Issue 42 by The Meducator

DECEMBER 2022 | ISSUE 42

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HEATWAVES: IMPLICATIONS ON HEALTH A N E X P LO RAT I O N O F P O L I CY I N C O L LA B O RAT I O N W I T H M U J P H

MEDUGALLERY: NEW CENTREFOLD ILLUSTRATION S E E PA G E 10

GLOBAL PERSPECTIVES: INDIGENOUS YOUTH RESILIENCE

OPINION: SARAB ROG KA AUKHAD NAAM

A C U LT U RA L J O U R N E Y O F WAT E R I N S E C U R I TY I N T H E I N D I G E N O U S C O N T E XT

O U T L I N I N G A S I K H-S P E C I F I C CA R D I A C R E H A B I L I TAT I O N P R O G RA M I N P E E L R E G I O N

CONTENTS

december 2022 | issue 42

01 INTRODUCTION

02 MEDPULSE

04 MEDBULLETIN

06 PATHOPROFILE

08 BIOTECH BLUEPRINT

GLOBAL PERSPECTIVE: 12 INDIGENOUS YOUTH RESILIENCE

POLICY BRIEF: 20 HEAT WAVES MEDUAMPLIFY: 26 STIGMA IN TRANSMISSIABLE DISEASE

10 MEDUGALLERY

OPINION: 16 SIKH-SPECIFIC CARDIAC REHAB PROGRAM MEDUAMPLIFY: 24 REPRODUCTIVE RIGHTS IN THE USA 29 CONTRIBUTORS

Bachelor of Health Sciences (Honours), Class of 2024, McMaster University Bachelor of Arts and Science (Honours), Class of 2025, McMaster University

TABLE OF CONTENTS: KATIE LIN 3

Bachelor of Health Sciences (Honours), Class of 2026, McMaster University 3

COVER ARTIST: NATALIE CHU 1 & ARIM YOO 2

MODELS: ALINA PACE & NATALIE CHU PHOTOGRAPHER: JAMES WANG

01 INTRODUCTION meducator | december 2022

DEAR READER, As we celebrate the completion of another cycle on The Meducator, we also celebrate the passage of time. We celebrate the completion of a semester, the relationships we have made, and the experiences in which we have steeped ourselves to enrich our character. Simultaneously, time is a daunting concept that forces us to grow and change against our will. In many ways, The Meducator is a reflection of us students. As we enter our twenties, The Meducator does as well. While time drags us along the path to maturity, we find ourselves holding on to the traces of our past. Likewise, The Meducator has also wavered when ebbing away from the content we traditionally produce. Despite being a health sciences journal, The Meducator has mainly produced content in the biomedical sciences. In reality, the concept of “health” also includes the lived experiences of people, their histories, and their social positions. This year, we have been making significant strides towards diversifying our content and represented values. Jasmine Uppal examines a Sikh-specific cardiac rehabilitation program local to her home, while Corinne Moss underscores McMaster’s allyship towards Indigenous youth resilience. Aisling Zeng and Olivia Kim have helped us make advances into political territory, as we critique the overturning of Roe v. Wade in the United States. That being said, our goal is to not advocate a political agenda but provide you —our reader— with a holistic understanding of the voices that need to be heard. Two figures on our cover look in opposite directions as they perceive the night in different ways. Metaphorically, they reserve different views, but one cannot exist without the other. Cutting into the cover, we see that they are made of the same flesh and bone, and the fact that they lie against each other reveals how they are different sides to the same coin. In an increasingly divisive society, it is important for us to find solace in our shared humanity. We must embrace our differences and forge a future together. As much as we have been advocating for change, we still hope to preserve scientific foundations rooted in evidence. Topics emerge as Sepehr Baharestan Khoshhal and Alex Wang discuss DNA Origami, while Jacqueline Chen and Dalraj Dhillon examine mental health through bipolar disorders. Blood meets water as Anna McCracken, Audrey Dong, and Florence Deng review transmissible diseases through the social lens of stigma. We would also like to express gratitude towards the McMaster Undergraduate Journal of Public Health (MUJPH) for our first cross-journal collaboration. Thank you to the Editors-in-Chief —Adil Haider and Vaibhav Arora— for working with our Managing Editors on our review of heatwaves. Issue 42 would not have succeeded without our executive team. To Aisling, Arim, Carolyn, David, Diane, Eric, Gurleen, James, Ken, Leena, Natalie, Olivia, Shanzey, Suraj, and Yiming, thank you for being our strength and placing unwavering faith into us. Time passes but you will forever be imbued in the memories of our youth. All the best,

JEFFREY SUN Bachelor of Health Sciences (Honours) Class of 2024

MADELINE CHAN

Bachelor of Science (Honours Life Sciences) Class of 2024

MEDPULSE

AUTHORS: ALLISON FANG 1 & ZAHRA TAUSEEF 2 Bachelor of Health Sciences (Honours), Class of 2025, McMaster University 2 Bachelor of Health Sciences (Honours), Class of 2026, McMaster University 1

ARTIST: HAMNA MALIK 3

Bachelor of Engineering & Biomedical Engineering, Class of 2025, McMaster University 3

Coming Soon: A Psychedelic Prescription CANADA | October 2022 Alberta is the first province in Canada to introduce therapeutic regulations for psychedelic drugs: a class of psychoactive substances that alter perception, mood, and cognition. While many of these drugs —such as magic mushrooms or LSD— remain illegal in Canada, new policies would allow physicians and researchers to utilize them for special interventions, clinical trials, and other specific circumstances. While it is still unclear which individuals would be eligible for prescribed psychedelics, doctors believe that treatment could best address post traumatic stress disorder, anxiety, and opioid addictions. However, psychedelics remain a risky drug; the government will require medical professionals to apply for a license and supervise patients for the duration of the drugs’ effects. Despite this, there remains optimism in the potential of psychedelics in the future of healthcare.3,4

Maple Tree (Canada)

Unsuspecting Risk Factor for Inflammatory Bowel Disease USA | October 2022 As rates of inflammatory bowel disease (IBD) rise, investigators at Harvard University are searching for environmental causative factors. The investigators uncovered a positive correlation between a common herbicide, propyzamide, and intestinal inflammation. They found that propyzamide impacts anti-inflammatory signalling pathways involving dendritic cells and T lymphocytes. Although propyzamide is used on crops and athletic turfs, the pathogenesis of IBD remains unclear and researchers emphasize that more work is required to confirm the correlation.5,6 English Oak (USA & Germany)

MEDPULSE meducator | december 2022

Molecular Structure of B-Cell Antigen Receptor GERMANY | October 2022

Researchers at the University of Freiburg have published the exact three-dimensional structure of an IgM-class B-cell antigen receptor (BCR). The BCR consists of a membrane-bound immunoglobulin molecule and two smaller proteins (Ig-α and Ig-β) responsible for signal transduction. The nature of the connection between these elements was previously unknown.11 Using cryo-electron microscopy, researchers revealed that the Ig-α and Ig-β chains are bound to the immunoglobulin on only one side, forming an asymmetrical complex similar to that of the T-cell receptor. They also discovered conserved amino acids on the surface of the BCR, suggesting that the receptor is part of a larger complex.12 These findings help explain the quiescent behaviour of the BCR. Continued study can help develop therapies against BCR-mediated diseases.

Therapeutic Resistance Mechanism Inhibited in HER-2 Positive Breast Cancer SPAIN | June 2022 Researchers at the Hospital del Mar Medical Research Institute have discovered how to overcome treatment resistance in an aggressive form of breast cancer. In human epidermal growth factor receptor 2 (HER2)-Positive Breast Cancer, tumours are enclosed in fibroblast-saturated microenvironments, in which fibroblast activation protein (FAP) shields tumours from immune cells. Researchers have shown that targeting fibroblast-expressed FAP molecules via immunotherapy can suppress treatmentresistance in microenvironments, restoring the effectiveness of several drugs. These findings may guide the design of future clinical trials, highlighting the importance of precision oncology in translational medicine.13,14 Evergreen Oak (Spain)

English Oak (UK)

The Push for Nutritional Education UK | October 2022 Aston University and the Association of Nutrition have designed a new nutritional education program for medical students in Britain. The curriculum illustrates the importance of nutrition in health and disease. The developers hope to highlight the connection between nutrition and other systems —something that is not explored within the few hours of nutrition education in medical training. Such a program will ensure that doctors can provide more holistic treatment to their patients. Students can look forward to learning content guided by thirteen key nutritional competencies, facilitated through educational activities and practical-skills workshops.9,10

Orchid Tree (Hong Kong)

‘Eye-Opening’ Therapy for Depression and Dementia HONG KONG | August 2022 According to the University of Hong Kong, non-invasive electrical stimulation of corneal surface can alleviate depression-like symptoms and improve cognitive function in animal models. Transcorneal electrical stimulation (TES), when used in rat models of retinal degeneration, induces antidepressant-like effects through neurogenesisindependent and -dependent mechanisms.15,16 One hallmark of Alzheimer’s disease is the presence of beta-amyloid deposits in the hippocampus. Findings show that TES reduces these deposits and improves memory. This study warrants further investigation of TES as a potential treatment for cognitive dysfunction in patients with depression and/or dementia.17

Genetic Link Between Alzheimer’s Disease and Gastrointestinal Disorders AUSTRALIA | July 2022

Golden Wattle (Australia)

A study from Edith Cowan University uncovered significant genomic overlaps between Alzheimer’s disease (AD) and gastrointestinal tract disorders (GIT). Analysis of existing genome-wide association studies uncovered that genes associated with metabolism and autoimmunity increase susceptibility to AD and GIT. Findings also revealed a significant, positive correlation between the diagnosis of AD and gastroesophageal reflux disease and irritable bowel syndrome.1 Though observational studies have long suggested a relationship between the two, this publication is the first to identify the specific loci shared by AD and GIT.2

A Worm’s Perspective on Human Aging SINGAPORE | September 2022 Roundworms may be an asset in the future of aging research, according to Nanyang Technological University’s discoveries regarding roundworm longevity. Researchers found that inciting a stress response in mature worms via a high-glucose diet results in longer life spans compared to a normal diet, an effect that is reversed in younger worms. Scientists focused on the unfolded protein response, which removes problematic unfolded proteins formed during periods of stress. Although the response runs normally in juvenile worms, inducing stress exacerbates the mechanism and shortens their lifespan. However, when the response slows significantly in older roundworms, the high-glucose diet returns the mechanism to normal speeds. Further studies are needed to understand the biology behind the observed effects of a high-glucose diet.7,8

References can be found on our website: www.themeducator.org

Tembusu (Singapore)

MEDPULSE meducator | december 2022

medbulletin.

THE IMPLICATIONS OF GLUCOCORTICOID TREATMENT FOR COVID-19

ZAHRA TAUSEEF

MEDBULLETIN meducator | december 2022

The Targeted Real-Time Early Warning System (TREWS) is a program that scans electronic patient health records for factors that increase the risk of developing sepsis, such as age and medical history. The program combines this information with current vital signs and lab tests to create a score indicating which patients are likely to develop septic shock.3 In 2012, JHU implemented the TREWS system in five affiliated sites where it was used in >760,000 patient encounters, over 17,000 of which developed sepsis.4 In 2022, two clinical cohort analyses corroborated these results, confirming TREWS led to earlier diagnoses and reduced mortality in sepsis patients by approximately 18%.4,5

Bachelor of Health Sciences (Honours), Class of 2025, McMaster University

GLUCOCORTICOIDS & COVID-19:

ARTIFICIAL INTELLIGENCE IN EARLY SEPSIS DETECTION

Sepsis is caused by an unusually severe immunological response in patients with infectious disease(s). Septic shock, a severe complication of sepsis, is responsible for nearly ⅓ of in-hospital deaths in the US.1 Unfortunately, the speed at which the condition escalates and manifests (i.e. through flu-like symptoms) makes timely treatment difficult. Recently, an algorithm developed by researchers at Johns Hopkins University (JHU) has proven to bypass this issue.2

ARTIST: ASHLEY LOW

JACQUELINE CHEN Glucocorticoids are stress response hormones that play a key role in physiological processes like metabolic homeostasis, cognition, cell proliferation, and reproduction. More importantly, glucocorticoids are one of the most commonly prescribed drugs due to their antiinflammatory and immunosuppressive properties. In response to severe cases of COVID-19, glucocorticoids have emerged as a powerful and effective intervention for physicians to treat acute lung injury.2 However, there are multiple side effects associated with long-term usage of glucocorticoids, especially when administered in high doses. These adverse events range in severity, from fluid retention and weight gain to muscle atrophy, hypertension, and neuropsychiatric disorders.1 In some COVID-19 patients, glucocorticoids can lead to an increase in adverse outcomes. A study by Keller et al. reports that glucocorticoid usage increases the odds of mortality or mechanical ventilation in patients with C-reactive protein (CRP) levels <10 mg/dL by almost three times. In contrast, it decreases the odds in patients with CRP levels ≥20 mg/dL (OR: 0.23).3 Because CRP levels are markedly elevated in cytokine storm syndrome, a hyperinflammatory condition that occurs in some COVID-19 patients, studying the outcomes associated with glucocorticoid use and CRP levels is clinically important. Thus, patients with lower CRP levels may experience more harm than benefit associated with glucocorticoid treatment.3 In contrast, Liu et al. found that there was no significant difference in virus clearance between COVID-19 patients with pneumonia administered low (≤2 mg/kg/day) and high (>2 mg/kg/day) doses of glucocorticoids.3 A study conducted by Yang and Yu suggests that glucocorticoids are most beneficial for short-term use in patients with severe COVID-19, and advises against chronic glucocorticoid exposure.1 Future research should focus on the associated adverse effects of glucocorticoid usage to treat COVID-19.

Despite its positive reception, there are still several drawbacks to the widespread adoption of TREWS.6 Notably, the program must be revised to accommodate the differences between electronic systems used by medical facilities.3 Limitations aside, TREWS is just one of the many recent advances in the intersection between emergency medicine and artificial intelligence. With continued development, TREWS and other predictive algorithms may drastically improve patient outcomes. 1. 2. 3. 4. 5. 6.

Gyawali B, Ramakrishna K, Dhamoon A. Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Med. 2019;7(1):97-9. Available from: doi:10.1177/2050312119835043. Adams R, Henry K, Sridharan A, Soleimani, Zhan A, Rawar N, et al. Prospective, multi-site study of patient outcomes after implementation of the TREWS machine learning-based early warning system for sepsis. Nat Med. 2022;28(1):1455-60. Available from: doi:10.1038/S41591-022-01894-0. Inside Precision Medicine. AI-Driven Clinical Sepsis Screening Approach Demonstrated to Save Lives [Internet]. 2022 Jul 25. Available from: https://www.insideprecisionmedicine.com/artificial-intelligence/ai-driven-clinical-sepsis-screening-approachdemonstrated-to-save-lives/# [cited 2022 Sep 16]. Henry KE, Adams R, Parent C, Soleimani H, Sridharan A, Johnson L, et al. Factors driving provider adoption of the TREWS machine learning-based early warning system and its effects on sepsis treatment timing. Nat Med. 2022;28(1):1447-54. Available from: doi:10.1038/s41591-022-01895-z. Henry KE, Kornfield R, Sridharan A, Linton R, Groh C, Wang T, et al. Human–machine teaming is key to AI adoption: Clinicians’ experiences with a deployed machine learning system. NPJ Digit. 2022;5(1):97. Available from: doi:10.1038/s41746-022-00597-7. Bushwick S. Algorithm that detects sepsis cut deaths by nearly 20 percent [Internet]. 2022 Aug 1. Available from: https://www. scientificamerican.com/article/algorithm-that-detects-sepsis-cut-deaths-by-nearly-20-percent/ [cited 2022 Sep 6].

1. 2. 3. 4.

Yang R, Yu Y. Glucocorticoids are double-edged sword in the treatment of COVID-19 and cancers. Int J Biol Sci. 2021;17(6):1530. Available from: doi:10.7150/ijbs.58695. Webb SA, Higgins AM, McArthur CJ. Glucocorticoid dose in COVID-19: Lessons for clinical trials during a pandemic. JAMA. 2021;326(18):1801-2. Available from: doi:10.1001/jama.2021.16438. Liu F, Ji C, Luo J, Wu W, Zhang J, Zhong Z, et al. Clinical characteristics and corticosteroids application of different clinical types in patients with coronavirus disease 2019. Sci Rep. 2020;10(1):1-9. Available from: doi:10.1038/s41598-020-70387-2. Keller MJ, Kitsis EA, Arora S, Chen JT, Agarwal S, Ross MJ, et al. Effect of systemic glucocorticoids on mortality or mechanical ventilation in patients with COVID-19. J. Hosp Med. 2020;15(8):489-93. Available from: doi:10.12788/jhm.3497.

CAR T-CELL THERAPY FOR NOVEL TREATMENT OF RELAPSED ACUTE MYELOID LEUKEMIA

FAN ZE (ALEX) WANG

AUDREY DONG Acute myeloid leukemia (AML) is a cancer characterized by uncontrolled production of immature blast cells in peripheral blood and bone marrow. AML accounts for 80% of all leukemia cases in adults and relapse occurs in 40–50% of patients. Currently, allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the most prevalent therapy for relapsed patients, however it has poor prognosis as 40% of those patients relapse again after HSCT.1

In 2022, the United States recorded 268,490 new cases and 34,500 deaths from prostate cancer.1 Metastatic castration-resistant prostate cancer (mCRPC) is an advanced form of metastasized prostate cancer that grows with low levels of testosterone in the body. mCRPCs are almost always incurable, thus physicians currently pursue therapies that postpone or delay disease progression rather than cure it.2 Recently, researchers have developed lutetium-177-PSMA-617 (177Lu–PSMA-617) as a potential therapy for mCRPCs. This treatment targets the prostate-specific membrane antigen (PSMA), a transmembrane glutamate carboxypeptidase highly expressed on prostate cancer cells, while preserving normal surrounding tissues.3 Metastatic tumors often present with PSMA-positive markers. High PSMA expression has been associated with poor disease prognosis and reduced survival.4 In combination with standard therapy, 177Lu–PSMA-617 selectively emits beta-particle radiation to PSMA-positive cells and has been correlated with improved response rates, reduced pain, and low toxicity in patients with mCRPC.4

A novel alternative for relapsed AML cases is chimeric antigen receptor (CAR) T-cell immunotherapy.2 T-cells are a subset of immune cells that can recognize and target specific foreign particles. T-cells are extracted from the patient and genetically altered to produce CARs that recognize and destroy cancer cells before being re-infused into the patient. Two distinct phases of the treatment may be identified. First, initial infusion is characterized by the onset of CD8+ cells, or killer T-cells, dominating immune cell response to destroy cancerous cells.3 Then, CD4+ cells subvert dominance to control longterm remission by suppressing further cancer cell growth.3 Recent clinical trials at the University of Pennsylvania tested interleukin-3 receptor alpha chain (CD123)-specific CAR T-cells on relapsed AML.4 CD123 is prevalent in AML blasts and leukemia stem cells, with significantly higher levels in leukemia blasts than normal myeloid progenitors. By engineering CD123-CAR T-cells to target CD123 AML cells, clinical results reported strong anti-tumor cytotoxicity and long-term memory T-cell proliferation. As such, CD123-CAR T-cells show a promising future for relapsed AML patients.5 Currently, the application of CAR T-cell immunotherapy is being expanded, as oncologists explore its effects on solid malignancies, such as prostate tumors and brain cancer glioblastomas.6

Clinical trials of 177Lu–PSMA-617 were performed on 831 randomized patients from June 2018 to October 2019. Compared to the overall survival period of standard care (11.3 months), 177Lu–PSMA-617 combined with standard care prolonged overall survival to 15.3 months. However, the prevalence of severe and undesirable adverse effects was higher with 177Lu– PSMA-617 than without (52.7% vs. 38.0%, respectively).4 Overall, the efficacy of 177Lu–PSMA-617 shows promise as a potential treatment for PSMA-positive mCRPCs. Further clinical trials could improve 177Lu–PSMA-617 into a reliable therapy to what would otherwise be an incurable and fatal form of prostate cancer.

1. 2. 1. 2. 3. 4.

American Cancer Society. About Prostate Cancer [Internet]. Available from: https://www.cancer.org/cancer/prostate-cancer/ about/key-statistics.html#references [cited 2022 Sep 16]. Henríquez I, Roach MIII, Morgan TM, Bossi A, Gómez JA, Abuchaibe O, et al. Current and emerging therapies for metastatic castration-resistant prostate cancer (mCRPC). Biomedicines. 2021;9(9):1247. Available from: doi:10.3390/biomedicines909147. Israeli RS, Powell CT, Fair WR, Heston WD. Molecular cloning of a complementary DNA encoding a prostate-specific membrane antigen. Cancer Res. 1993;53(2):227-30. Available from: https://aacrjournals.org/cancerres/article/53/2/227/499352/Molecular-Cloning-of-a-Complementary-DNA-Encoding [cited 2022 Nov 17]. Sartor O, de Bono J, Chi KN, Fizazi K, Herrmann K, Rahbar K, et al. Lutetium-177-PSMA-617 for metastatic castration-resistant prostate cancer. N Engl J Med. 2021;385(12):1091-103. Available from: doi:10.1056/NEJMoa2107322.

3. 4. 5. 6.

Thol F, Ganser A. Treatment of relapsed acute myeloid leukemia. Curr Treat Options in Oncol. 2020;21(8):66. Available from: doi:10.1007/s11864-020-00765-5. Mardiana S, Gill S. CAR T cells for acute myeloid leukemia: State of the art and future directions. Front Oncol. 2020;10(1):697. Available from: doi:10.3389/fonc.2020.00697. Melenhorst JJ, Chen GM, Wang M, Porter DL, Chen C, Collins MA, et al. Decade-long leukaemia remissions with persistence of CD4+ CAR T cells. Nature. 2022;602(7897):503-9. Available from: doi:10.1038/s41586-021-04390-6. Marofi F, Rahman HS, Al-Obaidi ZMJ, Jalil AT, Abdelbasset WK, Suksatan W. Novel CAR T therapy is a ray of hope in the treatment of seriously ill AML patients. Stem Cell Res Ther. 2021;12(1):465. Available from: doi:10.1186/s13287-021-02420-8. Sugita M, Galetto R, Zong H, Ewing-Crystal N, Trujillo-Alonso V, Mencia-Trinchant N, et al. Allogeneic TCRαβ deficient CAR T-cells targeting CD123 in acute myeloid leukemia. Nat Commun. 2022;13(1):2227. Available from: doi:10.1038/s41467-022-29668-9. Ledford H. Last-resort cancer therapy holds back disease for more than a decade [Internet]. Nature. 2022 Feb 2. Available from: https://www.nature.com/articles/d41586-022-00241-0 [cited 2022 Nov 7].

MEDBULLETIN meducator | december 2022

A NOVEL INTERVENTION FOR ADVANCED PROSTATE CANCER

doi: 10.35493/medu.42.6

AUTHORS: JACQUELINE CHEN 1 & DALRAJ DHILLON 2

Bachelor of Health Sciences (Honours), Class of 2026, McMaster University 2 Bachelor of Health Sciences (Honours), Class of 2024, McMaster University

ARTISTS: JULIO DIAZ L’HOESTE 3 & ASHLEY LOW 3

Bachelor of Health Sciences (Honours), Class of 2025, McMaster University

PAATHOPROFILE meducator | december 2022

INTRODUCTION Bipolar disorder (BD), previously known as “manic depressive illness,” is a recurrent chronic disorder characterised by mood and energy-state fluctuations.1 People who have BD comprise more than 1% of the world’s population from all nationalities, ethnic origins, and socioeconomic statuses. There are four different types of bipolar-related disorders: bipolar disorder I, bipolar disorder II, cyclothymic disorder, and unspecified BD, which are classified by different patterns of manic, hypomanic, and depressive episodes.1 Where manic and hypomanic episodes are both states of increased activity, energy, or agitation, hypomanic episodes only last around four consecutive days and are less severe compared to manic episodes, which last around one week. Depressive episodes are characterised by feelings of despair and a loss of interest in previously enjoyed activities.1 Like many other psychological disorders, BD is often difficult to diagnose accurately in clinical practice due to large variations in individual symptoms, symptom overlap, or lack of approved biomarkers.1 Additionally, because many patients with BD only seek treatment for depressive episodes, many BD patients are initially misdiagnosed.2 Two studies conducted in 1999 and 2000 found that nearly 40% of patients with BD are initially diagnosed with unipolar depression.2 Previous diagnosis criteria for the types of BD were also overly restrictive. For example, according to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) criteria, bipolar disorder II requires an episode of mania or hypomania lasting four days, even though many experts believe that the average duration of the hypomanic state ranges between one to three days.2 Moreover, it is often difficult to elicit a past history of hypomanic episodes from patients because of its milder presentation. For many patients, the increased energy and activity experienced during hypomanic episodes may not even be considered negative, and thus will go unreported.2 Currently, the DSM-5 contains the most widely acknowledged diagnostic classifications for bipolar disorder.1 PATHWAYS Current literature provides evidence that certain autoimmune illnesses influence the onset of BD. In a study of non-bipolar twins,

Vonk et al. found a higher prevalence of autoimmune thyroiditis in discordant monozygotic (27%) and dizygotic non-bipolar cotwins (17%) and matched healthy control twins (16%).3 In the study’s total sample of 51 bipolar and 35 control twin pairs, the pairwise concordance rate for positive thyroperoxidase antibodies (TPO-Abs) in monozygotic twins was 50% compared with 20% for dizygotic twins.3 This seems to suggest that increased TPOAbs levels are related to the genetic vulnerability of developing BD and not the disease process. Additionally, existing literature also suggests that there are elevated levels of autoantibodies in patients with mood disorders. A 2002 study by Kupka et al. found that the presence of TPO-Abs was more prevalent in patients with BD (28%) than in population and psychiatric controls (3–18%), irrespective of age, gender, or mood state.4 Together, these two areas of research suggest that TPO-Abs have the potential to act as a biomarker for the diagnosis of BD. Concerning heredity, it has also been recognized that BD tends to run in families. First-degree relatives of affected individuals are about 10 times more at risk of BD compared to relatives of unaffected individuals.5 Twin studies reveal similar findings. Smoller and Finn found that monozygotic twins had a greater concordance (75%) for BD compared to dizygotic twins (10.5%).5 Despite differences in ascertainment, assessment, and diagnostic methods, this trend has been observed in several twin studies. This provides compelling evidence for the existence of genes that can increase an individual’s susceptibility to BD in addition to factors like environment. Furthermore, several research groups are currently focusing on BD candidate genes involved in many neurohormone pathways that have been implicated in BD. Ongoing investigation into increased dopamine, norepinephrine, cortisol levels and the resulting increase in stress and inflammatory responses has proved fruitful in discovering how the functional structure of brain activity is altered.6 TREATMENTS While no cure currently exists for BD, many pharmacological therapies exist which aim to provide continued treatment to reduce symptom burden and increase patient function. The current gold standard treatment for BD is lithium, which serves as a

Furthermore, the isolation experienced by many during the COVID-19 pandemic has increased the burden of mental health challenges.11 This “hidden pandemic” has thus sparked an interest in championing accessible mental health care with a focus on the use of technology in more personalized care provision.11 An example of this type of innovation is the introduction of daily monitoring technologies and devices which capture the dynamic nature of BD.12 This may include tracking behavioural patterns and mood variability to better accommodate for the cyclical nature of the disorder and help guide early intervention into potential future episodes.12 This may pave the road in assessing prognostic factors and providing more timely treatment to ultimately prevent any adverse events. AREAS FOR FURTHER INVESTIGATION A major focus of current BD research involves improving diagnostic methods, with an additional goal of expanding current treatment options and care systems. One avenue of current research involves the use of neuroimaging to identify neural circuit biomarkers for BD.13 The identification of biomarkers which represent the pathophysiological processes involved in BD could not only support the early and accurate diagnosis of BD, but also help develop targets for future pharmacological interventions and gain a better understanding of its mechanisms.13 Traditionally undetected or misdiagnosed cases of BD using current diagnostic methods may thus be better detected in cases when patients do not clearly fit DSM-5 criteria or when the distinction between unipolar depression and BD is not clearly evident, particularly during depressive episodes.14 One identified area for discovery of these biomarkers include genetic factors that alter susceptibility to 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. Lancet. 2016;387(10027):1561-72. Available from: doi:10.1016/S0140-6736(15)00241-X. Singh T, Rajput M. Misdiagnosis of bipolar disorder. Psychiatry (Edgmont). 2006;3(10):57-63. Available from: https://pubmed.ncbi.nlm.nih.gov/20877548/ [cited 2022 Oct 18]. Eaton WW, Pedersen MG, Nielsen PR, Mortensen PB. Autoimmune diseases, bipolar disorder, and non-affective psychosis. Bipolar Disord. 2010;12(6):638-46. Available from: doi:10.1111/j.1399-5618.2010.00853.x. Kupka RW, Nolen WA, Post RM, McElroy SL, Altshuler LL, Denicoff KD, et al. High rate of autoimmune thyroiditis in bipolar disorder: Lack of association with lithium exposure. Biol Psychiatry. 2002;51(4):305-11. Available from: doi:10.1016/S0006-3223(01)01217-3. Smoller JW, Finn CT. Family, twin, and adoption studies of bipolar disorder. Am J Med Genet. 2003;123(1):48-58. Available from: doi:10.1002/ajmg.c.20013. Magioncalda P, Martino M. A unified model of the pathophysiology of bipolar disorder. Mol Psychiatry. 2022;27(1):202-11. Available from: doi:10.1038/s41380-021-01091-4. Geddes JR, Miklowitz DJ. Treatment of bipolar disorder. Lancet. 2013;381(9878):1672–82. Available from: doi:10.1016/S0140-6736(13)60857-0. Pérez de Mendiola X, Hidalgo-Mazzei D, Vieta E, González-Pinto A. Overview of lithium’s use: A nationwide survey. Int J Bipolar Disord. 2021;9(1):10. Available from: doi:10.1186/s40345020-00215-z. McCormick U, Murray B, McNew B. Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. J Am Assoc Nurse Pract. 2015;27(9):530–42. Available from: doi:10.1002/2327-6924.12275. Butler M, Urosevic S, Desai P, Sponheim SR, Popp J, Nelson VA, et al. Treatment for bipolar disorder in adults: A systematic review. AHRQ. 2018. Available from: doi:10.23970/ AHRQEPCCER208.

BD and the limbic system, which has been implicated in emotion and reward processing —areas that are often altered in affective disorders.13 Furthermore, studies from Versace et al. and Silverstone et al. found that patients with BD had an increased number of abnormalities and hyperintensities in emotion-processing neural circuits compared to those with depression.15,16 This provides another potential location of biomarkers to help differentiate BD and unipolar depression during depressive episodes.15,16 Ultimately, the benefits of discovering BD-specific biomarkers are multifold as it will improve diagnostic accuracy, support the development of novel therapies, and potentially help provide a better understanding of the pathophysiology of BD.14 Alongside this, many physicians and care providers are advocating for the development of safer and more effective pharmacological treatments, while also broadening available non-pharmacological cognitive and psychological options.17 Concerning the former, many current therapies for BD, such as lithium-based therapies, provide adequate stabilisation, but also have harmful side effects such as kidney failure.8,17 Increasing availability of nonpharmacological treatments would require further research on the efficacy of other biological treatments. Particularly, further research on psychological and psychosocial interventions, such as family-focused therapy or dialectical behavioural therapy, may lead to more holistic care for patients with BD.17-19 REVIEWED BY: RAHA HASSAN (PhD CANDIDATE) Raha Hassan is a PhD Candidate in McMaster’s Clinical Psychology program. She is involved in the Anxiety Treatment and Research Clinic, and Mood Disorders Program at St. Joseph’s Healthcare Hamilton, where she has experience treating individuals with various anxiety, anxiety-related, trauma, and mood disorders. Currently, her research interests focus on the influence temperament, including shyness and self-regulation, has on social, emotional, and psychological adjustment in childhood. 11. 12. 13. 14. 15.

16.

17. 18. 19.

Perna G, Cuniberti F, Nemeroff CB. Special issue editorial: Personalized medicine in psychiatry in the COVID-19 era: Fighting the impact of the pandemic on mental health. J Pers Med. 2021;27–8:100077. Available from: doi:10.1016/j.pmip.2021.100077. Fristad MA, Algorta GP. Future directions for research on youth with bipolar spectrum disorders. J Clin Child Adolesc Psychol. 2013;42(5):734–47. Available from: doi:10.1080 /15374416.2013.817312. Phillips ML, Kupfer DJ. Bipolar disorder diagnosis: Challenges and future directions. Lancet. 2013;381(9878):1663–71. Available from: doi:10.1016/S0140-6736(13)60989-7. Angst J. Bipolar disorder-methodological problems and future perspectives. Dialogues Clin Neurosci. 2008;10(2):129–39. Available from: doi:10.31887/DCNS.2008.10.2/jangst. Versace A, Almeida JRC, Quevedo K, Thompson WK, Terwilliger RA, Hassel S, et al. Right orbitofrontal corticolimbic and left corticocortical white matter connectivity differentiate bipolar and unipolar depression. Biol Psychiatry. 2010;68(6):560–7. Available from: doi:10.1016/j.biopsych.2010.04.036. Silverstone T, McPherson H, Li Q, Doyle T. Deep white matter hyperintensities in patients with bipolar depression, unipolar depression and age-matched control subjects: Hyperintensities in bipolar disorder. Bipolar Disord. 2003 Feb;5(1):53–7. Available from: doi:10.1034/j.13995618.2003.01208.x. Maassen EF, Regeer EJ, Bunders JFG, Kupka RW, Regeer BJ. Research needs for bipolar disorder from clinicians’ perspectives: Narrowing the research–practice gap. SAGE Open. 2019;9(2):215824401985390. Available from: doi:10.1177/2158244019853904. Miklowitz DJ, Chung B. Family-focused therapy for bipolar disorder: Reflections on 30 years of research. Fam Proc. 2016;55(3):483–99. Available from: doi:10.1111/famp.12237. Eisner L, Eddie D, Harley R, Jacobo M, Nierenberg AA, Deckersbach T. Dialectical behaviour therapy group skills training for bipolar disorder. Behav Ther. 2017;48(4):557–66. Available

PATHOPROFILE meducator | december 2022

mood stabilizer drug aimed at treating manic episodes and preventing suicides.6,8 Alongside lithium, other pharmaceutical treatments, including atypical antipsychotic drugs (e.g. quetiapine), are used to treat manic episodes with varying levels of efficacy.7 Aside from pharmaceutical treatments, many psychosocial and physiological treatments including cognitive behavioural therapy and psychoeducation are gaining traction as alternative treatments which avoid harmful side-effects.9 The development of adjunctive psychosocial and pharmacological interventions provides an opportunity for effective individualised long-term stabilisation of BD symptoms.10

DNA Origami Biotech Blueprint

INTRODUCTION There is art in science. Few innovations embody this axiom as well as DNA origami. Nearly three decades after Watson, Crick, and Franklin’s groundbreaking research established a set of base-pairing rules for DNA strands, research published in the Journal of Theoretical Biology suggested the idea of turning DNA into building blocks for nanostructures.1 Today, the use of DNA as a structural material has become more prevalent. These advances use the specific complementary base pairing properties of DNA for applications in drug delivery, biosensors, and enzyme-cascades.2 This article will review the DNA origami design process and its promising applications.

DESIGNING THE STRUCTURE DNA origami involves the directed folding of a long singlestranded DNA (ssDNA), called the scaffold, through the binding of hundreds of specifically designed shorter ssDNA, called staples. The scaffold is usually sourced from viral DNA (e.g. M13 bacteriophages) and is typically 7,000 nucleotides long.3 The staples are capable of base pairing to different regions of the scaffold, thereby bringing physically distant regions of the long ssDNA together. The design of the DNA origami structure is dependent on the staple sequences.3 Designing a DNA origami structure requires translating the desired structure into a series of folds followed by synthesizing the appropriate staples to perform them. Creating a DNA origami structure is simplified through computer-assisted design. Currently, three generations of DNA origami design tools exist. While the first-generation tools require manually routing the scaffolds and generating the crossovers where staples are needed, second and thirdgeneration tools, such as ATHENA and Adenita, are more user-friendly and demand less technical knowledge.3

BIOTECH BLUEPRINT meducator | december 2022

Designing a DNA origami nanostructure begins with the manual generation of a block diagram, which consists of rectangular blocks representing the width of one DNA turn (~3.6 nm) and the height of roughly two helical widths (~4 nm).4 Next, a folding path is manually designed using a

AUTHORS: SEPEHR BAHARESTAN KHOSHHAL 1 & FAN ZE (ALEX) WANG 2 1

Bachelor of Science (Honours Neuroscience) Class of 2024, McMaster University 2 Bachelor of Health Sciences (Honours) Class of 2026, McMaster University

raster filling pattern to fit the block diagram. This process mimics how DNA strands would line and fill the block diagram.4 A “first pass” design is then generated by computer software. This design is displayed in the form of a series of numerical coordinates that map out the sequence of the scaffold and the positions at which staples are annealed to the scaffold. This software output constitutes a rudimentary DNA filling design for the structure.4 To minimize torsional strain on the DNA in the first pass design, the computer modifies the crossover patterns, which are produced by the staple positioning. This ensures a more secure design.4 This process is aided by DNA staples, which use complementary base pairing to secure a stable antiparallel position at the crossover regions.4 Upon completion of the software-assisted design, the complementary strands of the staples and scaffolds are annealed and DNA nicks are placed in the scaffold backbone of the DNA to balance strain in the overall structure.4

APPLICATIONS OF DNA ORIGAMI: CONTROLLED DRUG DELIVERY DNA origami nanostructures (DONs) hold potential for use in drug delivery systems. The structural versatility of DONs allows them to be programmed to bind to different therapeutic agents, facilitating the delivery of these agents to their targets.5 In addition, the charge of DONs may be altered by surface modifications (capsid proteins, cationic polymers, etc.) to improve uptake by certain organs or intracellular organelles. Overall, the performance of these nanostructures are dependent on factors such as size, geometry, charge, stability, degradation, and drug capacity.5 The efficacy of conventional cancer therapy is limited due to low solubility, low stability, and cytotoxicity of conventional chemotherapeutic agents. DONs can help overcome these drawbacks by acting as a targeted drug delivery system that can deliver the agents specifically to tumour cells.6 DONs have notably been used to deliver the anticancer drug doxorubicin in chemotherapy treatments.5,6 Doxorubicin (Adriamycin®) is used to treat solid tumours by inhibiting tumour DNA synthesis and causing cell death in areas such as the breast,

Staples

DNA origami nanostructure Folding

Scaffold DNA

doi: 10.35493/medu.42.8

Annealing

Figure 1. Illustration of structural design for the DNA origami nanostructure.3

09 REVIEWED BY: DR. SARA ANDRES (PhD.) Dr. Sara Andres is an Assistant Professor under the Department of Biochemistry and Biomedical Sciences at McMaster University. She has previously worked at the National Institute of Environmental Health Sciences in North Carolina. Her research aims to understand the role of DNA repair proteins in bacteria in promoting antimicrobial resistance.

EDITED BY: DALRAJ DHILLION & JACQUELINE CHEN ARTIST: KATELYN MOORE

Bachelor of Science (Honours Kinesiology) Class of 2023, McMaster University

The potential of DONs as drug delivery systems is enhanced by their biocompatibility. Cell line studies of DONs have revealed a lack of cytotoxicity.11 Studies involving hematological indices (e.g. measurements of kidney function and liver enzymes in blood) and histological examinations (e.g. spleen, kidney, lungs, liver, and skin) following administration of DONs showed no toxicity.5,13-15 Overall, these studies highlight the versatility and biocompatibility of DONs as a drug carrier and show DONs’ potential as a drug-delivery mechanism.

FUTURE DIRECTIONS The future direction of DNA origami is spearheaded by the user-base’s drive for the discovery of new applications and development of new technologies and software. For instance, there are efforts to increase the user-friendliness of DNA origami synthesis through automating an even greater portion using computer aids. A better understanding of the folding process can provide better rulesets for software to design, automatically synthesize, and assemble DNA origami structures.3 Another branch of improvements aims to implement DNA origami procedures for in vivo applications. Namely, researchers are exploring the effectiveness of in vivo RNA origami: folding of single-stranded nascent RNA as it is being transcribed. This process is preferable to DNA origami, as it can occur in conditions isothermal to living cells. The design would also incorporate RNA-binding proteins to help with the stability of the structure in an intracellular setting.3

References can be found on our website: www.themeducator.org

BIOTECH BLUEPRINT meducator | december november 2022

bile ducts, and endometrial tissue.7 DONs readily incorporate doxorubicin in their DNA structure through intercalation between G-C base pairs to form DON–doxorubicin (DONdox) complexes.8 By increasing the stability of the drug, DON–dox complexes increase delivering efficiency of doxorubicin to target tumour cells. Upon uptake by the cell, the DON is degraded by the endolysosomal pathway and releases doxorubicin for translocation to the nucleus, where doxorubicin can inhibit tumour DNA synthesis.5 DON–dox complexes may also hold additional cargo or modifications to further inhibit tumour growth. For example, Liu et al. used DONs to simultaneously deliver the anticancer p53 gene (which would then be expressed as protein in the cell) and doxorubicin in vitro in tumour-bearing mice.9 They discovered that the co-delivery of p53 and doxorubicin in mice displayed effective inhibition of tumour growth without apparent systemic toxicity.9 However, the delivery performance of the DON–dox complexes depends on environmental factors such as pH.10 Currently, in vitro studies on pH dependence have only focused on the release of dox between pH 4.5– 5.5, which cannot be generalized to intracellular conditions with an approximate pH of 7.4.5,11,12 Zeng et al. found that the accumulated release of the DON–dox complexes at pH 4.5 was double the accumulated release at pH 7.4 and 6.6.11

ARTIST: STEPHANIE ALELUYA

MEDUGALLERY meducator | december 2022

Bachelor of Health Sciences (Honours), Class of 2026, McMaster University

My work explores the lack of access to abortion. Although abortion is fully legal in Canada, many women face obstacles in accessing this medical service. They are restrained by a variety of factors in life, much like how the woman is shackled in the painting. All women do not have full autonomy over their own bodies with a primary example demonstrating this as overturning Roe V Wade. The chaos in the painting represents the messy battle that women have gone through in order to fight for this full autonomy. The soft hand placement of the woman on her stomach compared to the messy background represents the dichotomy between the delicate subject matter and the apathy regarding these rights being stripped away or not being given at all.

MEDUGALLERY meducator | december 2022

GLOBAL PERSPECTIVE meducator | december2022

GLOBAL PERSPECTIVE: 12

Indigenous Youth Resilience ARTIST: ELAINE WANG

Bachelor of Health Sciences (Honours), Class of 2026, McMaster University

13 AUTHOR: CORINNE MOSS

Bachelor of Health Sciences (Honours), Class of 2023, McMaster University

THE CRISIS Indigenous is a collective name for the original peoples of North America and their descendants. The First Nations, Innuit, and Métis groups represent the fastest growing and youngest populations at more than 1.6 million as of 2016.1 The long legacy of colonial Canada has instilled many problems upon Indigenous peoples. Consequently, Indigenous youth are more likely to experience abuse, discrimination, suicidal thoughts, and shorter life expectancies.2,3 Historical injustices have been present since settlers introduced a variety of infectious diseases (e.g. smallpox, influenza, measles) to Indigenous communities in the 16th century.2 In 1831, the Canadian government opened the first residential school on the nearby Six Nations of the Grand River, called the Mohawk Institute (1831–1996). In 1831, this Anglican Church-run boarding school only accepted boys, before beginning to accept girls in 1834. This institute is now a memorial site and museum, known as The Woodlands Cultural Centre. Residential schools emerged across Canada and forcefully removed Indigenous children from their homes and placed them in a physically, psychologically, and sexually abusive environment.4 Their goal was to eliminate Indigenous cultural identity by assimilating Indigenous youth into Euro-Canadian Christian culture.4 To date, over 4000 burials have been discovered at residential school sites —this number continues to grow as investigations continue. These premeditated attacks did not take place in a distant world; in fact, several occurred just a 30-minute car ride from McMaster University in Brantford, Ontario.6 “Hunger was never absent”; despite the children being able to visibly see full apple trees and milk cows for local farmers, this abundance was not offered to Indigenous youth.5 In 2013, Historian Dr. Ian Mosby published Administer ing C o l o n i a l Science, which discussed

how nutritional experiments for Canada’s Food Guide were performed in residential schools.7 According to Dr. Mosby, “The nature of the experiments that [Pett] conducted in residential schools was determined based on a whole series of internal debates among nutrition professionals and bureaucrats about Canada's Food Guide and about what a healthy and nutritionally adequate diet looked like. Pett used the opportunity of hungry kids in residential schools … who had no choice in what they were going to eat and whose parents had no choice in what they were going to eat … to attempt to answer a series of questions that were of interest to him professionally and scientifically.”7 Current health inequities that Indigenous people face include high unemployment rates, social exclusion, primary care inaccessibility, and inadequate health infrastructure.8-10 To that end, one of the greatest challenges in First Nations reserves is insufficient access to clean drinking water. Unlike off-reserve communities, the Canadian government does not regulate the water quality on First Nation reserves.11 This water crisis not only strips First Nations persons of their basic human rights of health, hygiene, and participation, but also prevents community members from performing customary cultural traditions such as fishing practices, medical ceremonies, creating ceremonial objects like water drums, and supporting childbirth. THE RESULT I had the privilege of interviewing Makasa Looking Horse —a local Indigenous leader and internationally prominent water right activist— to learn more about the cultural importance of water and the individual effects of water insecurity. Makasa Looking Horse is of both Mohawk Wolf Clan and Lakota heritage, living on a reserve at the Six Nations of the Grand River, Ontario, Canada. Following her completion of the Six Nations Traditional Medicine Practitioners course, she enrolled in the Indigenous Studies program at McMaster University. Her accomplishments include co-creating and hosting a YouTube and podcast series called Ohneganos: Let’s Talk Water, which discusses traditional ecological knowledge and current events. She also works as a health research trainee on adapting a resilience mobile app, JoyPopTM, to an Indigenous context.

SCAN TO VISIT THE RESILIENCE IN YOUTH WEBSITE

SCAN TO VISIT THE LET'S TALK WATER PODCAST

Acting as a Youth Leader of Ohneganos, she teaches young women useful skills, such as basket-making, and speaks to audiences across North America and abroad about Indigenous rights. In 2016, she was present at the Standing Rock protest against extractive exploitation of the land and personally handed Nestlé’s CEO a

GLOBAL PERSPECTIVE meducator | december 2022

doi: 10.35493/medu.42.12

Makasa shared how water is essential to most Indigenous traditional ceremonies and teachings, such as the daily Thanksgiving Address, which gives thanks for natural living. Its basis regards the Creator of the world’s gifts as kin and upholding a law of peace among peoples, animals, and the environment. It forms the basis of a unified mindset for the greater good of one’s personal and community life, creating the inner resourcefulness to practice a good mind. Additionally, it is believed that it is the woman’s responsibility to protect the water since it played a vital role in the creation story of Sky Woman falling to earth. Water was here first, humans are developed in a water womb, and water is, thus, considered humanity’s first medicine. To the Six Nations, water does not merely represent hydration. As stated by Makasa, “It's alive, it’s a spirit, and it’s a powerful being.”

GLOBAL PERSPECTIVE meducator | december 2022

Looking Horse describes the physical and emotional suffering caused by water insecurity. According to the water protector, sewage tanks from the elevated surrounding cities have been dumping waste into their water reserve, contributing to the erosion of the water sensors that the Ohneganos’ water project put into the Mackenzie Boston Creek. Furthermore, Makasa personally discovered traces of contaminants in the tap water which are poisonous and detrimental to health; this finding drove her to begin

investigating Nestlé’s water theft. The Youth Leader then spoke about the emotional burden that young people carry as they observe their own mothers having to worry and wonder, “Is there going to be enough clean drinking water for their kids to live off of?” For those on reserves, water is not a free-flowing resource unlike in non-reserve communities. Water is a financial cost, from the creation and maintenance of water sources to waste removal from septic tanks. For drinking, cleaning, washing, and more, water is a dollar value in the budgets of Six Nations homes. Many can take water for granted in Canada —a country of the Great Lakes— when water is so costly for those nearby. Water is precious, and part of Canada’s global sustainable development goal is to ensure that water is a right for all.

THE SOLUTION These deeply-rooted discriminatory policies need a comprehensive solution, but change takes time. Indigenous youth must learn resilient strategies so that they can protect their mental wellness as the fight for equality continues. As Makasa shows, there is much resilience in resistance, to be part of the fight for rights and adhere to the time-honoured responsibility of showing respect and care for the environment. A rich heritage of resilience comes from connections to both ancestors and future generations, allowing traditional ecological knowledge to carry forward. In recent years, grants from Global Water Futures and the Canadian Institutes of Health Research have supported the potential combination of Western psychological science and Indigenous science philosophies to resolve a lack of ecological care. In affiliation with McMaster University, Dr. Christine Wekerle’s research team and I have worked to support Indigenous communities by discovering methods to promote resilience in Indigenous youth. The JoyPopTM app is a mobile application based on trauma-informed care models that have shown promise in reducing depression and increasing emotional regulation among first-year university students.12 JoyPopTM was developed in response to youth adversity experiences. Users can engage in positive thinking via journaling or art exercises, find relaxation in the breathing or sleeping functions, and receive personalized

SCAN ME!

cease and desist letter in 2019 after learning that they removed 4.7 million litres of water from her community’s aquifers daily. Nestlé obtained a permit from the Ontario government to take water from the reserve without their knowledge. Canada’s Truth and Reconciliation Report, as well as the United Nations Declaration on the Rights of Indigenous Persons, call on Indigenous participation in the decision-making for the environment as stewards, and sovereignty for their treaty lands.

CHECK OUT THE RESILIENCE IN YOUTH YOUTUBE

support from an Indigenous-specific hotline if they need care. As community is extremely relevant on reserves, users can also input their aunties’ and uncles’ contact information for immediate connection in the Circle of Trust feature. This technique of social connection is one of the key features that interested health researchers and service providers at Six Nations. One study, led by McMaster trainee Noella Nohorona, discussed how mobile health apps can benefit Indigenous youth by removing barriers to services and promoting resilience for those in need.13 Consultations with Indigenous youth and leaders from diverse communities were held during the development of the app and after its launch to ensure cultural relevance.14 Makasa Looking Horse provided a review of the app, along with 19 adults from the Six Nations Grand and River community and 17 Indigenous-

To promote resilient strategies among Six Nations youth, Dr. Wekerle’s research trainees developed short lessons that teach Indigenous middle school students about varying health topics and how the techniques can be integrated into their daily life on the reserves. The Resilience Curriculum includes engaging videos that discuss exercise, mental health, gender and health, water and health, and more. These lessons are accompanied with an interactive learning activity (e.g. breathing exercises, crosswords) to engage students and an infographic for them to seamlessly integrate what they have learned into everyday tasks. Individuals on Dr. Wekerle’s research team also post TED-Ed lessons onto YouTube. Titles such as “Water Insecurity in Indigenous Communities” and “Indigenous Youth and Resilience” aim to educate Indigenous and non-Indigenous individuals about challenges that reserves face and how the viewer can support the well-being of Indigenous youth.

WHAT CAN YOU DO? I asked Makasa Looking Horse, “What can the readers do to support the Six Nations of the Grand River?” Firstly, she cautioned the readers to keep a watch on water bottling plants in their area and oppose them from taking clean aquifer water to protect it from mass consumption. Secondly, she urged individuals to stop buying Nestlé water to further her call for justice, as well as refrain from buying bottled water and use reusable water containers instead. Thirdly, if you wish to actively assist the reserve, donate any jugs of water to the Six Nations Food Bank. To promote youth resilience, take the time to research issues from the reserves, listen when afflicted people speak their truth, and speak to your friends and family about what you have learned. The Woodlands Cultural Centre provides an excellent virtual tour of the residential school’s history —you will be surprised at what you learn really happened recently. To support your readings, please refer to the YouTube channel, “ResilienceInYouth,” and check out the JoyPopTM app. Do not let your Indigenous neighbour’s voices and concerns stay silent —educate yourself and advocate for our shared health and wellness community.

REVIEWED BY: DR. ADRIANNE LICKERS XAVIER (PhD) Adrianne Xavier is an Associate Professor in the Faculty of Social Sciences at McMaster University and serves as the acting director of the Indigenous studies and anthropology department. Currently, her research is focused on community wellbeing, Indigenous rights and health, and socio-cultural anthropology. EDITED BY: ALEXANDER XIANG 1. 2. 3.

4. 5. 6. 7.

8. 9.

10. 11. 12. 13. 14.

Government of Canada; Crown-Indigenous Relations and Northern Affairs Canada. Indigenous peoples and Communities [Internet]. 2022 Aug 30. Available from: https://www.rcaanc-cirnac. gc.ca/eng/1100100013785/1529102490303 [cited 2022 Feb 3]. Kirmayer LJ, Brass GM, Tait CL. The mental health of aboriginal peoples: Transformations of identity and community. Can J Psychiatry. 2000;45(7):607–16. Available from: doi:10.1177/070674370004500702. Elias B, Mignone J, Hall M, Hong SP, Hart L, Sareenn J. Trauma and suicide behaviour histories among a Canadian indigenous population: An empirical exploration of the potential role of Canada's Residential School System. Soc Sci Med. 2012;74(10):1560–9. Available from: doi:10.1016/j. socscimed.2012.01.026. Indigenous Foundations. The Residential School System [Internet]. Available from: https:// indigenousfoundations.arts.ubc.ca/the_residential_school_system/ [cited 2022 Feb 3]. Mosby I, Galloway T. “Hunger was never absent": How residential school diets shaped current patterns of diabetes among indigenous peoples in Canada. CMAJ. 2017;189(32):E1043–5. Available from: doi:10.1503/cmaj.170448. Aboriginal Healing Foundation. A condensed timeline of events - AHF [Internet]. Available from: https://www.ahf.ca/downloads/condensed-timline.pdf [cited 2022 Feb 3]. CBC. The dark history of Canada's Food Guide: How experiments on Indigenous children shaped nutrition policy [Internet]. Available from: https://www.cbc.ca/radio/unreserved/howfood-in-canada-is-tied-to-land-language-community-and-colonization-1.5989764/the-darkhistory-of-canada-s-food-guide-how-experiments-on-indigenous-children-shaped-nutritionpolicy-1.5989785 [cited 2022 Feb 7]. Boksa P, Joober R, Kirmayer LJ. Mental wellness in Canada’s Aboriginal communities: Striving toward reconciliation. J Psychiatry Neurosci. 2015;40(6):363–5. Available from: doi:10.1503/ jpn.150309. First Nations Centre. First Nations and Inuit Regional Health Surveys, 1997 FNIGC [Internet]. 2004. Available from: https://fnigc.ca/wp-content/ uploads/2020/09/71d4e0eb1219747e7762df4f6a133a3d_rhs_1997_synthesis_report.pdf [cited 2022 Feb 7]. Aspin C, Brown N, Jowsey T, Yen L, Leeder S. Strategic approaches to enhanced health service delivery for Aboriginal and Torres Strait Islander people with chronic illness: A qualitative study. BMC Health Serv Res. 2012;12(1). Available from: doi:10.1186/1472-6963-12-143. Human Rights Watch. Make it safe [Internet]. 2016. Available from: https://www.hrw.org/ report/2016/06/07/make-it-safe/canadas-obligation-end-first-nations-water-crisis [cited 2022 Feb 7]. MacIsaac A, Mushquash AR, Mohammed S, Grassia E, Smith S, Wekerle C. Adverse childhood experiences and building resilience with the JOYPOP app: Evaluation study. JMIR Mhealth Uhealth. 2021;9(1):e25087. Available from: doi:10.2196/25087. Noronha N, Smith SJ, Martin Hill D, Davis Hill L, Smith S, General A, et al. The use of mobile applications to support Indigenous Youth Wellbeing in Canada. IJCAR. 2021;8(1):124-34. Available from: doi:10.7202/1077724ar. Resilience in Youth. The History of JoyPop [Internet]. Available from: https://youthresilience.net/ the-history-of-joypop [cited 2022 Feb 3].

GLOBAL PERSPECTIVE meducator | december 2022

identifying undergraduates from McMaster University. From these consultations, we learned how to adapt specific features of the app to better support Indigenous youth. For example, we learned the value of including culturally significant colours and patterns, featuring words in Indigenous languages, and using significant icons (e.g. feathers, wampum, animals) within the app. JoyPopTM is constantly being reviewed and adapted so Indigenous youth can receive mental wellness support that resonates with their unique culture. Twice a month, the research team discusses their projects with a Six Nations Advisory Committee to ensure that their work is culturally informed, respectful, and accurate. The experts provide guidance and cultural insight so the developer can further improve the efficacy of their work. Additionally, every member of the research team must complete the Indigenous Canada course by the Faculty of Native Studies at the University of Alberta to guarantee cultural competency.

OPINION meducator | december 2022

OPINION

ARTISTS: ASEEL ABONOWARA 1, MADELINE CHAN 2, NATALIE CHU 3 , ARIM YOO1 Bachelor of Health Sciences (Honours), Class of 2024, McMaster University Bachelor of Science (Honours Life Sciences), Class of 2024, McMaster University 3 Bachelor of Arts & Science (Honours), Class of 2025, McMaster University 1 2

doi: 10.35493/medu.42.16

AUTHOR: JASMINE UPPAL

Bachelor of Health Sciences (Honours), Class of 2025, McMaster University

INTRODUCTION AND NECESSITY

“Sarab rog ka aukhad naam” (“The recitation of God’s name cures all diseases”) is a quotation from the Guru Granth Sahib —the Sikh Holy Book— highlighting Sikhism’s perspective on illness, referring to the Guru Granth Sahib as the primary source of guidance regarding issues of health.1 However, in the decades since this quotation was first written, the burden of chronic illness in the Sikh community has become more severe.1 Notably, cardiovascular disease (CVD) has become increasingly prevalent within the Sikh and broader South Asian (SA) populations.2 Several studies have outlined how the SA community has the highest prevalence of CVD in Canada, along with a higher CVD mortality rate compared to other ethnic groups.2,3 Although some biological factors may explain the SA community’s increased risk for CVD, there is no denying the social and psychological factors at play.4 It has been established that sedentary behaviour, depression, and psychological stress increase CVD risk.5-7 As such, the fact that SA individuals in Canada are more likely to be sedentary and diagnosed with depression than their non-SA counterparts only intensifies their likelihood of developing CVD.5,6 Moreover, much of the SA population in the West exists as visible racial and religious minorities, subjecting them to additional social and psychological harms, including stress stemming from migration and discrimination, all of which contribute to CVD.2,7 SA individuals in Canada are also more likely to experience lower quality-of-life one year post-surgical interventions for CVD-related events, as well as increased recurrent CVD events.8 That is, not only are SAs more likely to develop CVD, but their disease prognosis appears to be worse than non-SAs.8 As such, improving CVD management procedures for the SA population would prove valuable, given the significant prevalence of the disease in this community.2,3,8 More specifically, areas with a prominent SA population, like the Peel Region of Ontario, should consider providing CVD interventions specific to SAs, such as culturally sensitive rehabilitation programs.9 As SA is a broad term encompassing many distinct ethnic and cultural backgrounds, this paper recommends focusing on interventions tailored to a specific population within the SA community, to avoid cultural generalizations.1

For the purposes of this paper, the focus population is the Sikh community, defined specifically as individuals with an ethnic background from the Punjab region in India who practice Sikhism. The Sikh community as a target population is optimal as it falls under the broader SA community and it is one of the largest religious minorities in the Peel Region; thus, this plan would ensure that a sizeable community in the Peel Region receives access to treatment that acknowledges their religious and cultural diversity.10 Peel Regional Health should design a rehabilitation plan specific to the Sikh community for patients diagnosed with CVD, or recovering from a CVD-related incident. However, it is critical to note that there are certain challenges associated with implementing such a program, specifically relating to funding issues and the program’s perceived practicality.

PROGRAM FRAMEWORK

Several studies have examined the Sikh community’s perspective on cardiac rehabilitation.1,11-14 These studies can serve as a guide in developing the Peel Region’s version of a rehabilitation plan specific to the Sikh community by developing a culturally competent and safe rehabilitation program including the following elements: 1. HEALTHCARE PROFESSIONALS THAT ARE FLUENT IN PUNJABI OR IDENTIFY AS BEING SIKH AND/OR PUNJABI. Numerous studies identified that Sikh patients enrolled in rehabilitation programs preferred interacting with healthcare professionals that spoke their first language, Punjabi, and identified as being part of the Sikh religion and/or Punjabi culture.11-13 As such, these professionals were able to provide culturally relevant advice, particularly regarding dietary changes in cultural cuisine to promote healthier lifestyles, and overall, increasing patients’ willingness to practice the interventions.12-14 Galdas et al. found when reflecting on their post-myocardial infarction recovery, Sikh patients stressed the value of having Punjabi-speaking healthcare professionals to sufficiently comprehend and implement their cardiac rehabilitation plan, indicating the benefits of hiring professionals fluent in the patients’ primary language.1

OPINION meducator | december 2022

SARAB ROG KA AUKHAD NAAM: OUTLINING A SIKH-SPECIFIC CARDIAC REHABILITATION PROGRAM IN PEEL REGION

2. IMPLEMENTATION OF SIKHISM. When Sikh patients were asked about their recovery, researchers noted that they would highlight the importance of Sikhism in coping with diagnosis and attempts at leading healthier lifestyles.1,11-13 As an example, Galdas et al. noted that some patients engaged in Seva —a key Sikh principle which is a form of volunteering— at their local Gurdwaras in place of traditional methods, such as exercise.1 As such, these patients felt that they were able to improve their health in a comfortable, familiar, and spiritually fulfilling method, thus serving as motivation to continue the rehabilitation process.1 3. AN OPTION TO RECEIVE COMPREHENSIVE HOME-BASED CARE. Despite the benefit of cardiac rehabilitation programs, there is a historically low participation rate, mainly due to patients’ lack of transportation to program centers.13,15 Similarly, senior Sikh patients cited their discomfort when asking their adult children for transportation to rehabilitation programs, since their children were the breadwinners of the family and were often preoccupied with work during the day.13 However, certain studies have demonstrated that home-based cardiac rehabilitation programs are equally effective at improving cardiac health outcomes as centrebased care, while further enhancing patient quality of life and psychological well-being.15,16 For example, in a study by Akeroyd et al. on Indian CVD patients, when health professionals completed telephone-based health checkins, the medication non-adherence rate of those patients dropped from 51.2% to 4.6%, underscoring the value of personalized home-based care in the Sikh population.17

OPINION meducator | december 2022

CRITICISMS

Despite the justifications for creating a cardiac rehabilitation program specific to the Peel Region’s Sikh community, there are valid criticisms that may offset its benefits. Notably, the SA community has displayed historically lower adherence rates to traditional cardiac rehabilitation programs relative to their nonSA counterparts.8,18 Thus, it appears that efforts should be focused on increasing CVD awareness and prevention, as opposed to treatment.19 It is crucial to note, however, that the studies that examined adherence in rehabilitation programs were not tailored to SA lifestyles and needs, thus highlighting the necessity for the type of program outlined in this article.18,19 As for awareness regarding CVD, several studies have demonstrated that although the Sikh community lacks some knowledge of CVD, many individuals understand the unhealthy aspects of their lifestyles that may increase their CVD risk.20-22 In spite of this knowledge, the Sikh community still has a concerningly high prevalence of CVD.5 As such, focusing on CVD awareness may not prove as impactful as alternative solutions, such as addressing the shortcomings of rehabilitation programs to improve health outcomes. Furthermore, the logistical implications of a unique, culturallycentric cardiac rehabilitation program to the healthcare system must be considered; this program may be costly and difficult to implement, especially when fulfilling cultural background requirements.23 However, similar programs established in the

United Kingdom reported no significant difference in cost between a traditional and more accessible rehabilitation plan for SA individuals.16 Moreover, a Canadian study completed by Agarwal et al. addresses the issue of language and cultural barriers through volunteers who spoke and identified as Punjabi.23 This program was widely used by the community, thereby rendering it successful enough to be implemented in similar prominently Sikh communities.23 Therefore, well-trained volunteers serve as a reliable solution if there is a shortage of healthcare professionals meeting the aforementioned program criteria.23

19 The Sikh community, as part of the larger SA community, is disproportionately at risk for CVD.1,2,11,12 It is thus imperative that the Peel Region, which consists of the largest Sikh population in the GTA, develops a targeted cardiac rehabilitation program.2,10 Several research studies have demonstrated that a program including (1) Punjabi or Sikh-identifying healthcare professionals, (2) some aspects of Sikhism, and (3) an accessible home-based care option, is bound for success.1,12,13,16 Despite the need for a culturally specific approach to cardiac rehabilitation, there are legitimate concerns regarding the feasibility of this plan. Therefore, it is recommended the Peel Region implements a pilot cardiac rehabilitation program that utilizes volunteers in the community.

THIS PIECE WAS PEER REVIEWED BY AN ANONYMOUS ASSOCIATE PROFESSOR AT MCMASTER UNIVERSITY. EDITED BY: RAYMOND QU & RIDA TAUQIR 1. 2. 3.

4. 5.

More specifically, launching a pilot program would provide a low-risk method of determining if a comprehensive cardiac rehabilitation plan would have a positive, measurable impact on cardiac health and program adherence within the Sikh community. The use of volunteers who identify as Sikh and/or Punjabi would help mitigate the program’s financial concerns and provide better care, while increasing CVD awareness in the community.23 Ultimately, by appealing to the Sikh community’s existing perspectives on illness, this program would encourage healthier lifestyles by utilizing the community and its beliefs to effectively combat CVD.

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Galdas P, Oliffe J, Wong S, Ratner P, Johnson J, Kelly M. Canadian Punjabi Sikh men’s experiences of lifestyle changes following myocardial infarction: Cultural connections. Ethn Health. 2012;17(3):253–66. Available from: doi:10.1080/13557858.2011.610440. Sekhon S, Jhajj A, Gill HP, Khan N, Tang T. Undiagnosed hypertension in Vancouver’s Punjabi Sikh community: A cross-sectional study. J Immigrant Minority Health. 2022;24(5):1371-4. Available from: doi:10.1007/s10903-022-01355-3. Anand S, Yusuf S, Vuksan V, Devanesen S, Teo K, Montague P, et al. Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada: The Study of Health Assessment and Risk in Ethnic groups (SHARE). Lancet. 2000;356(9226):279-84. Available from: doi:10.1016/S0140-6736(00)02502-2. Williams ED, Kooner I, Steptoe A, Kooner JS. Psychosocial factors related to cardiovascular disease risk in UK South Asian men: A preliminary study. Br J Health Psychol. 2007;12(4):55970. Available from: doi:10.1348/135910706X144441. Bainey K, Gupta M, Ali I, Bangalore S, Chiu M, Kaila K, et al. The burden of atherosclerotic cardiovascular disease in South Asians residing in Canada: A reflection from the South Asian Heart Alliance. CJC Open. 2019;1(6):271-81. Available from: doi:10.1016/j. cjco.2019.09.004. Dhar A, Barton D. “Depression and the Link with Cardiovascular Disease.” Front. Psychol. 2016;7(33). Available from: doi:10.3389/fpsyt.2016.00033. Karasz A, Gany F, Escobar J, Flores C, Prasad L, Inman A, et al. Mental Health and Stress Among South Asians. J Immigrant Minority Health. 2019;21(suppl 1):7-14. Available from: doi:10.1007/s10903-016-0501-4. Rana A, de Souza RJ, Kandasamy S, Lear SA, Anand S. Cardiovascular risk among South Asians living in Canada: A systematic review and meta-analysis. CMAJ Open. 2014;2(3):18391. Available from: doi:10.9778/cmajo.20130064. Anand S, Arnold C, Bangdiwala SI, Bolotin S, Bowdish D, Chanchlani R, et al. Seropositivity and risk factors for SARS-CoV-2 infection in a South Asian community in Ontario: A crosssectional analysis of a prospective cohort study. CMAJ Open. 2022;10(3):599-609. Available from: doi:10.9778/cmajo.20220031. Peel Data Centre. 2011 NHS Bulletin: Ethnic Diversity and Religion. Peel Region and Greater Toronto Area (ON): Region of Peel; 2013. 4 p. Sidhu MS, Griffith L, Jolly K, Gill P, Marshall T, Gale NK. Long-term conditions, selfmanagement and systems of support: An exploration of health beliefs and practices within the Sikh community, Birmingham, UK. Ethn Health. 2016;21(5):498–514. Available from: do i:10.1080/13557858.2015.1126560. King-Shier KM, Dhaliwal KK, Puri R, LeBlanc P, Johal J. South Asians’ experience of managing hypertension: A grounded theory study. Patient Prefer Adherence. 2019;13:321-9. Available from: doi:https://doi.org/10.2147/PPA.S196224. Galdas PM, Kang HBK. Punjabi Sikh patients’ cardiac rehabilitation experiences following myocardial infarction: A qualitative analysis. J Clin Nurs. 2010;19(21-22):3134-42. Available from: doi:10.1111/j.1365-2702.2010.03430.x. Darr A, Astin F, Atkin K. Causal attributions, lifestyle change, and coronary heart disease: Illness beliefs of patients of South Asian and European origin living in the United Kingdom. Heart Lung. 2008;37(2):91-104. Available from: doi:10.1016/j.hrtlng.2007.03.004. Jolly K, Lip GY, Sandercock J, Greenfield SM, Raftery JP, Mant J, et al. Home-based versus hospital-based cardiac rehabilitation after myocardial infarction or revascularisation: Design and rationale of the Birmingham Rehabilitation Uptake Maximisation Study (BRUM): A randomised controlled trial [ISRCTN72884263]. BMC Cardiovasc Disord. 2003;3(10). Available from: doi:10.1186/1471-2261-3-10. Jolly K, Lip GY, Sandercock J, Greenfield SM, Raftery JP, Mant J, et al. The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospitalbased cardiac rehabilitation in a multi-ethnic population: Cost-effectiveness and patient adherence. Health Technol Assess. 2007;11(35):1-118. Available from: doi:10.3310/ hta11350. Akeroyd JM, Chan WJ, Kamal AK, Palaniappan L, Virani SS. Adherence to cardiovascular medications in the South Asian population: A systematic review of current evidence and future directions. World J Cardiol. 2015;7(12):938-47. Available from: doi:10.4330/wjc. v7.i12.938. Jolly K, Greenfield SM, Hare R. Attendance of ethnic minority patients in cardiac rehabilitation. J Cardiopulm Rehabil. 2004;24(5):308-12. Available from: doi:10.1097/00008483200409000-00004. Banerjee AT, Grace SL, Thomas SG, Faulkner G. Cultural factors facilitating cardiac rehabilitation participation among Canadian South Asians: A qualitative study. Heart & Lung. 2010;39(6):494-503. Available from: doi:10.1016/j.hrtlng.2009.10.021. Cunningham CT, Sykes LL, Metcalfe A, Cheng A, Riaz M, Lin K, et al. Ethnicity and health literacy: A survey on hypertension knowledge among Canadian ethnic populations. Ethn Dis. 2014;24(3):276-82. Available from: https://pubmed.ncbi.nlm.nih.gov/25065067/ [cited 2022 Aug 2]. Gany FM, Gill PP, Ahmed A, Acharya S, Leng J. “Every disease…man can get can start in this cab”: Focus groups to identify South Asian taxi drivers’ knowledge, attitudes and beliefs about cardiovascular disease and its risks. J Immigrant Minority Health. 2013;15(5):986– 92. Available from: doi:10.1007/s10903-012-9682-7. Ratner P, Tzianetas R, Tu AW, Johnson JL, Mackay M, Buller CE, et al. Myocardial infarction symptom recognition by the lay public: The role of gender and ethnicity. J Epidemiol Community Health. 2006;60(7):606-15. Available from: doi:10.1136/jech.2005.037952. Agarwal G, Pirrie M, Bhandari M, Angeles R, Marzanek F. Feasibility of implementing a community cardiovascular health promotion program with paramedics and volunteers in a South Asian population. BMC Public Health. 2020;20(1). Available from: doi:10.1186/ s12889-020-09728-9.

OPINION meducator | december 2022

CONCLUSION

IMPLICATIONS FOR PUBLIC HEALTH AND POLICY

POLICY BRIEF meducator | december 2022

INTRODUCTION Dr. Samantha Green often remembers an elderly patient with asthma, who lives alone without any close family members available for regular check-ins. She used to worry that, during a heat wave, this patient might die alone in his apartment because he did not have access to air conditioning, no one could checkin and drive him to a cooling facility, and the heat likely exacerbated his asthma. Dr. Green managed to get her patient an air conditioner through the Ontario Disability Support Program, ensuring he would not be at risk during future heat waves.1 However, most people do not have any such advocates during extreme heat events.1-4

Heat waves, also known as extreme heat events, are characterized by most jurisdictions as hot weather conditions with the potential to result in unacceptable levels of health effects, including increased rate of mortality. Consistently high temperatures are one component of heat waves, with humidity, wind speed, and sunlight intensity also contributing to health risks. Extreme heat events have the potential to aggravate underlying health conditions, including respiratory,

cardiovascular and psychological conditions, to a point of fatality, and also cause heat stroke that could result in death.1-5 The effect of extreme heat may also be compounded by the side effects of certain medications, such as psychiatric medications that decrease the ability to self-regulate body temperature.1,6 Although the Canadian Disaster Database only observed five extreme heat events between 1900 and 2005, several other media and expert reports highlight current, more common occurrences of heat waves.5 Unfortunately, it is difficult to quantify the true impact of extreme heat events. Even though it is known that heat exacerbates existing health conditions, leading to death, there is no scientific way to understand the degree to which this occurs. As such, in many jurisdictions, deaths caused by extreme heat events are only reported as deaths caused by the underlying health condition of the deceased, such as reporting natural causes for the death of a patient with cardiovascular disease who passed away because of a heart attack triggered by heat. Still, recent estimates in Ontario have linked a 5°C increase in temperature with a 2.5% increase in the death rate.1 Given the above, it is clear that heat waves have preventable health effects that increase public health burden. However, given that the health effects of heat waves are avoidable, there exists a straightforward path to combatting this public health burden, making it imperative that policymakers and health officials act now to prevent these unnecessary deaths and health impacts.2-5 The purpose of this policy brief is to explore the environmental, political, and socioeconomic factors contributing to heat wave-related health effects, as well as providing a critique of commonly proposed policy solutions.

AUTHORS: SHANZEY ALI 1, VAIBHAV ARORA 1, SURAJ BANSAL 2, ADIL HAIDER 1, JEFFREY SUN 1 & YIMING ZHANG 1 Bachelor of Health Sciences (Honours), Class of 2024, McMaster University 2 Bachelor of Health Sciences (Honours), Class of 2025, McMaster University 1

ENVIRONMENTAL CAUSES OF HEAT WAVES Climate change has resulted in extreme weather variations, characterised by dramatic increases in the frequency and intensity of warm and cold weather extremes.7 As a result, heat waves now occur at least 2.8 times more frequently compared to the pre-industrial age. Analysis conducted by the World Weather Attribution (WWA), using simulations, suggested that the global average temperature increase of 1.2°C since pre-industrial times has made heat waves at least 150 times more likely to occur.8 Current policies focus heavily on air conditioning access and provision; however, studies have demonstrated that a greater consideration of costs, energy usage, and targeted demographics must be maintained.7 With rising temperatures, heat waves are increasing in prevalence. Consequently, a comprehensive understanding and reassessment of the current political counteractions to this global environmental crisis is warranted.7 Rising global temperatures contributed to a week of recordbreaking heat in Canada and the US in 2021.9 This heat wave affected large cities that rarely experience extreme heat, such as Seattle, Washington and Vancouver, Canada. On June 29, the village of Lytton in British Columbia (BC) reported a peak temperature of 49.6°C, the highest temperature historically reported in Canada.9 Among impacts on the village’s water supply, forest fires, and the elderly population, citizens were forced to evacuate to protect their health. Greater worries arise due to the village’s growing familiarity with forest fires, which are beginning to spread even more rapidly and frequently due to dryer climates and heat domes, areas of high pressure that trap heat. Temperature differences between the warm western Pacific Ocean and the cold eastern Pacific Ocean create winds that blow dense, tropical western air eastward. This warm air then becomes trapped in the jet stream, creating a current that maintains heat for long periods of time.10 According to the BC coroner’s report released after this heat event, human activity was a notable contributor given the severity and rarity of the events, particularly due to rising greenhouse gas emissions.10 Human influences also have ramifications in urbanized areas. The urban heat island (UHI) effect describes that cities can be between 10–15°C hotter than their surroundings due to increased albedo and minimal greenspace. Modern car-dependent cities consist of concrete and asphalt in buildings, streets, and parking lots. These dark materials have very low reflectance and absorb massive amounts of heat, which prevents nighttime cooling. The consequent accumulation of heat results in extreme heat waves.11-13

21 ARTISTS: ARIM YOO 3 & NATALIE CHU 4

Bachelor of Arts & Science (Honours), Class of 2025, McMaster University Bachelor of Health Sciences (Honours), Class of 2024, McMaster University 3 4

CURRENT POLICIES WORSEN ENVIRONMENTAL IMPACT Decades of policy choices about home cooling regulations have led to exceptionally heat-vulnerable cities in Canada.1,10,14 Although Canadian jurisdictions have a robust framework for regulating home heating in winter, a similar framework does not exist for cooling over hotter summers. For example, current Ontario building codes require heating, which are also backed up by municipal laws. Regarding cooling however, only 6% of Toronto apartments have central air, and only an additional 9% have at least one air conditioned room. The Ontario Building Code has no requirements for air conditioning (AC), and local municipal laws may not be exhaustive enough to curb the effects of extreme heat events.1,14 According to the coroner’s report, most of those who died in the BC heat wave lived in homes without in-unit AC.10

POLICY BRIEF meducator | december 2022

doi: 10.35493/medu.42.20

SOCIOECONOMIC FACTORS WORSEN INEQUITIES CAUSED BY HEAT WAVES Many social, economic, and community factors contribute to the increased vulnerability of certain individuals. These groups can be referred to as heat-vulnerable groups. It is important to understand these factors to conceptualize the full extent of the problem, and to determine policies to tackle the systemic issues creating inequities during extreme heat events.5

POLICY BRIEF meducator | december 2022

Low-income and racialized neighbourhoods are often the most affected by UHI effects, have the least access to green space, and are the most likely to live without AC; consequently, they are more likely to experience negative effects during heat waves.10-13,15 Further, individuals experiencing homelessness are impacted by extreme heat events due to their reliance on cooling from public spaces that are often hostile towards them, together with the complications of multiple comorbidities that are characteristic of homelessness.2-4,16,17 Additionally, low-income populations may experience 40% higher exposure to heat waves than their higher income counterparts.18 This discrepancy is attributable to location and unequal access to cooling options, like AC. Additionally, the global energy demand for AC may triple by 2050.19 Without cheaper, more sustainable methods of heat adaptation, lowincome populations will continue to be disproportionately affected by extreme heat. By 2100, the lowest-income quarter of Canada’s population may experience 23 more days of extreme heat annually when compared to the highest income quarter.17

The individuals in heat-vulnerable communities are often lowincome, speak English as their second language, and are disengaged from political processes; thus, they carry a greater risk of illness and morbidity. In contrast, the majority of political decision makers are homeowners, who may be spared from the negative impact of heat waves because of access to greener neighbourhoods, tree-shaded backyards, secure homes, and air conditioned cars. Therefore, the risks of extreme heat events may be downplayed in political decision-making and in mortality reports. For example, despite undergoing heat waves around the same time, Ontario, Quebec, and BC displayed death counts that differed by orders of magnitude due to classification disparities. While BC and Quebec account for all causes of deaths during the heat wave, including tangential cases that may have been worsened or triggered by extreme heat, Ontario only considers deaths directly related to heat pathologies (e.g. heat stroke). This dramatically under reports the issue, reflecting a concerning lack of awareness in provincial urban cooling policies, which may impact availability and accessibility to city cooling centres and services.1,16,17,20-23 Another particularly heat-vulnerable group is the elderly population, many of whom are at risk because of pre-existing health conditions and living conditions, whether in homes, apartments, rooming houses, or long-term care homes (LTCs). LTCs have been in a spotlight recently due to their drastically unsafe conditions during the pandemic, but negligent conditions

have prevailed, particularly concerning air conditioning.24 While LTCs are mandated to have at least one air conditioned area, seniors with limited mobility in facilities with limited staffing are unable to escape the stifling heat of their personal rooms.25 The BC coroners report indicates that most of the heatrelated deaths in 2021 were of elderly individuals, especially those living alone who may not have been able to access help.1,10 A study also showed that on average, 22 hours per worker was lost each summer due to extreme heat exhaustion, which corresponds to 1% of annual work hours and a loss of $1,100 to each individual.23 Multiple areas of the economy suffer from reduced worker productivity during heat waves, notably agriculture and construction. Roughly 2% of annual working hours is lost globally due to extremely hot working conditions that preclude on-site workers from maintaining their working pace. Global productivity loss from on-site heat exhaustion is valued at $4.2 trillion dollars per year.26 With the agriculture system employing 2.1 million Canadians and generating $134.9 billion of Canada’s GDP, heat waves entail devastating impacts on many Canadians’ livelihood.27,28 Heat waves engender lost productivity for Canada’s economy, smaller harvests for farmers, and higher prices for consumers. CRITIQUE OF COMMONLY PROPOSED POLICY SOLUTIONS Affordable residences in Toronto are often fitted with decadesold heating and cooling systems that take days to turn on or off, and they deliver inconsistent heating throughout the building. Unexpected heat waves may strike while these heating systems remain turned on. Retrofitting these apartments, along with those lacking AC, would be expensive and cost millions. A mass retrofit will only become more challenging as time goes on, as heat stress has the potential to cause mass power failures.11 In contrast, a policy of refit incentives and mandates for passive cooling, a building design that promotes passive heat dissipation, and AC on new builds has been pursued. For passive cooling measures, studies have shown high effectiveness under heat wave conditions along with substantial energy savings.29 However, landlords have historically been resistant to

Heat mitigation policy faces an array of challenges. Electrical grids are at extreme risk of damage from heat, which has historically led to grid-wide failures. This risk is worsened by increased AC usage.11 Toronto’s grid is based on outdated infrastructure primed for failure, which is further exacerbated by the long term crisis of power generation caused by the current Conservative government.30 More concerning is the crisis of housing affordability, which Bill 23 is ostensibly meant to address. Many Canadian cities, such as Toronto, Vancouver, and Hamilton, rank among the least affordable cities in the world. Expensive and scarce rental housing availability along with factors like restrictive zoning policies and parking requirements have provided landlords with a massive degree of leverage with tenants. These same circumstances deter developers from building new, affordable housing and allow landlords to employ climate concerns to push forward further economic costs for their tenants. Bill 23 is one example of this, pairing liberalisation of zoning measures with repeal of the Toronto Green Standards (though this is being walked back by the province).32,33 On a smaller scale, this dynamic played out in a recent case in Parkdale, Toronto, where tenants were faced with eviction if they refused to pay extra fees for AC.34,35 1. 2. 3.

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Roy I. As Toronto temperatures rise, inequalities widen [Internet]. The Local. 2022 Jun 21. Available from: https://thelocal.to/toronto-heat-wave-inequality/?fbclid=IwAR1HZYrwdW1dIUPE_VUtEvNODQ-iQpuK0PNM5LJEAht1DXcrWqT4Z1uBpA [cited 2022 Nov 26]. Aufiero P. Witness: ‘Like the whole system is collapsing’ [Internet]. Human Rights Watch. 2021 Oct 5. Available from: https://www.hrw.org/news/2021/10/05/witness-whole-systemcollapsing [cited 2022 Nov 26]. LaFortune R. One year since deadly heatwave in Canada, protections still needed [Internet]. Human Rights Watch. 2022 May 27. Available from: https://www.hrw.org/ news/2022/05/27/one-year-deadly-heatwave-canada-protections-still-needed?fbclid=IwA R0TpEUj0o1zzRNYuyyL4LUEgHu7Mgbw3Nd6-53STHOuWm-V-11BwdeLGR8 [cited 2022 Nov 26]. Human Rights Watch. Canada: Disastrous impact of extreme heat [Internet]. Human Rights Watch. 2021 Oct 5. Available from: https://www.hrw.org/news/2021/10/05/canadadisastrous-impact-extreme-heat?fbclid=IwAR0Mvidiojbz82hL15r1lGpQhCgtgL87m0ldFDCXpnkP0d7BZXg7b7vNd4 [cited 2022 Nov 26]. Government of Canada. Communicating the Health Risks of Extreme Heat Events [Internet]. 2020 Dec 14. Available from: https://www.canada.ca/en/health-canada/ services/environmental-workplace-health/reports-publications/climate-change-health/ communicating-health-risks-extreme-heat-events-toolkit-public-health-emergencymanagement-officials-health-canada-2011.html#ref [cited 2022 Nov 26]. Westaway K, Frank O, Husband A, McClure A, Shute R, Edwards S, et al. Medicines can affect thermoregulation and accentuate the risk of dehydration and heat-related illness during hot weather. J Clin Pharm Ther. 2015;40(4):363-7. Available from: doi:10.1111/jcpt.12294. Clarke B, Otto F, Stuart-Smith R, Harrington L. Extreme weather impacts of climate change: An attribution perspective. Environ Res. 2022;1(1):012001. Available from: doi:10.1088/27525295/ac6e7d. WWA. Western North American extreme heat virtually impossible without human-caused climate change [Internet]. Available from: https://www.iea.org/news/air-conditioning-useemerges-as-one-of-the-key-drivers-of-global-electricity-demand-growth [cited 2023 Jan 11]. Schiermeier Q. Climate change made North America’s deadly heatwave 150 times more likely [Internet]. Nature. 2021 Jul 8. Available from: https://www.nature.com/articles/d41586021-01869-0 [cited 2022 Nov 26]. Egilson M. Extreme heat and human mortality: A review of heat-related deaths in B.C. in summer 2021. Victoria (BC): BC Coroners Service; 2022. 53 p. Doiron D, Setton EM, Shairsingh K, Brauer M, Hystad P, Ross NA, et al. Healthy built environment: Spatial patterns and relationships of multiple exposures and deprivation in Toronto, Montreal and Vancouver. Environ Int. 2020;143:106003. Available from: doi:10.1016/j.envint.2020.106003. Rinner C, Hussain M. Toronto’s urban heat island—exploring the relationship between land use and surface temperature. Remote Sens. 2011;3(6):1251-65. Available from: doi:10.3390/ rs3061251. Greene CS, Robinson PJ, Millward AA. Canopy of advantage: Who benefits most from city trees? J Environ Manage. 2018;208:24-35. Available from: doi:10.1016/j.jenvman.2017.12.015. Executive Director, Municipal Licensing and Standards. Mitigating the Negative Impacts of Extreme Heat in Apartment Buildings. Toronto (ON): City of Toronto; 2018. 30 p. Report No.:LS25.1. Pinault L, Christi’s T, Olaniyan T, Crouse DL. Ethnocultural and socioeconomic disparities in exposure to residential greenness within urban Canada. Ottawa (ON): Statistics Canada; 2021. 14 p. Report No.:82-003-X. Pagliaro J. John Tory announces commitment to Toronto parks, critics cite encampment evictions, lack of basic facilities [Internet]. Toronto Star. 2022 Oct 9. Available from: https:// www.thestar.com/news/gta/2022/10/09/john-tory-announces-commitment-to-torontoparks-critics-cite-encampment-evictions-lack-of-basic-facilities.html [cited 2022 Nov 26]. Braga M. A park for all, or a park for some? [Internet]. The Local. 2019 Jul 23. Available from: https://thelocal.to/a-park-for-all-or-a-park-for-some/ [cited 2022 Nov 26]. Alizadeh MR, Abatzoglou JT, Adamowski JF, Prestemon JP, Chittoori B, Asanjan AA, et al. Increasing heat-stress inequality in a warming climate. Earth’s Futur. 2022;10(2):e2021EF002488. Available from: doi:10.1029/2021EF002488. AGU. POOREST PEOPLE BEAR GROWING BURDEN OF HEAT WAVES AS TEMPERATURES RISE [Internet]. Available from: https://news.agu.org/press-release/poorest-people-bear-

CONCLUSION As temperatures continue to rise, further political action is required to properly protect civilians from the health effects of extreme heat events. It must be recognized that the current political and socioeconomic systems prevent adequate legislative change, although there may exist well-intentioned efforts from municipalities and provinces. Certainly, more robust, accessible cooling systems are mandatory; however, a greater emphasis must be placed upon the underprivileged, such as the development of effective public health and emergency response countermeasures. More research is thus required to explore current technologies and infrastructure to fully address the repercussions of heat waves, as well as better ways of measuring and reporting the full health impact of extreme heat events.

REVIEWED BY: ALLISON WILLIAMS Dr. Allison Williams is a Professor in the School of Earth, Environment & Society at McMaster University. Her research interests involve career-employees, quality of life, critical policy/program evaluation and therapeutic landscapes, with additional contributions in gender equality and equity research.

20. 21.

22. 23.

24.

25. 26. 27. 28. 29. 30. 31.

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growing-burden-of-heat-waves-as-temperatures-rise/#:~:text=Lower%20income%20 populations%20currently%20face,rest%20of%20the%20population%20combined [cited 2023 Jan 11]. IEA. Air conditioning use emerges as one of the key drivers of global electricity-demand growth [Internet]. https://www.iea.org/news/air-conditioning-use-emerges-as-one-of-thekey-drivers-of-global-electricity-demand-growth [cited 2023 Jan 11]. The Canadian Press. A timeline of B.C.’s record-setting extreme heat event in June 2021 [Internet]. Toronto Star. 2022 Jun 24. Available from: https://www.thestar.com/news/ canada/2022/06/24/a-timeline-of-bcs-record-setting-extreme-heat-event-in-june-2021. html?fbclid=IwAR0ZjLBdas58Ar2axKl6450407MLHBdMvUDKjwbIsMEzEwK3JXk2epk9HxI [cited 2022 Nov 26]. Lorinc J. Why we can’t go: A report on Toronto’s public washrooms, pt. 1 [Internet]. Spacing Toronto. 2022 Jun 14. Available from: http://spacing.ca/toronto/2022/06/14/why-wecant-go-a-report-on-torontos-public-washrooms-pt-1/ [cited 2022 Nov 26]. Skjerven K. Toronto is a city flush with parks. So why aren’t there more public washrooms available? [Internet]. Toronto Star. 2022 Oct 17. Available from: https://www.thestar.com/ news/gta/2022/10/17/toronto-is-a-city-flush-with-parks-so-why-arent-there-more-publicwashrooms-available.html [cited 2022 Nov 26]. City of Toronto. Cool spaces near you [Internet]. Available from: https://www. t o ro nt o . c a /c o m m u n i t y - p e o p l e/ h e a l t h - w e l l n e s s - c a re/ h e a l t h - p ro g ra m s -a d v i c e/ h ot- w eat h e r/c o o l - s pa c e s - n ea r-yo u / # l o c at i o n = 2 7 2 7 % 2 0 V i c to r i a % 2 0 Pa r k % 2 0 Ave&lat=43.77793179961336&lng=-79.32272648049143 [cited 2022 Nov 26]. Vanos J. Workplace heat exposure, health protection, and economic impacts: A case study in Canada. Am J Ind Med. 2019;62(12):1024-37. Available from: doi:10.1002/ajim.22966. International Labour Organization. Working on a WARMER planet: The impact of heat stress on labour productivity and decent work. Geneva (CH): International Labour Office; 2019. 98 p. CIHI. COVID-19’s impact on long-term care [Internet]. Available from: https://www.cihi.ca/en/ covid-19-resources/impact-of-covid-19-on-canadas-health-care-systems/long-term-care [cited 2023 Jan 11]. Dangerfield K. ‘It’s a death trap’: Families horrified by lack of air conditioning in long-term care homes [Internet]. Global News. 2020 Jul 14. Available from: https://globalnews.ca/ news/7161608/long-term-care-homes-heat-wave-air-conditioner/ [cited 2023 Jan 11]. Government of Canada. Overview of Canada’s agriculture and agri-food sector [Internet]. 2022 Jul 18. Available from: https://agriculture.canada.ca/en/canadas-agriculture-sectors/ overview-canadas-agriculture-and-agri-food-sector [cited 2022 Nov 26]. Hogan S. Building code changes could take decades to ‘future-proof’ homes for extreme heat that’s here now [Internet]. CBC. 2022 Jun 15. Available from: https://www.cbc.ca/news/ canada/heat-dome-retrofit-building-codes-passive-cooling-1.6488244 [cited 2022 Nov 26]. Lorinc J. Will Doug Ford’s housing reforms kill the Toronto Green Standard? [Internet]. The Globe and Mail. 2022 Nov 18. Available from: https://www.theglobeandmail.com/real-estate/ article-will-doug-fords-housing-reforms-kill-the-toronto-green-standard/ [cited 2022 Nov 26]. Syed F. More green construction, less gravel mining: Ford walks back some environmental changes in Ontario housing bill [Internet]. The Narwhal. 2022 Nov 25. Available from: https:// thenarwhal.ca/ontario-housing-bill-changes/ [cited 2022 Nov 26]. Syed F. Ontario could be entering an energy supply crisis. Here’s what you need to know [Internet]. The Narwhal. 2022 Jul 22. Available from: https://thenarwhal.ca/ontarioelectricity-grid/ [cited 2022 Nov 26]. Cohen B. ‘We feel violated and traumatized’: Parkdale tenants outraged after dozens served eviction notices over air conditioning [Internet]. Toronto Star. 2022 Jun 29. Available from: https://www.thestar.com/news/gta/2022/06/29/we-feel-violated-and-traumatizedparkdale-tenants-outraged-after-dozens-served-eviction-notices-over-air-conditioning.html [cited 2022 Nov 26]. CBC News. Facing eviction for using air conditioning, residents of a Parkdale building speak out [Internet]. CBC. 2022 Jun 28. Available from: https://www.cbc.ca/news/canada/toronto/ eviction-air-conditioning-parkdale-1.6504633 [cited 2022 Nov 26].

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refits, and the passing-on of costs to tenants remains an issue. Policies around new builds can only impact roughly 4% of the housing stock annually, and have minimal impact on long-tenured residents. Regardless, these measures are precarious; Toronto Green Standard, the municipal program which includes passive cooling and air conditioning mandates, is facing resistance due to the recent passing of Ontario’s Bill 23, the government’s recent housing bill.30-32

WADING THROUGH THE OVERTURN doi: 10.35493/medu.42.24

AUTHORS: OLIVIA KIM 1 & AISLING ZENG 2 1 2

Bachelor of Health Sciences (Honours), Class of 2026, McMaster University Bachelor of Health Sciences (Honours), Class of 2024, McMaster University

ARTIST: JULIO DIAZ L’HOESTE 3 3

Bachelor of Health Sciences (Honours), Class of 2025, McMaster University

MEDUAMPLIFY meducator | december 2022

BACKGROUND After her request for an abortion was denied in Texas, Norma McCorvey, commonly known by her legal pseudonym “Jane Roe,” brought forth her case against the district government in 1969.1,2 She argued that restricting abortion access was a violation of individuals’ right to privacy and autonomy —and she won.1 Though her 7-2 Supreme Court ruling was short-lived, having been overturned in 2022, it was a landmark case that set an international precedence for the rights of those who identify as women.3

The recent appointment of Justice Amy Coney Barret in 2020 ensured a conservative court, allowing the Republican agenda to instate major change.4 This was reflected in May 2022, when an early draft outlining the majority opinion, authored by Justice Samuel Alito, was leaked.5 Immediately, several states passed trigger laws that would strictly regulate abortion rights and these would be implemented should the Supreme Court overturn Roe v. Wade. As expected, following this draft, on June 24, 2022, Roe v. Wade and the constitutional right to abortion was overruled in a 6-3 landslide vote by the Dobbs v. Jackson’s Women Health Organization (JWHO) case, allowing individual states to regulate abortion rights.6 Several states including Alabama, Oklahoma, and Texas have placed abortion bans with no exceptions for rape

REPRODUCTIVE RIGHTS IN THE UNITED STATES or incest, while others such as Georgia, Utah, and Florida have enacted restrictive gestational limits to abortion.7 Ultimately, the court ruled against abortion as a constitutional right on the basis that the right had not been deeply rooted in the country’s history.6 IMPLICATIONS ON HEALTHCARE Roe v. Wade laid the foundation for advancements in the field of reproductive healthcare and its associated legal protections. Thus, the overturning has created a nebulous situation for access to contraceptives, prenatal genetic screening, along with miscarriage and ectopic pregnancy care.8 The laws enacted in numerous states place increased surveillance on people seeking abortion care, as well as the healthcare professionals providing the care. Consequently, healthcare professionals are situated in a legal and ethical dilemma when treating pregnant individuals in the aforementioned medical emergencies.9 For instance, Texas law criminalizes abortion after the detection of cardiac activity, even in medical emergencies.10 However, the federal Emergency Medical Treatment and Labor Act, initiated under the Biden administration, remains fully in effect, meaning hospitals must provide treatment to pregnant patients in an emergency situation.10 In response to this bill, Texas Attorney General Ken Paxton filed a lawsuit against the policy —as of November 12, 2022, the case is still under review.25,26 These unclear guidelines and contradictory laws can make it difficult for healthcare professionals and patients alike to navigate dire situations.

IMPLICATIONS ON THE RIGHTS FOR THOSE WHO IDENTIFY AS WOMEN AND THOSE WHO ARE CAPABLE OF PREGNANCY The overturning of Roe v. Wade has had global implications on the privacy and autonomy of individuals who identify as women and others capable of pregnancy. Scholars argue that this new ruling has reduced these individuals to reproductive bodies, with their bodily integrity and right to accessible healthcare dictated by the government.13 It begs the question of what comprises the autonomy of individuals who identify as women, and has further implications about the extent to which governments intervene in personal health decisions. Moreover, under the USA Health Insurance Portability and Accountability Act, sensitive health information cannot be disclosed without patient consent, except when required under judicial orders.14 Legal difficulties arise when unexplained miscarriages, stillbirths, or ectopic pregnancies occur.15 In 2021, after a stillbirth, a 15-yearold girl was forced to undergo an exhaustive investigation into her personal and digital life. Similarly, another woman was detained for 36 hours after her stillbirth.16 Additionally, Dr. Leah Torres details her experience as a physician in Alabama, a state where abortions are outright banned.27 Physicians are scared and will no longer treat patients who are actively going through miscarriages.27 Patients who are bleeding and at risk for sepsis due to pregnancy complications are being turned away from care due to legal fears.27 Dr. Torres herself even had her medical license temporarily suspended for “unprofessional conduct” when she made public opinionated statements about reproductive rights.28 These legal repercussions mark an area of uncertainty in reproductive care and fosters fear amongst individuals capable of pregnancy and health providers alike.27,28 Though affecting all individuals capable of pregnancy, abortion inaccessibility is prejudiced in nature, impacting ethnic minorities, individuals of low socioeconomic status (SES), and vulnerable populations disproportionately.13 Estimates suggest that over subsequent years, this ruling will lead to a 21% increase in pregnancy-related deaths, and a 33% increase of pregnancy-related deaths in Black patients specifically.13,15 Additionally, individuals of low SES bear the heaviest burden of this ruling, as they are often unable to provide for their children, further fueling the poverty cycle.16 Social determinants such as SES play an integral role in healthcare impact and can clarify the breadth of the impact of this ruling.13

FURTHER IMPLICATIONS Due to the USA’s extensive global influence, the effects of overturning Roe v. Wade are not isolated, depriving low- and middle-income countries that receive global health assistance. In 2017, the Trump administration expanded the Global Gag Rule —a government policy requiring foreign organizations receiving government funding to agree not to provide, refer for, or promote abortion as a method of family planning— from its previous iteration.18 The overturning of Roe v. Wade will solidify the USA’s stance on abortion and reproductive care, most likely leading to the withdrawal of funds from the USA to support foreign non-governmental organizations providing abortion care.17 Contrarily, Latin America is seeing a trend in the decriminalization of abortion, known as the “green wave.” The organized social mobilization of abortion rights activists in Latin America has passed the green wave to the USA, as activists adopt the colour green in their protests.20 After the legalization of abortion in Argentina, Mexico passed legislation that decriminalized elective abortion in the first 12 weeks of pregnancy, and Colombia legalized abortion within the first 24 weeks of pregnancy.19,20 Furthermore, the overturning of Roe v. Wade will detrimentally affect medical education, impeding future physicians’ ability to provide safe, evidence-based clinical recommendations to patients.22 Out of 6,007 current USA obstetrics and gynecology residents, 43.9% will lack in-state abortion training.23 Consequently, the treatment of a series of pregnancy complications in which abortions are medically indicated will be limited.22 Abortion training is also necessary in teaching professionalism through competencies such as humanism, patient autonomy, and supersession of patient needs over physician self-interest.24 Moreover, Dobbs v. JWHO may exacerbate the healthcare disparities and physician shortage that already exist in the USA. With no option but to carry pregnancies to term, an increased number of healthcare professionals —a disproportionate number of whom are also carrying a pregnancy to term— will be on parental leave or travelling for abortion care.25 Further inequities may arise in personal and patient interests, as medical students decide to pursue clinical training in states with accessible abortion care, exacerbating clustering in certain areas of the USA.22 CONCLUSION The overturning of Roe v. Wade impacts not only the physical and psychological health of individuals who identify as women and/or are capable of pregnancy, but also their autonomy and right to privacy.13,15,17 Further, it has changed global perspectives in healthcare, justice, and political landscapes and is an area that continues to be heavily debated and discussed. REVIEWED BY: JENNIFER WILLIAMS (PhD CANDIDATE) Jennifer Williams is a PhD candidate under the Kinesiology Department at McMaster university. She holds an MSc from Queen’s university and currently works in the Vascular Dynamics Lab. Her research focuses on the impact of hormonal contraceptives on cardiovascular indicators in women. Additionally, she is a sessional instructor, teaching courses that explore sex, gender and their relation to health. EDITED BY: SEPEHR BAHARESTAN KHOSHHAL & FAN ZE (ALEX) WANG

References can be found on our website: www.themeducator.org

MEDUAMPLIFY meducator | december 2022

Additionally, the right to contraceptive use may be threatened, as the right to abortion was an extension of the right to contraceptives.10 Although the majority opinion of several Supreme Court Justices emphasized that prior cases would not be threatened, Justice Thomas wrote that the court should reconsider cases concerning the right to privacy, including Griswold v. Connecticut —the case legalizing contraception for married couples.11 Medications with alternative uses of inducing abortions are also under scrutiny, impacting the treatment of cancers, arthritis, and autoimmune diseases. Following Arizona’s abortion ban, a 14-year-old rheumatoid arthritis patient’s prescription refill for methotrexate —an essential medication for arthritis management— was denied, highlighting the extensive scope of impact that Roe v. Wade has had on healthcare.12 Healthcare professionals will now need to navigate various legal frameworks in addition to the minefield of ethical and professional quandaries.

doi: 10.35493/medu.42.26

1 2

MEDUAMPLIFY meducator | december 2022

AUTHORS: ANNA MCCRACKEN 1, AUDREY DONG 2 , & FLORENCE DENG 2

Bachelor of Health Sciences (Honours), Class of 2025, McMaster University Bachelor of Health Sciences (Honours), Class of 2026, McMaster University

ARTISTS: MISHAL HOSSAIN 3 & ELAINE WANG 3

Bachelor of Health Sciences (Honours), Class of 2026, McMaster University

INTRODUCTION In the context of public health, stigma is defined as a negative stereotype towards a group of people in relation to a disease. Stigma most often manifests as stereotyping, isolation, harassment, and refusal of service.1 These behaviours are more likely to occur in pandemic and epidemic settings, as fear and anxiety perpetuate stigma during these times.2 Beyond its social implications, stigma can have negative repercussions on disease mitigation strategies. This was highlighted by a meta-analysis of 21 studies which found that human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) stigma has an inverse correlation with HIV/AIDS disclosure.3 Thus, stigma is a substantial obstacle in controlling disease outbreaks and significantly reduces compliance with public health measures. AN OVERVIEW OF STIGMA Stigma-imposed discrimination deprives an individual or group from full social acceptance. This limits one’s access to resources, fuelling social inequalities.4 A helpful way to conceptualise and apply the mechanisms of stigma onto past,

Bruce Link and Jo Phelan conceptualise stigma using a framework that begins with labelling people based on their differences.5 Observing differences is human nature, but the differences deemed societally notable are dependent on an individual’s social environment. For example, sexual orientation is a noteworthy difference in the United States, whereas other differences —such as being double jointed— are less striking in our social context.5 In the Link-Phelan framework, undesirable characteristics become attributed to certain groups. Especially in epidemic and pandemic settings, groups may become associated with the origin of disease, leading to marginalisation. The separation of “us” from “them” creates a dehumanising narrative, leading to status loss and discrimination.5 From a sociological standpoint, Stangl et al. provide another framework to conceptualise the stigmatization process by dissecting the phenomena into domains consisting of drivers and facilitators, stigma ‘marking,’ manifestations, and outcomes.7 Drivers of health-related stigma consist of disease avoidance, social and economic reparations, judgement, and blame, and facilitators further enable stigma through cultural norms and health policy.8 Individuals and groups are marked by their differences as health condition-related stigma intersects with race, gender, class, and sexual orientation-related stigma.9 Labelling theory and social network theory could then manifest as discrimination, internalization, and prejudice.10 As a result, stigma is ingrained within affected populations and institutions in the form of policies, accessibility to healthcare, and advocacy.8 Thus, stigma is crucially dependent on power as it enables the manipulation of resources and reliability to one’s benefit.4 Link-Phelan’s framework summarises the intentions of stigma reinforcement as exploitation, norm enforcement, and disease avoidance.5 The framework of Stangl et al. outlines the institutionalisation of stigma as being primarily reinforced by drivers and facilitators.7 STIGMA IN TRANSMISSIBLE DISEASE Link-Phelan’s framework can be applied to the emergence of HIV/ AIDS —a disease with long-standing impact on the LGBTQ+ community— in the 1980’s.11 The Stonewall riots of 1969 and the modern gay rights movement led to the initial establishment and increased visibility of gay culture in the United States.12 In accordance with the Link-Phelan framework, this interpersonal difference was deemed notable due to homophobia in the US.5 When HIV/AIDS was first clinically observed in 1981, it primarily affected homosexual men, and was briefly called gayrelated immunodeficiency disease (GRID).11 Some speculated that HIV/AIDS was caused by “lifestyle issues” that were being associated with homosexuality.13 Marshall Forstein, a Boston physician and openly gay practitioner at the time of the first outbreak, served as Chair of the Steering Committee on HIV/ AIDS for the American Psychiatric Association.12 He recalls

public figures engaging in extreme anti-gay discourse, funeral homes refusing the bodies of HIV/AIDS-positive men, and religious figures asserting punishment for “unnatural behaviour.”12 Over time, the case demographics of HIV/AIDS have changed. The stigma that homosexual men faced in the 1980’s infiltrated communities who have been denigrated by society, often with discriminatory tone. Disproportionately affected groups include women of colour, gay and bisexual men of colour, and intravenous drug users.11 It should also be noted that in 2018, 33.4% of all HIV/AIDS cases in Canada were a result of heterosexual sex, although stigma surrounding the disease remains.14 This is illustrated by a study conducted in 2017, which found that 41% of healthy participants would feel ashamed upon an HIV/AIDS diagnosis, highlighting the dangerous outcomes associated with disease stigma.15 More recently, COVID-19 is an additional example of stigma associated with transmissible disease. COVID-19 first emerged in late 2019 in Wuhan City, China. In early 2020, the virus began spreading globally, transducing a wave of stigma with it.16 The media placed emphasis on Wuhan as the origin of COVID-19, establishing association of the disease with the Chinese community.17 As the virus spread, non-East Asian people began openly expressing their xenophobia, attributing hate-driven characteristics to East Asian people. This subsequently isolated these communities from society, and in congruence with the Link-Phelan framework, separated “them” from “us.”5, 17 The result of this stigma was startling. In a Canadian statistical review with over 43,000 participants, it was found that perceived harassment and attacks based on race, skin colour, or ethnicity since the start of the COVID-19 pandemic were three times as frequent in visible minorities than in the rest of the population.18 The reported increase in these discriminatory actions was most pronounced in Chinese (30%), Korean (26%), and Southeast Asian (19%) participants.18 In Montreal, there were reports of Asian-Canadians being denied medical services with responses such as, “Go back to China,” or “Take the virus back.”16 The thousands of anecdotal assaults in the literature highlight the discrimination and violence that afflicted the East Asian community as a result of social stigma. CONCLUSION Eliminating stigma requires both individual and institutional changes. The reconstruction of public health approaches towards transmissible diseases can target stigma occuring on a wider scale. Governments may collaborate with community-based advocacy organisations and social service providers to develop a comprehensive assessment of the structural, behavioural, and social vulnerability of marginalised groups.19 First-hand insight from marginalised populations allows for the design and execution of case finding, contact tracing, and prevention to prioritise vulnerable communities.19 In Canada, the Chief Public Health Officer, Theresa Tam, has taken initiative to address the prevalence of stigma. A 2019 report summarises the overall health of Canadians and how populations experience healthcare services differently as a result of stigma.20 In sparking public discourse and awareness, first steps are being taken. Working jointly with community-focused groups will also increase accessibility of primary risk reduction programs for marginalised groups, many of whom also lack equitable access to healthcare resources.19

MEDUAMPLIFY meducator | december 2022

present, and future epidemics is to generate a framework that addresses both sociological and psychological contributors.5 Through this method, intervention development, research, and public policy may be implemented to mitigate the detriments of stigma on society.6

Individual mindfulness regarding the usage of more considerate and unbiased language when conversing about transmissible diseases can reduce segregation of a group of people, connection of them to a disease, and implication of blame on the stigmatised for their membership in the group and associated disease.21

Volunteering in organisational efforts to reform social and prevention programs can aid in the minimization of stigma in local communities through improving access to health services.22 As the dynamic landscape of transmissible disease inevitably continues to shift, although stigma remains ingrained in healthcare systems and diseases, it can be rectified through institutional and personal efforts combined with proper education.

REVIEWED BY: DR. ALBINA VELTMAN (MD, FRCPC, M.A.) Dr. Albina Veltman is Associate Professor of Psychiatry at McMaster University. From 2013–2016, she was the Inaugural Chair of Diversity and Engagement for the Undergraduate Medical Education Program at McMaster. Her clinical focus in psychiatry is on traditionally marginalised groups, including those with persistent severe mental illness, intellectual disabilities, and the LGBTQ+ community. EDITED BY: RIDA TAUQIR & RAYMOND QU

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Issue 42

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STIGMA IN TRANSMISSIABLE DISEASE

REPRODUCTIVE RIGHTS IN THE USA

PATHOPROFILE

HEAT WAVES

INTRODUCTION

MEDBULLETIN

INDIGENOUS YOUTH RESILIENCE

MEDPULSE

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