 2 (above): This image shows the main patient area of the Moyo Nutritional Rehabilitation and Research Unit (known as â&#x20AC;&#x153;Moyoâ&#x20AC;?), one of five pediatric wards at the Queen Elizabeth Central Hospital. Children with severe acute malnutrition (SAM) who also have acute illnesses require hospital treatment at nutritional rehabilitation units like Moyo. The inpatient mortality rate at Moyo is over 20%, with many of these deaths occurring because children are taken to hospital too late, only once they are in critical condition.

Date and location: August 5, 2016, Queen Elizabeth Central Hospital, Blantyre, Malawi

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PhoTo 3 (below): Following admission for SAM, the first phase of treatment is known as the â&#x20AC;&#x153;stabilization phaseâ&#x20AC;?, during which acute illnesses are managed. An important part of the stabilization phase is preventing and treating hypothermia, as hypoglycemia or acute illnesses can cause impairments in body temperature regulation in children with SAM. As pictured, there are heaters above the hospital beds to keep children warm. Other ways that hypothermia is prevented and treated in these children are the administration of antibiotics to target acute infections and feeding of children soon after admission, with continued frequent feeding including throughout the night2,3.

Date and location: August 24, 2016, Queen Elizabeth Central Hospital, Blantyre, Malawi

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PhoTo 4 (lefT): Every three hours throughout the stabilization phase, children are given therapeutic milk feeds known as F-75, containing 75 calories per 100 millilitres of milk. After children are stabilized, they transition to the â&#x20AC;&#x153;rehabilitation phaseâ&#x20AC;? and receive either F-100, which has 100 calories per 100 millilitres, or ready-to-use therapeutic foods every three hours3. Shown in this image is the kitchen where therapeutic milk feeds are prepared for children in Moyo.

Date and location: August 24, 2016, Queen Elizabeth Central Hospital, Blantyre, Malawi

PhoTo 5 (righT): There are only an estimated 18 physicians per 100 000 people living in Malawi, yet the number of nurses and midwives is more than 18 times the number of physicians4. The role of nurses is therefore remarkably important in the Malawi medical system. Because nurses are in high demand and wards like Moyo are understaffed, mothers or other caregivers are greatly involved in monitoring, providing care, and feeding their children all day and night during their childrenâ&#x20AC;&#x2122;s hospital treatment.

In this image, mothers are waiting for nurses to conduct anthropometric assessments of children to weigh their progress.

Date and location: August 24, 2016, Queen Elizabeth Central Hospital, Blantyre, Malawi

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Juxtaposition

Air Pollution and Cyber-Protest: Civic Activism in China

KELSEY YANG

Creating legislation is no longer China’s Environmental Protection (MEP) collaborates with most pressing challenge in regulating air polluthe Ministries of Commerce and Public Security tion. In fact, there is already a holistic legislative to enforce Rules on the Standard for Compulframework that includes policies at the nationsory Retirement of Motor Vehicles, which make al, local and international levels. The pervasive it mandatory to retire vehicles that do not meet problem is now the violation of these existing current emission standards5. The MEP also sets environmental regulations, which slips through the Ambient Air Quality Standards, of which the China’s improving, but presently weak, law en2012 revision added new control benchmarks for 1 forcement system . With the escalating costs of PM2.5 and ozone and tightened previous stanair pollution, there is increasing recognition that dards for other pollutants5. civic society must exert pressure on the Chinese government to help enforce regulatory compli While China’s national policies stipulate ance2. However, invoking the basic right to envithat local governments must enforce the adminronmental safeguarding by the state, and indeed istrative regulations, there is no clear indication activism itself, operates within various constraints as to who will take legal and fiscal responsibility in an authoritarian state. Yet, remarkably, with if regional ambient air quality standards are not limited freedom of speech, press, and demonmet. In China’s one-party central government, stration, Chinese citizens have made significant upper-level officials promote and demote local progress in demanding environmental transparleaders based on performance evaluations. A 3 ency and legal action through cyber-protest . study investigating promotion propensities for mayors in 83 Chinese cities showed that while air Institutional Structures and Policy Progress pollution reduction correlates with promotion, local GDP growth is by far the most statistical To explore why China needs citizen acly significant factor in determining promotion tivists in the first place, we need to examine the rate. Therefore, local governors may choose to shortcomings of the current state-led air polluneglect their environmental responsibilities in tion prevention and control plan. Since 2012, the favour of output-based growth metrics6.

Chinese government has developed a series of overlapping policies to accelerate its efforts to

Furthermore, conflicts of interest compli4 address air pollution . Broadly speaking, most of cate institutional accountability to air pollution the new regulations fall under one of five catego- regulations. Local Environmental Protection ries: fuel-switching to cleaner sources, transform- Bureaus (EPBs) cannot enforce pollution laws on ing the economic structure by shifting away from state-owned enterprises that enjoy regulatory energy-intensive industries, increasing energy privileges from both national and local governefficiency, moving high emission sources out of ments. For example, a 2014 Greenpeace study already-polluted areas, and finally, investing in of emission data showed that 85% of key facilitechnologies that reduce emissions. These regu- ties in the Hebei and Jiangsu regions consistentlations are operationalized by the State Council, ly violate emission standards, and most of these China’s chief executive body. For example, the are state-owned steel, power and cement faciliState Council specifies the Regulation on Levy ties7. Even when the local bureaus are in a posiand Use of Pollutant Emission Fees, imposing tion to levy emission penalties, polluters prefer fines based on the type and quantity of pollutto pay the relatively low fines to continue their ants businesses emit5. Various ministries and illegal emissions. commissions under the State Council also detail regulations. For example, the Ministry of Juxtaposition

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Non-State Approaches to Compliance: Citizen Activism

Growing knowledge and awareness about air pollution and its health effects have galvanized many citizens into taking action. Every year, air pollution contributes to more than 1.2 million premature deaths in China, and delays in implementing existing regulations come with immense costs to health and wellbeing8. According to a 2015 Greenpeace report, 293 out of 366 cities in China, a staggering 80.1% of the country’s regulatory regions, did not reach the National Ambient Air Quality Standard for airborne particulates smaller than 2.5 microns, PM2.59. China attracted global attention after experiencing episodes of severe haze between 2012- 2013. During these episodes, the highest level of PM2.5 recorded exceeded 690μg/m3, which is almost 30 times the WHO recommended PM2.5 standard of 25μg/ m3 10. Super-fine airborne particulates, including PM2.5, penetrate deep into the respiratory tract, and dramatically increase susceptibility to respiratory infections and non-communicable diseases10. They can also cross into the bloodstream and lead to cardiovascular diseases that are difficult to treat. Furthermore, lung cancer is a leading cause of disease and death in China, and not surprisingly, both ambient and household air pollution are top risk factors for lung cancer.

These health risks and effects are a tangible consequence of the air pollution in China, making it clear that an activist response is required.

Many citizens have also become activists for economic reasons. In 2010, the Ministry of Environmental Protection (MEP) estimated that China suffered 1.54 trillion Chinese Renminbi in economic losses, or 3.5% of its GDP that year, because of pollution4. Work absences due to air quality-related health problems, reduced crop yields, lower real estate prices, road traffic, air travel disruptions, and reduced tourism revenue may affect all individuals directly and indirectly.

Rise of Information Communication Technologies

In the past decade, activists have gained considerable traction online in calling for environmental transparency and in mobilizing public 22

action. The soaring prevalence of social media, and the ubiquitous use of a Twitter-like platform called Weibo in particular, has allowed advocates to engage a massive community of environmentalists11.

While government forces preclude most forms of dissent and organized physical protests, the political regime has allowed environmental activism to thrive online11. Some scholars speculate that this is because air pollution is not a very politically sensitive topic, and therefore public participation is welcome as long as it does not challenge the state’s authority12. The Chinese government has even been responsive to these web-based movements, such as requests for information disclosure and legal action against polluters2.

Twitter, Weibo and Requests for Information Disclosure

In 2008, the U.S Embassy in Beijing installed a sensor on its own rooftop and created a Twitter feed, @BeijingAir, to publish hourly PM2.5 readings. The embassy’s immediate goal was to provide warnings of ‘bad air days’ to protect the health of Americans living in Beijing. Although Twitter is blocked in mainland China, immense local interest in PM2.5 readings spurred the development of many third-party apps that imported the Twitter feed’s data. These apps made the hourly updates accessible to all who wanted to monitor PM2.5 levels, which the Chinese government did not disclose. On many days when the Beijing Environmental Protection Bureau (EPB) said the air quality was ‘slightly polluted’, the U.S Embassy’s PM2.5 reading was classified as ‘hazardous’ or worse13.

The same year, China implemented the Open Government Information and Open Environmental Information regulations in an effort to enhance transparency2. Both laws impose legal obligations upon government agencies to disclose information at their own will or upon individual request. As soon as these regulations came into effect, netizens and NGOs started to request information on air pollution. However, it was clear from the outset that the new open Juxtaposition

information laws alone could not overcome the “longstanding closeness, secrecy and monopoly of information in China’s political system.14” For example, when a Beijing resident named Yu Ping requested PM2.5 readings between 1 October 2011 and 18 November 2011, a period of severe haze and smog, the EPB denied his request, claiming that PM2.5 readings were only used for government research and thus could not be disclosed2.

Yet the heated PM2.5 campaign online showed no signs of quieting even after such requests were denied. In the following months, celebrity environmental activists such as Ma Jun and Feng Yongfeng each posted upwards of 200 Weibo microblogs containing the word “PM2.5”, fueling widespread conversation and protest both on- and offline11. These efforts culminated in December 2011, when a journalist from Southern Metropolis Daily requested PM2.5 readings for a total of 31 provinces11. Many believe this catalyzed China’s amendment of its air pollution monitoring plan, which was announced later that month11. Between 2012 and 2015, the Chinese government gradually established an online air quality disclosure platform, which now publishes real-time data including PM2.5 for all 367 Chinese cities. ‘under The dome’ – a hiT documenTarY The Internet has also become the predominant platform environmental activists use to disseminate information. As China has the largest population of internet users in the world, of which more than 388 million have mobile access, new resources diffuse at breakneck speed to inform and mobilize the public15.

Notably, a 2015 documentary about air pollution called ‘Under the Dome’ was viewed by more than 200 million people in just over 48 hours. Produced by Chinese reporter Chai Jing, the documentary became an instant online sensation16. ‘Under the Dome’ not only explains the sources, chemistry and health effects of air pollution, it also exposes the weak links in society, the economy, and policies that have allowed pollution to become a problem of this magnitude.

Juxtaposition

While the Chinese government initially acclaimed ‘Under the Dome’, it was soon blocked, and the central government even silenced ensuing media discussions. Nonetheless, it has been argued that the film’s initial release in China “clearly met a need for knowledge and understanding of a phenomenon the Chinese people endure daily”17 and achieved its goal to further incite national discussion among the public. looking forward In the past two decades, citizen activism has been critically facilitated by the rise of social media.

Along with the new informational disclosure regulations, the public has gained the motivation and capacity to interact with and push government agencies to fulfill their legal obligations.

While the Chinese government’s reaction to “Under the Dome” is a step back in its progress towards environmental transparency, the provision of real-time air quality data raises new possibilities for citizen surveillance. Looking forward, it will be up to the engaged community of environmental activists to further rouse public awareness about air pollution and galvanize civil participation in environmental decision-making. references 1. Lo, Carlos Wing-Hung, et al. “Effective Regulations with Little Effect? The Antecedents of the Perceptions of Environmental Officials on Enforcement Effectiveness in China.” Environmental Management, vol. 38, no. 3, 2006, pp. 388–410.

2. Wang, Xinhong. “Requests for Environmental Information Disclosure in China: an Understanding from Legal Mobilization and Citizen Activism.” Journal of Contemporary China, vol. 25, no. 98, 2015, pp. 233–247.

3. Deng, Yanhua, and Guobin Yang. “Pollution and Protest in China: Environmental Mobilization in Context.” The China Quarterly, vol. 214, 2013, pp. 321–336.

4. Hove, Anders, and Merisha Enoe. “Climate Change, Air Quality, and the Economy: Integrating Policy for China’s Economic and Environmental Prosperity.” Report. Climate Change & Air Quality Program, Paulson Institute, 2015.

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Air Pollution and Cyber-Protest: Civic Activism in China: References Continued 5. Feng, Lu, and Wenjie Liao. “Legislation, plans, and policies for prevention and control of air pollution in China: achievements, challenges, and improvements.” Journal of Cleaner Production 112, 2016.

6. Zheng, Siqi, Matthew Kahn, Weizeng Sun, and Danglun Luo. “Incentivizing China’s Urban Mayors to Mitigate Pollution Externalities: The Role of the Central Government and Public Environmentalism.” 2013.

7. Greenpeace. “85% of heavy industry in Hebei, Jiangsu exceeding emissions cap – Greenpeace” Greenpeace.

2015. Accessed at http://www.greenpeace.org/eastasia/ press/releases/climate-energy/2015/Hebei-Jiangsu-exceeding-emissions-cap/ 8. Zhou M, Wang H, Zhu J, et al. “Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study.” Lancet. 2016.

9. Greenpeace. “A Summary of the 2015 Annual PM2.5 City Rankings.” Report. 2015. http://www.greenpeace.org/ eastasia/Global/eastasia/publications/reports/climate-energy/2015/GPEA%202015%20City%20Rankings_briefing_int.pdf

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10. Guan, W., Zheng, X., Chung, K. F., & Zhong, N. “Impact of air pollution on the burden of chronic respiratory diseases in China: time for urgent action.” The Lancet, 2016, 388(10054), pp. 1939-1951.

11. Fedorenko, Irina, and Yixian Sun. “Microblogging-Based Civic Participation on Environment in China: A Case Study of the PM 2.5 Campaign.” VOLUNTAS: International Journal of Voluntary and Nonprofit Organizations, vol. 27, no. 5, 2015, pp. 2077–2105.

12. Chen, J. “Transnational environmental movement: Impacts on the green civil society in China.” Journal of Contemporary China, 2010, 19(65), pp. 503–523.

13. Chinadialogue. http://www.chinadialogue.net/article/ show/single/en/4661-Beijing-s-hazardous-blue-sky.

December 2011.

14. Wang, Xinhong. “Requests for Environmental Information Disclosure in China: an Understanding from Legal Mobilization and Citizen Activism.” Journal of Contemporary China, vol. 25, no. 98, 2015, pp. 234.

15. China Internet Network Information Center. “The 30th survey report.” 2012. http://www1.cnnic.cn/IDR/ ReportDownloads/201209/t20120928_36586.htm.

16. Powers, Diana S. “‘Under the Dome’ on Chinese air pollution, a documentary by Chai Jing.” Journal of Public Health Policy 37, 2015, no. 1: pp. 98-106. doi:10.1057/ jphp.2015.40.

17. Ibid., pp. 98

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The Mountain of Youth: What We Can Learn from Okinawa, Japan

JOCELYN CATENACCI Background dented level of autonomy and physical functionality when compared to a similar age cohort

The elderly population of Okinawa, Japan in most other high-income countries. This funchas gained worldwide recognition for enjoying tionality was measured by their ability to indeexceptionally long lives with autonomy even into pendently complete “activities of daily living” advanced age. This phenomenon has inspired (ADLs) such as bathing and dressing oneself and many researchers seeking to unlock the secrets through the preservation of cognitive capabiliof healthy aging. There is a stone in Ogimi - the ties. It is also common for the oldest old of Okipoorest and healthiest village in Okinawa - that nawa to partake in long of hours of field labour has a passage inscribed in it that reads, “At 80 every day, and historically, most have enjoyed you are still a child, if at 90 heaven calls, say ‘Go spending an exceptional 97% of their lives disaway!’ and come back when I am 100.1” When ability-free. Inspired by these observed differenca researcher interviewed one such centenarian, es in lifestyle, this article aims to further explore they said that they wanted to live another 20 the determinants of longevity in Okinawa–specifyears and that “life is beautiful.” It appears the ically environmental factors7.

Okinawans population has not only mastered

Okinawa is the lowest socio-economically lifespan maximization, but also life satisfaction, ranked prefecture, with the lowest income per even in advanced age! capita in Japan and the lowest physician-to-resi Okinawa is a chain of 169 islands in south- dent-rate in Japan, which disproves theories that west Japan that stretches between the Japanese the Okinawan phenomenon only occurred because of economic advantage and the availabilmainland and Taiwan2. It has a population of approximately 1.4 million and is sub-tropical and ity of medical care. Okinawans were also greatly discriminated against and disenfranchised in partially mountainous3. It is the southernmost prefecture of Japan, and has gained internamany ways as compared to the rest of Japan. tional recognition for having the highest prevMainland Japanese feel superior to Okinawans, alence of centenarians (people aged 100 years perceiving them as ‘barely Japanese’, due to the or over) in the world. The average prevalence of complex Okinawan history, isolated geography centenarians in high-income countries is approx- and diverse cultures8. imately 10-20 per 100,000, whereas in Okinawa the prevalence of centenarians is 40-50 per

Though Okinawa has produced hundreds 100,0004. In 2004, the average life expectancy of functional centenarians over the last several decades, it appears that the future generations at birth (LEB) was 81.8 years for Okinawa, 81.2 years in Japan as a whole and five years less in of Okinawans may not be able to enjoy the same 5 advantages due to now-decreasing LEB. This the United States at 76.8 years . The life expectancy in Japan overall is the highest in the world, exceptional longevity in Okinawa may be a pheand the Japanese prefecture of Okinawa ranks nomenon of the past. This has been attributed to lifestyle changes brought about by the ‘westfirst for not only life expectancy, but also quality ernization’ of Japanese culture. The ‘westernizaof life. tion’ of the Okinawan diet involves the increase

The World Health Organization has stated of protein and saturated fat and decrease in fish that Japan is already “leading the world in terms consumption in their diet, resulting in the increase of the fat to energy ratio which has draof healthy (disability-free) life expectancy” with Okinawa being its greatest success6. Even the matically impacted the expected lifespan of the next generation of Okinawans (those born after ‘oldest old’ in Okinawa maintain an unpreceWW2)9.

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This makes one wonder: what we can learn from this Japanese minority that has seemingly not only extended life but also youth?

The Okinawa Centenarian Study

The Okinawa Centenarian Study, initiated in 1976, is an ongoing, population-based study being conducted by Japan’s Ministry of Health10.

Since its inception, it has collected data from over 900 Okinawan centenarians through questionnaires and full geriatric physical and mental assessments.

The results of this ongoing study include the superior physical and cognitive functioning of the Okinawan centenarians, in comparison to non-Okinawan centenarians. Cognitive and physical capacity was measured through activities of daily living (ADLs) and range of motion as well as self-expression and comprehension of conversation, respectively. In terms of sensory functioning (auditory and visual functioning), Okinawan seniors were adequate, which is impressive considering their greatly advanced age. It is because of their superior physical and mental functioning that it is rare to see a bedridden centenarian in Okinawa. Indeed, all subjects studied could independently ambulate.

The Okinawa Centenarian Study, provided preliminary hypotheses to explain the longevity of the population and sparked the interest of researchers to delve deeper into the roots of this phenomenon.

Validation

Before we can explore further why the Okinawan population lives such long and healthy lives, one might ask the question: how do we know they are, in fact, as old as they say? Was there an accurate and comprehensive registration system in place in Japan old enough to provide birth information about centenarians (or any registration system, for that matter)? The answer is: Yes! The age claims made by the Okinawan centenarians were validated by the Japanese koseki registration system, which was a centralized birth registration system that was established in 26

187211. In terms of accuracy, the koseki records have been validated by the Japanese Annual Centenarian Report and other reputable organizations. The few discrepancies found did not involve age-overestimation, but age-underestimation. In other words, some of the subjects were even older than previously believed.

Significance

The study of this population is significant because ‘the oldest old’ are the fastest growing age cohort in North America and many other high-income regions. Determining how to reach age 100 and still be autonomous is of great interest and has inspired much scholarship and research. Due to the disproportionate consumption of health resources by citizens 65 years and above, prolonged health and disability-free life may have positive economic implications.

Another reason that the Okinawan centenarians are of great interest is that they represent an anomaly within the widely accepted Social Gradient Theory, which states that the higher the social rank, the longer a person’s lifespan12.

This idea was derived from the Whitehall studies conducted by Marmot et al. on civil servants in Britain from 1967-197713. Less political power, higher unemployment and lower income per capita collectively cause Okinawa to be the poorest prefecture in Japan.

Okinawa’s centenarians are also an anomaly due to Okinawa’s economically poor, uneducated and marginalized population that produced better longevity results than wealthier prefectures. Due to a complicated history between China and Japan with Okinawa being between them both, it has faced great oppression for the past hundreds of years. Japanese mainlanders feel a superiority over Okinawans who are considered to be their “second-class country cousins14”. Key differences in the culture of mainland Japan and Okinawa such as diet, language and attire also didn’t help the discrimination. Okinawans and mainland Japanese people rarely intermarried even after World War 2 when the prejudice did improve, but even today Okinawans aren’t seen as “fully Japanese” in the Juxtaposition

eyes of the Japanese mainland population15. This produced a geographically isolated subculture resistant to assimilation with Japanese culture. It is for this reason that determining the environmental factors that delay disease, disability, and death, is of great significance and requires further study.

Findings

Though much study is still needed, certain characteristics of this population have been discovered. The representative phenotype of an Okinawan is maintained short stature, low weight and low body-mass-index (BMI) throughout their lives16. This population exhibited a significantly lower rate of “age-associated diseases” like cardiovascular disease (CVD), stroke and cancer (especially hormone-based) – the leading causes of death in North America – when compared with their Japanese and North American counterparts17.

Further research has revealed through autopsies that at the time of death, Okinawan centenarians were free of common age-associated diseases like coronary heart disease (CHD), atrophic gastritis, kidney disease, hypertension, and metabolic syndrome18. Furthermore, Alzheimer’s and other neurodegenerative disorders are unheard of in Okinawa19.

The most common cause of death in Okinawa is infectious disease, such as pneumonia, rather than the aforementioned chronic diseases that plague the elderly populations of most high-income countries.

Studies have shown that when Okinawans migrate, their health and longevity resembles that of their new population.

Physical Activity

Elderly Okinawans (age 75 and over) on average spend 9-12 hours a day doing labour-intensive work such as farming, plowing, and even climbing up trees to retrieve fruit and showed no signs of slowing down20. Based on numerous interviews, elderly Okinawans, could not imagine not

working the majority of the day and attribute their health to enjoying their work. There isn’t even a word for “retirement” in most Okinawan dialects.

Other than participating in physical activity for their work, Okinawans also engage in group exercise frequently as this kind of social gathering is important in their culture. An example of this would be karate, which was invented in Okinawa.

Traditional Diet

The characteristics of the traditional Okinawan diet and culture that have been proven to aid in longevity are the caloric restriction and the nutrient-rich native foods, (such as sweet potatoes, goya and konbu) which proves to be a cultural diet highly cardio-protective and anti-hypertensive21.

Mild long-term caloric restriction (calorie deficit), was highly prevalent in this population and was beneficial to health22. Mild caloric restriction results in a negative energy balance due to fewer calories consumed as well as lowered insulin concentration and body temperature, both of which are known biomarkers of increased lifespan. Okinawans consume 83% of the average national intake perhaps inspired by the traditional Okinawan rule of eating until one is 80% full23.

The traditional Okinawan diet is low in fat, high in carbohydrates and 96% plant-based. The main foods that make up the traditional Okinawan diet are fish, soy, green vegetables, sweet potatoes, pork, seaweed, goya (bitter Okinawan melon) and tomatoes. In terms of drinking, Okinawans consume unsweetened green tea every day. These foods with green tea are high in phytonutrients, and most contain anti-oxidants and flavonoids that help prevent chronic disease by ‘quenching’ free radicals that would otherwise cause oxidative damage and inflammation in the body.

Sweet potatoes, for example, are the staple carbohydrate in the Okinawan diet and are

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credited with greatly enhancing their health due to the abundance of dietary fiber, natural sugars and vitamins in them24. They are also extremely beta-carotene dense, which prevents free radical-caused damage, slowing the aging process.

On the mainland, however, rice is more expensive and preferred over sweet potatoes which are associated with lower social rank25. Interestingly, this means that the less costly and less prestigious alternative was, in fact, the healthier one.

Also, seaweed, or konbu, is frequently found in Okinawan food, and is known to help prevent arthritis and reduce oxidative stress in the body. Goya, a bitter Okinawan melon, is also a staple in the Okinawan diet that is commonly used as a medicinal herb as well.

On average, Okinawans consume 80% less salt than the national average due to their fruit and vegetable-rich diet of the “functional foods” they harvest26. Meat and refined grain consumption is much lower in Okinawa than the national average along with saturated fat, sugar and salt.

The traditional Okinawan diet, with its low-fat and high-carbohydrate properties, is very similar to the ‘Mediterranean diet’ and the ‘Dietary Approaches to Stop Hypertensive’ (DASH) diet, although one key difference that sets the Okinawan diet apart from these is that it is cultural.

Social Culture

Okinawans have a very community-focused, low-stress culture with the vast majority of the population being native-born27. Okinawans tend to live either with, or close to, their family and participate in daily familial activities together. This family-oriented culture has greatly contributed to the prosperous lives in this subculture due to there being a lack of apathy and social isolation28.

Although Okinawans are ranked low within the national Japanese social hierarchy, there is a lack of social hierarchy within Okinawa itself.

Women in Okinawa are revered as spiritual

leaders, and in their culture, respect increases with age, unlike North America where abuse of the elderly has occurred. Despite examples of ageism in many high-income countries, many Okinawans value their own disability-free longevity as respect in Okinawa increases with age.

Also, Okinawans practise ancestor worship, which shows a respect for history and past generations, and helps them form a sense of identity, ethnic self-esteem, belonging and great kinship networks29.

Okinawans claim that all of these social aspects of their culture help reduce stress, therefore having a buffering effect on this population’s health, improving the resilience of their immune systems. Some potential negative health consequences of prolonged stress include depression, anxiety, arthritis, cancer, asthma and many other stress-induced illnesses30. The Okinawan culture focuses on achieving a minimal stress environment and succeeds with drastically lower average stress levels compared to those living in metropolitan areas of Japan and their international counterparts.

Conclusion

In conclusion, there is a lot to be learned from the case of the Okinawan centenarians that can aid in not only extending lifespan and functionality, but also maintaining a positive outlook even in advanced age. The characteristic intensity of elderly physical activity, native antihypertensive diet and stress-minimizing culture are the keys to the longevity of the Okinawans. It is through these environmental conditions that this subpopulation has achieved such lauded prosperity. It is also an anomaly to the widely accepted Social Gradient Theory because it maintains excellent health despite being a low-income and socially-marginalized prefecture.

What North Americans, especially, should take away from the Okinawa centenarians is that they not only had a highly active lifestyle with a highly nutritious diet but also their values. In all the research conducted, there was never a mention of money, prestige or competition amongst this population. They valued family, hard work

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and living simply, as well as having a profound respect for their elderly population and the generations that had preceded them. The Okinawans prove that North American culture has much to want for. It is through these cultural values that they have managed to achieve a seemingly uncomplicated prosperity.

Though studies have been conducted on this population, such as the OCS, there is still inadequate research to fully understand such a complex concept as longevity.

It is through emulating the Okinawan culture that we can have a profound impact not only on our long-term health but also on our economy through a lessened burden of disease. The traditional Okinawan culture, therefore, seems to be the key the world can use to unlock possibilities for the optimization of not just health, but also youth.

References 1. Video: At Eighty Still a Child (Saburou Makino): Link: https:// www.youtube.com/watch?v=qhd_7Gus4F0&t=72s 2. Willcox, D. C., Willcox, B. J., Sokolovsky, J., & Sakihara, S. The cultural context of â&#x20AC;&#x153;successful agingâ&#x20AC;? among older women weavers in a Northern Okinawan village: The role of productive activity. J Cross Cult Gerontol. 22(2), 145 (2007).

3. Cockerham, W.C., & Yamori, Y. Okinawa: an exception to the social gradient of life expectancy in Japan. Asia Pacific J. Clin Nutr. 10(2), 155 (2001).

4. Willcox, D. C., Willcox, B. J., Hsueh, W. C., & Suzuki, M. Genetic determinants of exceptional human longevity: insights from the Okinawa Centenarian Study. Age. 28(4), 313 (2006).

5. Bernstein, A. M., Willcox, B. J., Tamaki, H., Kunishima, N., Suzuki, M., Craig Willcox, et al. First autopsy study of an Okinawan centenarian: absence of many age-related diseases. J. Geronto Ser A: Bio Sci and Medl Sci. 59(11), 1195 (2004).

6. Willcox, D. C., Willcox, B. J., Shimajiri, S., Kurechi, S., & Suzuki, M. Aging gracefully: a retrospective analysis of functional status in Okinawan centenarians. Am J. Geri Psychiatry. 15(3), 253 (2007).

7. Wilson, E. Want to live to be 100? The Guardian. Jun 7 2001.

Accessed at https://www.theguardian.com/education/2001/ jun/07/medicalscience.healthandwellbeing.

8. Cockerham, W.C., & Yamori, Y. Okinawa: an exception to the social gradient of life expectancy in Japan. Asia Pacific J. Clin Nutr. 10(2), 155 (2001).

9. Gavrilova, N. S., & Gavrilov, L. A. Comments on dietary restriction, Okinawa diet and longevity. Gerontol. 58(3), 221-222 (2012).

10. Willcox, D. C., Willcox, B. J., Shimajiri, S., Kurechi, S., & Suzuki, M. Aging gracefully: a retrospective analysis of functional status in Okinawan centenarians. Am J. Geri Psychiatry. 15(3), 253 (2007).

11. Willcox, D. C., Willcox, B. J., He, Q., Wang, N. C., & Suzuki, M. They really are that old: a validation study of centenarian prevalence in Okinawa. J. Gerontol Ser A: Bio Sci and Med Sci. 63(4), 339-342 (2008).

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12. Cockerham, W.C., & Yamori, Y. Okinawa: an exception to the social gradient of life expectancy in Japan. Asia Pacific J. Clin Nutr. 10(2), 154 (2001).

13. Marmot, M. G., & Shipley, M. J. Do socioeconomic differences in mortality persist after retirement? 25 year follow up of civil servants from the first Whitehall study. BMJ, 313 (7066), 1177-1180 (1996).

14. Cockerham, W.C., & Yamori, Y. Okinawa: an exception to the social gradient of life expectancy in Japan. Asia Pacific J. Clin Nutr. 10(2), 155 (2001).

15. Cockerham, W.C., & Yamori, Y. Okinawa: an exception to the social gradient of life expectancy in Japan. Asia Pacific J. Clin Nutr. 10(2), 155-156 (2001).

16. Chan, Y. C., Suzuki, M., & Yamamoto, S. Dietary, anthropometric, hematological and biochemical assessment of the nutritional status of centenarians and elderly people in Okinawa, Japan. J. Am Col Nutr. 16(3), 231 (1997).

17. Willcox, D. C., Willcox, B. J., Todoriki, H., & Suzuki, M. The Okinawan diet: health implications of a low-calorie, nutrient-dense, antioxidant-rich dietary pattern low in glycemic load.

J. Am Col Nutr. 28(4), 511S (2009).

18. Bernstein, A. M., Willcox, B. J., Tamaki, H., Kunishima, N., Suzuki, M., Craig Willcox, et al. First autopsy study of an Okinawan centenarian: absence of many age-related diseases. J. Geronto Ser A: Bio Sci and Medl Sci. 59(11), 1196-1198 (2004).

19. Willcox, D. C., Willcox, B. J., Todoriki, H., & Suzuki, M. The Okinawan diet: health implications of a low-calorie, nutrient-dense, antioxidant-rich dietary pattern low in glycemic load.

J. Am Col Nutr. 28(4), 507-510S (2009).

20. Willcox, B. J., Willcox, D. C., Todoriki, H., Fujiyoshi, A., Yano, K., He, Q. et al. Caloric restriction, the traditional Okinawan diet, and healthy aging. Ann N.Y. Acad Sci. 1114(1), 438-449 (2007).

21. Willcox, D. C., Willcox, B. J., Todoriki, H., & Suzuki, M. The Okinawan diet: health implications of a low-calorie, nutrient-dense, antioxidant-rich dietary pattern low in glycemic load.

J. Am Col Nutr. 28(4), 503S (2009).

22. Willcox, D. C., Willcox, B. J., Todoriki, H., & Suzuki, M. The Okinawan diet: health implications of a low-calorie, nutrient-dense, antioxidant-rich dietary pattern low in glycemic load.

J. Am Col Nutr. 28(4), 500S-512S (2009).

23. Willcox, B. J., Willcox, D. C., Todoriki, H., Fujiyoshi, A., Yano, K., He, Q. et al. Caloric restriction, the traditional Okinawan diet, and healthy aging. Ann N.Y. Acad Sci. 1114(1), 450 (2007).

24. Willcox, D. C., Willcox, B. J., Todoriki, H., & Suzuki, M. The Okinawan diet: health implications of a low-calorie, nutrient-dense, antioxidant-rich dietary pattern low in glycemic load.

J. Am Col Nutr. 28(4), 504S-505S (2009).

25. Willcox, D. C., Willcox, B. J., Todoriki, H., & Suzuki, M. The Okinawan diet: health implications of a low-calorie, nutrient-dense, antioxidant-rich dietary pattern low in glycemic load.

J. Am Col Nutr. 28(4), 504S-505S (2009).

26. Miyagi, S., Iwama, N., Kawabata, T., & Hasegawa, K. Longevity and diet in Okinawa, Japan: the past, present and future.

Asia Pacific J. Pub Health. 15(1), S3 (2003).

27. Willcox, D. C., Willcox, B. J., He, Q., Wang, N. C., & Suzuki, M. They really are that old: a validation study of centenarian prevalence in Okinawa. J. Gerontol Ser A: Bio Sci and Med Sci. 63(4), 348 (2008).

28. Chan, Y. C., Suzuki, M., & Yamamoto, S. Dietary, anthropometric, hematological and biochemical assessment of the nutritional status of centenarians and elderly people in Okinawa, Japan. J. Am Col Nutr. 16(3), 233 (1997).

29. Cockerham, W.C., & Yamori, Y. Okinawa: an exception to the social gradient of life expectancy in Japan. Asia Pacific J. Clin Nutr. 10(2), 154-158 (2001).

30. Park, J., Kitayama, S., Karasawa, M., Curhan, K., Markus, H. R., Kawakami et al. Clarifying the links between social support and health: Culture, stress, and neuroticism matter. J. Health Psych. 18(2), 226-235 (2013).

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Toronto Thinks Global Health Case Competition: Best Overall Team

Alana Changoor, Himani Bhatnagar, Khalid Fahoum, Hoomam Homsi, Buvani Sivagnanasunderam and Nicole Viscek

Pollution is the world’s largest environmental cause of morbidity and mortality today1. In 2015, diseases caused by air pollution accounted for 16% of premature deaths worldwide2. Known as a “wicked” global health problem, the problem of air pollution is only expected to worsen with time. Negative health consequences include an increased risk of respiratory disease3,4,5, cardiovascular disease6, cancer7, and neurological effects8.

At Toronto Thinks 2018, we were challenged to develop a social enterprise business model to target traffic-related air pollution in the city of Toronto. With a budget of $5 million dollars over three years, we decided to target a key contributor to traffic-congestion and air pollution in the city: the number of individuals driving to work on a daily basis. According to Environment Canada, transportation is the second largest contributor to greenhouse gas emissions (second to the oil/gas sector), as it accounts for 24% of Canada’s total emissions9. Emissions from transportation have increased by 42% between 1990 and 2015, due in part to the increased number of cars on Canadian roads. In the Greater Toronto Area alone, there are 1.7 million drivers commuting to work, with the majority being the sole occupants of their vehicle: only 150,000 GTA dwellers report getting to work as a vehicle passenger10. Our goal was to increase the number of individuals in passenger positions and decrease the number of cars occupied solely by their drivers. Vehicles with single occupants present a significant source of pollution that also leads to increased traffic congestion, wasted time, unused space, and lost productivity.

Our team designed a unique ridesharing platform – Carmunity. There are four components of Carmunity we would like to highlight – convenience, community-building, contribution to the environment, and cultural shift. Unlike traditional

rideshare platforms, Carmunity targets commuters with a daily work schedule commuting within the GTA for work. Our platform would match both drivers and passengers based on residence and workplace location and operate on the basis of a monthly subscription. The key strength of our platform is that it allows drivers who are already commuting to work on a daily basis, to cut down on gas and parking costs by sharing their vehicle. Indeed, through our cost model estimates, drivers would be reimbursed 100% of their gas and parking expenses whereas passengers would be paying only 38% of their previous costs. This arrangement is made possible by the cost-effective nature of carpooling, with shared benefits for all participants involved.

Beyond the cost effective nature of our platform, another unique aspect of our approach to ridesharing is the matching process for riders and drivers. It is geared towards fostering community and building social networks. An increasing number of people driving to work alone, is a contributor to an increasingly isolationist social culture, and in the literature has been linked to poor community mental health outcomes11. However, with Carmunity, a specialized algorithm transforms the carpooling experience by matching drivers and passengers on interests and preferences, including after-work hobbies (e.g. gym, groceries), professional interests, music preferences, or even a preference for silent rides. Moreover, Carmunity would also offer a points-based incentivization for community building, awarding points to “carpool teams” for each ride-share that could be redeemed for local perks such as free parking vouchers, meals, massages, movie tickets, and more. In this way, we build a “carmunity” that is social, healthy, and rewarding.

While full of perks for participants, Carmunity is a social enterprise model with a lot to offer

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to the environment and health of the GTA community too. It is estimated that ridesharing can reduce greenhouse gas emissions by 588,000 tons over five years in the GTA, representing a 5.7% cut to personal transportation emissions12.

The structure of our model also targets the inequities associated with patterns of car ownership.

By incentivizing carpooling as a routine mode of getting to work, Carmunity makes it easier for those who may not be able to afford a car, such as recent graduates, low income families, and new immigrants, to be able to get to work and earn a living, without spending a significant amount of their paycheck on transit or gas/parking.

As a final challenge, teams were given a “twist” to implement their projects in a global context with two additional years of funding.

We decided to pilot Carmunity in Mexico City – the most traffic-congested city in the world13.

Upwards of 200,000 cars are being added to Mexico City’s streets each year14, and the cost of travel can exacerbate existing social inequities, amounting to almost 25% of the yearly income of low income workers15. With this in mind, we believe that the Carmunity enterprise model could achieve significant impact in this context.

Our plan was largely to engage local innovators, pre-existing traffic-reduction organizations, governments and private stakeholders, to learn from and form partnerships with organizations that are knowledgeable of the city’s unique socio-political and cultural dynamics.

Overall, the objective of Carmunity is to change the cultural norm of car ownership, to reduce its necessity and increase the convenience of getting to work, while building healthier and more social communities. To date, carpooling remains an untapped resource strategy to target traffic-related air pollution. Carmunity presents a sustainable, and equity-driven social enterprise model that takes advantage of this fact, to foster a greener, more united, and healthier Toronto.

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References 1. Landriga,n P., Fuller, R., Acosta, N., et al. The Lancet Commission on pollution and health. Lancet. October 2017:Epub ahead of print available from: https://www.ncbi. nlm.nih.gov/pubmed/29056410.

2. Landrigan, P., Fuller R., Acosta, N., et al. The Lancet Commission on pollution and health. Lancet. October 2017:Epub ahead of print available from: https://www.ncbi. nlm.nih.gov/pubmed/29056410.

3. Tanaka, T., Asai, M., Yanagita, Y., et al. Longitudinal study of respiratory function and symptoms in a non-smoking group of long-term officially-acknowledged victims of pollution-related illness. BMC Public Health. 2013;13:766.

4. Götschi, T., Heinrich, J., Sunyer, J., et al. Long-term effects of ambient air pollution on lung function: a review.

Epidemiology. 2008;19:690-701.

5. Marks, G. A critical appraisal of the evidence for adverse respiratory effects due to exposure to environmental ozone and particulate pollution: relevance to air quality guidelines. Aust. N. Z. J. Med. 1994;24:202–213.

6. Lee, B., Kim, B., Lee, K. Air Pollution Exposure and Cardiovascular Disease. Toxicol Res. June 2014;30(2):7175.

7. International Agency for Research on Cancer. IARC: Outdoor air pollution a leading environmental cause of cancer deaths. Lyon, France: World Health Organization; 2013.

8. Power, M., Weisskopf, M., Alexeeff, S., et al. Traffic-related air pollution and cognitive function in a cohort of older men. Environ Health Perspect. 2011;119:682–687.

9. Canada, Environment and Climate Change. “Greenhouse Gas Emissions by Canadian Economic Sector.”

Canada.ca, 13 Apr. 2017, 10. Statistics Canada. 2017. Toronto [Census metropolitan area], Ontario and Ontario [Province] (table). Census Profile. 2016 Census. Statistics Canada Catalogue no.

98-316-X2016001. Ottawa. Released November 29, 2017. http://www12.statcan.gc.ca/census-recensement/2016/dppd/prof/index.cfm?Lang=E (accessed February 25, 2018).

11. Hansson, E., et al. “Relationship between commuting and health outcomes in a cross-sectional population survey in southern Sweden.” BMC public health 11.1 (2011): 834.

12. Sud, S.. “Ride-Sharing Could Cut Greenhouse Gas Emissions by 6% in Toronto: MaRS Report.” MaRS, 7 Dec. 2016, www.marsdd.com/news-and-insights/ride-sharingcut-greenhouse-gas-emissions-toronto-mars-report/.

13. “TomTom Traffic Index 2017: Mexico City Retains Crown of ‘Most Traffic Congested City’ in World.” TOMTOM Corporate, 21 Feb. 2017, corporate.tomtom.com/ releasedetail.cfm?releaseid=1012517.

14. De Jong, F., and Graf, G. “Mexico City’s Endless Commute.” City Lab, 9 Feb. 2017, www.citylab.com/ transportation/2017/02/mexico-citys-endless-commute/515364/.

15. Peters, S. “Bringing in the Peri-Urban Poor: Options for Expanding Mexico City’s Transportation Network.” Sanford Journal of Public Policy: 37.

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Toronto Thinks Global Health Case Competition: Best Undergraduate Team

Heather Wong, Hui Wen Zheng, Zeus Eden, Will Zich

Air pollution has been proven to correlate with numerous detrimental health outcomes, from asthma and respiratory issues to cardiovascular diseases, pulmonary disorders and even cancer. The World Health Organization ranks air pollution as the fourth leading risk factor for death – and recommends it be limited to ten micrograms per cubic metre. Downtown Toronto exceeds that level on a daily basis. Health Canada estimates that almost 14,400 annual premature deaths can be linked to air pollution, especially in urban settings. As Canada’s largest city, Toronto is especially affected by this public health threat – resulting from the dense concentration of carbon emissions, caused primarily by vehicle emissions.

Vehicle emissions account for 27% of all pollution in To ronto. However, these emissions are not shared equally between automobiles. In fact, more than 80% of all emissions come from just 20% of cars – which are older, poorly tuned, and often lack catalytic converters. While Ontario does impose emissions standards on registered vehicles, through the Drive Clean program, it also contains a number of exemptions which allow highly-toxic vehicles to receive a ‘conditional pass’, even when they fail emissions standards. For example, drivers are required to repair their vehicles in-order to meet provincial emissions standards, but are exempt when costs exceed $450, meaning more expensive but badly-needed repairs are put off. Worst still, a number of vehicles

including those produced before 1988, historic automobiles, farm vehicles, and motorcycles are exempt from these emission standards entirely.

If the City of Toronto were able to reduce the highly-toxic emissions from these vehicles to normal levels by installing catalytic converters and subsidizing repairs for drivers, it would be possible to cut Toronto’s emissions from automobiles by more than half. Given a $5 million budget and three-year timeframe, our team designed a solution to do just that: Joyride. Using research conducted by the University of Toronto, we discovered that the largest amount of emissions came from daily commuters along the Mississauga-Etobicoke corridor, so we decided to target that area.

The Joyride program would have two steps.

First, the program would invest $3.8 million dollars over three years to fully subsidize necessary repairs for 7,000 cars to bring them up to provincial emissions standards. Drivers could apply to the program on their own, or with our partners at used car dealerships and auto repair shops. If they commute from Etobicoke or Mississauga to downtown Toronto a minimum of four times in a given week, the program would subsidize the full cost of repairs, estimated on average to be about $425 per car. Subsidizing the installation of catalytic converters and on-board diagnostic tools (OBDs) in Mississauga would serve as a model for what could be introduced as a more

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wide-ranging provincial program. User uptake for similar programs which offer free services like vaccinations is 60-70%, indicating that a subsidy program of this nature can be successful.

The second stage of the program targets driver behaviour. Almost all modern cars are equipped with OBDs, which record speed, acceleration, fuel efficiency, engine power, and transmission. Used most often to identify problems with the car and activate warning lights, this data can also be used to identify bad driving techniques such as accelerating quickly, braking abruptly, idling, and failing to maintain a constant speed. Joyride is an app which connects to a car’s OBD to provide driving tips in the form of insights which appear in the app on a user’s phone – such as “accelerate more slowly” and “avoid sudden stops at stop signs”. Drivers could improve fuel efficiency by up to 20% and are therefore incentivized to use the app to reap the savings of hundreds of dollars per year in reduced fuel costs. Furthermore, the app can generate revenue in the form of advertising and the licensing of driving big data. Revenue could be used to make the program sustainable, fund further catalytic converter upgrades in other regions, and make improvements to the app to adapt to new technologies.

Given the tremendous challenges that air pollution poses to Toronto – both in terms of the environment and public health – innovative solutions are badly needed. Joyride shows what could be possible if the city chooses to fund simple but significant changes.

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