Juxtaposition 3.1

At Home & Abroad Tackling health issues in Canadian and global contexts

Spring 2010 • Volume 3 • Issue 1

ISSN 1918-7653

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Juxtaposition Global Health Magazine 2010 / Volume 3 / Issue 1

VIew previous issues at www.juxtapose.ca

EXECUTIVE Division EDITOR-IN-CHIEF Brian Park, Jackie Wong STRATEGIC ADVISOR Neill Mears, Stephen Chen ADMIN. DIRECTOR

Jacky Chan

PRODUCTION EDITOR

Maggie Siu

PUBLICITY DIRECTOR Anna Nguyen PUBLICITY ASSOCIATE Sherry Chen SPONSORSHIP DIRECTOR WEBMASTER

Gretta Moy

Andrey Mikhaylov

EDITORIAL Division MANAGING EDITORS

2008 / Volume 2 / Issue 2 From Lab to Village

Luchen Wang,

Lucy Duan, Jennifer Kwan

SECTION EDITORS

Jill Murray, Jennifer Siu, Sarah Bailey, Stephen Chen

PHOTO CREDITS Available Online COVER PHOTO Brian Park CONTRIBUTORS

David Berliner, Graham Chamberlain, Hannah Geddie, Marzie Ibrahim, Moeza Merchant, Noori Tak, Rob Downie, Rochelle Burgess, Sophia Afzal, Waqas Khan

CONTACT Information WEBSITE www.juxtapose.ca EMAIL juxtaposition.ezine@utoronto.ca ADDRESS 21 Sussex Avenue Toronto, Ontario Canada M5S1J6

2007 / Volume 2 / Issue 1 Fear and Empowerment

For full manuscripts with references, email Juxtaposition

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Editors’ Note

Brian Park, Jackie Wong

The future of healthcare in India’s Liberal Economy Sophia Afzal, Moeza Merchant

A familar playbook: Canada, chrysotile & convention David Berliner

Behind the gold & glitter Graham Chamberlain

Lessons from history: in search of precept in the rubble of the AIDS response Rochelle Burgess

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The politics of disease Noori Tak

Sustainable cancer treatment in Kenya Rob Downie

Canada’s Gardasil and Big Pharma Hannah Geddie

Sport: a curb for the spread of HIV/AIDS? Marize Ibrahim

Issues of equity: primary healthcare for Canadian Aboriginals Waqas Khan, Imran Khan

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EDITOR’S NOTE

Welcome to the fifth issue of Juxtaposition Global Health Magazine! As a team this year we focused on the integration of the local community with broader global issues in an attempt to redefine global health in relation to its impact on our lives, our communities, and our country.

Juxtaposition would like to thank the McLaughlin-Rotman Centre for Global Health and the Human Biology Department at the University of Toronto for their ongoing support and dedication. We are proud, as well, to congratulate our executive team for their commitment and diligence. Their hard work made this publication possible and made the year truly rewarding.

We start our issue on the global scale with the topic of socioeconomic determinants of health. Noori Tak discusses political and social contributions to the recent outbreaks of the Bubonic Plague in the Democratic Republic of Congo.

Sophie Afzal and Moeza Merchant then explore the development and limitations of the National Health Policy of India. They conclude by providing suggestions for improvement of India’s health care system and policies.

Rob Downie enters the discussion with a focus on Canadian strategies for treatment of retinoblastoma in Kenya. We continue in a Canadian context with David Berliner, who presents an analysis on the Canadian government’s role in chrysotile asbestos exportation. He uncovers health concerns entangled in this little-discussed industry, casting a specific focus on Quebec’s involvement.

Hannah Geddie then critiques the Canadian response to pharmaceutical companies, specifically with regard to recent Gardasil advertising campaigns. This report is followed by a photo essay by Graham Chamberlain. In it, he reveals the global effects of Goldcorp, a Canadian mining corporation operating in the highlands of Guatemala.

Global health concerns have not yet been able to stray far from the spectre of HIV/AIDS. This severe and fatal disease ravages the developing world while continuing to cause serious health concerns in Canada and analogous developed nations. Marize Ibrahim advances the use of sport as therapy for HIV/AIDS in a promising new strategy for treatment. Rochelle Burgess considers the progress made in the HIV/AIDS struggle since its start in 1981 and introduces a conceptual framework with which we can approach future efforts.

We conclude our issue on the local scale with the topic of Aboriginal healthcare in Canada. Waqas and Imran Khan detail the influence of family physicians on the quality of healthcare and overall life in Aboriginal communities across the nation.

This exploration of international health challenges ultimately leads us back to the question of what our roles should be in solving these problems. I invite you to join us and to share your views and voices in this evolving discourse. We all have a stake in global health. Only through local and global collaboration can we hope to achieve success.

Jackie Wong Editor-in-Chief

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The politics of disease By: Noori Tak

The epidemiology of disease encompasses a multitude of factors, mastering the causes and effects of diseases around the world. While ease of transmission, climate, prevention and hygiene readily explain the microscopic process of disease transmission, an often overlooked variable- war and conflict, create a unique set of circumstances which are the perfect breeding ground for epidemics.

The destruction that war and conflict inflict on a country’s infrastructure can prevent basic care to citizens affected by other diseases or incidents such as malaria, HIV/AIDS, and rape – all of which are common in Africa. Though mass devastation has occurred by both war and disease individually of each other there are undeniable links between war and conflict and the transmission and outbreak of disease.

There are layered physical and mental human costs to conflict and war, graphic daily images in the war torn Iraqi and Afghani victims of crossfire demonstrate only one facet of human injuries due to conflict. The societal and infrastructural breakdown which occurs under the conditions of war translate to various, layered health consequences. Escalating conflict erodes the stability of a region, increasing the vulnerability of it’s populations to disease. A glaring example of conflict proving to be fertile grounds for the spread of disease lies in the recent outbreak of the Bubonic Plague in the Democratic Republic of the Congo.

The African nation has been embroiled in complex and bloody conflict since 2003, pitting troops supported by neighboring Angola, Namibia and Zimbabwe against rebel Congolese factions. The war has been termed “Africa’s World War” and has been relatively unnoticed by the international media.

The plague is one of the oldest identifiable diseases known to man, and is immortalized as the “Black Death” which caused the largest death toll in history for a non viral disease, reducing the world’s population by over 100 million.

Cases of the Bubonic Plague in the Congo were first reported in the Bas- Uele in the Northern Oriental province of the DRC by The World Health Organization in February of 2005. Since then the diseases has spread to the Western lying province of Iuteri and has ballooned to well over 1000 cases and some 50 deaths in the region in both its Pneumonic and Septicaemic forms. The disease is classified as a Zoonotic disease, circulating amongst rodents and fleas, with a casefatality ratio of 30-60 percent. Carrying fleas and animals transmit the Yersinia Pestis bacteria by biting humans, causing nausea, fever, chills, swollen lymph nodes, cracks in the skin and usually, death.

Though the Plague is prevalent throughout the world in Africa, the former Soviet Union, Americas and Asia with some 2118 confirmed cases as of 2003. 98.7% of all confirmed cases, and a shocking 98.9% cases of death are reported from Africa spreading across Zambia, to Madagascar. The natural foci of the disease are found readily in the continent specifically in the DRC, a landlocked nation. High temperatures create ample breeding ground for carrying fleas and animals.

The Congolese outbreak of the Plague is undoubtedly associated with the civil conflict, the World Health Organization has gone so far as officially stating “outbreaks of plague are often linked to poverty, civil disturbances and war, and when the health infrastructure and facilities have broken down”. Though outbreaks of plague have occurred in times of peace, the vulnerability and infrastructural weakness associated with war times undoubtedly weakens efforts to contain and manage the disease once detected.

Congolese villages, homes, health structures, schools and shelters have been destroyed, and this erosion of civilian resources has facilitated the disease by firstly, damaging existing healthcare infrastructure, secondly, by displacing Congolese citizens and finally, by limiting access to hygienic sites.

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As the Congolese outbreak of the Plague occurred in the background of humanitarian crisis limiting international efforts to curb the epidemic have remained weak and relatively ineffective.

The DRC, a poverty stricken, unstable nation is currently entirely dependent on external economic intervention from the likes of the World Bank and the IMF, and stands a pitiful 168th (out of 177) nations on the UN Development Programme’s human development index.

The public health care sector in the DRC is ill equipped to manage the Plague, and in the Lubutu region for example, is only able to see 1 in 6 patients successfully from “consultation to treatment”.

Doctors without Borders describes the Congolese health care system as “in total collapse”, coupled with 80% of Congolese citizens surviving on less than USD 0.30 a day, effective medical attention for patients is highly unlikely. A wide range medical intervention is undoubtedly necessary, and must address all aspects of patient care, in both preventative and emergency forms. Basic health care and nutrition is also a seriously inadequate in the DRC, as conflict related destruction of farm land and production capabilities as well as and stiff trade barriers, prevent the production and import and export of foodstuffs. Today 75% of Congolese citizens are undernourished.

The conflict has created such a violent and unstable state of affairs that international health care organizations are justifiably hesitant to place their personnel in the depths of Civil War. The WHO for example, has retracted all efforts at controlling the plague, including “health education, vector control, deratting and laboratory analysis as well as active surveillance”. The effects of this pull out are two fold: those who are not infected are then stripped of any forms of preventative medication. To those who are diagnosed with serious illness such as the Plague, access to treatment sites is limited, due to road blockages, damaged hospitals and the threat of rogue violence, bars citizens from seeking treatment. Hygiene kits, vaccinations, beds and epidemiological information gathering are among the invaluable resources now unavailable to vulnerable Congolese citizens.

Moreover, the conflict has created some 48,000 Internally Displaced Persons, with 63,000 refugees from neighbouring states living in the DRC. As villages and towns are looted and set ablaze, refugee camps and temporary shelters are stretched beyond capacity.

Refugee populations are classically identified as “high risk” for disease transmission, due to high population densities and poor sanitation. Fleeing families are met with poor hygiene standards, and often inadequate access to clean bathing and drinking water, which stimulates and nourishes diarrheal diseases, malaria, and measles – all of which are identified as leading causes of preventable death in the DRC.

Refugee camps are also at increased risk for war related violence as they contain masses of vulnerable and defenseless civilians. Analogous to the fact that simple and highly treatable diarrheal diseases are often death sentences in the DRC, non- life threatening treatable wounds sustained in conflict claim hundreds of lives, unnecessarily. With health infrastructure in the DRC effectively destroyed, wounded civilians are unable to acquire the medical attention they need in the time period where treatment is most crucial leading them susceptible to dangerous and painful infected flesh wounds and transmission of blood borne diseases such as Hepititis A & B, and HIV/AIDS. Furthermore, effective treatment and management of injuries (i.e.- physiotherapy) is unlikely.

Some 3 million Africans have been victims of disease and malnutrition associated with war. In 2005, the Crisis Group – a Brussels think-tank – stated 1000 people were dying a day due to war related causes, not exclusive to wartime violence. Rape is now identified as one of the most prevalent forms of wartime violence. Treatment of rape victims is most crucial within 2-3 days of attack. The Kivu province is home to some of the highest numbers of sexual violence in the world. Not only are worntorn nations like the DRC unequipped and unprepared to offer psychological support for rape victims, they are also unable to provide physical/medical treatment in a timely manner, increasing susceptibility to diseases like HIV/AIDS and other STDs and STIs.

In the third world, where rogue, guerilla fighting is the predominant medium of conflict, increasingly, enemy factions are increasingly employing brutal forms of physical violence and rape as a tool to victimize women and children, in its most horrific forms, sexual slavery and exploitation of children is used to serve armed troops, creating another venue for the transmission of HIV/AIDS and unwanted pregnancy.

In the DRC alone there have been 41 000 documented cases of rape since 1998 – the time which conflict substantially increased in the region. The problem is then exacerbated by the fact there are already so little health services available in areas of conflict that the treatment of rape victims is seen as unnecessary or as a “luxury,” and therefore they are overlooked and often do not survive because of a lack of basic medical care.

While the role of political conflict in inciting humanitarian crisis is not an unknown phenomenon, the complex linkage between political breakdown and disease is highly cyclical in nature, exacerbating existing health maladies and introducing new concerns.

War torn nations are particularly vulnerable as the protection and stability associated with times of peace are quickly stripped away. War ravaged citizens are amongst the most destitute, trapped in a barrage of violence and chaos, and without government protection, the onset of a disease epidemic is a catastrophic blow to any hope of rebuilding.

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© brian796 2006

The future of healthcare in India’s liberal economy By: Sophia Afzal, Moeza Merchant

India has acquired a strong economic and cultural presence on the world stage. Its industrial presence is largely due to the political restructuring in the last 20 years which have affected all aspects of life for Indians. Particularly, structural adjustment to the Indian healthcare sector in the 1990s was a result of increased liberalization of the economy aimed at reducing the budgetary deficit. Social programs deteriorated under the lack of governmental stewardship and are now becoming subject to various social trends. The majority of the healthcare burden now falls on the shoulders of the Indian states and this decentralization is representative of the disparities in healthcare across the nation.

The failure of the National Health Policy of 2002 is indicative of the decreased interest in health care rights for Indian citizens and the growing focus on India’s market potential. The policy’s objectives leave the most vulnerable citizens of India unprotected and suppress the notion of wellbeing under the agendas of the profitable pharmaceutical industry.

Many local and multi-national pharmaceutical corporations are involved in the marketing activities of their drugs, or conducting clinical trials in the country. These activities may be favourable for the Indian economy and, the research and development of new drugs, but do not necessarily translate into better healthcare and access to medicine for the Indian people.

The future scenario of health in India would be greatly improved with increased centralized government support for public health investment and improved collaboration within educational institutions and public health care facilities.

About 72% of the 1 billion people of India live in rural areas and they account for almost 70% of all deaths in the country.

These deaths occur among the rural communities and villages that harbor almost 716 million people. These rural areas represent the most neglected and poorly serviced areas of India and show patterns of disease that are significantly different than those seen in urban India. Infectious diseases, which account for 40% of the morbidity in villages, make up only 23% of the deaths in cities. Infectious diseases such as Malaria and filariasis, , are related to the agricultural development that has taken place without proper planning or consideration for the environment. Leprosy, vitamin deficiencies and death due to undernourishment are a daily occurrence. Illness related to pregnancy and childbirth is common and due to early marriages and pregnancies and lack of ante- and postnatal checkups observed. Major Indo-Canadian initiatives headed by World Literacy of Canada (WLC) have recognized the needs of women in the state of Uttar Pradesh and have established schools, women’s groups and local clinics to combat illiteracy and poor health awareness in India.

A summer internship through WLC in 2006 allowed me to conduct a qualitative survey in 8 villages to examine the inpact of WLC clinics in improving health knowledge. What I found was women lacked an understanding of the most common problems in the communities which included jaundice, measles, indigestion and swollen feet. Some of these symptoms were related to the work being done in the ricefields which required extended amounts of time spent in wet, insectinfested environments. Agricultural expansion has become a huge burden for rural populations and the paucity of government support is evidently harming the health of the people who work to feed India.

The rural population is also experiencing an alarming rate of growth and despite family planning being a central focus of previous health policies, there has been very little improvement

The Vulnerable Populations: Who carries the ‘burden of disease’ in India?

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in maternal and child health predictors. This state of rural health is particularly significant in the wake of diminishing community health practitioners and reliable family doctors. Most of the women in the villages were aware of the health centre but preferred approaching the doctor or the nurse when they came to the villages once a week. This “preference” was due to the lack of money for transportation to and from the centre and the lack of confidence they felt in travelling to the health centre alone. As a result, most waited for the doctor or the nurse to come to their village; however, this wait period is essential in preventing the progress of illnesses.

There is a great need for regular visits by government doctors in areas where there are no well-established transportation systems and overcoming the cultural barriers for visiting nearby hospitals.

About 78% of all doctors and 67% of all hospitals in India now fall under the private sector. In addition, an overwhelming 75% of health infrastructure, medical man power and other health resources are concentrated in urban centers where only 27% of the population resides. A 1998 national health surveys, conducted by the National Council for Applied Economic Research showed that medical treatment is the second-most important cause of rural debt. The inequities of Indian healthcare are growing and are further risking the lives of those who have already been the victims of past policies and government agendas.

The cycle of poverty in India is expanding and destabilizing the well-being and sociopolitical layers of the entire nation.

health and to reduce the dependence on foreign investment.

Research articles from South Asia (India, Pakistan, Bangladesh, Sri Lanka, Bhutan, Nepal, The Maldives and Afghanistan) constituted 1.2% of all annual research reported in the Institute for Scientific Information database from 1992 to 2001. This remarkably low percentage is reflective of the lack of research and shared information from resident scientists and institutions. Research needs to be more collaborative among South Asian countries, particularly on projects with common themes, such as infectious diseases. The Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) is an example of a successful cross border training program which offers research assistance and teaching facilities to regional and international physicians and scientists. Initiatives such as BIRDEM can be useful to develop networks and share information among a number of institutions.

The Big Pharma of India: Should industrial interests direct public healthcare?

In the past, the Indian Pharma industry primarily focused on developing new manufacturing processes for generic and reverseengineering of patented drugs already on the market. The primary export destinations included many developing nations, such as South Africa, where there is high demand for HIV/AIDS drugs at a low cost. Since 2005, India has signed the World Trade Organization’s multi-lateral Trade Related Aspects of Intellectual Rights (TRIPS) agreement setting out minimum standards for protection of many forms of intellectual property rights. The objectives of the TRIPS agreement are to promote technological innovation and transfer and disseminate technology to the mutual advantage of producers and users of technological knowledge, in a manner conducive to social and economic welfare, and to a balance of rights and obligations.

The implementation of the TRIPS agreement has given the Indian Pharma industry a competitive edge in exporting low cost, high quality manufactured drugs to highly regulated markets (e.g. the US). In addition, the low cost and high quality associated with research and development coupled with increased investor confidence in India’s commitment to intellectual property has attracted multinational pharmaceutical and clinical research organization (CRO) companies. Many of these companies have developed alliances with indigenous firms for outsourcing services and conducting clinical trials. Therefore, it has become less favourable for the Indian industry to export cheaper versions of new drugs to developing countries.

Studies have shown that innovative research activity has increased significantly in the chemical and pharmaceutical industries as measured by patent applications. Overall, pharmaceutical patent applications by Indian institutions in the US and India has increased significantly. In particular, patent applications in the US have increased by approximately 25-fold, up from 9 applications in 1990-1994 to 227 in the 1999-2002 period. This demonstrates that industry innovation has been targeted towards large markets like the US, rather than focusing on the unmet needs of the poor communities in India and other developing nations.

Beyond the shift in focus, Indian industry-sponsored and institutional clinical trials alike are likely to have violated human rights charters due to the lack of familiarity with clinical

The Privatization of Healthcare: What should the government’s role be in public health?

The decrease in governmental public health spending in the 1990’s and the increase in industrial potential has led to a growing amount of international investment in the Indian healthcare sector by non-resident Indians (NRIs). In 1993, the government was estimated to provide only 20-30% of total spending on healthcare while the private sector provided almost 67% of all healthcare investment capital; this represents a 50% increase from 1976.

The lack of public health spending affects the kinds of research being conducted and published in private academic journals developed over the last 10 years. The increasing publicprivate collaboration, mostly between pharmaceutical companies and government-funded research institutes, should promote research for local illnesses and use taxpayer money to secure the well-being of all Indians first and foremost. However, the diseases of poverty lack profit incentives and are often minimally funded. For example, only 1% of national research grants are spent on respiratory diseases, which are responsible for 20% of all deaths, while 20% of all research funds are spent on cancer studies, which accounts for only 1% of all deaths in India. The total amount of current research funding cannot be accurately estimated because of a lack of integrated information and resources on all the research being conducted. Only specific types of research are transparently funded such as India’s national leprosy program. India’s draft of the health policy, however, did acknowledge the need to develop a systemized database of surveillance information and health statistics by 2005.

This would improve the state and federal capacities significantly.

It is imperative for India to encourage research for public

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trial activity and lack of well-developed ethics committees to ensure that these human rights charters are upheld. As Asia is anticipated to constitute 40-50% of global clinical trials by 2010, processes are being put in place to ensure that all trials are registered with the Clinical Trial Registry-India (CTRI), as part of the World Health Organization’s Clinical Registry Platform (WHO ICTRP). This practice will allow for transparency and the protection of vulnerable population involved in the trials. However, policies need to be put in place to ensure that ethics review committees are accredited and play a critical role in implementing various guidelines, such as the World Medical Association’s guidelines for research to protect the rights of human subjects.

India’s main objectives in regards to the pharmaceutical industry have been to secure the availability of moderately-priced drugs and to promote domestic drug development initiatives. India has been slow to establish an essential drugs program necessary for stabilizing drug use and prices and this is primarily because pharmaceutical guidelines are considered under the umbrella of economic strategies rather than health policies. An example of how successful a centralized drug program can be is found within India’s State of Delhi itself. The Drug Policy, established with the help of a NGO in 1994, was set up to procure and dispense drugs rationally and to avoid overprescription. The successful Essential Drugs Lists (EDL) not only ensured that a minimum of 100 vital drugs would be available in all facilities, but also reduced the costs of these drugs by having an approved quality-assurance procurement system. The program led to 80% of drugs being dispensed for free in all levels of health care. The success of this program was due to the intensive educational and training services provided at conferences, governmental organizations and medical schools.

While WLC clinics in Uttar Pradesh were equipped to provide free supplementation pills and informed women of the free vaccines available, there was much confusion in the timing and delivery of these important medications. Women may be aware of vaccines but may miss out on vaccinations due to transportation costs. Hospitals and government representatives should ensure a well-crafted system of accessibility and delivery to these areas. A change in the status of pharmaceutical industry by including it in the public health sector might mitigate the effects of privatization in India.

clearly defined India’s interest in the western models of medicine.

To protect the well-being and human rights of the Indian population, implementation strategies for the National Health Policy need to be considered in relation to economic strategies of the country. This could be achieved by involving healthcare professionals in economic decisions relevant to healthcare and encouraging health systems research within institutions to allow for the development of evidence-based health policies. Selfregulatory mechanisms, such as peer-review of clinical practice, ethics committee review of research trials and transparency of the private sector activities should also be introduced and enhanced to ensure long-term implementation of policies and guidelines.

Conclusion

The National Health Policy of India in 2002 was expected to build on the socialist ideals of health and human rights recorded in the previous health policies of the 1980s. However, the intention of universal health care coverage has been largely ignored due to the lack of federal support and initiatives. The policy also fails to provide implementation strategies and is representative of the growing dependence of India on private and incentive-focused pharmaceutical and medical tourism industries. India still considers health as a dispensable expenditure and not as a justified investment.

Although the policy mentions leprosy and other common infectious diseases, such as polio, as the target of elimination, the platform does not mention any planned long-term changes to the current modes of treatment and prevention. There is an exaggerated emphasis on using biomedical, medication-oriented approaches that have

[Taken By: World Literacy of Canada Summer Interns, 2006 Location: Village District of Mau, Uttar Pradesh, India A local girl carrying her little brother.]

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Š charitywater.org

Sustainable Cancer Treatment in Kenya By: Rob Downie

Retinoblastoma (Rb) is a rare eye cancer of infancy and early childhood. In the developed world, about 90% of patients are diagnosed before 3 years of age. Early diagnosis and effective treatment in developed countries pushes survival above 96%. Based on global population distribution, an estimated 92% of affected children live in developing countries. The majority of advanced and fatal cases are observed in rural, underprivileged communities.

Many die before diagnosis and global survival is less than 20%.

Childhood cancer is often neglected in developing countries. Health systems are taxed responding to major public health challenges like high infant mortality rates; infectious diseases of childhood; infant malnutrition; and HIV/AIDS. As a result, these resource-limited countries bear the greatest burden of retinoblastoma, both in patient numbers and severity of disease.

Effective, life-saving therapy is already available in most of these countries. However, access to this vital care is frequently denied, delayed, or incomplete, due to poor cancer awareness among families and primary health care workers; sub-optimal allocation of available resources; and lack of family support services. Treatment of curable children is often refused or abandoned by families due to financial costs for transportation, accommodation, and treatment; cultural fears of mutilation from surgery (curative eye removal); and inadequate access to understandable disease and treatment information.

National strategies can focus on developing locallyadministered diagnosis and treatment programs.. Investment in these sustainable projects will ultimately improve the life and vision of survivors. A recent example is the Global Retinoblastoma Team at the Hospital for Sick Children. They are currently collaborating with medical professionals, families, survivors, and other stakeholders in East Africa to build a National Retinoblastoma Strategy in Kenya, capable of delivering effective

care to children and their families across the region of East Africa.

From Local to Global

Under the expert guidance of Dr. Brenda Gallie, the Retinoblastoma Team at Hospital for Sick Children the delivers state-of-the-art treatment to children from across Canada and around the world. In addition, Dr. Gallie and her interdisciplinary team have trained ophthalmology fellows from many developing countries.

These clinicians return home with knowledge and skills that build local capacity. Collaboration with Dr. Helen Chan from the Department of Paediatric Haematology/Oncology at the Hospital for Sick Children led to the development of a novel chemotherapy treatment for retinoblastoma. This protocol is currently being evaluated in international clinical trials. Additionally, the Retinoblastoma Team has pioneered the use of web-based technology to connect leading retinoblastoma treatment centres around the world and build a realtime global disease registry. Team members participated in the National Retinoblastoma Strategy for Canada. Collaboration with medical professionals, families, survivors, and other stakeholders has resulted in national treatment guidelines. These will be published in 2009 by the Canadian Ophthalmological Society.

Key Developments for a Global Model 1. A National Retinoblastoma Strategy This project began with a national panel of experts representing current multidisciplinary retinoblastoma care in Canada. They identified gaps in knowledge, evaluated equality and accessibility of care, and conducted literature searches for scientific evidence relating to each aspect of care. From this knowledge base, the

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www.juxtapose.ca group developed consensus-based best practice guidelines for the management of retinoblastoma that will encourage consistent, high-quality healthcare. The guidelines will be distributed to healthcare workers, hospitals, and service organizations caring for retinoblastoma patients and families. They define a cost-effective national care model; one that educates; facilitates prompt and appropriate referral; and ensures equitable access to the highest quality of care for all Canadians. Importantly, they will serve as a model for other countries to develop their own set of national guidelines.

goal of effective local treatment for children with retinoblastoma.

Developing a Retinoblastoma Strategy Model for Resource-poor Countries

Population estimates predict 1,500 to 2,000 African children develop retinoblastoma each year. Almost half of these children live in the ten countries constituting East Africa (Burundi, Djibouti, Eritrea, Ethiopia, Kenya, Rwanda, Somalia, Sudan, Tanzania, and, Uganda). Here, as in most developing countries, barriers to early diagnosis and treatment include high levels of illiteracy in the population; limited local primary health care services; inadequate training of rural health care providers; lack of referrals to regional hospitals; inaccurate, delayed, and missed diagnoses; and reliance on traditional medicine practices.

2. World Retinoblastoma Research Group An initial World Survey used secure web-based technology to gather retrospective information on 1411 children from 25 institutions on 6 continents. Results provided the first measures of the global impact of this rare eye cancer. Important treatment trends and global discrepancies in access to care were clear. This survey showed webbased collaboration can be effectively used to build a national or world registry without expensive or sophisticated tools. The prototype and methodology will be expanded to collect data from treatment centres around the world. Results will provide local incidence, treatments, and resources. These can be linked to imbalances in health care resources and social determinants of health. This information is of acute importance for developing regional strategies in resource-poor countries and supporting a strong global research community.

Based on the Canadian experience, there are 7 key components to a successful national strategy for retinoblastoma: • National awareness campaigns that target parents and health care workers to achieve early diagnosis and promote referral.

• Developing best practice guidelines to provide clear definitions for accurate clinical diagnosis and standards of care.

• Designating a retinoblastoma centre of excellence in each region or country and link with selected satellite centres.

• Expert pathological examination of removed eyes will accurately identify children at risk of recurrence, enable appropriate post-operative care, and make best use of available resources • Establishing a national registry to standardize record-keeping and follow-up care, and monitor impact of the strategy • Initiating child life programs to augment care of young children during treatment and reduce associated medical costs • Implementing family support programs providing access to educational resources; accommodation, transportation, and psycho-social support during treatment.

A Global Retinoblastoma Strategy

The journey from a local to a global model for retinoblastoma treatment and care was inspired by the experiences of two little girls who struggled to access life and vision-saving treatment. Daisy, a young girl from the UK, battled retinoblastoma for five years and required specialized treatment at the Hospital for Sick Children in Toronto. In 2003, Daisy’s parents established the International Retinoblastoma Daisy Fund (IRDF) to raise funds for her treatment and the family’s 16-month stay in Canada.

Rati was from Botswana. Her cancer-filled left eye was removed at 11 months of age. At 30 months, a tumor recurrence was detected in her eye socket and further treatment was unavailable in Botswana. Rati’s parents searched the Internet for help and contacted Abby White, a retinoblastoma survivor and patient advocate living in Oxford, UK. Abby helped the family connect with the IRDF, which covered the costs of transportation to Toronto for Rati and her mother and assisted with payment of initial medical fees.

In September 2004, Daisy’s Eye Cancer Fund (DECF) was established in England and Canada, to raise funds for Rati’s medical care. With support from around the world, Rati received expert care at the Hospital for Sick Children. DECF is a registered charity in the UK, a special fund within the SickKids Foundation, and holds non-governmental organization (NGO) status in Kenya.

Despite initial progress with treatment, Rati relapsed and died in August 2006, at age 4 years. In September 2006, ‘Rati’s Challenge’ was launched as a program within the DECF, to address the needs of families affected by retinoblastoma in Africa.

Focusing first on Kenya and East Africa, the program aims to build sustainable local capacity for retinoblastoma care with the

A National Retinoblastoma Strategy for Kenya: first steps

In November 2006, Abby White (DECF CEO) and Brenda Gallie (DECF Medical Director) travelled to Western Kenya to investigate retinoblastoma care in the country, carry out a pilot awareness campaign, and determine interest of the local team in developing a national strategy. They observed significant challenges for patients, families, and physicians in all areas of retinoblastoma care. It was noted that that simple steps might dramatically improve for affected children and their families, the prognosis for life and vision, and quality of life.

In November 2007, DECF members returned to Kenya to meet with physicians, nurses, and support staff who care for children with retinoblastoma at the country’s four main treatment centres – Nairobi, Eldoret, Kisumu, and Mombasa. The 3-week visit included medical seminars, extensive meetings with varied stakeholders, and media interviews to raise awareness of retinoblastoma. The group explored current treatments and obstacles to care in Kenya. On conclusion of this trip, there was local agreement to form a Kenyan National Retinoblastoma Strategy group and a commitment to hold

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www.juxtapose.ca the inaugural meeting within a year. The DECF funded the salary for an Executive Director in Kenya. Already on the job, Brian Ouma liaises with all stakeholders and the DECF-Kenya Board of Directors during the process of developing the strategy. As well, he will organize all Board-authorized events and programs used to build an effective Kenyan national strategy for retinoblastoma.

to care and positioning available resources to meet those needs.

Development of the Kenyan strategy shows resource-poor countries can develop and implement a local and sustainable national retinoblastoma treatment strategy to improve childhood cancer care.

Online Resources

Inaugural Meeting of the Kenya National Retinoblastoma Strategy Group (KNRbS)

United Kingdom - http://www.daisyseyecancerfund.org/ Canada - http://www.daisyseyecancerfund.ca/

The first meeting of the KNRbS Group was held from September 19-21, 2008 at the Lukenya Getaway Conference Centre in Athi River, Kenya. Funded by the Canadian Institute of Health Research and the Sir Halley Stewart Trust (UK), the meeting was attended by 70 invited participants including Kenyan parents, survivors, ophthalmologists, oncologists, pathologists, nurses and support staff, representatives from the Kenyan Ministries of Medical and Ophthalmic Services, and DECF members from Kenya, the UK, and Canada.

Using comprehensive situation analysis, the Kenyan group first assessed the current status of retinoblastoma treatment and management in the 3 health service regions of the country (East/ Coast region; Central/Nairobi; and West). Effective RB treatments and capable staff are available in most Kenyan centres. The group identified 4 key barriers to access of equitable retinoblastoma care.

Problems often begin as a result of delayed diagnosis. Improving awareness in both the population and the primary care health services is key to improving long-term treatment outcomes.

Once diagnosed, referral to specialist care is standard. Delays are common and most often related to family and economic issues including health beliefs, and the cost of regional travel and medical care. Lack of a timely and accurate pathology service for enucleated retinoblastoma specimens often leads to ineffective use of limited medical resources. Follow-up by treatment centres is inconsistent or lacking. It is necessary to improve patient record keeping as well as communication between physicians and from physician to family. The KNRbS strategy will initially focus on 4 key areas – awareness, treatment, family support, and resource mobilization. Focus groups defined priorities for each key area and set measurable program goals for the next year. The strategy group will develop and conduct a public awareness campaign, establish a regional retinoblastoma pathology service, define a standard clinical care protocol, and mobilize resources to fund family support programs. The KNRbS group will re-convene in August 2009.

Kenya - http://www.daisyseyecancerfund.org/aboutus/whatwedo/ africa/index.html

[Taken By: www.daisyseyecancerfund.org Leukocoria is the most common presentation of retinoblastoma.

By the time parents notice this ‘white reflex’ in their child’s pupil, the tumor is usually at an advanced stage but still usually contained completely within the eye. This condition is curable by surgical removal of that eye. Retinoblastoma that has spread into the brain or bone marrow requires intensive, costly therapies. Outcomes are very poor in these very advanced stages.]

Summary

Lack of awareness of childhood cancer in the population, along with delayed diagnosis and referral and the absence of public-funded treatment are key systemic barriers to care for many children in developing countries. Effective national strategies result from collaborative efforts among all stakeholders. The Canadian retinoblastoma strategy has demonstrated that situational analysis and collaboration among all stakeholders can optimize care for all children. Optimal care may not just be about access to more resources. It can be related to identifying major barriers

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A familar playbook: Canada, chrysotile & convention

The Rotterdam Convention- 2006 What do Indonesia, India, Iran, Russia, Kyrgyzstan, Peru,

Ukraine, Zimbabwe, and Canada agree on? Very little, except when it comes to asbestos. These were the only countries that blocked chrysotile asbestos from being added to the hazardous substance list of the UN Rotterdam Convention in 2006.

The Rotterdam convention is a United Nations agreement that came into force in 2004; Rotterdam was created to facilitate the transfer of information on hazardous chemicals between countries— specifically between developed and developing countries. Numerous states, including all members of the European Union (EU) and Canada, are signatories. If signatories agree (by consensus) to add a certain chemical to the ‘hazardous substance list’, then countries that export this chemical are required to obtain prior informed consent from the importing country. The idea here is that importing countries should be made aware of the dangers a chemical poses before introducing it into their workplace and environment.

By: David Berliner

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www.juxtapose.ca Asbestos: history and health health

Asbestos is a naturally occurring fiber that has been mined since the Roman times. Because of its durability and non-flammable properties, asbestos has been used in everything from napkins to medieval armor. Over the past century, asbestos was used ubiquitously in house insulation, car-brakes, and cement. Not all asbestos is the same; there are two main types of asbestos fibers used commercially, namely amphibole fibers and chrysotile fibers. These groups differ in durability, size and shape, and chemical composition. Because of these differences, amphibole fibers have been recognized as inherently hazardous, and as a result, have been banned in Canada and in many jurisdictions around the world for several decades. The current asbestos debate concerns the use and export of chrysotile fibers, which are still widely mined and used; some researchers argue that chrysotile asbestos does not pose the same risk as amphibole asbestos, while others argue it is equally as dangerous.

Asbestos’ hidden secret is its detrimental effects on health. The adverse effects of asbestos were not immediately discernable because of the lag up to 40 years—between exposure and the onset of symptoms. Yet we now conclude that inhalation of asbestos fibers, even in minute amounts, can lead to deadly lung diseases like mesothelioma (cancer of the inner lining of the lung), asbestosis (chronic inflammation of the lung), and lung cancer.

The World Health Organization (WHO) estimates that 125 million people still experience occupational exposure to asbestos, with 90,000 people dying annually due to past occupational exposure.

Furthermore, the WHO asserts that since all types of asbestos cause cancer, asbestos should be eliminated and replaced with known, safer alternatives. This view is supported by the International Agency for Research on Cancer (IARC) and other internationally recognized health authorities. Consequently, all forms of asbestos have been banned in the EU, Australia and other jurisdictions.

Asbestos in Canada

The asbestos industry in Canada is centered in Quebec, where it has been mined for over a century. In 2006, the two operational Quebec mines exported 170,000 tonnes of asbestos worth $93 million dollars. In Quebec, the asbestos industry also provides 800 direct and 1000 indirect jobs, where the majority (96%) of mined asbestos is exported to countries like India, Indonesia and Thailand. Thus, any decision regarding asbestos has political ramifications that affect the already unstable relationship between Quebec and the federal government.

Canada actively promotes the continued use of asbestos in foreign countries: the government has supplied $19M over 15 years to the Chrysotile Institute, an organization that advocates the use of asbestos abroad. Also, Canadian diplomats have often exerted pressure on foreign governments that were considering an asbestos ban. When France banned asbestos in 2000, Canada challenged the legality of the ban and attempted to overturn it at the World Trade Organization. Canada lost the case.

The Canadian government uses three main arguments to support its continued export of chrysotile asbestos. While it recognizes that chrysotile is carcinogenic, the government maintains that this fiber is not as dangerous as the other amphibole fibers. Secondly, the government insists that asbestos, whether used domestically or exported, is subject to rigorous controls.

Former foreign affairs minister Maxime Bernier explains that the “chrysotile industry does not export to companies that do not use chrysotile in a manner that is consistent with Canada’s controlled-use approach.” Finally, the asbestos industry and the government argue that the safety and health effects of alternative fibers to replace asbestos have not been demonstrated.

Who controls the controlled use?

[Asbestos continues to be used in the construction of private homes and office buildings.]

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The three aforementioned arguments for the continued use and export of chrysotile are weakly supported. Is chrysotile safer than other asbestos fibers? It depends who you ask. While some epidemiological studies show chrysotile is less dangerous than amphiboles, other studies suggest it is equally dangerous.

The risk assessments depend on what studies are included, what variables are assessed (and who foots the bill). Also, it is unclear whether pure chrysotile even exists in mines; these fibers are often contaminated with amphibole fibers. Unfortunately, the government doesn’t test the purity of exported asbestos.

Second, it is questionable whether international workers enjoy the privilege of a rigorous controlled-use policy followed in Canada. In Ontario, for example, the Occupational Health and Safety Act meticulously outlines safety procedures and equipment for any workers involved with asbestos. These policies greatly reduce the risk of exposure. “Anyone who says there’s controlled use of asbestos in the Third World is either a liar or a fool,” says Barry Castleman, an environmental consultant.

Former Minister Bernier concedes that Canada has no jurisdiction to implement or monitor the asbestos use in other countries.

Dr. Joshi, an industrial hygienist in India states it is nearly impossible for a country such as India to use asbestos safely. The depth of monitoring, safety inspection, and industrial hygiene we enjoy in Canada does not exist in his country. When photographer Louie Paul traveled to India, he witnessed this lack of regulation.

For example, during a surprise visit to the UP Asbestos factory, he saw “there was (asbestos) dust all over.” While in Canada workers would have been draped in protective equipment, Mr. Palu observed that in India there were “guys in shorts and flip flops.”

Finally, much research has been done on potential alternative fibers to asbestos. The WHO has identified many fibers that serve the same purpose as asbestos, without the deleterious health effects.

good life while working with asbestos products, why not die from it.” Although the Asbestos Textile Institute was well aware in 1973 that “25,000 past and present employees in the asbestos industry have died or will die of asbestos related disease”, they were optimistic enough to point out “the good news… that, despite all the negative articles on asbestos-health that have appeared in the press, very few people have been paying attention.” For decades, the asbestos industry has manipulated or suppressed the evidence which showed their product was harmful to health. Thousands of workers were placed at risk for lung cancer, mesothelioma, and asbestosis so that corporate profits could keep rolling in.

The Rotterdam Convention- Revisited

As of late, many more people are paying attention to the asbestos issue. The Canadian Cancer Society is calling for an asbestos ban. Ban Asbestos Canada, a coalition of laborers, advocates, doctors and scientists, continues to pressure the federal government. The editorial board for the Canadian Medical Association Journal has scolded the government for “knowing what it is doing is shameful and wrong.” The NDP and Green parties also support an asbestos ban. Only the federal government continues to turn a deaf ear.

In spring 2008, Health Canada convened a panel of experts to reassess the risk of asbestos. More than six months later, the report still remains unavailable to the public. The chair of the panel, renowned occupational toxicologist Trevor Ogden has lambasted the government for “needless secrecy”. On October 30th, 2008 the parties of the Rotterdam convention met in Rome. Once again asbestos was prevented from being added to the hazardous substances list; a play straight out of the book.

A page from a familiar playbook

It seems the asbestos industry has taken a page from a familiar playbook: “How to keep toxic substances on the marketplace: a dummies guide for industry.” The tobacco industry, benzene industry, and others have followed similar tactics. First, introduce a chemical with spectacular properties to the marketplace, since preliminary testing of this chemical suggests it is safe. Next, as some scientists begin to whisper about the chemical’s toxic effects, deny, suppress, or ignore this information. As this whisper slowly grows to a shout, it may become necessary to hire researchers to produce ‘junk science’ that confirms the safety of your chemical.

Other methods to confuse public opinion may also be employed. At this point it is important to use the powerful industry lobby to prevent government legislation. If legislation does pass, it may be necessary to move operations to another country where regulations are less strict.

Researchers have thoroughly documented how the asbestos industry (both in Canada and the US) took a page from this ‘playbook’ to keep their dangerous product in the market. For example, a memo from the National Gypsum Company in 1958 states that “just as certain as death and taxes…if you inhale asbestos dust you get asbestosis.” In 1966 a director at Johns Mansville Asbestos Company, Quebec wrote that “if you have enjoyed a

[Chrysotile serpentine collected from a river.]

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Canada’s Gardasil and Big Pharma By: Hannah Geddie

Pharmaceutical campaigns are a common presence within our society, a steady stream of ad campaigns and marketing ploys, which present consumers with the newest scientific discoveries in the form of an innovative drug, an exciting pill, or a miracle vaccine.

While these campaigns certainly play a role in our awareness of newly available products, they also simultaneously espouse enormous trust in the field of biomedicine and the miracles of science, often creating certain auras around various diseases and the drugs we use to treat them. This is particularly relevant in the case of Gardasil, one of the newest and most widely disputed scientific “discoveries” for women. It is a vaccine designed to prevent four types of HPV (human papilloma virus), and which, as increasing hype suggests, even has the potential to eliminate cervical cancer. A highly controversial vaccine, Gardasil has occupied enormous professional and public focus over the past 3 years, with a barrage of advertising both in the U.S. and Canada (despite direct to consumer advertising laws which prevent it). Marketing campaigns were swift and widespread, promoting praise of the vaccine, fear of the disease, and proudly presenting certain facts, while obscuring others. Gardasil is a highly important and relevant example of how the pharmaceutical industry operates on its consumers, how women in particular view their health, and whether the choices we are presented with are in fact choices at all.

images set amid a powerful backdrop of biomedical authority and a supporting “ask your doctor” conclusion, causes Gardasil and even HPV and cervical cancer itself to be publicly viewed in a light which is manipulated by industry goals; one which reinforces biomedical solutions to a severe sexually transmitted threat, and every woman’s personal responsibility to prevent this disease. Of course the corresponding cure comes at a price tag of at least $404 per required three doses (Comeau 2007:913).

To better situate Gardasil within Canada’s history of cervical cancer and the more recent development of the vaccine, the medical facts surrounding the disease and its prevention are extremely important. The burden of cervical cancer is a unique case, marking the combination of both chronic and infectious disease. Over the past 30 years cervical cancer research has seen marked advancement and come to the vital conclusion that this disease results solely from Human Papilloma Virus, an extremely common virus which is contracted sexually in a multitude of forms (Gross 2007:121). Though HPV is currently understood as the most common sexually transmitted disease, a majority of forms do not progress into cervical cancer, but will clear up spontaneously without any intervention at all in approximately 2 years for around 90% of women ((Lippman et al. 2007:484-485). While Gardasil boasts the ability to prevent four types of HPV (16, 18, 6, 11) there are also a variety of forms, and the extremely slow progression of the virus means that the most effective means of preventing cervical cancer are those which are already in place (Lippman et al. 2007:484-485).

The Gardasil campaigns, entitled “Make the Connection” and “One Less” were launched in 2006, focusing strongly around a number of key details, framed by the powerful imagery and catchy phrases designed by pharmaceutical company Merck. Predominant among these are the frequently reiterated messages of choice and responsibility, in commercials that conclude with smiling women proclaiming “You have a choice, choose Gardasil”, or “What do I do to protect myself? Everything I can”. The combination of these

While the Gardasil campaign does highlight awareness of the cause and severity of both HPV and cervical cancer, it also largely obscures the fact that prevalence has experienced marked decline

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www.juxtapose.ca in Canada over the past years (Lippman et al. 2007:484). Since scientific understanding of cervical cancer’s causes and progression has increased, incidence has steadily decline, which may be largely attributed to Canada’s healthcare system which enforces educating women on the importance of annual or biannual Pap smears, providing free Pap smears, good sexual education and health, and the importance of contraception to prevent sexually transmitted infections (STI’s). With such measures in place, the risk of contracting cervical cancer is extremely low, and within a screened population such as we are lucky enough to have in Canada it sits at approximately less than 1% (Ferenczy 2008:4). It bears examining then, that with such effective means, why there is any cervical cancer at all?

the recommended age groups of 9-26 as well as those outside of it are rushing to purchase this expensive vaccine, encouraged by increasing social concern and the powerful images which pharmaceutical company Merck has worked to design. Those who are often primary consumers in this model, the “wealthy, white and well” are however the last likely to come into contact with the disease. Educated, protected by strong immune systems and with access to cervical cancer screening, it is extremely unlikely that these women will develop cervical cancer from one of the 4 types Gardasil seeks to prevent. Those who do not have such backgrounds, often those who are marginalized and impoverished, both in developed countries such as Canada and the United States and especially those in developing contexts are not at the same level of risk. Addressing issues of health and cervical cancer therefore is based far more in infrastructure than the expensive quick fix which Gardasil promotes, despite its convincing aura of helping women and saving lives.

The fact is, that Gardasil commercials not only increase our awareness but raise our fear and our desire to consume, although we are not the ones most at risk. In reality, 80% of the burden of cervical cancer is suffered in the developing world (Gross 2007:124), in areas in which a fundamental lack of health infrastructure and education is responsible for lack of knowledge about sexually transmitted disease, unsafe sexual practices and inability to treat disease once it develops. These enormous problems are unlikely to be affected by the promotion of a vaccine that is extremely expensive by nature, which assuages the concern of disease without addressing its underlying causes, and finally which is not perfect in nature.

While women across the world have little access to education, disproportionate control over their life situations or sexual interactions and desperately inadequate access to healthcare, are the choices surrounding ones health really choices at all? And are the meaningful messages of women’s health and the eradication of cancer indeed altruistic attempts to educate the public, or a sad reminder of the ability of the wealth to afford healthcare choices that they may not ever need. The fact remains that as the situation is at present, those most likely to contract cervical cancer are least likely to have access to its new vaccine. Like so many other diseases, the power lies with those of greatest financial means, and as pharmaceutical companies are among the most powerful of the world, we as consumers must be skeptical as to what commodities we purchase, and what messages are we internalize.

Though Gardasil has been given approval by various drugregulating administrations worldwide, the vaccine’s efficacy and appropriateness for widespread use should not be accepted blindly.

While vaccination programs are being suggested for girls aged 9 to 15, few randomized controlled trials were completed on girls of this age group, and each was funded partly or in its entirety by the manufacturer, Merck (Lippman et al. 2007:485). Neither have concerns been addressed as to how the vaccine may interact with other vaccines or the health of the recipient (such as in the case of poor nutrition) (Lippman et al. 2007:485), and “serious adverse reactions” in 136 individuals have been reported in United States as of 2007 (Casper and Carpenter 2008:889). Only 5 years worth of data is being used to draw conclusions about Gardasil, yet for obvious reasons its unrestrained potential is being advocated by a company which seeks to profit the most from its acceptance. Furthermore, while Gardasil is thought to prevent four types of HPV (representing approx. 70% of the cause of cervical cancer), there are a wide variety of forms, and even more importantly, the vaccine is only thought to trigger the immune system for a mere 5 years (Lippman et al. 2007:485). In a society in which we are contemplating mass inoculation of young girls in grade eight (representing an enormous $300 billion dollars in Canadian government funds), we may only stimulate girls immune systems for 5 years, sending them to university with little to no immune protection against HPV but possibly a false sense of security towards sexual transmitted disease, and the knowledge that they are vaccine and doctor protected.

It is clear then, that while Gardasil is certainly an important scientific development and made center stage within public awareness, the true burden of cervical cancer and the ways in which it must be addressed both in Canada and across the world are not sufficiently understood. Huge numbers of women both in

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Behind the gold & glitter:

Even with the current economic downturn, described as the greatest financial crisis since the Great Depression, gold remains an attractive investment with prices reaching over US $900 an ounce.

Goldcorp, a Canadian mining corporation, is one of the world’s largest and fastest growing gold producers, with operations sprawled across the Americas and beyond.

In addition to impressive annual earnings, the company touts its commitment to look beyond the financial bottom line and responsibly integrate social and environmental components into its business decisions. However, the realties on the ground suggest otherwise. Local testimonies and reports circulated by non-profit and non-governmental organizations describe environmental and human rights abuses suffered by indigenous people residing in the areas.

The untold story of mining in the highlands of Guatemala

This photo essay stems from continuing efforts to raise awareness about resistance to mining in the highlands of Guatemala after the authors visited the mining site and surrounding communities in February 2008.

By: Graham Chamberlain Photos courtesy of Kristen Yee, Miry Choi and Alina Smirnova

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Most of the people in the region are subsistence farmers, making their living off the land of their ancestors. The vast majority of these people are Mayan; the indigenous Maya are the dominant ethnic group in Guatemala, and the group that has been most heavily persecuted. Although community relations were fragmented throughout the 36-year civil war, members of these municipalities were slowly starting over after the peace accords were signed. This, however, would soon end.

Since the official end of the civil war in Guatemala in 1996, the residents of San Miguel Ixtahuacรกn and Sipacapa have led a quiet existence. These two municipalities in the altiplano of Guatemala make up a total of 32 villages inhabited by 53 000 people.

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Hidden underneath the highland’s sloping fertile soil lies an abundance of minerals that immediately attracted Montana Exploradora, a subsidiary of Goldcorp. After securing a 25-year exploitation license from the Guatemalan government, operations began in 2005 at the Marlin mine. The mine was to become an openpit gold mine using cyanide leeching to extract the gold on site.

On the community level, company representatives spoke of the wonders of gold-mining. It was said that the initiative would help “develop” the area, bringing in more resources, jobs, and revenue for the community. Many people were sold on the project, but just as many were not. This difference of opinion divided the altiplano once again.

As local residents tried to educate themselves of the changes crisscrossing their lands, the mining company moved in. As the gap between community members grew, so too did the mine. It wasn’t long until the mine surrounded the communities of San Miguel and Sipacapa. For many residents, the mine was literally in their backyard.

As a result of the close proximity of many households to the mine, the community and the mining company began to compete for local resources. Water competition is among the fiercest. The mine uses 250 000 L of water per hour, whereas an average family uses 60 L/day. Many residents found that their wells had gone dry and were forced to search for water sources further and further away.

Moreover, as a result of many environmentally unfriendly mining practices, water sources around the mine are heavily contaminated with arsenic and heavy metals. Arsenic levels were found to be almost twice as high as permissible by World Bank standards in the region; these standards are generally higher than national ones in order to facilitate ‘development’. Dead zones have been created within the vicinity of the mine, where contaminated water has destroyed crops and harmed livestock.

Human life has also been adversely affected by the combination of water shortages and contamination, leaving many sick. The señora in the middle picture is thought to have suffered a stroke due to the contaminants found in her living environment.

The emergence of skin rashes within communities have been linked to the drinking, bathing, and general domestic use of the heavily contaminated water. Community members attribute an increase in the prevalence of bronchial infections and lung disease to mining activities.

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In addition to physical ailments, residents live in fear and unrest with the presence of private security forces patrolling the mine site, many of whom are believed to be former soldiers.

The mounting fear from the militarization of the community stems in part from the haunting memories of the Guatemalan civil war, where armed men committed atrocious acts of violence against rural and indigenous people. The violent deaths of two community members have already been accredited to the Marlin Mine’s security personnel.

The mine’s social and psychological impacts are just as damaging as its physical ones. Communities are fractured as the rift between those for and against the mine intensify. The social fabric has been ripped apart by the use of threats, intimidation, and

violence by those in support of the mine as a means of deterring the other side, creating strong divisions within and among communities.

Sometimes, the divisions extend into families, pitting husband against wife, father against son.

Along with severe health impacts, community members are seeing their homes collapse around them. Residents have made their homes from abode brick, which residents claim to be “bullet proof” and “stronger than cement”. However, dynamite explosions and heavy truck traffic have weakened the foundations of many homes in the community, leaving extensive damage. What began as small cracks in the brick, have now grown into open splits in the brick. Some residents now fear that their homes will crumble on top of them with continued mining activity.

Faced with these health and social challenges, the communities that once stood divided are now rallying together.

Using the International Labour Organization’s Convention (ILO) 169, community members have been able to affirm their rights as indigenous people to be consulted in good faith and to participate in the decision-making of policies surrounding the mining development.

Both the municipalities of San Miguel and Sipacapa have exercised their right to say “NO” to the mine. Local residents are advocating for alternative, community-based forms of development.

Mining, they say, is not the form of development they seek, as it has destroyed their ability to maintain their livelihood. Despite community, national, and international efforts, the company denies all claims made against it and states that the municipalities’ decision under ILO 169 is not legal. The mining continues.

Support affiliated NGOs RIGHTS ACTION www.rightsaction.org COPAE http://www.resistance-mining.org/english/index.php

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Sport: a curb for the spread of HIV/AIDS? By: Marize Ibrahim

The World Health Organization (2007) estimates that, globally, 40 million individuals, including adults and children, are living with HIV/AIDS. Its prevalence does not seem likely to abate any time in the near future as researchers continue to search diligently for a vaccine to decrease its spread and, more ambitiously, a cure. Among the attempts to decrease the spread of HIV/AIDS, pharmaceutical companies predominate in their efforts to find vaccines or provide medications to slow its progress, for example, antiretroviral drugs (ARVs). Although their attempts have an impact, the spread of HIV is continuing at a fast rate, predominantly in underdeveloped areas of the world such as Africa, and particularly amongst youth.

Does the long lost quest lie simply in the realm of sport?

The words sport and HIV/AIDS never seem to be found in the same context, unless an athlete has been infected with the virus. When one thinks of sport, one thinks of fit athletes competing in the Olympics for the gold medal or the excitement that the World Cup creates every four years. So, one may ask, how can sport possibly be used as a means to curb the spread of HIV/AIDS? The answer is that sport is not merely a form of activity that people engage in or enjoy watching, it is also a form of play that builds integrity, character and respect. Presently, sport is being used as a tool to curb the spread of HIV/AIDS and a number of organizations around the world are successfully using it as a potential catalyst for change, especially amongst youth. Because sport is one of the most popular activities among youth; it has a unique chance to educate and influence future generations (Kicking AIDS out: Case study, 2006). Sport, physical activity and educational games offer a unique, non-threatening, fun and safe environment where HIV/AIDS can be openly discussed to acknowledge the epidemic and learn life skills to avoid it. Sport is rapidly gaining recognition as a simple, low-cost, and effective means of achieving the Millennium Development Goals: a set of benchmarks

agreed on by the international community to be achieved by 2015.

The convening power of sport and its ability to effectively transmit messages about health and behaviour change, shows the significant role it plays in the prevention of infectious diseases not just with HIV/ AIDS, may also be extended to malaria, and tuberculosis (Koss & Alexandrova). As Carol Bellamy, the executive director of UNICEF states so eloquently, “Around the world sport, recreation and play are improving health [and] teaching important life lessons about respect, leadership and cooperation” (Tackling AIDS through sport, 2006).

Why the focus on youth? One point two billion—one fifth of the global population—are in their teen years (Dr. Brundtland as cited by Mwaanga, 2003). The largest generation of adolescents in human history is now entering their sexual and reproductive life.

According to UNAIDS, these young individuals are both “the most threatened—globally accounting for half of all new cases of HIV— and the greatest hope for turning the tide against AIDS” (Tackle AIDS through sport, 2006, p.7). The focus on youth has long predominated the non-pharmacological fight against HIV spread.

Youth have been particularly chosen as a focus for HIV/AIDS preventative programs because they are relatively free of HIV/ AIDS and may have not yet initiated sexual activity (Nduati & Kiai, 1997). Hence, educating youth about sexuality, gender issues, and preventative measures for use to protect themselves from the virus, may alter their future behaviours and prevent further spread of HIV.

Sport has been recognized as a fundamental tool for the battle against HIV prevention because of its ability to attract and engage youth. In fact, in 2003 the United Nations General Assembly called on governments to secure a place for sport in national programs and policies (Koss & Alexandrova, 2005). Furthermore, in 2003, a joint UNICEF, UNAIDS, and WHO report revealed that in the areas where infection rates were declining, young people were

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www.juxtapose.ca being empowered with information and the skills to adopt safer behaviours. Sport and play are the “natural forums for knowledge and information sharing, and hence should be used alongside other mechanisms to raise awareness of the HIV epidemic and to facilitate prevention” (Koss & Alexandrova, 2005 p.1). Innovative and courageous individuals have discovered the power of sport and have adapted this concept to create organizations that use sport to educate people, particularly children and youth in underdeveloped countries.

“Tackling AIDS through Sport” is a common motto amongst these organizations. HIV/AIDS can be tackled through sport in two major ways: firstly, by creating sports programmes as a way to engage adolescents, provide a platform for education and information all the while producing inspirational leaders for the future and secondly, by developing life skills for young girls and women through sport and team activities. More recent studies have identified sport as not just as a possible way to decrease the spread of HIV, but also beneficial in the form of exercise for people living with HIV/AIDS.

strategies), and this will hopefully encourage them to become future leaders themselves. The value of looking up to role models can be seen throughout sport. For example, when the World Cup is hosted every four years, people all around the world are mesmerized by the players, which inspires others to take up the sport or continue playing it. EduSport, trains youth peer coaches (now numbering more than 400 girls and boys) to teach sports and life skills to other youth (Whiteside, 2003). One particular individual who demonstrates outstanding leadership qualities is Oscar Mwaanga. He has dedicated his life to promoting leadership development using sport. His passion and dedication are expressed in his statement that, “When God gives you an opportunity to be able to look in the eyes of those kids, the only thing you see is hope! They’ve got nothing, but they are willing to find something out of the nothingness to contribute to their community” (Whiteside reference). Great leaders like Oscar imagine, inspire and give faith to adolescents by teaching them that the future is in their hands and that it is up to them to control their own destiny.

Sports programs for HIV education and leadership development

The “KICKING AIDS OUT” network has become the basis for an international network of groups using sport for HIV/ AIDS education. EduSport (Education through Sport) is one branch of the “KICKING AIDS OUT” network. It is a non-governmental organization (NGO) that was founded by Oscar Mwaanga (current PhD candidate at U of T), along with four other colleagues in 1999. This organization is aimed at tackling issues like HIV/ AIDS, poverty alleviation and child rights in underprivileged communities in Zambia using “Sport in the Development Process.”

The EduSport concept is based on the belief that “sport with a positive orientation, when integrated into the broader framework of human and social development goals and priorities, is a powerful vehicle for change” (Education through Sport, n.d., 2). One example of a game that is played in the program is tag. The player who is “it” is designated as the individual with HIV. Another player can only be tagged if he or she is not in possession of the ball that is passed between players. The ball acts as a protection against HIV. After the game has been played, the game leader takes this time to educate the youths involved about the HIV virus. He or she addresses the group by bringing to their attention the number of individuals who were tagged and educates the group by showing them just how quickly the HIV virus can spread. He or she can then explain the ball analogy in relation to reality, which is symbolic for the use of condoms (Mwaanga, 2003). By using a simple game such as tag, youth not only have fun participating in the game, but become educated about how quickly the HIV virus can spread and methods that may be used to decrease its spread. Modifications of contemporary games by including an educational component in the activity, creates as excellent recipe to engage youth and provide a platform of information regarding the spread of HIV/AIDS.

Sport may also be used to build leaders for the future. NGOs train youth to teach sport and life skills to other adolescents in the community. By creating positive role models within the community, other adolescents will look up to them, acknowledge what they are teaching (especially with regards to HIV/AIDS prevention

[Gender matters in the infection rate of HIV/AIDS.]

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www.juxtapose.ca Developing life skills for girls and women

“Go Sisters” empowers girls through sport programs by training and equipping them with skills and knowledge to pursue equality.

It strives to empower girls by building physical resources; giving social recognition and challenging some traditional gender myths (Go Sisters, n.d.). These are just two examples of organizations that have strived to help empower women and create a positive image for them in society; one where they are not objectified, viewed as equal, and fundamental to fight the spread of HIV/AIDS.

Girls and young women are being infected at a faster rate than boys of the same age (Robinson, n.d.). What accounts for this unequal rate of infection? According to the International Community of Women Living with HIV/AIDS, many girls become infected because older men prefer to have sex with teenage girls. A large number of young women become infected because of their vulnerable roles, such as working as house girls for richer relatives who may abuse them, or exchanging sex with their male teachers to get good grades at school. Often referred to as transactional sex, some girls have sex with older boys to get help with their school work, purchase basic stationery or clothing. Many girls—and married women— lack the necessary assertiveness skills to enable them to negotiate safer sex, if they choose to have sex with a partner (Robinson, n.d.).

The participation of women in sport is often a challenge.

The images of girls sitting on the side line while they watch their male counterparts play, resonates when thinking of girls and sport. Girls and women generally do not receive the same positive reinforcement regarding their participation in as males.

Inequality between women and men in all areas of life remains a global problem, and it is particularly pronounced in physical activity and sport (Darilson, 2000). The main reasons why inequality between women and men in sport exists are the result of the close association between the attributes required for sport and those associated with traditional concepts of stereotypical, hegemonic (Darilson, 2000). Physical difference have often been confused with socially constructed differences and used to justify women’s exclusion from participation in sport (Darilson, 2000).

Understanding gender constructions is a pre-requisite to addressing the inequalities between men and women. Using sport as a tool to decrease the inequality between men and women will be challenging and will require strong leaders, determination and much needed will power. Sport may be used to raise girls’ confidence, while they also gain respect from others. It is vital for girls because it teaches them leadership skills and demonstrating their capability to others (UNICEF: New Zealand, n.d.). By including girls in sporting activities, boys will learn to look at them not just as “girls,” but as part of their team, and subsequently, to respect them as they would their male counterparts. By practicing these values, boys will potentially grow up to be men who empower women in society and this may break gender barriers, reduce stigma and discrimination that have contributed to unequal infection rates.

Two excellent examples of organizations that develop life skills using sport in the processes are: The Association of Kigali Women in Sports (AKWOS) and “Go Sisters.” AKWOS is an organization based in Rwanda that aims to “empower women through sport and education to enhance unity and reconciliation, improve women’s rights, boost self confidence and prevent HIV/ AIDS” (Rwemalika, 2007). They believe that sport and education empowers Rwandan women and practicing sports is equivalent to “tearing down the walls of social paradigms and…making a statement for equality among men” (Rwemalika). In 2007, 714 young women participated in sports teams in 4 regions of Rwanda and in October and a 10K run/walk event for women in Kigali was scheduled with an expected 5000 women and girls participating (Rwemalika).

Conclusion

Sport as a vehicle to decrease the spread of HIV/AIDS shows a promising future not just for underdeveloped adolescents in Africa, but may be extended to the many underdeveloped areas of the world.

Sport, in conjunction with other traditional approaches to fighting the spread of HIV/AIDS, offers a unique tool that allows children and adolescents to feel like they belong to a team and that others are on their side, despite any stress that may arise in their difficult and unstable lives. As Dr. Brundtland, the director-general of the World Health Organization, states: “Out of Africa comes a new method of using sport to unite children and youth to form an alliance against the ravages of HIV/AIDS. Infected or not, young people can find strength and information in games and in the joy of sport!” (Mwaanga, 2003).

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Lessons from history:

In search of precept in the rubble of the AIDS response By: Rochelle Burgess

HIV/AIDS carries an overwhelming sense of permanence to every space it enters. One could venture to label it immutable.

There are many who would berate such a statement, label it’s author a pessimist, a doomsayer, or in this instance, an AIDS researcher not worth her salt. But it is precisely this positioning, as a researcher who straddles the frontlines of a response in a hyper epidemic country, and the classrooms of academics who propose the theories for this response, that drives such a conclusion. Current debates have positioned dominant scholars in a continued struggle with the notion of AIDS exceptionality. Unfortunately, for the over five million individuals who are diagnosed with HIV/AIDS, this rally of arguments could not have fallen at a worse time.

Currently the world faces a host of challenges, wherein the spread of the AIDS virus seems but a drop in a sea of issues. The effects of climate change continue to emerge within developed and developing nations alike. The global health shift towards chronic disease is well underway, with diabetes and ischemic heart disease claiming more and more lives world wide.

The global economic crisis has shocked the world to its core, foreshadowing a likely reduction in commitments to international aid as wealthy countries attempt to reign in spending. We are on the brink of disaster at various fronts, and with so many issues calling for immediate response to avoid global catastrophe, the appropriateness of our current dedication to this virus has been put under scrutiny. The question on many lips as we move into the future seems to be: why should AIDS continue stand above the rest?

In so many respects, the debate seems like a waste of valuable time and effort from the people who should be concentrating on mitigating a sustainable response to a problem that will more likely than, never be solved – given that even in a perfect world, individual choice can lead to mistakes which translate into the spread of the virus.

The sum of our efforts in the most affected regions has been recently called to question, in a way that has rarely existed for other development arenas. Billions of dollars in AIDS specific aid has not yielded the results we hoped. 7000 new infections are recorded across the world each day with the largest majority occurring in sub-Saharan Africa. Beyond this, for every two individuals we manage to reach with anti retroviral (ARV) therapies, are successes shadowed by three new patients who are in need.

The world has expected some twenty years later we would have figured it out. The reality of this failure has led many individuals, of whom Roger England is arguably the most ardent , to publicly rebuke the exceptionality and the global movement against the disease led in large party by UNAIDS. While there is credence to certain aspects of the commentary from England and others, the challenge does little to actually improve the way we respond to the continued scourge of the disease in Southern Africa and beyond.

Inarguably, AIDS stands alone from any biological threat we have known. It enters into our most intimate encounters and the most private of spaces, and puts our actions, decisions, and lives under a moral microscope to be judged by the whole world.

However, perhaps the most surprising feature has been its ability to strip bare our planet’s most embarrassing truths. International development foundations, multilateral organizations, philanthropists, and moguls have devoted infinite dollars and immeasurable effort to better our planet for decades. From the Universal Declaration of Human Rights in 1948 to the drafting of the South African freedom charter in 1994, governments and development organizations are constantly restating what individuals are entitled to by virtue of their humanness: access to safe clean water, food for their children, education and health care. Yet since its debut in 1981, HIV/AIDS, in it’s peregrination from house to house, from husband to wife, and

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www.juxtapose.ca mother to child, has forced many in the developed world to admit that the efforts and exponential funding commitments of past decades had done little to actualize the universal rights promised to all.

For example, the endemic links between economic inequity and infection rates highlight the inadequacies of our commitment to the eradication of poverty. Co-infectious diseases such as malaria and TB, which have been eradicated from western contexts a generation ago, expose on the abilities for individuals to access even the most basic of health services in these regions. Women in rich and poor countries alike often shoulder the brunt of the burden of care, treatment, and social scrutiny associated with a positive diagnosis, while displaying the highest prevalence rates: a reminder that the battle for female autonomy is far from over in many parts of the world.

Indeed AIDS embarrasses the activist in all development plans. It reminds us that had we kept the promises we started making with the declaration of human rights, HIV/AIDS would look much like it does in the west: an illness like any other; tragic in its outset, but manageable thanks to the advances of modern medicine. Thus, it would appear, that if we seek answers which will inform our future attempts to mitigate some of the risks facing our world, in such a way that learns from our ‘mistakes’ the question which bears answering should be turned inward. Perhaps we should ask ourselves: Why does HIV/AIDS continue to stand above the rest, in spite of our most ardent attempts to attack its spread?

I challenge those who continue in this vein to find a single biological threat in history wherein the majority of factors impacting transmission are mediated outside of the biological realm. The fact that AIDS is primarily transmitted through the sexual act has effectively hindered due consideration of the multi-variant factors which govern that act: the highly social, cultural, and psychological drivers of human nature. Nowhere is this more evident than in regions like Uganda, where a previously contained epidemic is showing new increases in prevalence rates, attributed factors including increased sexual risk behaviour . It is within this knowledge that we can maintain AIDS’ exceptionality: its ability as a disease to force our engagement with the most complex social facets of the human condition and society.

Unfortunately, a large part of our response to the spread of AIDS has been governed by questions isolated from these issues; for better or worse AIDS has been, and to a large degree still is, considered first in its impact as a medical emergency. UNAIDS itself was born of the World Health Organization, and although it currently works to coordinate actors that address the broader social issues connected to HIV/AIDS, a large impetus is still placed on the medical aspects of the disease. In short, this has been our error: we have not spent our efforts appropriately addressing this notion of exceptionality, reducing our impact considerably.

The answer however, is not to discard our current approach, as Roger England and his supporters may suggest.

To move backwards, with the dissolution of organizations like UNAIDS, would surely reverse the large gains we have seen. In South Africa, nearly half of the individuals needing ARV were being treated , and the response to AIDS has fostered a renewed impetus for addressing old battles such as women’s rights . We could easily reduce funding for AIDS programming, shifting focus towards topics like climate change, or as Roger England may prefer the establishment of a global fund for pneumonia. But if we are

to truly learn from our missteps in the AIDS response, change must focus on spending funds more effectively--not spending less.

To do so, requires that we accept the exceptionality of AIDS and work with it, not against it. In turn, effective spending requires complete understanding of the array of factors which influence the spread of the virus--an understanding borne only through the acceptance (in rhetoric and practice) of multi-disciplinary approaches which will mitigate the widest amount of risks by AIDS researchers and the organizations who fund them. In countries like South Africa, multi-disciplinary approaches hinge on addressing issues of violence, economic and social inequality, and access to health and social services in tandem with our AIDS response.

We cannot deny our world’s problems, nor can we attempt to downplay the one problem to support gains in addressing another. Research has effectively shown that the problems of our world are intricate and interrelated, and that our responses should reflect this knowledge. This is where we stand to learn the most from our battle against AIDS. It has shown us that linear approaches to issues of this scale will not work. As the fight against AIDS continues, we will inevitable learn more.

More importantly, as we prepare to engage with the plethora of our world’s ills, we should endeavour to learn from the mistakes made in our early approaches to AIDS; we should approach each issue in the same multi-disciplinary approach that currently informs AIDS research initiatives. In an ideal world, such an approach would mean that donors and policy makers alike consider the impacts of AIDS, TB, and non communicable disease with issues like climate change, economic sustainability--reducing the struggle for funding and attention between issues, which all contribute to the future of our planet. The interactions are there if we foresee them and are willing to engage with them. Failing to do so may mean that 10 years down the line our best efforts to address issues like global warming may be called to question and, as was the case for UNAIDS, may be found lacking. For the next time our efforts are questioned , we may not have the luxury of time to step back and reconfigure our approaches in staving off catastrophe.

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Issues of Equity:

Primary healthcare for Canadian Aboriginals By: Waqas Khan, Imran Khan

Introduction

Impact on Physical Development

Family physicians play a pivotal role in our society as essential gatekeepers to our healthcare system and they offer more than merely simple diagnoses of coughs and colds. General practitioners work hard to provide primary care such as health protection, healthy and active living encouragement, chronic disease management, and patient advocacy. Family physicians also participate in secondary and tertiary care (especially in rural areas), by promoting and teaching effective parenting, and participating in community organization. Numerous studies have shown that family physicians who can effectively communicate with their patients experience better patient outcomes when it comes to understanding medical information, adherence to treatment, and overall patient satisfaction with the medical process.

Despite having one of the most advanced healthcare systems in the world, Canada’s increasing shortage of family physicians has drastically hindered its ability to cope with a growing and aging population. Recent statistics show that approximately 1 million Ontarians are without a family physician. In rural areas, the effects of this shortage are much more pronounced, with many general practitioners having longer patient lists and more responsibilities than their non-rural counterparts. This heavier workload has forced many rural family physicians to reduce their patient time and, thus, quality of care. For Aboriginal communities, which are traditionally smaller and situated in remote settings, the primary healthcare system has all but abandoned them. First Nation communities in Canada and other developed countries (e.g. the USA and Australasia) typically have poorer quality of health than the non-Indigenous population in nearly every assessment. Their plight due to a lack of primary healthcare can be seen in their physical, psychological, and social development.

Over the past few decades, researchers have witnessed alarming trends that have had significant implications on the overall health and wellbeing of Canadian Aboriginals. These developments include a decrease in physical activity, increase in the consumption of unhealthy processed foods, and increase in unsafe sexual practices. With a lack of family physicians to advise them on healthy, active, and responsible living, numerous ailments such as obesity, diabetes, and HIV, have become prevalent amongst Native individuals.

According to a study conducted by Lavallee and Bourgault, Cree women living in northern Quebec are over four times more likely to suffer from obesity than non-Aboriginal women living in southern Quebec. Other risk factors associated with obesity have also become endemic within the Native population, especially type-2 diabetes. Although the number of individuals affected by diabetes has been rising worldwide, it has become an international phenomenon amongst the Aboriginal population. In Canada, type-2 diabetes is three times more common in First Nation communities than it is in the non-Aboriginal population. However, fifty years ago, diabetes and its associated health concerns were nearly nonexistent in Native society. The consequences of this dramatic increase in diabetes rates have proved to be severe, with many Aboriginal populations experiencing a surge in cardiovascular disease, retinopathy, nephropathy, and peripheral neuropathy. Problems associated with physical activities, diet, chronic pain, and fatigue have become re-occurring concerns impacting the lives of these individuals.

In addition to diabetes, government agencies and organizations such as Health Canada, Aboriginal Nurses Association of Canada, and Feather of Hope Aboriginal AIDS

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www.juxtapose.ca Prevention Society, have voiced their concerns about the rising rate of HIV infection in the Native population. Since 1985, Aboriginals have become one of the leading ethnic groups in new HIV-positive cases in Alberta, Canada. More specifically, Aboriginal women have become the overwhelming majority of HIV carriers amongst these ethnic groups. With a lack of family physicians to advocate safe sex practices and avoiding promiscuity and needle sharing, this dilemma is reaching epic proportions.

found to have a lower socioeconomic status, higher unemployment, poorer environmental quality, and a reduced standard of living. In Canada’s Aboriginal population, having fewer family physicians to prevent and treat physical and mental ailments has resulted in an increased number of social issues. First Nation communities have now one of the highest rates of smoking, alcohol, and drug abuse amongst Canadian ethnic groups. Not surprisingly, overindulging in alcohol and drugs has been linked to their high rates of diabetes and suicide.

Amidst the struggles with diabetes, North American Aboriginals are witnessing an increase in the number of deaths due to cardiovascular disease. In Ontario alone, hospital admissions due to ischemic heart disease doubled in First Nation populations between 1987 and 1997, while declining in the rest of the general population over the same period. Although this trend has been correlated to many changes in Aboriginal lifestyle, one of the principle causes seems to be cigarette smoking. In Sandy Lake, a typical North American Native community, the rate of smoking has exceeded 80% and 70% among Oji-Cree men and women. More shocking is that the prevalence of smoking had the greatest increase in youths aged 12-15 years. This trend towards smoking at a younger age is most likely the culprit for the climb in cardiovascular disease rates in Aboriginal communities.

Another social concern stemming from a lack of family physicians in Native populations is effective parenting. With very little medical guidance about the dangers of unprotected sex, Aboriginal females are becoming pregnant at a younger age. In Quebec, there is a fourfold increase in adolescent Aboriginal mothers when compared non-Native woman. According to Luo et al., this pattern can be explained using the discrepancy in maternal education. The number of Aboriginal mothers with less than a grade 11 education was four times higher than non-Aboriginal mothers. Since family physicians are responsible for promoting healthy living, drug prevention, and family planning, many of the social dilemmas experienced by First Nation communities would be preventable with an increase in the number of available physicians.

Impact on Psychological Development

Individuals suffering from physical illnesses often develop psychological problems due to stress. In an urban city centre, these problems can easily be treated with the appropriate preventative measures prescribed by one’s family physician. However, since most Aboriginal communities lack general practitioners, these ailments become unmanageable and lead to a higher incidence of mental health problems.

Suicide is one of the most dramatic indicators of stress and many First Nation communities in Canada display higher rates than the general population. Aboriginal men aged 15 to 25 have a suicide rate seven times greater than Canada’s national average.

Similarly, Native women are also suffering from a breakdown in mental health. Inuit women living in northern Quebec are reported to have an attempted suicide rate more than three times the average non-Aboriginal women living in southern Quebec. In a study conducted by Statistics Canada, it was found that Aboriginals living in Nunavut and Northwest Territory have a two-to five fold higher rate of suicide when compared to the general Canadian population. Other psychological and emotional illnesses that disproportionately plague the Native population include: depression, helplessness, and lack of motivation for attaining education.

Similar to non-native individuals, Aboriginals experience psychological disorders such as denial and helplessness when faced with health uncertainty. In contrast, these mental disorders are seen at a higher frequency than in the general population due to the decaying primary health care system servicing Native communities and the growing number of individuals suffering from physical ailments.

Lower attention span, understanding, and motivation to complete homework in Aboriginal students can also been correlated to having fewer family physicians. In the Sandy Lake school-based diabetes prevention program, researchers found that Ojibway-Cree students in grade 3 to 5 who completed the year long healthy diet plan displayed higher curriculum knowledge, greater self-efficacy, and healthier behaviours. With more family physicians to provide psychological counseling, acute and chronic illness advice, dietary advice, support group referrals, and suicide risk assessments, First Nation communities will see a steep improvement in terms of their mental health.

Conclusion

In many developed nations, studies examining the problems indigenous communities experience are without a doubt directly related to a lack of family physicians. Although there have been some improvements in the status of Native primary healthcare (more culturally sensitive care), there is still a significant disparity between the primary healthcare that Aboriginals and non-Aboriginals receive in Canada. Only when Aboriginal communities attain the primary healthcare enjoyed by other Canadians, can Canada truly be regarded as a beacon of social justice in the developed world.

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Impact on Social Development

In keeping with the notion that one’s mental health is affected by their physical state is the idea that social development influences one’s physical and mental wellbeing. In a paper published by Iwasaki et al., individuals with a higher rate of physical illnesses were often

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Volume 2 | Issue 1 | Fall 2007

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