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Table of Contents

PREFACE 3 Preface from the Editors COMMENTARIES 34 Climate change advocacy: a growing movement Arianne Cohen and Sasha Letourneau

EDITORIAL TEAM 4 2019-2020 Editorial Team 36 How our global health experience contributed to our developing identities as physicians Paula Gosse, Emily Kaunismaa and Roslyn Mainland

40 Comprehensive sexuality education in Rwanda AWARDS and Ontario: an important public health intervention 5 Award Winning Articles Hilary Stone

42 Mobile applications to improve antiretroviral therapy adherence: quality over quantity INVITED COMMENTARIES Calvin Diep, Majd Abdullah and Soo Chan Carusone 6 Canadian physician growth lagging behind demand, other nations Sohail Gandhi CASE STUDIES 9 Climate change: an unsustainable development for 44 Recurrent back pain in a five-year-old boy: global health a harbinger of tempest Edward C. Xie, Eileen Nicolle, Nazanin Meshkat Salwa Hasan, Fizza Manzoor, Rosemary G. Moodie, and Megan Landes Yousef Etoom, Ibrahim Al-Hashmi, Ivor Margolis and Peter D. Wong 14 Development of Maternal and Child Health (MCH) handbook digital application to promote MCH services: no one left behind to address sustainable development goals (SDGs) INTERVIEWS Shafi Bhuiyan 46 Interview with Dr. Lee Errett Annie Yu and Ryan Daniel

PRIMARY RESEARCH 49 Interview with Prabha Sati 16 Factors associated with the extent of the expected Happy Inibhunu and Jeff Park increase in leukocyte count during the perioperative period Yoshan Moodley and Marsha Ramburuth 53 Interview with Dr. Kamran Khan Kathleen O'Brien and Alexandra Florescu

REVIEWS 56 Interview with Dr. Eileen de Villa 21 The effect of urban density on mental health: a Imindu Liyanage and Kathleen Simms systematic review Kyle O. Lee and Pamela Kaufman

30 Evidence of stress and diabetes in Indigenous Peoples of Canada Leshawn Benedict, Mahdia Abidi, Harvir Sandhu, Allyson Gillespie, Qi Xue, Jessica Hill and Gerald McKinley

All articles are externally peer-reviewed with the exception of poetry, short stories and book reviews. All manuscripts are internally reviewed. Informed con- sent practices and any conflicts of interest are specified in the articles if applicable.

Front cover illustration by Jackie Tsang

UTMJ • Volume 97, Number 2, March 2020 1 Office of Health Professions Student Affairs Supporting Your Success http://www.md.utoronto.ca/OHPSA

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E-mail: [email protected] Telephone: 416.978.2764 C. David Naylor Building, 6 Queen’s Park Crescent West, 3rd Floor, Room 306 Preface

Preface

Dear UTMJ Reader,

e are thrilled to present Volume 97, Issue 2 of the In this issue of the University of Toronto Medical Journal, we will University of Toronto Medical Journal, which focuses on the address the important topic of global health. We believe that this important and emerging topic of Global Health. As issue will bring forth areas worth exploring, including but not ourW world becomes increasingly more interconnected, physicians limited to the effects of climate change on health, the spread of are beginning to recognize that their responsibilities lie beyond infectious diseases, the promulgation of global health policies, an individual clinic, transcending international boundaries to the ethics and regulation of global health ‘voluntourism,’ and deliver care to the broader global community. This impulse is Canada’s role within the broader conversation on global health. reinforced by our developing understanding of the determinants We hope that this issue will inform our international readership of health, considering not only our biology, but also our social, about current advances and practices in global health and identify cultural, economical, and political contexts. Emboldened with this priorities for future research. multifaceted and dynamic understanding of health, researchers, This is the second issue of the University of Toronto Medical physicians, and policymakers in the field of global health strive to Journal’s 97th volume. We would like to sincerely thank our achieve equity in health for all people. dedicated editorial team for all the hard work that went into In the wake of the recent Climate Change strike, conversations preparing this issue, and their continued efforts in upcoming issues. about global health, particularly in the context of environmental We are grateful for the patrons and faculty that continue to support change, have become increasingly more important. The World the University of Toronto Medical Journal and the authors that have Health Organization recognizes that climate change negatively allowed us to showcase their important work. We hope that you impacts human health, with a disproportionate effect in developing find this issue informative and thought-provoking. nations with weak health infrastructure, who are the least equipped to respond. Research both in this field and in global health more Sincerely, broadly can help identify underlying problems and begin to develop solutions aimed at achieving health equity. Tatiana Yeuchyk and Kathleen Simms Editors-in-Chief

We would like to acknowledge the invaluable contributions of our late colleague Mohammad Asadi-Lari to the corpus of Global Health research by dedicating this issue of the University of Toronto Medical Journal to him. His intellectual curiosity, humanitarianism, and focus on innovation served as a guiding example to all and he will be deeply missed.

UTMJ • Volume 97, Number 2, March 2020 3 A student-run scientific publication since 1923

University of Toronto Medical Journal

2019-2020 UTMJ Editorial Team

Editors-in-Chief Tatiana Yeuchyk & Kathleen Simms

Associate Editors Interview Editors Anders Erickson Happy Inibhunu Maleeha Qazi Alexandra Florescu Yuliya Lytvyn Jeff (Joo) Park Gil Yerushalmi Kathleen O'Brien Sina Hadipour-Lakmehsari Annie Yu Ryan Daniel Director of Development Imindu Liyanage Copy Editors Elena Wolff Section Editors Monisha Basu Alexander Dhaliwal Roslyn Mainland Niklas Bobrovitz Anson Cheung Brigid Conroy Raumil Patel Houman Tahmasebi Justin Brunet Nykan Mirchi Arjuna Maharaj Isabella Fan Jennifer Parker Rachel Greben Daniel Dongjoo Lee Sarah Ge Sophia Emerson Creative Director Jane Zhu Jeffrey Lam Shin Cheung Kevin Jia Qi Chen Monish Ahluwalia Social Media Director Michael Lee Kelly Dong Sahar Zarabi Xinghan (Hill) Du Typesetting and Printing Saumya Bansal Type & Graphics Inc.

Cover Artwork Jackie Tsang

University of Toronto Medical Journal, 1 King’s College Circle, Room 2260, Medical Sciences Building, Toronto, Canada M5S 1A8 E-mail: [email protected] • http://www.utmj.org • Phone: 416-946-3047 • Fax: 416-978-8730

4 UTMJ • Volume 97, Number 2, March 2020 A student-run scientific publication since 1923

University of Toronto Medical Journal

Award Winning Manuscripts

The University of Toronto Medical Journal (UTMJ) was established in 1923 and is Canada’s oldest student-run medical journal. We strive to uphold the UTMJ’s legacy of excellence by publishing interesting and timely research articles for our esteemed readers. Medical trainees continue to be important contributors to many of the research articles published by the UTMJ. We recognize the value in student research and are proud to serve as an outlet for this work. The UTMJ has established three awards to acknowledge outstanding submissions from medical trainees in each of our issues. We would like to congratulate the following award winners for the current issue on Global Health:

First Prize The effect of urban density on mental health: a systematic review Kyle O. Lee and Pamela Kaufman

Second Prize Evidence of stress and diabetes in indigenous peoples of Canada Leshawn Benedict, Mahdia Abidi, Harvir Sandhu, Allyson Gillespie, Qi Xue, Jessica Hill and Gerald McKinley

Third Prize How our global health experience contributed to our developing identities as physicians Paula Gosse, Emily Kaunismaa and Roslyn Mainland

These awards would not be possible without the continued support of the University of Toronto Medical Society and generous donations from our readers. Please consider supporting the UTMJ so that we can further our efforts to promote student research, publish impactful articles and grow our readership. Donations can be made online through our website, www.utmj.org, or sent to the following address: University of Toronto Medical Journal, 1 King's College Circle, Room 2260, Toronto, ON, Canada, M5S 1A8.

University of Toronto Medical Journal, 1 King’s College Circle, Room 2260, Medical Sciences Building, Toronto, Canada M5S 1A8 E-mail: [email protected] • http://www.utmj.org • Phone: 416-946-3047 • Fax: 416-978-8730

UTMJ • Volume 97, Number 2, March 2020 5 Invited Commentaries

Canadian physician growth lagging behind demand, other western nations

Dr. Sohail Gandhi

President, Ontario Medical Association

have been a family physician for over a quarter century, 1. Ontario Ranks Seventh of Ten Provinces in and chose to practice in the small community of Stayner, Physician-Population Rates Ontario. Working in a rural community has given me a closer Even with a 3.5% percent growth in physicians to population connectionI to my patients, and a stronger understanding of the over 2017, Ontario still ranks seventh out of ten provinces. challenges in Ontario’s current health care model and how it Ontario was ahead of only PEI (1.97), Saskatchewan (2.05) and could be improved. In the end, everything doctors do is in aid of Manitoba (2.25). Ontario is also below Canada’s rate overall of better patient care and better patient outcomes. 2.41 physicians per 1,000 population.1 What I’ve seen and experienced shows me that we need to change the landscape of medical care. It’s one of the reasons I 2. Recent Growth is Making Up for Past Stagnation became involved in medical politics. It’s something I continue to The growth in Ontario’s physician-to-patient ratio is a focus on as President of the Ontario Medical Association. relatively recent phenomenon. A review of CIHI data for the period 2001 to 2018 shows that First and Foremost, We Need More Physicians in the number of Ontario physicians has grown an average annually Canada of 1.6% more than the growth in the province’s population. Our population is aging. Our patients are becoming However, the rate of growth during the period 2001-2008 more complex. The rate of growth of Canadian physicians to was essentially flat, with the ratio stuck at about 1.8 physicians population needs to keep pace. How many more doctors do we per 1,000 people for eight years. Therefore, some of the recent need? Well, it really depends. increase in annual growth is actually catching up to meet demand There is no straight-line comparison between these factors from the past. and the number of physicians required. I would suggest it also Additionally, whether or not the rate of growth of physicians depends on the distribution and prevalence of specialties and meets or exceeds the population growth is not the whole story. It’s sub-specialties, the age of physicians, their models of practice, simply not enough to say that the population has grown by, say, and other resources (particularly allied health care professionals one percent so we need one percent more doctors, as there are to assist physician led teams) available within the health care many other determinants of the need for physician services, such system. There are many nuances. as aging and increasing clinical complexity and multimorbidity. Although there is no magic target number to reach for, we need to look at making a significant investment into training and 3. Ontario Sees an Annual 3.6% Growth in Physician hiring physicians in Canada in order to fully meet the health care Services demands of our patients. Ontario experiences a 3.6% annual average growth in services To those who say we cannot afford it, I pose an only somewhat provided to Ontario patients, representing the cumulative impact rhetorical question: How much money does it cost right now to of population growth, aging, patient complexity, advances and care for a high needs diabetic with COPD and heart disease who availability of technology, and other factors.2 goes to the Emergency Room regularly because he or she doesn’t Recent analysis carried out by the Ontario Medical have a doctor? Association’s Economic, Policy and Research department demonstrates that prevalence of multiple chronic conditions in Growth in physician ratios not keeping pace with Ontario has grown from 2008 to 2017. need This has caused an increase in something called patient When the Canadian Institute for Health Information (CIHI) resource intensity. As of 2017, the number of patients with at reported that in 2018, Ontario had 2.34 physicians per 1,000 least one out of a baseline list of 84 chronic conditions was people – up from 2.26 in 2017 – this was heralded by some as a estimated to be 9.8 million, an increase of 11.0% from 2008. dramatic increase.1 Although I was very pleased to see growth in Multimorbidity also rose. The number of patients with two or physician numbers – because I believe this is necessary to improve more chronic conditions increased by 12.2%, while those with patient care – I would have been more bullish had I not noted three or more increased by 13.5%. four things that make this statistic somewhat less rosy. This means that Ontario patients are becoming more complex, and thus require more time, resources and physician manpower to look after. Given that the majority of health spending can be attributed to multimorbidity, these findings have

6 UTMJ • Volume 97, Number 2, March 2020 Invited Commentaries

Canadian physician growth lagging behind demand, other western nations

major implications for population health management and health 4. Canadian Physician Rates Are Low Compared with care spending. Other Western Countries Although this analysis is based on Ontario patients, it is hard to In contrast with other comparable countries, Canada’s imagine that the same demand does not exist, in whole or in part, physician-to-population ratio is low. While there are many factors in other jurisdictions across the country. determining the optimal number of physicians, it is hard to argue Advances in technology to both diagnose and treat have also that Canada has too many physicians relative to its peers. increased the ability of physicians to provide care to their patients, World Bank figures demonstrate that other Western countries which puts further demand on physician resources. are outstripping Canada in the rate of physicians to population. In All of this illustrates that patient demand for services is growing 2015, the Euro area had 3.8 physicians per 1,000 people, while in the significantly, and we need more doctors each year to meet it. The European Union it was 3.6, and OECD countries saw a rate of 2.9. ones we have will have to work ever harder. According to the Some of the physician-to-population rates for individual Canadian Medical Association, doctors already work an average countries are even more impressive. Sweden, for example, had a of 52 hours a week, and in many cases work more hours being rate in 2016 of 5.4 – over double that of Canada’s. “on-call” on top of that. It is not sustainable or even tenable to ask doctors to work more.

UTMJ • Volume 97, Number 2, March 2020 7 Invited Commentaries

Canadian physician growth lagging behind demand, other western nations

What does this all mean? The reality is that Canada often gets References 1. Canadian Institute for Health Research [Internet]. c1996-2020. Supply, distribu- lambasted for poor health care metrics in the press (e.g. wait times). tion and migration of physicians in Canada, 2018 — Data Tables; 2019 [cited However, it is clearly impossible to meet some of the noble goals Jan 17, 2020]. Available from: https://secure.cihi.ca/estore/productFamily. when there simply aren’t enough physicians to do the work. We can htm?pf=PFC4053&lang=en&media=0. 2. Ontario Medical Association. Brief of the OMA re: Phase I - physician services invest in programs like public health, telemedicine, pharmacare budget: Baseline, growth and cap, appropriateness. 2018. Available from: https:// and so on. These are all good and noble causes that have been content.oma.org//wp-content/uploads/private/OMA-Brief-PSB-Growth-Cap- clearly shown to benefit populations of patients. But until we Appropriateness.pdf. recognize that our main problem is a shortage of physicians and that the growth needs to accelerate even more, our overall health metrics will not achieve those of the countries we aspire to.

8 UTMJ • Volume 97, Number 2, March 2020  Invited Commentaries

Climate change: an unsustainable development for global health

Edward C. Xie, MD, MSc, CCFP(EM)1; Eileen Nicolle, MD, CCFP1; Nazanin Meshkat, MD, MHSc, FRCPC2; Megan Landes, MD, MSc, CCFP(EM)1

1Department of Family and Community Medicine, University of Toronto 2Department of Medicine, University of Toronto

mong all the unresolved global health issues, climate Since the Second World War, the average annual temperature change is now widely acknowledged as “the greatest in Canada has risen by nearly two degrees Celsius.10 This increase health challenge of the 21st century”.1 Far more than an has been roughly twice as fast as the global average, and even Aenvironmental threat, climate change poses problems for every more rapid in northern regions (Figure 1). Changing climatic facet of our society, affecting the social and ecological determinants conditions in Canada expands suitability for vector-borne diseases of health.2 On a global scale, inaction on climate change risks and increases the likelihood of extreme weather events, floods, “undoing the last fifty years of progress in development, global droughts, and fires.10-12 health, and poverty reduction”.3 These effects of climate change can have a direct impact At the heart of this statement, from a report of the United on health or be mediated through determinants of health and Nations (UN) Special Rapporteur on extreme poverty and human belie structural inequities, such as those related to income, rights, lies a central injustice: disadvantaged populations around gender, or access to essential resources (Figure 2). For example, the world have contributed least to climate change, but are most the contribution of climate change to water scarcity can, under likely to be harmed, through greater exposure and reduced certain conditions, aggravate conflict, forced migration, and health capacity to adapt.4 Comparing internationally in 2014, people emergencies.2,13 This association has been implicated in the war in in high-income countries produced in 2014, on average, over 35 Syria, where severe droughts were thought to be an inciting factor. times the emissions of individuals in low-income countries.5 This To date, approximately 60 thousand Syrian refugees have been imbalance in distribution of the benefits and burdens of fossil fuel resettled in Canada.14 use is repeating a familiar pattern of increasing inequities, with Compared to the rest of the world, Canada has no national major implications for health and its determinants worldwide.6 shortage of water (Figure 3). Yet within its borders, at the close Promisingly, the aims of global health and development align of 2019, over 3 thousand homes on First Nations reserves still with the most effective means of protection from climate change, lacked access to clean drinking water.15 In common with other including poverty alleviation, universal health coverage, and global communities, Indigenous peoples in Canada, including First access to clean water.7 Recognizing this link, the UN Sustainable Nations, Inuit, and Métis peoples, often face deep inequities in Development Goals and the Paris Agreement on limiting climate access to natural and economic resources and high-quality health change were both adopted five years ago as road maps for progress. services.16 These inequities are further compounded by climate Both affirm the right to health and recognize that determinants of change, for example, by contributing to food insecurity, safety health are adversely affected by climate change.8 hazards, barriers to physical activity, and a communal sense of Consequently, global mobilization around shared goals of grief and loss.17 controlling climate change can also be an opportunity to improve The rising effects of climate change are tangible inside Canada lives and address past and ongoing injustices. Applying “relational” and increasingly felt as international pressures on food, security, understandings of the problem, conscious of how our economic, economies, and health. In the decades since global heating was social, and political relationships and systems have contributed first described, we have experienced other emergent challenges to to global heating, can help to inform sustainable solutions.7 We global health with similarly wide-ranging impacts. The history of examine connections between climate change and global health our struggle with the HIV/AIDS epidemic can inspire action and to illustrate the harms we must counteract and explore models for also offer cautionary lessons for approaching climate change. progress. HIV: Lessons for Global Action Connecting the Dots: Canada in a Heating World Encouragingly, coordinated international efforts have managed Global health has been described in association with issues to bend the curve on the HIV/AIDS epidemic. The timeline of that transcend national boundaries, organized around the idea the global HIV crisis from recognition to gradual control can be of health as a shared social good and principles of health equity.9 explored for insights into our urgent need for action on climate Within this framework, global health concerns are situated within change. and circulate to Canada, and are increasingly linked to threats From the first reports of HIV in the 1980s, the virus spread from climate change. to pandemic status, with low-income countries carrying the bulk of the illness burden. During the 1990s, the crisis accelerated,

UTMJ • Volume 97, Number 2, March 2020 9 Invited Commentaries

Climate change: an unsustainable development for global health

a) Winter

b) Spring

Figure 2. Conceptual model of the effects of climate change on health through direct and indirect pathways.

predominantly in sub-Saharan Africa.20 However, while treatment became available, and was beginning to sustain and save lives in c) Summer high-income countries, a small minority of the total population living with HIV had access to antiretroviral therapy (ART).20 During these years, the pandemic became highly politicized, partially as a result of strong advocacy by affected groups, but also from recognition that the spread of HIV laid bare gross global inequities driven by social determinants of health, including poverty, gender, race, migration, and the effects of colonization.21,22 In the early 2000s, we saw 2 key aspects of the response develop, which led to some successes in the fight against the disease. First, international cooperation and considerable political will arose, with the UN General Assembly endorsing the Declaration of Commitment on HIV/AIDS in 2001. Funding and coordination followed, with the establishment of major joint programs through d) Autumn the UN, large-scale donors, governments, and non-governmental organizations. A second critical development was interdisciplinary and intersectoral collaboration. The response moved well beyond a biomedical approach to recognize that the humanities and social sciences were necessary to understand the epidemiology of the disease and design appropriate interventions. To enhance effectiveness, multiple sectors were engaged, including education, media, security, and finance.20 These coordinated global efforts brought the crisis down from a peak of 2.9 million new infections in 1997 to 1.7 million in 2018.23 Over the last 2 decades, we have celebrated a remarkable rise in the number of people accessing ART, accompanied by steady falls in AIDS-related deaths.23 Nevertheless, even at a mature stage, a myriad of challenges remain in the global response to HIV/AIDS. As ART increases Figure 1. Trends in seasonal mean temperatures across Canada between 1948 and 2016 for the four seasons. Reprinted with permission from Zhang the lifespan of people living with HIV, the infection converts to et al. 2019.18 a chronic disease that strains the resources of over-stretched

10 UTMJ • Volume 97, Number 2, March 2020 Invited Commentaries

Climate change: an unsustainable development for global health

Figure 3. National levels of water stress (Sustainable Development Indicator 6.4.2), measured by freshwater withdrawal as a proportion of available resources in 2014.19 Darker colours indicate greater water stress. Grey shading indicates missing data. health systems worldwide. Funding has consistently fallen short of on Climate Change (IPCC) recommendations, international resource requirements to end the epidemic, while simultaneously, mitigation targets are not aspirational, but critical for preventing responses often fail to address the structural inequities of the the worst outcomes. Unfortunately, much like the goals for crisis.21,23 Symptomatic of this is that while the global incidence of eliminating the threat of HIV, countries are on a course to miss the HIV continues to decrease, the rate of new infections is rising in Paris Agreement targets for emissions reductions. some countries and regions (Figure 4).23 As we begin 2020, despite Learning from the global HIV/AIDS response, a convergence considerable progress, figures from the Joint United Nations of interests – including health sector leadership – must prevent Programme on HIV/AIDS (UNAIDS) show us falling well short politics from superseding the science on climate change. of the 2020 targets for HIV control. Furthermore, structural changes must accompany technological These challenges are familiar to our current approaches advances for durable solutions, supported by shared goals, to climate action. According to the Intergovernmental Panel secure collaborations, multi-sectoral coalitions, and sufficient

Figure 4. UNAIDS estimates of the number of new HIV infections among uninfected people aged 15-49 per 1000 uninfected population in 2017.19 Grey shading indicates missing data.

UTMJ • Volume 97, Number 2, March 2020 11 Invited Commentaries

Climate change: an unsustainable development for global health consignments of money and political will.22,24 Alarmingly, current around the world need to find points of unity. For Canada, projections place the annual burden of climate change in the multilateralism can be the cornerstone of effective leadership to trillions of dollars by 2100.2 In light of this, we must not allow the address climate change.30 As we have seen, the health of Canadians crushing health, economic, and social costs of inaction to grind and the challenges of global health are intertwined with ever- away a lifetime of progress in global health. As much as the global growing environmental concerns. In this respect, global citizenship HIV response would benefit from strengthened universal health is a resilience factor and an opportunity for collaboration.1,22 coverage, the price of delaying pollution reductions may impede The need for greater and more inclusive inter- and its expansion. transnational engagement is highlighted by the narratives in “shared socioeconomic pathways”, a set of scenarios used for Climate Action Without Harm climate models that describe different levels of global cooperation We cannot afford to consider the challenges of climate change and development.31 Going beyond greenhouse gas emissions, these and global health in isolation. A unified approach to finding pathways explore how our societies could evolve and interact in the solutions would fulfil much of the promise of the Sustainable next century. At one end of the spectrum, inequity, environmental Development Goals. The concept of sustainable development is exploitation, and national self-interest feature prominently. At built on principles of stable, inclusive, and equitable growth that the other end, an emphasis on shared human well-being marks protects the rights of people and the environments they need to committed efforts towards achieving sustainable development. attain health.25 Accordingly, climate action must respect human With good reason, we are frightened of one vision, and hopeful dignity and rights. Interventions to manage climate change must for the other. be careful to “do no harm.” Although finding collective approaches to climate change is Sadly, in some cases, mitigation projects have already been in a global health imperative, this does not signal a turn away from contravention. The Barro Blanco hydroelectric dam in Panama existing priorities, such as HIV/AIDS or poverty reduction. is one recent example. Despite knowledge that the settlements, Neglecting the complexity or “relational” nature of the climate livelihoods, medicines, and sacred places of thousands of crisis risks undercutting our own efforts and lowering our potential Indigenous people would be flooded by the renewable energy for future gains. Instead, we can embrace the coherence of creating project, the developers neither consulted nor obtained consent programs and redesigning frameworks for multiple benefits. from affected communities.26 Approaching climate action as a To accomplish this, the health sector needs to play a greater role solely technical challenge ignores the role of societal structures through leadership and collaboration. As we saw during the HIV/ in producing climate change, and risks perpetuating the same AIDS epidemic, health actors should actively seek partnership inequities that have plagued global health efforts, such as economic with other disciplines and sectors. At the same time, we also need domination, devaluation of local knowledge, and overemphasis on to rapidly build deep foundations of education, advocacy, and narrow interventions that favour donor interests over community research on the health effects of climate change. needs.22,27,28 Governments across the globe have declared “climate In contrast, the Enhancing Community Resilience Programme emergencies”. This attention and support must be escalated and in Malawi was designed to integrate with local realities.29 With sustained over decades, not election cycles. Despite the growing high dependence on rain-fed agriculture and high levels of poverty, societal, geopolitical, economic, and health impacts of climate people in Malawi are increasingly vulnerable to climate change. change, we remain – tenuously – in a position to reverse our The project was funded by international donors but developed current course. The longer we delay, the more difficult and costly through community participation to encompass activities that the necessary changes become. Just as the HIV/AIDS epidemic elevated incomes, reduced greenhouse gas emissions, and improved exposed global inequities, existing gaps in health systems and social resilience. Notably, interventions – such as improved cookstoves, protections are made acute and amplified by a hostile and shifting solar energy, and the promotion of more effective land-use – were environment. Climate change is a global health emergency: a not only designed to avoid harm, but also were able to capture unified and inclusive approach is the only sustainable response. multiple benefits: mitigating climate change while improving quality- of-life and social conditions. This alignment of interests supports References the “policy coherence” called for by the WHO Commission on 1. World Health Organization. COP24 Special Report: Health and Climate Change 24 [Internet]. Geneva, Switzerland: World Health Organization; 2018. Social Determinants of Health. 2. Watts N, Amann M, Arnell N, et al. The 2019 report of The Lancet Countdown Even with successful models to work from, care must be taken on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. The Lancet. 2019;394(10211):1836-78. to secure fair and just distributions of benefits and maintain agency 3. United Nations Human Rights Council. A/HRC/41/39 Climate change and for affected communities. As with global health projects, funding poverty. Report of the Special Rapporteur on extreme poverty and human rights of climate action by Canadian institutions and governments [Internet]. Geneva: United Nations; 2019. Available from: https://www.ohchr. org/Documents/Issues/Poverty/A_HRC_41_39.pdf. should be accompanied by inclusive design and participatory 4. Hoegh-Guldberg O, Jacob D, Taylor M, Bindi M, Brown S, Camilloni I, et al. implementation. Impacts of 1.5C Global Warming on Natural and Human Systems. In: Masson- Delmotte V, Zhai P, Pörtner H-O, Roberts D, Skea J, Shukla PR, et al., editors. Global Warming of 15°C An IPCC Special Report on the impacts of global Conclusion: A Global Health Imperative warming of 15°C above pre-industrial levels and related global greenhouse gas Progress in global health requires collective efforts. However, emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate pov- scarcity – of resources and safe environments – due to climate erty: IPCC; 2018. change will increasingly produce unfavourable conditions for success. To continue our advances in global health, communities

12 UTMJ • Volume 97, Number 2, March 2020 Invited Commentaries

Climate change: an unsustainable development for global health

5. The World Bank. CO2 emissions (metric tons per capita) - World Bank Data 19. The World Bank. World Bank Open Data. 2019 [cited 2019 September 25]. [Internet]. Washington DC: The World Bank; 2019 [cited 2019 September 25]. Available from: https://data.worldbank.org/indicator/SH.XPD.CHEX.PP.CD. Available from: https://data.worldbank.org/indicator/EN.ATM.CO2E.PC. 20. Piot P, Quinn TC. Response to the AIDS pandemic--a global health model. N 6. Levy BS, Patz JA. Climate Change, Human Rights, and Social Justice. Ann Glob Engl J Med. 2013;368(23):2210-8. Health. 2015;81(3):310-22. 21. Makofane K, Spire B, Mtetwa P. Tackling global health inequities in the HIV 7. Doan M, Sherwin S. Relational Solidarity and Climate Change in Western Na- response. The Lancet. 2018;392(10144):263-4. tions. 2016. In: Bioethical Insights into Values and Policy: Climate Change and 22. Bekker L-G, Alleyne G, Baral S, et al. Advancing global health and strengthening Health [Internet]. Electronic Book: Springer, Cham. the HIV response in the era of the Sustainable Development Goals: the Interna- 8. United Nations Development Programme. Sustainable Development Goals [In- tional AIDS Society – Lancet Commission. The Lancet. 2018;392(10144):312-58. ternet]. New York: UNDP; 2019 [cited 2019 Oct 28]. Available from: https:// 23. Joint United Nations Programme on HIV/AIDS. UNAIDS Data 2019 [Inter- www.undp.org/content/undp/en/home/sustainable-development-goals.html. net]. Geneva, Switzerland: UNAIDS; 2019. Available from: https://www.unaids. 9. Taylor S. ‘Global health’: meaning what? BMJ Global Health. 2018;3(2):e000843. org/sites/default/files/media_asset/2019-UNAIDS-data_en.pdf. 10. Bush E, Lemmen DS, editors. Canada’s Changing Climate Report. Ottawa, 24. Commission on Social Determinants of Health. Closing the gap in a generation: Canada: Government of Canada; 2019. health equity through action on the social determinants of health. Final report of 11. Ryan SJ, Carlson CJ, Mordecai EA, et al. Global expansion and redistribution of the commission on social determinants of health. Geneva: World Health Organi- Aedes-borne virus transmission risk with climate change. PLoS Negl Trop Dis. zation; 2008. 2019;13(3):e0007213. 25. United Nations General Assembly. A/RES/66/288 - The Future We Want [In- 12. Gasmi S, Ogden N, Lindsay L, et al. Surveillance for Lyme disease in Canada: ternet] New York: United Nations; 2012. Available from: https://sustainablede- 2009–2015. Can Commun Dis Rep. 2017;43(10):194-9. velopment.un.org/index.php?menu=1298. 13. Abel GJ, Brottrager M, Crespo Cuaresma J, et al. Climate, conflict and forced 26. UNICEF. No Place To Call Home: Protecting children's rights when the changing migration. Global Environmental Change. 2019;54:239-49. climate forces them to flee [Internet]. London, UK: UNICEF; 2017. Available 14. Immigration, Refugees and Citizenship Canada. Syrian Refugees Family Com- from: https://www.unicef.org.uk/publications/no-place-to-call-home/. position – Ad Hoc IRCC (Specialized Datasets) [Internet]. 2018. Available from: 27. Crewe M, Aggleton P. Racism, HIV/AIDS and Africa: Some issues revisited. https://open.canada.ca/data/en/dataset/ca243c40-a6d3-4a46-a578-b4fad South African Journal of International Affairs. 2003;10(1):139-49. 4369df0. 28. Chapter 11: Fair Financing. In: Commission on Social Determinants of Health, 15. Indigenous Services Canada. Ending long-term drinking water advisories [Inter- editor. Closing the gap in a generation: health equity through action on the social net]. Ottawa: Government of Canada; 2019 [cited 2019 December 18]. Available determinants of health. Final report of the commission on social determinants of from: https://www.sac-isc.gc.ca/eng/1506514143353/1533317130660. health [Internet]. Geneva: World Health Organization; 2008. 16. Greenwood M, de Leeuw S, Lindsay N. Challenges in health equity for Indig- 29. Wood B, Quinn C, Stringer L, et al. Investigating Climate Compatible Develop- enous peoples in Canada. The Lancet. 2018;391(10131):1645-8. ment Outcomes and their Implications for Distributive Justice: Evidence from 17. Harper SL, Edge VL, Ford J, et al. Climate-sensitive health priorities in Nunatsia- Malawi. Environmental Management. 2017;60:436-53. vut, Canada. BMC Public Health. 2015;15:605. 30. Nixon SA, Lee K, Bhutta ZA, et al. Canada's global health role: supporting equity 18. Zhang X, Flato G, Kirchmeier-Young M, et al. Chapter 4: Changes in Tempera- and global citizenship as a middle power. The Lancet. 2018;391(10131):1736-48. ture and Precipitation Across Canada. In: Bush E, Lemmen DS, editors. Canada’s 31. Riahi K, van Vuuren DP, Kriegler E, et al. The Shared Socioeconomic Pathways Changing Climate Report. Ottawa, Canada: Government of Canada; 2019. p. and their energy, land use, and greenhouse gas emissions implications: An over- 112-93. view. Global Environmental Change. 2017;42:153-68.

UTMJ • Volume 97, Number 2, March 2020 13 Invited Commentaries

Development of Maternal and Child Health (MCH) handbook digital application to promote MCH services: no one left behind to address sustainable development goals (SDGs)

Dr. Shafi Bhuiyan, MBBS, MPH, MBA, MJF, PhD

Asst. Prof., Dalla Lana School of Public Health, U of T; Adjunct Prof., Faculty of Community Services and Co-founder ITMDs Post-graduate Training Program, Ryerson University; Founding Board Member, MCH Handbook International Committee; Board Chair, Canadian Coalition for Global Health Research (CCGHR)

he incidence of maternal and child (MCH) death is highest public health while having a sense of control over their health and within 75 countries in South East Asia and Africa. The wellbeing.4 A second function of the MCH handbook is education. most critical contributing factor is the awareness levels of The handbook comes with healthcare information for pre- and women,T families and communities about the potential negative post-natal care for the mother and baby.5 Since parents are better consequences associated with the delayed seeking of MCH care.1 equipped with information, they are able to notice abnormal signs A two-way communication tool in the form of an MCH handbook with the child or the mother. This enables them to actively seek is being used in many countries to enhance MCH knowledge, healthcare service and practice health. By coming in prepared for practice, and continuum of care. appointments, women can better understand their child’s health The Maternal and Child Health (MCH) handbook is a and growth progress to address illness or disease earlier and make record-keeping tool that has had demonstrated success in several informed decisions on a daily basis.5 countries in improving health for pregnant women, mothers and Globally, with increasing interest in health, maternal and child babies.2 Japan and other selected countries’ experiences showed healthcare tools have already successfully been transferred over to that the MCH handbook as a low-cost, user-friendly tool could the app form in several countries, including South Korea, Japan, easily be upgraded to an innovative digital version. There are no Sri Lanka, and India.6,7 By enabling the use of MCH handbook perceived immediate harms coming from the MCH handbook on a smartphone, data sharing between parents and healthcare digital application. However, as healthcare professionals would be professionals has been made even easier. Because of the nature of asked to record every procedure, doing so on the MCH handbook an app, it is convenient to store and extract information through application could reduce their workload during check-ups. Since the cloud. It also allows additional functions not available in the this application will be made available to all smartphone users, conventional book form such as ultrasound videos, pregnancy anyone with a smartphone would have access to this application. music, appointment reminders, online support groups, a Those without one would not be able to have access to the same marketplace, and an information search function. An MCH pre/post-natal care information and an electronic recording handbook application would be most useful in remote communities platform. where residents are faced with geographical and social inequalities According to the “Tokyo Declaration” made at the recent in addition to the lack of family doctors and inconvenient access MCH Handbook Conference (Nov 2016), the use of the MCH to healthcare services. For those who own a smartphone but do not Handbook has already expanded to around 42 countries. This has utilize internet connection daily, offline features of the app can be been and continues to be a wonderful initiative that aims to ensure used, and all data input can be synced during scheduled check-ups – and has already demonstrated great success with regards to – at a medical facility. continuum of care and health promotion in mothers and children. MCH handbook is an effective way to convey information By providing women with knowledge and tools suitable for their about safe pregnancy and childcare to women, and to act as a living environment that are appropriate to all levels of education, motivational tool for health care providers, pregnant mothers, and the MCH Handbook bridges the gap resulting from geographical their families. Various studies have shown that handbooks assist, and socio-economic inequalities. Going forward, the development encourage, and empower pregnant mothers to seek needed care and utilization of an MCH Handbook application is a noble and and to inform them as to when, where, and how to obtain that care. innovative evidence tool to promote MCH in geographically Handbooks also help assure continuity of care. remote villages, suburban areas, towns, and cities. MCH handbook was introduced in Japan in 1947 and along The MCH handbook has two main functions: recording and with other public health interventions, it contributed to decreasing educating. The recording section of the MCH handbook gives Japan’s infant mortality rate from 76 per 1000 live births to 2 per ownership to the participant by assigning a significant responsibility 1000 live births by 2015. The world’s average infant mortality to her. The handbook also complements the current health rate is at 32 per 1000 live births.8 It has been adopted in over record system that relies on the healthcare providers to collect 42 countries, both developing and developed, and has proven its and manage ante/post-natal information.3 Through consistent efficacy in enhancing MCH.9 The MCH Handbook is an effective record-keeping, a participant actively contributes to individual and integrated home-based tool for accelerating mothers’ and families’

14 UTMJ • Volume 97, Number 2, March 2020 Invited Commentaries

Development of Maternal and Child Health (MCH) handbook digital application to promote MCH services: no one left behind to address sustainable development goals (SDGs)

Figure 1. International Committee on MCH Handbook with Japanese Princess Kiko. awareness, and utilization of community clinics. Mothers can keep References 1. World Health Organization (WHO). (2014). Adolescent pregnancy. Retrieved this booklet at home for reference and are also encouraged to bring from: http://www.who.int/mediacentre/factsheets/fs364/en/. it to the clinic at each visit. 2. Nakamura, Y. (2012). Is maternal and child health handbook effective?: meta- The concept of the MCH Handbook is similar in many different analysis of the effects of MCH handbook. Kokusai Hoken Iryo (Journal of Inter- national Health), 27(2), 121-127. settings. However, handbook contents, illustrations, colours, and 3. Lauson, S., McIntosh, S., Obed, N., Healey, G., Asuri, S., Osborne, G., & Arbour, pictorials vary depending on local customs and culture. The L. (2011). The development of a comprehensive maternal–child health informa- MCH Handbook is an integrated health education and promotion tion system for Nunavut-Nutaqqavut (Our Children). International journal of circumpolar health, 70(4), 363-372. resource which is easy to understand and keep by parents. It also 4. Brown, H. C., Smith, H. J., Mori, R., & Noma, H. (2015). Giving women their helps ensure continuity between maternal and childcare services, own case notes to carry during pregnancy. The Cochrane Library. 5. Takeuchi, J., Sakagami, Y., & Perez, R. C. (2016). The Mother and Child Health thereby empowering family members and reducing discrepancies Handbook in Japan as a Health Promotion Tool: An Overview of Its His- between providers and clients. The Handbook helps relay user- tory, Contents, Use, Benefits, and Global Influence. Global Pediatric Health, 3, friendly health information and maintains a health record, which 2333794X16649884. 6. Jayaseelan, R., Pichandy, C., & Rushandramani, D. (2015). Usage of Smartphone can be used as a referral document. This is more cost-effective than Apps by Women on Their Maternal Life. Research Journal of Science and Tech- using the existing 3 or 4 health cards. Use of the Handbook is an nology, 7(3), 158. effective strategy to empower communities, families, and pregnant 7. Rotheram-Borus, M. J., Tomlinson, M., Swendeman, D., Lee, A., & Jones, E. (2012). Standardized functions for smartphone applications: examples from ma- mothers to maintain good health and obtain quality services. ternal and child health. International journal of telemedicine and applications, Globally, with over 2 decades’ utilization and implantation of 2012, 21. 8. World Bank Group. (2016). Mortality rate, infant (per 1,000 live births). Retrieved the MCH handbook tool in many countries, now is the time to from http://data.worldbank.org/indicator/SP.DYN.IMRT.IN. shift toward digital MCH handbook application development and 9. MCH Handbook. (2017). Our Mission. Retrieved from: http://www.mchhand- utilization to ensure safe delivery and MCH services locally and book.com/our-mission/. globally. The MCH handbook digital application is also expected to help reduce delays in decision-making at the family level, as well as delays in arranging quality services at the facility level.

UTMJ • Volume 97, Number 2, March 2020 15  Primary Research

Factors associated with the extent of the expected increase in leukocyte count during the perioperative period

Yoshan Moodley, PhD1; Marsha Ramburuth, MBChB2

1Faculty of Health and Environmental Sciences, Central University of Technology, Bloemfontein, South Africa 2Department of Anaesthetics, University of KwaZulu-Natal, Durban, South Africa

Abstract and preoperative/postoperative leukocyte counts. The Background: Orthopedic surgery patients are at risk of difference between postoperative and preoperative infectious complications such as septicemia, pneumonia, leukocyte counts (delta-leukocyte count, unit: x 109 urinary infection, and surgical site infection. Perioperative cells/L) was determined for each patient. Potential infection is associated with poor clinical outcomes and associations between various characteristics and median increased healthcare resource utilization. In light of delta-leukocyte count were statistically tested, with these consequences, efforts to improve our understanding p<0.050 considered a statistically significant result. of the pathophysiological mechanisms which underlie Results: The median delta-leukocyte count in smokers perioperative infection have gained momentum. One of was 2.4 versus 3.0 in non-smokers (p=0.045). The the most widely accepted pathophysiological mechanisms median delta-leukocyte count in patients who experienced underlying perioperative infection is immune dysfunction. major blood loss was 2.1 versus 3.5 in patients who did The classic physiological response to surgery is marked by not experience major blood loss (p=0.001). No other an increase in leukocyte count. However, there are several statistically significant results were observed. factors which might potentially reduce the extent of this Conclusion: The extent of the increase in perioperative increase. These factors might possibly include patient leukocyte count was lower in smokers and patients who demographics, comorbidity, use of certain medications, experienced major blood loss. These patients might be at and surgery-related variables such as surgical approach. increased risk for postoperative infection. Leukocytes are an important defense mechanism against infection, and reduced numbers of these immune cells during the perioperative period might predispose surgical patients to infectious complications. Published reports Introduction ver 234 million patients around the world undergo of factors associated with a reduction in leukocyte count surgical procedures every year.1 A proportion of surgical following orthopedic surgery are rare. The current patients experience postoperative complications, most study sought to address this paucity in the literature. Ocommonly those that are infectious in nature.2 Postoperative Identification of these factors could assist surgeons with infections include septicemia, pneumonia, urinary infections, 3 risk stratification for perioperative infection, or even guide and surgical site infections. Not only are postoperative infections future research on ways to improve the perioperative associated with patient morbidity and mortality, but they are also associated with increased healthcare expenditure and healthcare immune response in surgical patients. resource utilization.2,4 Methods: A retrospective chart review study was Accordingly, the underlying pathophysiological mechanisms conducted, involving 171 hip arthroplasty patients. giving rise to postoperative infections and the factors predisposing Data collected for each patient included demographics, patients to these infections are a growing area of interest for comorbidities, medications, surgery-related parameters, surgical researchers. One such proposed pathophysiological mechanism involves perturbations in the leukocyte response during the perioperative period.5 Leukocytes, such as neutrophils and monocytes, are important components of the immune response in settings of injury and bacterial infection.6 An estimated 100 billion neutrophils enter and leave the circulation each day.7 The primary Corresponding Author: function of these immune cells is the elimination of invading bacteria Yoshan Moodley via phagocytosis. During this process, neutrophils engulf and destroy [email protected]

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Factors associated with the extent of the expected increase in leukocyte count during the perioperative period

bacteria thereby helping to reduce likelihood of infection.7,8 An collected on a paper case report form and eventually transferred to estimated 5-12% of the total circulating leukocyte population are an electronic spreadsheet in preparation for subsequent statistical monocytes.9 As with neutrophils, monocytes are able to eliminate analysis. The difference between postoperative and preoperative invading bacteria through their phagocytic activity.9 Monocytes LC (delta-LC, unit: x 109 cells/L) was determined for each patient. also have a key role in modulating inflammation during infection, A substantially higher postoperative LC, and therefore higher through the release of cytokines such as interleukin-6 and tumour delta-LC, would be expected as a typical physiological response to necrosis factor-alpha.9 The combined activities of neutrophils and surgery. A lower delta-LC would suggest that perioperative LC has monocytes contribute to the clearance of bacterial infections. increased, but only to a lesser extent. Leukocyte counts (LCs) increase substantially during the typical Descriptive statistics were used to determine the distribution physiological response to surgery.10 However, there are several of various characteristics in the study sample. Results for the factors which might potentially reduce the extent of this increase. descriptive statistical analysis are presented as frequencies and These factors may include patient demographics, comorbidity, percentages. Potential statistical associations between various use of certain medications, and surgery-related variables such as characteristics and median delta-LC were assessed using bivariate surgical approach. Leukocytes are an important defense mechanism statistics, namely the Mann-Whitney test. Results for this aspect of against infection, and reduced numbers of these immune cells the statistical analysis are presented as medians with interquartile during the perioperative period might predispose surgical patients range (IQR) and a corresponding p-value. A p-value of <0.050 to infectious complications.6 Published reports of factors associated was considered to be a statistically significant result. All statistical with perioperative LC following orthopedic surgery are rare. analyses were performed using the Statistical Package for the Social A single study by Deirmengian and colleagues reported that Sciences (SPSS) version 25.0 (IBM Corp, USA). postoperative leukocytosis was common in orthopedic surgery This study was approved by the University of KwaZulu-Natal patients.11 The same study identified knee arthroplasty (versus Biomedical Research Ethics Committee (Protocol: BE595/16). hip arthroplasty), bilateral procedures, older age, and increased comorbidity as being associated with a higher postoperative LC.11 However, a limitation of this study was that it did not investigate Table 1. Description of the study sample potentially important factors such as preoperative medications, Characteristic n (% of study sample) other preoperative blood tests, and anesthesia. Further investigation of factors associated with perioperative LC is required. This could Age >65 years 39 (22.8) assist orthopedic surgeons with risk stratification for perioperative Male 76 (44.4) infection in individual patients, or even guide future research on ways to improve the perioperative immune response in orthopedic Current smoker 39 (22.8) surgery patients. Therefore, the objective of this study was to Obese 82 (47.9) determine which factors impact the extent of the expected increase in LCs during the perioperative period in hip arthroplasty patients. Diabetes 16 (9.4)

Hypertension 78 (45.6) Methods This was a retrospective chart review study of 171 consecutive Cardiovascular disease 10 (5.8) adult patients who received hip arthroplasty surgery at a tertiary Chronic obstructive pulmonary disease 21 (12.3) hospital in KwaZulu-Natal, South Africa. Patients were identified from the hospitals’ operating room schedules between September HIV 39 (22.8) 23, 2014 and July 28, 2016. Data collected from each patient’s medical record included Preoperative renal impairment 0 (0.0) demographics and clinical comorbidities, surgery-related Preoperative anemia 48 (39.0) parameters (anaesthesia used, surgical approach, duration of surgery, blood loss), and pre- and postoperative LCs. Patient Preoperative platelet count abnormal 0 (0.0) comorbidities were considered present if there was supportive Preoperative aspirin use 21 (12.3) evidence of a physician’s diagnosis. The duration of surgery was measured as the time between surgical incision and surgical wound Preoperative statin use 11 (6.4) suturing. Surgeries more than 2 hours in duration were considered Preoperative non-steroidal anti-inflammatory use 55 (32.2) to be surgeries of extended duration. Clinical blood loss was routinely recorded in the operative notes for all surgical patients. American Society of Anesthesiologists Score >2 64 (37.4)

Major blood loss was defined as a recorded clinical blood loss of General anesthesia 88 (51.5) >1500mL. It is general practice at the hospital to perform at least one LC test for surgical patients in the four weeks prior to surgery Fluranes 36 (21.1) and at least one LC test the day after surgery. Where several Opiod analgesia 144 (84.2) preoperative LCs were done, the test performed closest to the date of surgery was used. Where several postoperative LCs were done Surgery of extended duration 47 (27.5) while the patient was in hospital, the test with the lowest LCs result Major perioperative blood loss 87 (50.9) within the 3 days postoperatively was used. All data were initially

UTMJ • Volume 97, Number 2, March 2020 17 Primary Research

Factors associated with the extent of the expected increase in leukocyte count during the perioperative period

9 Table 2. Comparison of median delta-LC x 10 cells/L (IQR) in the presence These factors may place orthopedic surgery patients at higher risk or absence of various characteristics for postoperative infection. Characteristic Present Absent p-value Smoking is a well-known risk factor for postoperative infection. Significant results** In a cohort study of almost 400,000 surgical patients, Hawn et al., reported that current smokers had a 77.0% higher risk of Current smoker 2.4 (0.5-3.5) 3.0 (1.7-4.9) 0.045 developing postoperative pneumonia when compared with non- 12 Major perioperative blood loss 2.1 (1.1-3.5) 3.5 (2.2-5.1) 0.001 smokers. Current smokers also had an 18.0% higher risk of developing postoperative surgical site infection when compared Non-significant results with non-smokers.12 A recent meta-analysis confirmed the

Age >65 years 3.5 (1.0-4.6) 2.9 (1.6-4.4) 0.884 association between current tobacco use and a 79.0% higher risk of postoperative surgical site infection when compared with non- Male 3.0 (1.6-5.1) 2.6 (1.4-4.4) 0.487 smokers.13 Ex-smokers appear to have a reduced risk of postoperative infection when compared with current smokers. However, the Obese 2.6 (1.6-4.4) 3.0 (1.4-4.8) 0.836 levels of risk reported for ex-smokers are still significantly higher 12 Diabetes 2.2 (0.5-3.8) 3.0 (1.6-4.6) 0.159 than that reported for non-smokers. The association between smoking and an increased risk for postoperative infection appears Hypertension 2.4 (1.1-4.5) 3.1 (1.8-4.5) 0.348 paradoxical, as smokers generally have persistently higher LCs,

Cardiovascular disease 3.6 (1.1-5.0) 2.9 (1.6-4.4) 0.574 and therefore a greater perceived protection against bacterial infection when compared with non-smokers.14,15 In a non-surgical Chronic obstructive pulmonary 2.7 (1.0-4.0) 2.9 (1.6-4.6) 0.405 setting, Van Tiel and colleagues reported an acute decrease in LC disease for current smokers who had not smoked within the last 24 hours.16 HIV 3.1 (2.1-5.8) 2.8 (1.3-4.4) 0.140 Overall, LCs dropped by 9.8% in males and 7.1% in females who

Preoperative anemia 3.1 (1.4-4.4) 2.8 (1.6-4.6) 0.833 did not smoke within the last 24 hours. Monocyte counts dropped by 4.0% in males and 9.8% in females. Furthermore, neutrophil Preoperative aspirin use 3.4 (2.0-5.3) 2.8 (1.5-4.4) 0.343 counts dropped by 14.7% in males and 7.2% in females.16 While the exact physiological process behind this acute decrease in LC Preoperative statin use 4.1 (0.8-4.9) 2.9 (1.6-4.4) 0.736 following smoking cessation is unclear, it appears that it might be Preoperative non-steroidal 2.5 (1.2-3.6) 3.0 (1.7-5.1) 0.055 related to the elimination of the low-grade systemic inflammation anti-inflammatory use associated with smoking.17,18 Current smokers who have had hip American Society of 2.4 (1.1-4.4) 3.1 (1.7-4.6) 0.227 arthroplasty are immobile for several days postoperatively, and Anesthesiologists Score >2 cannot leave the smoking-free surgical ward for smoking breaks General anesthesia 2.7 (1.1-4.6) 3.1 (1.9-4.4) 0.322 during this period. It is likely that this period of smoking cessation Fluranes 2.7 (1.7-4.9) 3.0 (1.5-4.4) 0.955 might cause acute decreases in LC (particularly of monocytes and neutrophils) in these surgical patients in a manner which is similar Opiod analgesia 2.9 (1.6-4.4) 3.0 (0.1-5.0) 0.663 to that reported in non-surgical settings, thereby placing them at

Surgery of extended duration 3.5 (1.2-5.6) 2.7 (1.6-4.2) 0.184 increased risk of postoperative infection. While some blood loss should be expected following hip 19 **Statistical significance set at p<0.050. arthroplasty, significant blood loss can result in anemia. Anemia is a risk factor for a variety of postoperative complications, including postoperative infection.20 In their study of 227,425 surgical patients, Musallam and colleagues reported that patients with Results anemia had a 23-76% higher risk of urinary infection, a 12-56% A description of the study sample is provided in Table 1. The higher risk of surgical site infection, and a 24-83% higher risk of 9 median delta-LC for the study sample was 2.9 (IQR: 1.6-4.4) x 10 sepsis when compared with patients who did not have anemia.20 cells/L. Blood transfusion is usually recommended to correct for excessive The results of the bivariate statistical analysis are shown in blood loss during the perioperative period.19 In most settings, blood Table 2. Statistically significant results were observed for smoking products are leukocyte-depleted prior to administration in order to status and major blood loss. Median delta-LC was 2.4 in smokers reduce the risk of transfusion reactions.21 While blood transfusion versus 3.0 in non-smokers (p=0.045). Median delta-LC was 2.1 in addresses the loss of the erythrocyte component of whole blood patients who experienced major blood loss versus 3.5 in patients in patients suffering from blood loss, it does not address the loss who did not experience major blood loss (p=0.001). No other of the leukocyte component of the whole blood. Restoration of statistically significant associations at p<0.050 were observed for LC would therefore have to occur over a few days solely through the remaining variables investigated in this study. leukocyte generation in the bone marrow, during which time the patient might be more susceptible to infection.22 The published Discussion literature also reports an association between smoking and poor Smoking and major blood loss were the only two factors in wound healing in surgical patients.13 In addition to intraoperative this study which were statistically associated with a smaller than blood loss, postoperative bleeding through slow healing surgical expected increase in perioperative LC following hip arthroplasty. wounds would further exacerbate leukocyte loss in smokers.

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Factors associated with the extent of the expected increase in leukocyte count during the perioperative period

This study was not without limitations. This was an analysis of In conclusion, this study has identified smoking and data collected from a single, tertiary level hospital. Therefore, there perioperative blood loss as factors which reduce the extent of the is no guarantee that the findings of this study are generalizable expected leukocyte response during the perioperative period. As to patients at other tertiary facilities or lower level facilities. This leukocytes are integral to the body’s defense against infection, is also important as patients attending a tertiary hospital would patients who are smokers or who suffer excessive blood loss usually present with more complex or severe disease which cannot might be at higher risk for postoperative infection. Our research be managed at lower level healthcare facilities. Furthermore, the had several limitations related to the overall generalizability of study sample was only comprised of hip arthroplasty (orthopedic our findings, missing variables, and our inability to perform an surgery) patients and the same findings might not apply to other adjusted (multivariate) statistical analysis of the data. Future studies surgical specialties. Current non-smokers were not stratified as are required to confirm these findings and address the limitations lifelong non-smokers and ex-smokers as this information cannot which have been reported for the current study. be reliably obtained through a retrospective chart review process. Due to the retrospective nature of this study, information for References some potentially relevant variables was missing. These variables 1. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the glob- al volume of surgery: a modelling strategy based on available data. Lancet. could not be investigated in the current study. An example would 2008;372(9633):139-144. Available from: http://dx.doi.org/10.1016/s0140- be the preoperative use of vitamin supplements and immune 6736(08)60878-8. 2. International Surgical Outcomes Study group. Global patient outcomes after boosters. Most vitamin supplements and immune boosters elective surgery: prospective cohort study in 27 low-, middle- and high-income contain Vitamin C. Vitamin C supports the functioning of countries. Br J Anaesth. 2016;117(5):601-609. Available from: http://dx.doi. components from both the innate and adaptive immune system.23 org/10.1093/bja/aew316. 3. Wallace WC, Cinat ME, Nastanski F, et al. New epidemiology for postoperative It maintains the integrity of the skin and promotes healing of the nosocomial infections. Am Surg. 2000;66(9):874-878. surgical incision. Accumulation of Vitamin C in neutrophils and 4. Herwaldt LA, Cullen JJ, Scholz D, et al. A prospective study of outcomes, health- macrophages enhances the chemotactic and phagocytic activity care resource utilization, and costs associated with postoperative nosocomial in- fections. Infect Control Hosp Epidemiol. 2006;27(12):1291-1298. Available from: of these leukocytes. Vitamin C also promotes the generation of http://dx.doi.org/10.1086/509827. antimicrobial reactive oxygen species.23 Recent evidence suggests 5. Barton GM. A calculated response: control of inflammation by the innate im- mune system. J Clin Invest. 2008;118(2):413-420. http://dx.doi.org/10.1172/ that Vitamin C therapy can even increase leukocyte counts in jci34431. 24 patients with previously relapsed acute myeloid leukemia. It is 6. Prame Kumar K, Nicholls AJ, Wong CH. Partners in crime: neutrophils therefore possible that if we investigated vitamin supplements/ and monocytes/macrophages in inflammation and disease. Cell Tissue Res. 2018;371(3):551-565. Available from: http://dx.doi.org/10.1007/s00441-017- immune boosters in this research, that these would have been 2753-2. identified as factors associated with higher leukocyte counts. We 7. Teng TS, Ji AL, Ji XY, et al. Neutrophils and Immunity: From Bactericidal Ac- concede that the missing variables in our study can only be reliably tion to Being Conquered. J Immunol Res. 2017;2017:9671604. Available from: http://dx.doi.org/10.1155/2017/9671604. established through prospective data collection. Lastly, as with 8. Fang FC. Antimicrobial actions of reactive oxygen species. MBio. 2011;2(5). pii: most exploratory and hypothesis-generating studies, the results of e00141-11. Available from: http://dx.doi.org/10.1128/mBio.00141-11. 9. Karlmark KR, Tacke F, Dunay IR. Monocytes in health and disease - Minireview. the statistical analyses presented were not adjusted for potential Eur J Microbiol Immunol (Bp). 2012;2(2):97-102. Available from: http://dx.doi. confounders. org/10.1556/EuJMI.2.2012.2.1. The findings of this study have potentially important 10. Rosenberger PH, Ickovics JR, Epel E, et al. Surgical stress-induced immune cell redistribution profiles predict short-term and long-term postsurgical recovery. A implications with regards to the perioperative management of prospective study. J Bone Joint Surg Am. 2009;91(12):2783-2794. Available from: surgical patients, more specifically with approaches to reduce http://dx.doi.org/10.2106/jbjs.h.00989. the risk of postoperative infection in patients who are smokers 11. Deirmengian GK, Zmistowski B, Jacovides C, et al. Leukocytosis is common after total hip and knee arthroplasty. Clin Orthop Relat Res. 2011 Nov;469(11):3031-6. or patients who experience major blood loss. Healthcare workers Available from: http://dx.doi.org/10.1007/s11999-011-1887-x. should counsel smokers to quit well in advance of surgery.25 This 12. Hawn MT, Houston TK, Campagna EJ, et al. The attributable risk of smok- ing on surgical complications. Ann Surg. 2011;254(6):914-920. http://dx.doi. would contribute toward the stabilization of LC in these patients org/10.1097/SLA.0b013e31822d7f81. 16 prior to their surgical procedures. In addition, smoking cessation 13. Sorensen LT. Wound healing and infection in surgery. The clinical impact of prior to surgery might facilitate improved wound healing following smoking and smoking cessation: a systematic review and meta-analysis. Arch 13 Surg. 2012;147(4):373-383. Available from: http://dx.doi.org/10.1001/arch- surgery. Smokers who are unable to quit should be targeted for surg.2012.5. more careful postoperative monitoring for infectious complications 14. Sunyer J, Munoz A, Peng Y, et al. Longitudinal relation between smoking and while in the ward. The perioperative administration of tranexamic white blood cells. Am J Epidemiol. 1996;144(8):734-741. 15. Higuchi T, Omata F, Tsuchihashi K, et al. Current cigarette smoking is a re- acid by the anesthetic team could also be used as a strategy to address versible cause of elevated white blood cell count: Cross-sectional and longitu- perioperative blood loss.26,27 Unfortunately, there may be situations dinal studies. Prev Med Rep. 2016;4:417-422. Available from: http://dx.doi. org/10.1016/j.pmedr.2016.08.009. where these strategies for reducing perioperative blood loss are 16. Van Tiel E, Peeters PH, Smit HA, et al. Quitting smoking may restore hemato- not effective or cannot be implemented. In these situations, major logical characteristics within five years. Ann Epidemiol. 2002;12(6):378-388. perioperative blood loss should be used as a “flag” for a patient who 17. Liu J, Liang Q, Frost-Pineda K, et al. Relationship between biomarkers of ciga- rette smoke exposure and biomarkers of inflammation, oxidative stress, and might require additional monitoring for postoperative infectious platelet activation in adult cigarette smokers. Cancer Epidemiol Biomarkers Prev. complications. It should be noted that infectious complications in 2011;20(8):1760-1769. Available from: http://dx.doi.org/10.1158/1055-9965. the postoperative period are often multifactorial and might occur epi-10-0987, 18. Yasue H, Hirai N, Mizuno Y, et al. Low-grade inflammation, thrombogenicity, via other physiological mechanisms besides perturbations in the and atherogenic lipid profile in cigarette smokers. Circ J. 2006;70(1):8-13. immune response.28 Therefore, while addressing concerns related 19. Song JH, Park JW, Lee YK, et al. Management of blood loss in hip arthroplasty: Korean Hip Society Current Consensus. Hip Pelvis. 2017;29(2):81-90. http:// to smoking and blood loss might mitigate at least some of the risk dx.doi.org/10.5371/hp.2017.29.2.81. for postoperative infection, it may not eliminate all of this risk.

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Factors associated with the extent of the expected increase in leukocyte count during the perioperative period

20. Musallam KM, Tamim HM, Richards T, et al. Preoperative anaemia and post- 25. Wong J, Chung F. Peri-operative cessation of smoking: time for anaesthetists to act. operative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet. Anaesthesia. 2015;70(8):902-906. Available from: http://dx.doi.org/10.1111/ 2011;378(9800):1396-1407. Available from: http://dx.doi.org/10.1016/s0140- anae.13183. 6736(11)61381-0. 26. Ghadimi K, Levy JH, Welsby IJ. Perioperative management of the bleeding pa- 21. Sharma RR, Marwaha N. Leuko-reduced blood components: Advantages and tient. Br J Anaesth. 2016;117(suppl 3):iii18-iii30. Available from: http://dx.doi. strategies for its implementation in developing countries. Asian J Transfus Sci. org/10.1093/bja/aew358. 2010;4(1):3-8. Available from: http://dx.doi.org/10.4103/0973-6247.59384. 27. Zhu J, Zhu Y, Lei P, et al. Efficacy and safety of tranexamic acid in total hip 22. Rankin SM. The bone marrow: a site of neutrophil clearance. J Leukoc Biol replacement: A PRISMA-compliant meta-analysis of 25 randomized controlled 2010;88(2):241-251. Available from: http://dx.doi.org/10.1189/jlb.0210112. trials. Medicine (Baltimore). 2017;96(52):e9552. Available from: http://dx.doi. 23. Carr AC, Maggini S. Vitamin C and Immune Function. Nutrients. 2017;9(11). org/10.1097/md.0000000000009552. pii: E1211. Available from: http://dx.doi.org/10.3390/nu9111211. 28. Rubin RH. Surgical wound infection: epidemiology, pathogenesis, diagnosis 24. Foster MN, Carr AC, Antony A, et al. Intravenous Vitamin C Administration and management. BMC Infect Dis. 2006;6:171. Available from: http://dx.doi. Improved Blood Cell Counts and Health-Related Quality of Life of Patient with org/10.1186/1471-2334-6-171. History of Relapsed Acute Myeloid Leukaemia. Antioxidants (Basel). 2018;7(7). pii: E92. Available from: http://dx.doi.org/10.3390/antiox7070092.

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The effect of urban density on mental health: a systematic review

Kyle O. Lee, BMLSc, BM BS, CCFP1,2,3; Pamela Kaufman, PhD3

1Sumac Creek Health Centre, St. Michael’s Hospital, Toronto 2Department of Family and Community Medicine, University of Toronto 3Dalla Lana School of Public Health, University of Toronto

Background rather than personal vehicle use.19 Increased activity and sense of ental illness is a growing international public health safety are also associated with improved social well-being outcomes concern and is expected to become the most common and mental health.19,20 Beyond density and built environment disability worldwide.1 Anxiety, depression, and factors, other mechanisms have been proposed to interact through Mschizophrenia appear to be more prevalent in urban environments.2-6 a complex interplay of factors, including socioeconomic factors. Suicide rates also appear to be higher in urban areas compared to Potential confounding factors, such as socioeconomic more rural regions.7,8 However, the difference between urban and status, income, education, occupation, and social support may suburban mental health outcomes are inconsistent.9-11 influence mental health of a larger population. Living in poor Many factors, including the built environment, have been neighbourhoods is associated with depression and schizophrenia, proposed to influence mental health and mental illness.12 More potentially due to inadequate social supports or increased exposure than 10% of the world’s population is estimated to have a mental to trauma.21-23 Reciprocally, mental health may also lead to poverty health disorder.13 While more than half of the world's population as low resource settings do not provide sufficient resources to currently live in cities, this number will rise to over 70% in 2050.14 prevent, diagnosis and treat mental disorders.24 Migration status, For example, Canadians living in an urban area has increased social exclusion, and visible ethnic minority status may also affect from 76% (about 19 million) in 1986 to 81% (about 24 million) in schizophrenia risk although this is unclear once familial and 2016 this will also increase in other parts of the world such as Asia hereditary factors were assessed.25-27 and Africa.15 As an increasing proportion of the world becomes The association between density of the built environment urbanized, more research is needed to determine what factors play and mental health has not been extensively studied. Previous a role in mental health outcomes. The way in which our cities are mechanisms proposing how density influences mental health being built may thus increasingly affect the mental health and well- have included: physiological or psychosocial stressors, availability being of its citizens. of mental health providers, and social supports.28-31 A recent Relevant aspects of the built environment that are commonly systematic review was also conducted on the urban environment measured include residential density, housing, food security, noise, and its effect on psychological, depression and anxiety.32,33 However, air quality, daylight, green space, crime, food security, walkability, more research needs to be done to look at density and its effect on and access to public transportation. Some of these, such as noise broader mental health disorders and well-being. and green space may be associated with mental health outcomes.16 Specifically, neighbour noise, feeling over-crowded in the home, Objectives lack of access to green open spaces and community spaces, and This systematic literature review aims to advance our fear of crime has been negatively associated with mental health understanding of how urban density can affect mental health. and vitality.12 Access to nature and physical activity have also noted to be positively associated with mental health in women.16 • Research Question: How does urban density impact Density and neighbourhood features have also been proposed mental health outcomes among adults (18 years or older) in to influence the behaviour of populations, which impact both Westernized society (including North American, Western physical and mental health.17 Design of complete neighbourhoods Europe, and Oceania)? where residents are able to have adequate access to mixed land uses • Exposures: Urban density, residential density, population for a wide range of transportation, retail, housing, education and density, urban, rural. other services has been shown to be increase physical activity and • Outcome Measures: Validated mental health rating scales, thus improve health outcomes.18 These safe, compact, connected quality of life scales, standardized diagnosis of mental illness, and efficient areas would promote walking, cycling or transit use health care utilization for mental health (including visits to mental health providers and psychiatric drug use).

Corresponding Author: Kyle O. Lee [email protected]

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The effect of urban density on mental health: a systematic review

limited to those written in English, concentrating on Westernized societies and countries of North America, Western Europe and Oceania such as Canada, the United States, Australia, New Zealand, and the United Kingdom. Westernized countries were chosen in order to decrease the variability in how city planning is approached, as well as the society’s attitudes towards mental health disorders. The study designs included were cross-sectional and longitudinal. This review focused on those studies done in or exploring that of urban settings, often compared to other more rural settings. These criteria were chosen in order to focus on a more homogenous sampling of the ways in which cities and urban centres are planned and structured.

Exclusion Criteria Articles identified in the literature search were excluded if they focused on: indoors, interior or architectural design elements of individual buildings; or did not include density quantifiers. Articles on health were excluded if they focused on only physical health outcomes, or studied factors unrelated to the built environment. Qualitative studies and non peer-reviewed literature were also excluded. Studies published prior to 2008 were excluded. Figure 1. Selection Flow (PRISMA 2009) Diagram35 Data Extraction All articles that were eligible for inclusion were extracted for Methods review. As articles were reviewed, relevant data were extracted into Search Strategy tabular format and triple-checked for accuracy. Specific data A systematic review of the literature was conducted in January were compiled for the following information: authors, year of 2018. Date restrictions were placed for articles published within publication, city and/or country of study, aim of the study, type of the last 10 years (January 2008 to January 2018). Searches were study design, eligibility criteria, sample size, density measurement, conducted for peer-reviewed articles from: Pubmed and Google/ mental health outcomes, and positive or negative association of Google Scholar databases. Only relevant databases were included density with mental health outcome. in the search given there is evidence that gains from searching multiple sources beyond PubMed and EMBASE are modest.34 • Exposures: Urban density, residential density, population The search strategy was based on the Preferred Reporting Items density, urban, rural. for Systematic Reviews and Meta-Analyses (PRISMA) template.35 • Outcome Measures: Validated mental health rating scales, PRISMA is primarily used for reviews that evaluate randomized quality of life scales, standardized diagnosis of mental illness, trials. The template provides an evidence-based set of items for health care utilization for mental health (including visits to analysing systematic reviews and meta-analyses. mental health providers and psychiatric drug use). The following medical subject headings (MeSH) were developed to be as relevant and specific to the topic as possible Synthesis and Quality Appraisal while at the same time acknowledging the wide range of The Newcastle-Ottawa Quality Assessment Scale (NOS) was interdisciplinary literature: (("Environment Design"[MeSH]) OR used to assess eligible studies from the literature search.36 This ("Urban Health"[MeSH])) AND (("Mental health"[MeSH]) OR scale has been validated to review case-control and cohort studies. ("mental disorders"[MeSH])). The search was adapted with similar However, the studies selected in this review were cross-sectional search terms ("built environment" AND "mental health") for the or longitudinal studies. Thus, the NOS was adapted based on a Google and Google Scholar database in order to search for grey previous study that used this scale for cross-sectional studies.34 literature. A star system ranks the quality of each study based on the Figure 1 illustrates the process by which studies were screened following domains: appropriateness of the research design, and selected. Study screening occurred in three general phases. In recruitment strategy, response rate, representativeness of the phase I, duplicate studies were identified and excluded. In phase sample, objectivity/reliability of outcome determination, power II, studies were screened by title and abstract for using criteria calculation, and appropriateness of statistical analyses. The determined a priori. During phase III, full text articles were appraisal is summarized in the Appendix. reviewed in detail for eligibility. Results Inclusion Criteria The inclusion criteria encompassed peer-reviewed articles Study Selection published between January 2008 to January 2018 (inclusive), The database search returned a total of 381 articles through

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The effect of urban density on mental health: a systematic review

Table 1. Characteristics of Included Studies

Study Authors, City and/or Study Aim Study Design Eligibility Criteria of Selected Study Sample size Year Country

Bilszta et al., Australia Compare the contribution of demo- Longitudinal 1. Women who gave birth 2002 to 2004 in urban and ru- N=1,966 adults 2008 graphic and psychosocial variables on cohort ral health centres and part of the beyondblue National (n=908 “urban” and the prevalence of, and risk for, postnatal Postnatal Depression Program n=1058 “rural”) depression in urban and rural women.

Dhingra et al., United States Describe rural and urban differences in Cross-section- 1. Age ≥18 N=62,913 adults 2009 the prevalence and correlates of psycho- al survey 2. U.S. Behavioral Risk Factor Surveillance System logical distress. (BRFSS) in 94 counties in 24 states of the metropolitan and micropolitan statistical areas (MMSAs) with ≥500 respondents and ≥19 sample members in each of the age and sex, or age, sex, and age categories and met the criteria for county-level weights

Luciano et al., Italy Explore the levels of perceived insecurity Cross-section- 1. Age 18-65 N=426 adults 2016 in patients with mood or anxiety disor- al survey 2. 24 Italian community mental health centres or univer- ders and assess whether living in more sity settings urbanized contexts can influence the 3. Diagnosis of anxiety or unipolar affective disorders ac- levels of patients’ perceived insecurity cording to Diagnostic and Statistical Manual of Mental and social contacts compared to living in Disorders, Fourth Edition, Text Revision (DSM-IV-TR) non-urbanized contexts. (American Psychiatric Association (APA), 2000) 4. No hospital admission in the previous 2 years 5. No diagnosis of learning disability, dementia, sub- stance use/abuse or organic brain disorder, or severe cognitive impairment

Maguire and Northern Ireland Determine if urban residence is associ- Cross-section- 1. Age 22-70 N=236,939 adults O’Reilly, 2015 ated with an increased risk of anxiety/ al survey 2. 2001 Census as part of Northern Ireland Longitudinal depression independent of psychosocial Study (NILS) with prescribed medication data 2008 to stressors, concentrated disadvantage or 2010 selective migration between urban and rural areas, based on receipt of prescrip- tion medication linked to area level indi- cators of conurbation and disadvantage.

Melis et al., Turin (Italy) Identify variations in antidepressant Cross-section- 1. Age 20-64 N=547,263 adults 2015 prescriptions depending on specific al survey 2. Prescribed antidepressant medication from 2004 to dimensions of the built environment. 2006 3. Not residents of wealthy, residential hills of Turin and other 13 areas with extreme values and high specific- ity (cemeteries, parks, low density)

Patterson et Australia Compare health risk factors between Cross-section- 1. Age 26-36 N=2567 adults al., 2014 metropolitan and non-metropolitan al survey 2. Data from Childhood Determinants of Adult Health young adults and examine whether (CDAH) study, a follow-up of participants from the socioeconomic position (SEP) mediates 1985 Australian Schools Health and Fitness Survey any differences. (ASHFS)

Riva et al., United Kingdom Examine the extent of inequalities in Cross-section- 1. Age ≥18 N=36,254 adults 2009 health between urban and rural areas, as al survey 2. Health Survey for England (HSE) survey from 2000- well as inequalities in health across rural 2003 areas of England.

Ruijsbroek et Stoke-on- Examine the relationship between Cross-section- 1. Age 18-75 N=3771 adults al., 2017 Trent (United neighbourhood green space, the neigh- al survey 2. 30 neighbourhoods selected by predefined criteria, Kingdom), bourhood social environment (social via mail, individual selected via “next birthday rule” Doetinchem cohesion, neighbourhood attachment, or random by face-to-face interview; or by postal (Netherlands), social contacts), and mental health. questionnaire Barcelona 3. Conducted May to Oct 2013 (Spain), and Kaunas (Lithu- ania)

Pubmed and an additional 8 articles through Google Scholar. After Index of Australia" (ARIA+) scores.38,39 One study used population inclusion and exclusion criteria were applied, 349 were excluded as the number of inhabitants in a given area, such as persons/ through the initial screening of abstracts and titles. Finally, eight km2.40 Three studies quantified the number of inhabitant into studies were included in the final review (Figure 1). Seven cross- separate categories.41-43 There were no consistencies between how sectional studies and one longitudinal prospective cohort design these categories were defined. Only one study looked at the ratio of type were included. Majority of the studies were done in Europe, built volume by a total surface area, thereby explicitly taking into with two in Australia, and one in the United States. The extracted consideration the physical built form.44 data is available in Table 1 and 2. Mental Health Urban Density Definitions of mental health also varied between studies. The “Urban density” was described differently in each study. Three majority of studies reviewed symptoms of generalized anxiety and of the eight studies defined density based on local or national depression, and less so stress, as a measure of common mental governmental population data indices such as "The Rural, Remote health outcomes. The majority focused on surveys or questionnaires and Metropolitan Area" (RRMA), or "Accessibility/Remoteness

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The effect of urban density on mental health: a systematic review

Table 2. Outcome Data

Study, Year Density Measurement Mental Health Outcome Association of Density Association of Density with Mental Health Outcome with Mental Health Outcome (Positive/ Negative)

Bilszta et al., Rural, Remote and Met- Demographics/psychosocial risk factor + Urban group had a diagnosis of AND more commonly compared 2008 ropolitan Area (RRMA) questionnaire to the rural group (8.5% vs 3.4%, p=0.006) Index uses population size and an index of Edinburgh Postnatal Depression Scale No significant difference in the prevalence of PND (6.6% vs 8.5%, remoteness related to (EPDS) at baseline and at 8 weeks p=0.165) distance from an urban postnatal for diagnosis of antenatal centre into ‘metropoli- depression (AND) and postnatal depres- For urban mothers, antenatal EPDS score was the best predictor tan’, ‘rural’ or ‘remote’ sion (PND) of PND

For rural mothers, antenatal EPDS score, socioeconomic status and psychiatric history had a significant influence on postnatal mood

Dhingra et al., Rural-Urban Continuum Kessler-6 (K6) scale assessed non-specif- + Urban county residents had a 22 % higher likelihood (OR 1.22; 95 2009 Codes (RUCC) with 4 ic psychological distress in the past 30 % CI 1.09–1.36) of having either MPD or SPD groups based on resi- days, and screened for the Diagnostic dent population: and Statistical Manual, Fourth Edition 17 % higher (95 % CI: 1.04–1.31) after adjusting for sociodemo- • two metropolitan or (DSM-IV) anxiety and mood disorders graphic characteristics (age, sex, race, education, marital status). “urban” • two nonmetropolitan Sum of the scores indicated mild (MPD) Urban county residents had 17 % higher odds (95 % CI: 1.04–1.33) “rural” areas or serious (SPD) psychological distress of having MPD

14% higher odds of having MPD (OR 1.14; 95 % CI: 1.00–1.30) after adjustment

40 % higher odds (95 % CI: 1.13–1.73) of having SPD;

42% higher odds of having SPD (OR 1.42; 95 % CI: 1.12–1.79) after adjustment

Luciano et al., Population density of Psychiatric diagnoses assessed through + Residents in ‘big cities’ more likely to: have a diagnosis of a 2016 catchment area: ‘rural’ the Structured Clinical Interview for mood disorder (p<.05), more frequently uncertain (p<.05), had at (<100,000), ‘urban’ DSM-IV-TR (SCID-I) least one daily fear (p < .001), and believed that fears increased (100,000 - 300,000) and in the last 10 years due to the rise of homeless persons, immi- ‘big cities’ (>300,000) Levels of fears of crime and perceived grants and criminals in their neighborhood (p<.05) insecurity assessed with the Question- naire about Perceived Insecurity (QPI)

Levels of psychiatric symptomatology assessed by the Brief Psychiatric Symp- toms Rating Scale, the Hamilton Rating Scale for Anxiety, the Hamilton Rating Scale for Depression and the General Health Questionnaire

Maguire and Three categories of Receipt of anxiolytic or antidepressant + Anti-anxiety medication use was 75% higher in urban compared O’Reilly, 2015 settlements: medication from British National For- to rural areas (7% compared to 4%) Urban (>75,000 people), mulary (BNF) categories 4.2.1 and 4.3, intermediate (2250– respectively, listed in the Enhanced Pre- After adjustment for factors known to be associated with depres- 75,000 people) and rural, scribing Database (EPD), an electronic sion and anxiety disorders (age, sex, marital status, education, (<2250 people) record of all prescriptions provided by economic activity and health): urban areas were 74% (95% CI a General Practitioner and dispensed 1.11, 2.73) more likely to receive anxiolytic medication in community pharmacies in Northern Ireland from 2008 onwards Anti-depressant medication use was 30.1% higher in urban compared to rural areas (19% compared to 14.6%)

After adjustment, residents in urban areas were 65% (95% CI 1.24, 2.19) more likely to receive antidepressant medication than their rural peers

Moving from more rural to more urban areas is associated with an increased likelihood of being on either anti-anxiety or antide- pressant medication

Melis et al., Ratio of built volume Patients with ≥1 antidepressant prescrip- - Men and women aged 50-64 living in a higher urban density 2015 (multiplication of the tion from the National Health Services area were significantly less likely associated with having any sum of the footprint area between 2004–2006 antidepressant prescription of all buildings by the eaves height) (m3) over Antidepressants were identified by Men: incidence rate ratio 0.92 (0.86; 0.97) the total surface of the their Anatomical Therapeutic Chemical statistical area (m2) (ATC) classification code (N06A) (WHO Women: incidence rate ratio 0.95 (0.92; 0.98) for multivariate Collaborating Centre for Drug Statistics model A and 0.96 (0.92; 0.99) for multivariate model B.2 Methodology 2004) and included: monoamino-oxidase inhibitors (MAOI), selective serotonin reuptake inhibitors (SSRI), tricyclic antidepressants (TCA) and others

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The effect of urban density on mental health: a systematic review

Table 2. Outcome Data (continued)

Study, Year Density Measurement Mental Health Outcome Association of Density Association of Density with Mental Health Outcome with Mental Health Outcome (Positive/ Negative)

Patterson et Accessibility/Remote- Depression and anxiety measured using Unclear No significant association al., 2014 ness Index of Australia the Computerised International Diagnos- (ARIA+) scores based tic Interview (CIDI) on ‘census collection district’ (CCD) of par- ticipant’s residential ad- dresses, then categorized into “metropolitan” ver- sus “non-metropolitan”

Riva et al., Department for Environ- 12-item General Health Questionnaire + Common mental disorders (i.e. anxiety and depression) were 2009 ment, Food, and Rural (GHQ): rated “1” if score of 3 or more significantly more prevalent in urban ‘other cities’, but not in the Affairs 2001 classifica- (signs of anxiety and/or depression), Greater London area, compared to rural areas tion: or “0” • Urban areas as Urban-rural disparities were attenuated after controlling for area Greater London area deprivation (n = 554) or in ‘other cities’ (n = 2468) • Rural areas as small town and fringe set- tlements (‘semi-rural areas’; n = 271) or as villages, hamlets, and isolated dwellings (‘villages’; n = 352)

Ruijsbroek et Average population den- Mental health inventory (MHI-5) as- Unclear City of lowest density Doetinchem, The Netherlands, was associ- al., 2017 sity (pers/km2) of each of sessed nervousness and feelings of ated with better mental health (mean score = 80.2) compared to the four cities depression in the past month, ranging Kaunas, Lithuania (mean score = 70.8) from ‘all the time’ to ‘never’ on a six- point scale

Sum scores of the five answers were transformed into a scale from 0 to 100, with higher scores reflecting better mental health of self-reported symptoms.40,41,43 One study measured antenatal and depression to be significantly more prevalent in some urban and postnatal depression.39 Two studies measured the number of ‘other cities’ (excluding Greater London Area) at 18.4%, compared prescribed antidepressant and/or anti-anxiety medications.42,44 to villages (14.6%).43 Others looked at psychological distress.45,32 There were no common The rest of the studies either found a negative association mental health outcomes in the studies reviewed. between density and poor mental health outcomes or were inconclusive as the authors did not primarily focus on this link. Overall Study Association Melis et al. found those aged 50-64 living in higher density areas Five of the eight studies found a significantly positive association with fewer antidepressant prescriptions.44 However, this result between urban density and poor mental health outcomes. These was not found to be significant for other ages in their population. poor mental health outcomes were described either as antenatal Patterson et al. and Ruijsbroek et al. noted no significant or unclear depression, mood disorder, symptoms of anxiety and depression, association between urban density and mental health outcomes.38,40 or rates of prescribed medications.35-42 Overall, the studies in this review appear to show a positive Each of the studies had a variable degree of significance in the association between urban density and poor mental health association between density and mental health outcomes. Bilszta outcomes in adults 18 years of age or older living in primarily et al. noted a significant difference of antenatal depression in its European or other Westernized countries. urban group compared to its rural counterpart (8.5% vs 3.4%, p=0.006).39 Dhingra et al. found that urban county residents have Discussion a 22% higher likelihood of having either mild-moderate or serious This systematic review analyzed eight articles in order to psychological distress than rural residents (odds ratio [OR]: 1.22, determine the role of urban density on mental health outcomes. 95% confidence interval [CI]: 1.09–1.36).45 Luciano et al. showed The overall findings suggesting poor mental health outcomes with that residents in ‘big cities’ more likely to: have a diagnosis of a higher urban density are consistent with the reviews of psychological mood disorder (p<.05), more frequently uncertain (p<.05), had at distress.32 Some of the challenges of studying neighbourhood least one daily fear (p < .001), and believed that fears increased in effects on health have been described in the literature.46 Specifically, the last 10 years due to the rise of homeless persons, immigrants census aggregate measures are non-specific and crude measures and criminals in their neighborhood (p<.05).45 Maguire and of physical and social features of neighbourhoods. In addition, O’Reilley found anti-anxiety medication use to be 75% higher it is difficult to separate built environment factors with individual in urban compared to rural areas (7% vs. 4%) whereas anti- socioeconomic attributes. depressant medication use was 30.1% higher in urban compared Other mental illnesses such as schizophrenia and bipolar to rural areas (19% vs. 14.6%).42 Finally, Riva et al. found anxiety disorder were not assessed in this review. Some of the studies used

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The effect of urban density on mental health: a systematic review

Table 3. Potential Limitations The majority of studies lacked consensus on a common measure Study Authors, Potential Limitations or definition of density. Recently, Geographic Information Systems Year (GIS) and spatial analysis techniques have offered additional and Bilszta et al., • Participants recruited may not truly represent their respective 50 2008 populations precise ways of measuring space. However, there still is no standard • Questionnaires that may have been done in the presence of validated, objective tool of density measurement, especially in a patient’s partner may have influenced reporting of sensitive information eg. domestic violence relation to health outcomes. While some studies categorized • Did not evaluate availability of services for women in different density into either a dichotomous rural-urban divide or multiple regions gradient levels, the rationale of how geographic areas were divided

Dhingra et al., • Self-report data subject to recall and response bias was often not explicitly explained. Some studies used a previously 2009 • Convenience sample may underestimate those individuals predetermined spatial geographical type based on census or without telephone service due to surveys done by telephone • 94 counties included in study do not represent all 3,141 coun- government level data. Riva et al. reasoned that separating London ties of USA from other cities in their study was important due to its distinct Luciano et al., • Schizophrenia or other psychotic disorders not included ethnic composition and more global socioeconomic drivers.43 The 2016 • Tools to assess insecurity not validated and developed for people with mental disorders majority of studies of this search were based in European countries • No direct comparison group and thus provided a greater gradient of densities. • Limited sample size • Reverse causality bias due to cross-sectional design, limiting Although positive associations were drawn between urban comments on casuality density and poor mental health outcomes, causality could not be Maguire and • No record of prescription indications or private prescriptions drawn due to the types of study designs. The lack of longitudinal O’Reilly, 2015 • Does not include therapy-only patients • Limited to reported crime levels, not entire complexity of fear data limited the ability to examine the association of density and of crime and other issues mental health on the population over time. Melis et al., • Out-of-pocket prescriptions excluded The populations studied were mostly residents whose data 2015 • Antidepressant prescription does not fully describe extent of depression was accessible by census data or via government databases (eg. • Prescribing habits affected by other factors (physicians’ at- prescriptions). Some studies also describe the limits of generalizing titudes) • Confounding factors (income, social capital, other environmen- their outcome data due to underrepresented data of immigrant tal stressors) data unavailable eg. pollution, noise, air quality or Aboriginal groups.38,44 Bilszta et al. studied only antenatal and Patterson et • Reverse causality bias due to cross-sectional design, limiting postnatal patients, but Riva et al. excluded all pregnant patients.39,43 al., 2014 comments on casuality • Self-report bias Previous studies have targeted specific ethnic enclaves or • Limited participants in rural areas resulted in pooling of those populations to better understand their health outcomes and needs, areas into ‘non-metropolitan’ such as in immigrants from Morocco, Suriname, and Turkey in Riva et al., • Reverse causality bias due to cross-sectional design, limiting 51,52 2009 comments on casuality The Netherlands or Korean Americans in New York City. • Range of sample sizes in each area Different populations may have specific regional needs based on • Does not incorporate other health-related behaviours (eg. tobacco and alcohol use) their demographics. • Indices of deprivation may not be designed for rural areas While most of the studies found an association between urban Ruijsbroek et • Reverse causality bias due to cross-sectional design, limiting density and mental health, few have proposed exact mechanisms. al., 2017 comments on casuality • Low response rate Some have theorized possible pathways involving higher • Low reliability scores resulted in exclusion of one city studied (Kaunas) psychosocial stressors of material disadvantage, unemployment • Inconsistency of homogeneity and size of cities and marital breakdown in densely populated areas.28,29 Others have suggested that urban centres concentrate and intensify social disorder as higher socioeconomic groups migrate out of dense validated screening tools in their methods, such as the Kessler-6 neighbourhoods.31,53,54 (K6), Structured Clinical Interview for DSM-IV-TR (SCID-I), Many studies also analyzed potential confounding and mental health inventory (MHI-5) respectively, to predict environmental factors. Within the urban rural spectrum, there clinical diagnoses such as major depressive disorder and anxiety exists both environmental as well as individual mediating and disorders.40,41,45,47-49 However, other studies in our review did not moderating factors. Common environmental factors studied were use these validated methods. There was no consistency of mental green space, crime rates, access to cultural and sport facilities, and health outcome measures, making it challenging to directly functional mix or land use mix. Common individual factors studied compare the results of each study. were gender, marital status, race or ethnicity, physical activity level, Two of the studies used anti-depressant and anxiolytic educational level, employment, public transport accessibility, medication prescription rates.41,42 Medication prescription rates past psychiatric history, and socioeconomic status. Thus, studies often are not able to fully depict the full range of mood disorders reviewing density alone may not fully encapsulate the psychological and psychological distress. These studies are limited by a lack of impact of an individual’s environment on their mental health. data around prescription indications, although most are assumed to be used for depression and anxiety. In addition, since data on Future Directions prescription rates are derived from government databases, they do Future studies would benefit from using unified, standard not include private pay prescriptions. Patients using other means validated tools to assess both density and mental health outcomes. of treatment (eg. therapy) were also not included. Finally, physician Future systematic reviews may consider an extended timeline with attitudes and patient acceptance towards prescribing of these additional databases from interdisciplinary fields to widen the medications may vary greatly between regions.

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The effect of urban density on mental health: a systematic review

Appendix. Critical Appraisal of Studies Based on Modified Newcastle Ottawa Scale36 (Adapted from Modesti et al.37)

Bilszta et al., Dhingra Luciano et Maguire and Melis et Patterson Riva et Ruijsbroek et 2008 et al., al., 2016 O’Reilly, 2015 al., 2015 et al., 2014 al., 2009 al., 2017 2009

Selection (Maximum 5 stars)

1) Representativeness of the sample:

a) Truly representative of the average in the target popu- lation. * (all subjects or random sampling)

b) Somewhat representative of the average in the target * * * * * * * * population. * (nonrandom sampling)

c) Selected group of users.

d) No description of the sampling strategy

2) Sample size:

a) Justified and satisfactory. * * * * * * *

b) Not justified. * *

3) Non-respondents:

a) Comparability between respondents and non- respondents characteristics is established, and the response rate is satisfactory. *

b) The response rate is unsatisfactory, or the compara- * * * * bility between respondents and non-respondents is unsatisfactory

c) No description of the response rate or the characteris- * * * * tics of the responders and the non-responders.

4) Ascertainment of the exposure (risk factor):

a) Validated measurement tool. ** ** ** ** ** **

b) Non-validated measurement tool, but the tool is * * * available or described. *

c) No description of the measurement tool

Comparability (Maximum 2 stars)

1) The subjects in different outcome groups are compara- ble, based on the study design or analysis. Confounding factors are controlled.

a) The study controls for the most important factor * * * * * * * * (select one).*

b) The study control for any additional factor. * * * * * * * * *

Outcome (Maximum 3 stars)

1) Assessment of the outcome:

a) Independent blind assessment. **

b) Record linkage. ** ** ** ** ** ** ** ** **

c) Self report. * * * * * *

d) No description.

2) Statistical test:

a) The statistical test used to analyze the data is clearly * * * * * * * * described and appropriate, and the measurement of the association is presented, including confidence intervals and the probability

b) The statistical test is not appropriate, not described or incomplete

Overall score (/10) 9 9 9 8 8 8 10 9

UTMJ • Volume 97, Number 2, March 2020 27 Reviews  

The effect of urban density on mental health: a systematic review literature search. Evaluation of only one mental health outcome, 13. Roser M, Ritchie H, Ortiz-Ospina, E. World Population Growth, 2019. Available from: https://ourworldindata.org/world-population-growth. such as anxiety alone or depression alone, may also provide 14. United Nations, Department of Economic and Social Affairs, Population Divi- greater consistency, although the overlap of symptoms may prove sion. United Nations. New York: 2015. World urbanization prospects. The 2014 challenging. Although not within the scope of this paper, future revision; 1p pp. 15. Statistics Canada. Table 32-10-0197-01 Number of persons in the total popula- studies may also identify how other beneficial design elements in tion and the farm population, for rural areas and population centres, classified by the urban fabric may be associated with mental health. sex and age. 16. Annerstedt M, Ostergren PO, Bjork J, et al. Green qualities in the neighbourhood and mental health – Results from a longitudinal cohort study in Southern Swe- Conclusion den. BMC Public Health, 2012;12:337. In this systematic review, a positive association was found 17. Public Health Agency of Canada (PHAC), The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2017: Designing Healthy Living between urban density and poor mental health outcomes in adults Ottawa Public Health Agency of Canada, 2017. Retrieved from https://www. aged 18 years or older living in Westernized societies. Urban canada.ca/en/public-health/services/publications/chief-public-health-officer- density and mental health outcomes were defined in multiple reports-state-public-health-canada/2017-designing-healthy-living.html#a8. 18. James P, Holden M, Lewin M, et al. Managing metropolises by negotiating urban inconsistent ways. Additional analysis on the broad socioeconomic growth. In: Harald Mieg and Klaus Topfer (ed.). Routledge, United Kingdom: factors identified in each study that affect mental health may be Institutional and Social Innovation for Sustainable Urban Development. pp. 217- useful. This may lead to a greater understanding between health 232. 19. BC Centre for Disease Control. Healthy Built Environment Linkages Toolkit: professionals, policy makers, and other stakeholders in improving making the links between design, planning and health, Version 2.0. Vancouver, the mental health of populations living in the entire urban-rural B.C. Provincial Health Services Authority, 2018. 20. Comstock N, Dickinson LM, Marshall JA. Neighborhood attachment and its spectrum. correlates: Exploring Exploring neighborhood conditions, collective efficacy, and gardening. J. Environ. Psychol. 2010 Dec; 30(4):435-442. Declaration of Interests 21. Eaton WW, Muntaner C. Socioeconomic Stratification and Mental Disorder. In: A Handbook for the Study of Mental Health: Social Context, Theories and Sys- • Kyle O. Lee: received an honorarium for participation in a tems, ed. New York: Cambridge University Press; 1999. p. 275-277. medical advisory board for Eli Lilly, Pfizer, and Bausch. 22. Bertotti M, Watts P, Netuveli G, et al. Types of social capital and mental disorder • Pamela Kaufman: none. in deprived urban areas: a multilevel study of 40 disadvantaged London neigh- bourhoods. PLoS One. 2013; 8(12):e80127. 23. Stockdale SE, Wells KB, Tang L, et al. The importance of social context: neigh- Acknowledgments borhood stressors, stress-buffering mechanisms, and alcohol, drug, and mental health disorders. Soc Sci Med. 2007; 65(9):1867-81. The views expressed are those of the authors and not necessarily 24. Mental health and development: targeting people with mental health conditions those of the Department of Family & Community Medicine, The as a vulnerable group Geneva, World Health Organization, 2010. Dalla Lana School of Public Health, the University of Toronto, or 25. Cantor-Graae E, Selten JP. Schizophrenia and migration: a meta-analysis and review. Am J Psychiatry. 2005; 162(1):12-24. St. Michael’s Hospital. 26. Veling W, Susser E, van Os J, et al. Ethnic density of neighborhoods and incidence KL designed the study, conducted searches, screened titles of psychotic disorders among immigrants. Am J Psychiatry. 2008; 165(1):66-73. and abstracts and full-text papers and extracted data, wrote the 27. Sariaslan A, Fazel S, D'Onofrio BM, et al. Schizophrenia and subsequent neigh- borhood deprivation: revisiting the social drift hypothesis using population, twin manuscript. KL and PK have critically revised the manuscript and and molecular genetic data. Transl Psychiatry. 2016 May 3; 6():e796. approved the final version. 28. Backhans MC, Hemmingsson T. Unemployment and mental health – who is (not) affected? Eur J Public Health. 2012;22(3):429-33. 29. Boyle PJ, Kulu H, Cooke T, et al. Moving and union dissolution. Demography. References 2008;45(1):209–222. 1. WHO. Mental health action plan 2013-2020. Geneva, 2013. Retrieved from 30. Holzer CE, Goldsmith HF, Ciarlo JA. The Availability of Health and Mental http://apps.who.int/iris/bitstream/handle/10665/89966/9789241506021_ Health Providers by Population Density. J. Wash. Acad. Sci., 2000 Dec;86(3),25- eng.pdf;jsessionid=FCBF725218F46E129DC36862715047DB?sequence=1. 33. 2. Paykel E, Abbott R, Jenkins R, et al. Urban - rural mental health differences in 31. Berry HL. ‘Crowded suburbs’ and ‘killer cities’: A brief review of the relation- Great Britain: findings from the National Morbidity Survey. Int Rev Psychiatry. ship between urban environments and mental health. N S W Public Health Bull. 2003;15(1-2):97-107. 2007;18(11-12):222-7. 3. van Os J, Hanssen M, Bijl RV, et al. Prevalence of Psychotic Disorder and Com- 32. Gong Y, Palmer S, Gallacher J, et al. A systematic review of the relationship munity Level of Psychotic Symptoms: An Urban-Rural Comparison. Arch Gen between objective measurements of the urban environment and psychological Psychiatry. 2001;58(7):663-8. distress. Environ Int. 2016;96:48-57. 4. Weich S, Twigg L, Lewis G. Rural/non-rural differences in rates of common 33. Peen J, Schoevers RA, Beekman AT, et al. The current status of urban-rural dif- mental disorders in Britain - Prospective multilevel cohort study. Br J Psychiatry. ferences in psychiatric disorders. Acta Psychiatrica Scandinavica, 121, 84-93. 2006;188:51-7. 34. Halladay CW, Trikalinos TA, Schmid IT, et al. Using data sources beyond 5. Kelly BD, O’Callaghan E, Waddington JL, et al. Schizophrenia and the city: A PubMed has a modest impact on the results of systematic reviews of therapeutic review of literature and prospective study of psychosis and urbanicity in Ireland. interventions. J Clin Epidemiol. 2015;68:1076-1084. Schizophr Res. 2010;116(1):75-89. 35. Moher D, Liberati A, Tetzlaff J, et al.Preferred Reporting Items for Sys- 6. Saunderson T, Haynes R, Langford IH. Urban-rural variations in suicides and un- tematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. determined deaths in England and Wales. J Public Health Med. 1998;20(3):261-7. 2009;6(7):e1000097. 7. Middleton N, Gunnell D, Frankel S, et al. Urban-rural differences in suicide trends 36. Wells GA, Shea B, O'Connell D, et al. The Newcastle–Ottawa Scale (NOS) for in young adults: England and Wales, 1981-1998. Soc Sci Med. 2003;57(7):1183- Assessing the Quality of Non-Randomized Studies in Meta-Analysis, 2019. Avail- 94. able from: http://www.ohri.ca/programs/clinicalepidemiology/oxford.asp. 8. Eberharddt M, Pamuk E. The importance of place of residence: Examining 37. Modesti PA, Reboldi G, Cappuccio FP, et al. Panethnic differences in blood health in rural and nonrural areas. Am J Public Health. 2004; 94(10): 1682–1686. pressure in Europe: a systematic review and meta-analysis. PLoS One. 2016 9. Wang JL. Rural–urban differences in the prevalence of depression and associated 25;11(1):e0147601. impairment. Soc Psychiatry Psychiatr Epidemiol. 2004;39(1):19-25. 38. Patterson KA, Cleland V, Venn A, et al. A cross-sectional study of geographic 10. Lehtinen V, Michalak E, Wilkinson C, et al. Urban-rural differences in the occur- differences in health risk factors among young Australian adults: The role of so- rence of female depressive disorder in Europe. Soc Psychiatry Psychiatr Epide- cioeconomic position. BMC Public Health. 2014;14:1278. miol. 2003;38(6):283-9. 39. Bilszta JL, Gu YZ, Meyer D, et al. A geographic comparison of the prevalence 11. Steinheuser V, Ackermann K, Schönfeld P. Stress and the city: impact of urban and risk factors for postnatal depression in an Australian population. Aust N Z J upbringing on the (re)activity of the hypothalamus-pituitary-adrenal axis. Psycho- Public Health. 2008;32(5):424-30. som Med. 2014;76(9):678-85. 40. Ruijsbroek A, Mohnen SM, Droomers M, et al. Neighbourhood green space, 12. Guite H, Clark C, Ackrill G. The impact of the physical and urban environment social environment and mental health: an examination in four European cities. on mental well-being. Public Health, 2006;120,1117–1126. Int J Public Health. 2017;62(6):657-667.

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41. Luciano M, Rosa CD, Vecchio VD, et al. Perceived insecurity, mental health 49. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): and urbanization: Results from a multicentric study. Int J Soc Psychiatry. I. Conceptual framework and item selection. Med Care. 1992;30(6):473-83. 2016;62(3):252-61. 50. Rushton G. Public health, GIS, and spatial analytic tools. Annu Rev Public 42. Maguire A, O’Reilly D. Does conurbation affect the risk of poor mental health? Health. 2003;24:43-56. A population based record linkage study. Health Place. 2015;34:126-34. 51. Veling W, Susser E, van Os K, et al. Ethnic Density of Neighborhoods and 43. Riva M, Curtis S, Gauvin L, et al.Unravelling the extent of inequalities in health Incidence of Psychotic Disorders Among Immigrants. Am J Psychiatry. across urban and rural areas: Evidence from a national sample in England. Soc 2008;165(1):66-73. Sci Med. 2009;68(4):654-63. 52. Roh S, Jang Y, Chiriboga DA, et al. Perceived neighborhood environment affect- 44. Melis G, Gelormino E, Marra G, et al. The Effects of the Urban Built Environ- ing physical and mental health: A study with Korean American older adults in ment on Mental Health: A Cohort Study in a Large Northern Italian City. Int J New York City. J Immigr Minor Health. 2011;13(6):1005-12. Environ Res Public Health. 2015;12(11):14898-915. 53. Halpern D. Mental Health and the Built Environment. London, England: Taylor 45. Dhingra SS, Strine TW, Holt JB, et al. Rural-urban variations in psychological and Francis; 1995. distress: findings from the Behavioral Risk Factor Surveillance System, 2007. Int J 54. O'Reilly, D. Stevenson, M. Selective migration from deprived areas in Northern Public Health. 2009;54 Suppl 1:16-22. Ireland and the spatial distribution of inequalities: implications for monitoring 46. Diez-Roux AV. Neighborhoods and health: where are we and were do we go from health and inequalities in health. Soc Sci Med. 2003;57(8):1455-62. here? Rev Epidemiol Sante Publique. 2007; 55(1):13–21. 47. Kessler RC1, Green JG, Gruber MJ, et al. Screening for serious mental illness in the general population. Int J Methods Psychiatr Res. 2010;19 Suppl 1:4-22. 48. Lobbestael J, Leurgans M, Arntz A. Inter-rater reliability of the Structured Clini- cal Interview for DSM-IV Axis I Disorders (SCID I) and Axis II Disorders (SCID II). Clin Psychol Psychother. 2011;18(1):75-9.

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Evidence of stress and diabetes in Indigenous Peoples of Canada

Leshawn Benedict, MPH1; Mahdia Abidi, MPH1; Harvir Sandhu, MPH1; Allyson Gillespie, MPH1; Qi Xue, MPH1, Jessica Hill, MPH1; Gerald McKinley, PhD1,2

1Schulich School of Medicine & Dentistry, Western University, Western Centre for Public Health and Family Medicine, 1465 Richmond St, London, Ontario 2Department of Pathology and Laboratory Medicine, Western University, Dental Sciences Building, London, Ontario

Canadians in their lifetime.1 This higher prevalence contributes to Abstract Indigenous people experiencing a higher burden of diabetes and 1 The health outcome examined by this paper explores the related complications. Stress is known to be a contributing factor for diabetes. Studies evidence relating stress and diabetes within Indigenous have suggested experiencing stressful situations can affect the communities of Canada. It has been shown previously control and onset of diabetes.3 Kelly and Ismail (2015) suggest that the rates of diabetes in Indigenous populations in the physiological stress response is activated from exposure to Canada are approximately 3 to 5 times higher than in non- chronic stressors, low socioeconomic status, and mental health Indigenous people of Canada. Diabetes can be caused concerns, which can increase an individual’s risk of developing 4 by chronic stress, but there is limited research conducted type 2 diabetes mellitus (T2DM). T2DM is a chronic disease affecting the body’s ability to process glucose and can be caused within Indigenous communities of Canada. A large by chronic stress. However, this relationship is not heavily proportion of Indigenous communities in Canada have discussed within Indigenous communities of Canada. Chronic experienced high levels of stress through intersectionality stress and allostatic load are significant contributing factors to the and intergenerational trauma. Considering Indigenous development of diabetes. Allostatic load refers to the effects or people of Canada are among the most high-risk “cost” of the body dealing with prolonged stress and the associated fluctuation in endocrine or neural responses.5 The majority of populations for the development of type 2 diabetes mellitus Indigenous communities in Canada have experienced high levels and many stressors affect this population, this paper sets of stress through intersectionality and intergenerational trauma.6 out to assess the current academic literature available Intersectionality is a framework acknowledging that people’s to examine the relationship between stress and diabetes experiences are shaped by several factors (sex, age, race, class etc.) in Indigenous populations. Regarding the relationship and that these experiences cannot be understood adequately by 7 between stress and diabetes in Indigenous people of looking at a single factor. Intergenerational trauma refers to adverse consequences on Canada, three key findings were identified: the need for Indigenous peoples that are transmitted across generations due to community involvement and decolonized approaches, historical oppressions.8 holistic coping mechanisms, and the emphasis on diet and The Indigenous peoples of Canada are considered the most physical activity as causal links to stress. high-risk population for the development of diabetes along with related complications.9 Diabetes within this population is affected by the many complexities of social factors affecting health.9 The scope of this paper is to analyse current literature available to assess Introduction this relationship. iabetes is a health concern in Canada and worldwide Methods with adverse consequences to morbidity, mortality, A comprehensive search was conducted using PubMed, Ovid life expectancy, and healthcare costs.1 In 2018, there Medline, and Scopus for published literature from any date that had wereD over 3.5 million individuals in Canada with a diagnosis of connections between stress and diabetes in Indigenous populations diabetes.2 Approximately 8 in 10 Indigenous people in Canada in Canada. A preliminary search was conducted using PubMed to develop diabetes in comparison to 5 in 10 for non-Indigenous help identify key articles related to stress and diabetes in Indigenous populations of Canada. These articles helped generate key terms to identify relevant articles in the search engines mentioned above. Corresponding Author: Key search terms such as First Nation*, Indigenous*, Aboriginal*, Gerald McKinley Native, Canada*, Ontario*, Stress, and Diabetes* were used. [email protected]

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Evidence of stress and diabetes in Indigenous Peoples of Canada

Studies were eligible for inclusion in this review if they discussed rumination.12 Implementing these 5 themes into practice is both stress and diabetes in Indigenous populations in Canada. We important when developing an intervention for Indigenous peoples excluded articles that were not published in the English language who are living with diabetes and stress. or any studies outside of Canada. To obtain a more comprehensive The last finding showed a commonality in healthcare practice picture, we did not restrict our review to any particular study that emphasizes physical activity and a healthy diet more than methodology. Upon using search terms in PubMed, Medline Ovid, the dynamic relationship between stress and diabetes. Current and Scopus, we retrieved 45, 20, and 11 articles respectively, for a research and literature are beginning to dive deeper into alternative total of 76 articles. The list of articles was screened manually based associations of diabetes with factors such as stress, trauma, and on abstracts and further de-duplicated to yield a total of 4 articles social and economic inequities in Indigenous populations. In a that met the inclusion criteria. study conducted by Iwasaki and colleagues, the authors begin to understand the role of stress in Indigenous peoples’ lives among Results those living with diabetes.13 The study considers the different types All articles included in this review examined different aspects of stresses and how different stressors go beyond the physical realm of the relationship between stress and diabetes. Three key and into psychological and spiritual aspects in relation to diabetes. findings were identified once all articles were reviewed: the need Aside from physical symptoms when blood sugars are abnormal, for community involvement and decolonized approaches, holistic individuals with diabetes also experience stress psychologically coping mechanisms, and the emphasis on diet and physical activity regarding management of diabetes, fears about the future, and as causal links to stress. financial strain due to diabetes.13 In other studies, authors exemplify The first finding demonstrated the need for community the shortfall of healthcare practices that emphasize intervention involvement and decolonized approaches in intervention programs strategies that target inactivity and poor diet more than a stress for Indigenous peoples who experience stress associated with prevention approach. Rock (2003) argues this important focus on diabetes. Decolonizing approaches focus on regaining several stress and diabetes is not taken into consideration as much as physical factors such as political strength, culture, and self-determination.10 inactivity and poor diet.14 The author also suggests the recent rise Bartlett et al. conducted a study examining the stress and trauma of diabetes as a public health issue in Indigenous communities is a experienced by urban First Nations and Métis people.11 The social and cultural process in which resources and identity play a study examined the coping methods used to help individuals significant role in understanding diabetes-related health disparities with their survival and healing. The study found progressive, and stress.14 There is currently a gap between healthcare practice asset-based approaches need to be considered when developing and emerging literature around understanding stress and diabetes intervention programs for Indigenous peoples living with diabetes in an Indigenous context and how to incorporate this knowledge and combating stress. Asset-based approaches require community into practice. input and involvement as Indigenous community members with knowledge of the culture and practices would assist researchers to Discussion interpret information from a decolonized lens.11 The second finding suggested various coping mechanisms Decolonized Approaches utilized by Indigenous populations to combat stress. Iwasaki et The first finding highlighted by this review is the necessity for al. conducted 3 focus group studies with 26 participants in total: decolonized approaches to be incorporated alongside Western First Nations women with diabetes (n=8), First Nations men with approaches in combating diabetes within Indigenous populations. diabetes (n=9), and Métis women with diabetes (n=9).12 The main This is based on needs expressed by Indigenous communities purpose of the focus groups was to understand the causes of themselves. For interventions within Indigenous populations stress and related coping strategies among individuals living with to be effective and meaningful, consultation and involvement diabetes. The focus groups resulted in the development of 5 themes. with Indigenous communities is required.11 This approach was The first theme was interdependence and connectedness, relating not found within the literature included in this review. Western to the importance of social support from friends and family who approaches did not consider the spiritual and cultural relevance have similar life circumstances.12 This is a significant component of healing within these communities, which may contribute to in how Indigenous peoples facilitate healing. The second theme decreased uptake and acceptance amongst Indigenous peoples was spirituality and transcendence, which are culturally relevant that value that aspect within their care plans.15 An inclusive and essential to the healing of Indigenous peoples, and can approach to implementing effective diabetes intervention be achieved through church-based revitalization and support programs necessitates that individuals, families, and community groups.12 Enculturation and facilitation of Aboriginal cultural are at the centre of care.11 This holistic intervention approach is identity also arose as another theme from the focus groups.12 This both trauma-informed and encourages proactive participation identified a key way of dealing with stress through linking stress in one’s health.15 In past interventions, the norm was researchers and trauma to the destruction of traditional cultural rituals and and practitioners considering exclusively Westernized practices as values.12 The fourth theme was self-control, self-determination opposed to consideration for blended approaches of Western and and self-expression, which consisted of individuals learning to traditional practices.15 A holistic intervention approach requires live with stress and diabetes. The last theme identified was leisure relationship-building practices to develop the trust that has been activities to deal with stress and relates to coping mechanisms.12 lost due to historical experiences between Indigenous communities This theme consisted of leisure travel or overnight camping to and Westernized health care.16 One holistic intervention approach benefit individuals by keeping their mind occupied to discourage is through the two-eyed seeing model blending traditional and

UTMJ • Volume 97, Number 2, March 2020 31 Reviews 

Evidence of stress and diabetes in Indigenous Peoples of Canada

Westernized strength-based perspectives with the foundational spaces and improving existing housing conditions. Economic values of respect and humility to ensure both worldviews are inequities such as higher prices of goods and services in northern considered in interventions.17 Stress is highlighted as an underlying communities make it difficult for Indigenous communities to cause of unhealthy consumption habits which is a behavioural factor purchase healthy food. Finding and maintaining a steady job is also that adversely affects the well-being of Indigenous communities, a type of economic inequity faced by Indigenous peoples. There feeding into the allostatic load placed on individuals.13 This could is often a shortage of jobs on reserves and northern communities, suggest a focus on building capacity through empowering the while in bigger cities, Indigenous people tend to face discrimination community and understanding the application of decolonized in the hiring process. This can result in an unequal opportunity approaches facilitated by researchers and practitioners.16 for a stable source of income leading to higher rates of poverty in Indigenous communities.24 Lastly, intergenerational trauma can Coping Methods be passed down in the form of harmful and destructive learned Within the literature, there is a positive focus on general coping behaviours that become incorporated into personal and community methods. What is missing is the incorporation of using traditional identities and adversely impacting their health status.25 The stress ways of healing. Some literature observes that cultural practices are from historical and ongoing colonization and assimilation has often not used in current prevention and treatment of diabetes for resulted in inequitable conditions like the higher rates of diabetes Indigenous populations and no indication of movement towards within Indigenous populations in Canada.13 In order to reconcile Indigenous practices for stress management.16 A study investigated with and accommodate the needs of the Indigenous populations, coping methods for stress where Indigenous women reported the upstream and downstream solutions should be considered through desire for connection to a social support network, spirituality, a social determinants of health lens. and the facilitation of Indigenous cultural identity within their management of stress.13 Enculturation is important to deal with Limitations in Current Body of Evidence as a source of stress and trauma as it is linked to the destruction The relationship between stress and diabetes is evident.26 of traditional cultural values and ceremonies and communities Currently, it is understood that the development of diabetes is are expressing a desire to learn to manage this stressor.13 Overall, directly linked to the social determinants of health.4 Further the Indigenous women reported wanting to learn to live with and research should be conducted to examine how research and policy control their experience of stress.13 There is literature to support around diabetes impacts the social and cultural determinants of the importance of coping and using strengths-based approaches health. The link between the physiological stress response from that closely tie to Indigenous identity. Another study highlighted the prolonged exposure to various stressors and the social and cultural need for incorporating coping strategies and tying it in with stress determinants of health is evident within the literature and this body management.12 The research reports the importance for holistic of evidence continues to grow. Diabetes intervention programs healing – a balance of the mind, body, and spirit for individuals, should work to incorporate evidence-based practices and move families, and Indigenous communities – to be integrated into towards addressing social disparities.4 Considering the prevalence coping strategies.12 This holistic care approach is rarely provided of diabetes in Indigenous communities, focused efforts should be as an option for Indigenous people in current healthcare settings. placed on understanding the nature of diabetes within Indigenous Further research should be conducted in order to understand how populations and in the context of cultural and traditional practices. traditional forms of healing and coping mechanisms can impact It can prove difficult to deliver specific care to a population if diabetes for Indigenous populations. precursors to the disease are not understood and if all treatment options are not explored. The current lack of evidence around the Social Determinants of Health relationship between diabetes and stress can hinder intervention Developing impactful interventions within Indigenous planning efforts and prevent effective wrap-around service delivery communities involves understanding and addressing the social for diabetes to Indigenous communities. determinants of health. The 3 important social determinants of Indigenous health to emphasize in this context are housing, Conclusion economic inequities, and intergenerational trauma.18 These 3 The scope of this paper examined the evidence relating stress determinants should be examined in relation to stress experienced and diabetes within Canadian Indigenous communities. Articles by Indigenous people. Housing insecurity can refer to a lack of included in this paper explore the relationship between stress and housing availability, dangerous or unstable housing situations diabetes. The 3 main findings that were identified were the need for such as infrastructural issues, and social aspects such as safety more community-based involvement and decolonized approaches and belonging.19 Housing insecurity is a known contributor to to treatment, coping mechanisms that are holistic, and that diet Indigenous peoples’ levels of stress.20 Housing First is a harm and physical activity are causally linked to stress. Many Indigenous reduction approach to addressing housing insecurity that prioritizes communities of Canada are considered vulnerable populations providing individuals in need with permanent and stable housing due to long-term suffering, mistreatment, cultural genocide, without any restrictions on eligibility.21 This approach centres on and loss at the hands of Western government powers. These the belief that providing those in need with a home first, followed factors have led to the intergenerational trauma seen throughout by other support services, would reduce a significant burden Indigenous communities today and is related to Indigenous people of stress.22,23 Housing First policies tailored towards Indigenous experiencing poor social determinants of health. The failure communities would help to ease the burden of associated stress to study, examine, and understand the prevalence of diabetes and could include increasing funding for the construction of living through the lens of Indigenous cultures will continue to perpetuate

32 UTMJ • Volume 97, Number 2, March 2020  Reviews

Evidence of stress and diabetes in Indigenous Peoples of Canada

misunderstanding and knowledge gaps in providing care. Future 13. Iwasaki Y, Bartlett J, O’Neil J. An examination of stress among Aboriginal women and men with diabetes in Manitoba, Canada. Ethnic Health. 2004;9(2):189-212. studies examining the relationship between diabetes and stress 14. Rock M. Sweet blood and social suffering: Rethinking cause-effect relationships in within Indigenous communities should include interventions that diabetes, distress, and duress. Med Anthropol. 2003;22(2):131-74. are upstream and focus on community involvement and culturally 15. Auger M, Howell T, Gomes T. Moving toward holistic wellness, empowerment and self-determination for Indigenous peoples in Canada: Can traditional Indig- relevant treatments. enous health care practices increase ownership over health and health care deci- sions?. Can J Publ Health. 2016;107(4-5):e393-8. References 16. Pilon R, Benoit M, Maar M, et al. Decolonizing Diabetes. Int J Indig Health. 2019;14(2):252 – 275. Available from: 10.32799/ijih.v14i2.31895. 1. Turin TC, Saad N, Jun M, et al. Lifetime risk of diabetes among First Nations and 17. Hovey RB, Delormier T, McComber AM, et al. Enhancing Indigenous health non–First Nations people. CMAJ. 2016;188(16):1147-53. promotion research through Two-Eyed Seeing: A hermeneutic relational process. 2. Diabetes Canada. Diabetes in Canada [Internet]. 2018. Available from: https:// Qual Health Res. 2017;27(9):1278-87. www.diabetes.ca/getmedia/6960f8d5-0869-4233-8ac2-6c669dae7c59/2018- 18. Greenwood M, De Leeuw S, Lindsay NM, Reading C, editors. Determinants of Backgrounder-Canada_KH_AB_KB-edited-13-March-2018_2.pdf.aspx. Indigenous Peoples' Health. Canadian Scholars’ Press; 2015. 3. Lloyd C, Smith J, Weinger K. Stress and diabetes: a review of the links. Diabetes 19. Ziersch A, Walsh M, Due C, et al. Exploring the relationship between housing Spect. 2005;18(2):121-7. and health for refugees and asylum seekers in South Australia: a qualitative study. 4. Kelly SJ, Ismail M. Stress and type 2 diabetes: a review of how stress contributes Int J Environ Res Public Health. 2017;14(9):1036. to the development of type 2 diabetes. Ann Rev Publ Health. 2015; 36:441-62. 20. Alaazi DA, Masuda JR, Evans J, et al. Therapeutic landscapes of home: Explor- 5. Kudielka BM. International Encyclopedia of the Social & Behavioral Sciences, ing Indigenous peoples' experiences of a Housing First intervention in Winnipeg. Stress and Health Research. 2001; 15170-15175. Soc Sci Med. 2015;147:30-7. 6. Bombay A, Matheson K, Anisman H. Intergenerational trauma: Convergence 21. Australian Housing and Urban Research Institute Limited. What is the Housing of multiple processes among First Nations peoples in Canada. Int J Indig Health. First model and how does it help those experiencing homelessness? [Internet]. 2009;5(3):6-47. AHURI. Australian Housing and Urban Research Institute Limited; 2018 [cited 7. Hancock AM. When multiplication doesn't equal quick addition: Examining in- 2019 Dec 26]. Available from: https://www.ahuri.edu.au/policy/ahuri-briefs/ tersectionality as a research paradigm. Perspect Politics. 2007;5(1):63-79. what-is-the-housing-first-model. 8. Urban Society for Aboriginal Youth, YMCA Calgary, & University of Calgary. 22. DeSilva MB, Manworren J, Targonski P. Impact of a Housing First program on Intervention to Address Intergenerational Trauma: Overcoming, Resisting and health utilization outcomes among chronically homeless persons. J Prim Care Preventing Structural Violence [Internet]. 2012. Available from: https://www. Community Health. 2011;2(1):16-20. ucalgary.ca/wethurston/files/wethurston/Report_InterventionToAddressInter- 23. Copeland C. The Indigenous Homelessness Crisis in Canada: Analyzing the Gov- generationalTrauma.pdf. ernment of Canada’s current Indigenous homelessness strategy [Internet]. Avail- 9. Crowshoe L, Dannenbaum D, Green M, et al. Type 2 diabetes and Indigenous able from: http://westerncommunicationreport.ca/wp-content/uploads/2019/ peoples. Can J Diabetes. 2018;42:S296-306. 03/Download-as-a-PDF-here_-Celine-.pdf. 10. Mundel E, Chapman GE. A decolonizing approach to health promotion in 24. Taylor J. Indigenous economic futures in the Northern Territory: The demo- Canada: the case of the Urban Aboriginal Community Kitchen Garden Project. graphic and socioeconomic background. Canberra, ACT: Centre for Aboriginal Health Promot Int. 2010;25(2):166-73. Economic Policy Research (CAEPR), The Australian National University; 2004. 11. Bartlett JG, Iwasaki Y, Gottlieb B, et al. Framework for Aboriginal-guided decolo- 25. Bombay A, Matheson K, Anisman H. The intergenerational effects of Indian nizing research involving Métis and First Nations persons with diabetes. Soc Sci Residential Schools: Implications for the concept of historical trauma. Transcult Med. 2007;65(11):2371-82. Psychiatry. 2014;51(3):320-38. 12. Iwasaki Y, Bartlett J, O’Neil J. Coping with stress among Aboriginal women and 26. Crump C, Sundquist J, Winkleby MA, et al. Stress resilience and subsequent risk men with diabetes in Winnipeg, Canada. Soc Sci Med. 2005;60(5):977-88. of type 2 diabetes in 1.5 million young men. Diabetologia. 2016;59(4):728-33.

UTMJ • Volume 97, Number 2, March 2020 33 Commentaries 

Climate change advocacy: a growing movement

Arianne Cohen, B.A.Sc, MD Candidate 20201 and Sasha Letourneau, MD Candidate 20212

1Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario. 2Faculty of Medicine, Queen’s University, 80 Barrie Street, Queen's University, Kingston, Ontario.

t has been just over one year since Greta Thunberg’s brave case-based sessions, extra-curricular opportunities, or reflections, protest outside the Swedish government. In this short span, others had no formal or informal education.7 Encouragingly, there one girl created an entire movement, which has grown vastly in is scope and motivation to address this gap. momentum.I Greta has been named Time’s Person of the Year and Future physicians must understand the connection between the Collins Dictionary has named “climate strike” as their Word human health and the natural environment. A continuation of of the Year, after a 100-fold increase in usage this year.1 To call advocacy efforts is crucial. The health effects of climate change for further action, over 4 million people worldwide came together are expected to worsen. Although certain groups – such as the between September 20, 2019 – September 27, 2019 for the Global elderly, children, and populations living in Northern Canada – will Week of Climate Action. Weekly strikes continue to be held. experience increased impact, climate change is a threat to “global The actions that we are seeing are grounded in scientific health” across age groups, gender, and socioeconomic status. evidence. Experts have recorded a 1 °C temperature rise above In the face of this threat, physicians and medical students pre-industrial levels, with amplifications at our poles to as high increasingly play a crucial role as stewards of human health. as 3 °C.2,3 Climate change is a human problem, driven mainly by Health professionals are ideally placed to educate, lead by example, fossil fuel combustion.4 The health-care sector is responsible for and advocate for positive change in this ongoing movement. approximately 4.6% of global emissions.1 The health implications At the individual level, physicians can provide education of such change are vast: heatwaves and temperature extremes, on behavioral changes. One example is encouraging others to wildfires, floods and draughts, windstorms, spread of infectious transition to balanced plant-based diets, which are generally more and vector-borne disease, food insecurity and undernutrition.5 Our cost-effective and sustainable. This movement is supported by most vulnerable populations will suffer the most. the new Canada Food Guide released in 2018.8 Another patient In Canada, climate change has been a large focus of the 2019 education strategy can include encouraging patients to use federal election. A recent poll conducted by IPSOS revealed that sustainable active transport in their daily commutes (e.g., biking or climate change was the second most important election issue to walking). This can both reduce our society’s pervasive sedentarism voters, behind healthcare.6 According to the Lancet Report 2019, while also mitigating traffic congestion contributing to smog. engagement in climate change has increased over the past decade. Education is not, however, only limited to patients. Health However, it is most often being portrayed in ways that do not professionals have a responsibility to learn about planetary health connect it to human health.1 The report concludes that the public as a part of providing wholistic patient care, starting in medical sees health and climate change as different areas of concern, and school. Canada’s future healthcare professionals must be prepared connections between them are most often driven by an interest in for the challenges of practice in a climate-changing Canada. A health rather than in the global climate.1 comprehensive tool kit for physicians is also available from the Canadian medical students are attempting to change this Canadian Association of Physicians for the Environment.9 perspective through advocacy work in climate change and Further, as “experts” in human health, physicians are in a health. The Canadian Federation of Medical Students’ Health position to advocate for changes that benefit both the environment and Environmental Adaptive Response Task Force (CFMS and human health. For example, physician advocates have been HEART) has been heavily advocating through media channels, central to the Canadian Medical Association’s decision to divest educational campaigns, and academic conversations to keep these from fossil fuel companies and Alberta’s coal-power phase-out.10 conversations at the forefront of medicine. HEART is a student Physicians and medical students can urge politicians and policy advocacy group that works alongside physicians and community makers to tackle the climate emergency more aggressively by organizations to promote planetary health education, including the striving for better solutions to achieve and surpass our 2030 target impacts that climate change and other environmental issues have of preventing a further temperature climb above 1.5 °C. on health. In 2019, HEART conducted a qualitative survey of all It is equally important that we act as health educators to our 17 Canadian medical schools. The results demonstrated consistent friends, family, neighbours, and patients to ensure the connection student interest in planetary health and increasing yet inadequate is made between health and the environment. Medical students education on the topic.7 While some schools had dedicated lectures, are at the forefront of ensuring that medical education reflects a changing climate. A detailed set of recommendations for faculty is available in the HEART Educational Report.6 Another avenue Corresponding Author: is by proposing Quality Improvement and research projects that Arianne Cohen touch on issues of planetary health. The consequences of climate [email protected]

34 UTMJ • Volume 97, Number 2, March 2020  Commentaries

Climate change advocacy: a growing movement

change will impact our careers and we must be educated to prepare 4. IEA. Coal 2018: analysis and forecasts to 2023. Paris, France: International En- ergy Agency, 2019. for these challenges. 5. Cunsolo A, Ellis N. Ecological grief as a mental health response to climate Medical professionals have a powerful voice and are trusted change-related loss. Nature Climate Change. 2018;8 275-81. health experts. All trainees and practitioners should be encouraged 6. IPSOS, 2019: Press release. Four Weeks In, Climate Change is Fastest Moving (29%, +4), but Health Care (35%) Still Top Issue to Make a Difference at the Bal- to consider this privilege a responsibility to enact positive change lot Box. 2019. Available from: https://www.ipsos.com/en-ca/news-polls/Four- and social action. Trainees represent the future of medicine and so Weeks-In-Climate-Change-Fastest-Moving-Health-Care-Still-Top-Issue. must not allow planetary health to rest in the past. By keeping it at 7. CFMS HEART. National Report on Planetary Health Education 2019. Canadian Federation of Medical Students. 2019. Available from: https://www.cfms.org/ the forefront of discussions within both the medical and political files/HEART/CFMS%20HEART%20REPORT-Final%20(2).pdf. communities, as a united front, we can achieve a healthier future 8. Canada’s Food Guide. Available from: https://food-guide.canada.ca/en/ 9. Canadian Association of Physicians for the Environment (CAPE). Climate for all. Change Toolkit for Healthcare Professionals. 2017. Available from: https://cape. ca/campaigns/climate-health-policy/climate-change-toolkit-for-health-profes- References sionals/. 1. Watts N, Amann M, Arnell N, et al. The 2019 report of The Lancet Countdown 10. Lough S. CMA votes to divest from fossil fuels. Canadian Medical Association on health and climate change: ensuring that the health of a child born today is not Journal. 2015;187(14): E425. defined by a changing climate. The Lancet. 2019;394(10211):1836-78. 2. Haustein K, Allen MR, Forster PM, et al. A real-time global warming index. Sci Rep. 2017;7: 15417. 3. IPCC. Global warming of 1·5°C. An IPCC Special Report on the impacts of global warming of 1·5°C above pre-industrial levels and related global green- house gas emission pathways, in the context of strengthening the global response to the threat of climate change. Geneva, Switzerland: World Meteorological Or- ganization, 2018.

UTMJ • Volume 97, Number 2, March 2020 35 Commentaries 

How our global health experience contributed to our developing identities as physicians: four lessons learned while working abroad

Paula Gosse1; Emily Kaunismaa1; Roslyn Mainland1

1MD Program, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario

diabetes among Malaysian patients, as well as the biopsychosocial Abstract factors associated with poor glycemic control. We used clinical As three University of Toronto medical students, we had interviews, validated questionnaires, and medical records to gather information required to answer our research questions. the privilege of assisting with a study at the Universiti Our summer was filled with challenges as we navigated an Kebangsaan Malaysia Medical Centre (UKMMC), unfamiliar healthcare system and interacted with patients of in Kuala Lumpur, Malaysia, through the CREMS diverse backgrounds. There were times when we questioned International Health Summer Research program. During our place as researchers working in a hospital so far from home; the seven-week program, we studied the prevalence and however, we were fortunate to have been supported by staff and predictors of mental health comorbidities of diabetes, supervisors who helped orient us to the healthcare environment and introduce us to local customs. With their guidance, we gained as well as the biopsychosocial factors associated with a wealth of knowledge and life experience that has influenced poor glycemic control among Malaysian patients. Here, our trajectory as future physicians. In this article, using some of we outline four lessons learned while working abroad: our most memorable anecdotes, we identify four valuable lessons 1) working with diverse patient populations provides learned while working abroad. an opportunity to challenge implicit biases and develop Lessons Learned cultural competency; 2) collaborating with team members from diverse backgrounds poses unique challenges and 1. Working with diverse patient populations provides embracing these differences results in a stronger team; an opportunity to challenge your implicit biases and 3) establishing trust is crucial when building relationships develop cultural competency with patients; and 4) implementing a patient-centred Malaysia’s distinct sociocultural landscape provided an approach is essential because each patient is the expert excellent opportunity to work with patients from a variety of backgrounds. To offer some context, there are three predominant of their own story. For each lesson, we share relevant ethnic groups in Malaysia: Malay (62%), Chinese (21%), and Indian personal experiences from our time in Malaysia and (6%).1 Although these groups each have their own languages and describe how the learning opportunity has impacted us dialects, English is commonly spoken – especially amongst Chinese as future clinicians. Finally, we illustrate how global health and Indian populations. Further, there are several major religions initiatives provide students with an opportunity to gain practiced in Malaysia: Islam (61%), Buddhism (20%), Christianity 1 valuable insight into another way of life. (9%), and Hinduism (6%). Religion is often an important aspect of an individual’s identity, and we noticed this to be especially true in Malaysia. In our study, over 80% of our three hundred participants reported having strong religious beliefs. During our time in Malaysia, we had many opportunities to learn about these various Introduction cultures and religions. For example, one of our most memorable his summer, we participated in the Comprehensive experiences was celebrating the holiday of Hari Raya Haji with Research Experience for Medical Students (CREMS) our supervisor and his extended family. International Health Summer Research program, which Not only did we learn from our colleagues and hosts, but also endowsT medical students at the University of Toronto to conduct from the patients themselves. Most of our time was spent in the research abroad. For seven weeks, we worked at the Universiti UKM clinic, interviewing patients with diabetes mellitus who Kebangsaan Malaysia Medical Centre (UKMMC), a tertiary were interested in participating in our study. We administered six hospital in Kuala Lumpur. We collaborated with the endocrinology different questionnaires to participants, which assessed factors such and psychiatry departments to assist with a cross-sectional clinical as personality, mental health, and quality of life. In doing so, we study of outpatients with diabetes mellitus. Our team aimed to study often gained insight into the unique medical, psychological, and the prevalence and predictors of mental health comorbidities of social challenges that participants faced. This allowed us to develop

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How our global health experience contributed to our developing identities as physicians: four lessons learned while working abroad

a better understanding of each patient’s illness experience, and us had previous research experience and travelled to Malaysia to helped us gain a deeper appreciation of how the illness fit into the assist with the project, our three Malaysian colleagues had greater greater context of his or her life. medical expertise and a rich knowledge of the language and This seven-week placement provided an opportunity for us culture. to challenge our unconscious biases. Within the first few days of Because our team was composed of members from diverse piloting the study, we noticed most of our participants were younger backgrounds, it was sometimes difficult to make decisions about and non-Malay. Without realizing, we had preferentially recruited project methodology. While we prioritized methodological rigor in individuals who we thought would be more capable of participating scientific research, our colleagues often valued cultural pragmatism. and who we assumed were more likely to speak English. After For example, during the piloting phase, the six of us disagreed on recognizing these biases, we changed our recruitment strategy; how the questionnaires should be administered. Our Malaysian we systematically approached every single person in the clinic, colleagues asserted that family members knew participants well providing everyone an equal opportunity to participate. By the end enough to complete questionnaires on their relative’s behalf – that of the study, our demographics closely matched the population it was a cultural norm for family members to be heavily involved demographics of the clinic. Had we not recognized and challenged in a patient’s care. However, we felt that the questionnaires were our implicit biases, our study would not have been representative designed for participants to answer themselves and thus, responses of the clinic population, and it would not have accurately reflected to questions about mental health and personality provided by the needs of the community that we worked with. In both research anyone other than the participant were inherently invalid. After and clinical care, we have realized how important it is to recognize discussing the issue as a team, we agreed that if family members and challenge implicit biases so that high quality, equitable care is interviewed the participant and consulted with them directly, we provided to all patients. could include their data. This compromise honored the cultural Although most physicians are well-intentioned, a 2017 role of family members in patient care while still accurately international systematic review showed that implicit biases among capturing participant responses and maintaining the integrity of healthcare professionals negatively impacts quality of patient the questionnaires. As the research continued, we navigated our care.2 The researchers further identified that one of the main differences in research preferences to ensure our protocols were implicit biases studied in healthcare professionals is a racioethnic consistent, ethical, and culturally informed. bias, which often works to further disadvantage populations that Embracing the unique strengths and skills of each team member are already marginalized in society.2 Studies have suggested that was absolutely essential to the overall success of the project. By implicit biases in healthcare may be addressed through direct collaborating with our native Malay-speaking colleagues, we interaction with members of other groups,3,4 which can further were able to compensate for not knowing the local language. Our help to develop healthcare providers’ cultural competencies. colleagues addressed participants who only spoke Malay, while the Working with patients in Malaysia exposed us to cultures, three of us recruited individuals who spoke English in addition religions, languages, and ethnicities that are unique from those to their native dialect. Using this collaborative strategy, we were in Canada. For nearly two months, we immersed ourselves in able to accommodate almost all of our potential participants. Our Malaysian culture. We toured religious sites, including the National colleagues also provided us with information about local customs Mosque of Malaysia and the Thean Hou Chinese Temple, shopped that we used to help build rapport with patients. For example, they at several markets, tasted traditional foods, attended a local taught us how to respectfully greet older adults, and how to ask medical conference, and celebrated holidays with our colleagues. about personal topics such as sexual health and substance use in a This allowed us to develop a deeper understanding of the various culturally sensitive manner. On several occasions, our Malaysian factors that contribute to health beyond what is observed in the colleagues also introduced us to potential participants and endorsed hospital. We had the privilege of listening to patients’ stories, asking us as trustworthy members of the research team. By working as a questions about their lives, and building meaningful connections. team, we collected data for over three hundred participants in less Through these patient interactions, we developed a self-awareness than two months. of our attitudes and beliefs that allowed us to challenge our implicit Conducting research in an unfamiliar environment challenged biases and build our cultural competencies. Canada is becoming us to identify the strengths of each team member and harness these an increasingly diverse country and as medical trainees who work strengths to achieve a common goal. With a diverse population of with patients from diverse backgrounds, it is crucial to be cognizant healthcare providers in Canada, it will be important to embrace of the implicit biases we each carry. Regularly challenging these different backgrounds when collaborating with colleagues whose biases will enable us to provide higher quality care to patients from perspectives are different from our own. In our future careers as all walks of life. physicians in Canada, we will use our experiences in Malaysia as a foundation to continue building a culturally competent, 2. Collaborating with team members from diverse collaborative approach to both research and patient care. backgrounds poses unique challenges and embracing these differences results in a stronger 3. When it comes to building relationships with team patients, establishing trust is crucial On a daily basis, we collected data alongside three Malaysian Throughout our placement, some patients expressed hesitancy medical students. While it was clear that our supervisor was the about participating in the study and inquired about our intentions leader of the larger research team, we were unsure about leadership with the project. Early in the summer, one patient asked if we within our six-person data collection team. Although the three of intended to take the data back to Canada for our own use, without

UTMJ • Volume 97, Number 2, March 2020 37 Commentaries

How our global health experience contributed to our developing identities as physicians: four lessons learned while working abroad making it available to clinicians in Malaysia. Another patient the Beck Depression Inventory, a validated questionnaire used to expressed that our questionnaires were westernized and forced him measure depressive symptoms. He explained that questions about to “fit inside a box”. Although these were not our intentions, the “life satisfaction” and “whether life was worth living” were not statements made us question our place as Western medical students appropriate in the context of his religious beliefs. In a subsequent conducting research in a Southeast Asian middle-income country, encounter, a female patient admitted that a healthy diet and regular and challenged us to consider how we could earn the trust of these physical exercise were not feasible options in her life. She explained participants. that her parents and husband struggled with serious chronic health Interacting with hesitant participants helped us develop tools to problems, and that she was responsible for financially supporting build rapport and establish trusting relationships. To ensure patients the entire family. Her family sought affordable food options, and felt accurately informed, we thoroughly explained our roles within therefore lived on a diet composed primarily of rice and street the project, our professional relationships with local healthcare food. Since she worked long hours to support her family, she providers, and our intention to collaborate with Malaysian expressed that making time for physical activity was not practical. physicians for the distribution of data. When patients expressed These stories highlighted a few of the many possible factors that dissatisfaction with the use of questionnaires, we explained the can impact a patient’s lifestyle and, therefore, their health. When theory behind the study tools used, and acknowledged that people are struggling to secure basic necessities to survive, it is questionnaires may fail to gain a comprehensive understanding unreasonable to expect them to think about nutrition, physical of a patient’s emotions and experiences. We offered patients the activity, regular check-ups, medication adherence, and other opportunity to share any feelings and thoughts that they believed recommendations that healthcare professionals espouse. were not captured in questionnaires. As we sometimes faced a These stories emphasize the importance of allowing patients language barrier, we observed and employed non-verbal tactics to help guide the conversation, especially if the clinical or research in order to interact more effectively with patients. For example, tools that you are using were not designed specifically for the patient we found that patients seemed more comfortable when we sat population that you are working with. Although we used validated down to speak with them compared to when we stood. In order to questionnaires, most of these tools were developed in a Western respect local customs, we wore conservative clothing that covered context, and some of our participants felt that the questions our arms and legs. Further, we attempted to find common ground did not consider their unique sociocultural background. Their with patients and felt we had a more trusting relationship when feedback clearly highlighted how it is impossible for a finite list of we did so. For example, some patients had travelled to Toronto checkboxes to capture a patient’s entire story. These lessons also and were excited to talk about their favourite tourist spots, while illustrate the importance of employing a patient-centred approach others had travelled to Singapore and provided recommendations as future physicians. By remaining open-minded and listening, for our upcoming weekend trip. Though we did not gain the we hope to better understand the multitude of factors that shape trust of everyone we approached, we were able to build many patients’ lives, which will enable us to recommend more feasible positive relationships with patients after clearly explaining our treatment plans. As we continue in our training, we will carry this intentions and processes, validating patient concerns, and finding lesson forward, hopefully improving the health and quality of care common ground. Without first establishing trust, it would have of our future patients. been extremely difficult to recruit participants willing to complete questionnaires on sensitive topics such as mental health. Conclusion Although earning the trust of patients is important when During our placement in Malaysia, we learned several valuable working in a new part of the world, it will also be crucial in our lessons. We worked with patients from diverse backgrounds, future careers as physicians. Previous studies have reported that challenged implicit biases, and collaborated within a diverse team. patients’ trust in their healthcare providers has been associated Further, we witnessed the importance of building rapport and with better medication adherence,5-7 better blood pressure control,5 establishing trusting relationships with patients. We learned from higher self-reported ability to manage chronic conditions,8 and less the patients with whom we interacted, as each was the expert of perceived hassle associated with self-care tasks.8 Unfortunately, there his or her own story. are many challenges to gaining patient trust, including patients’ We acknowledge that some individuals may question the previous negative experiences with the healthcare system, fear of value of medical personnel conducting health research abroad, physician biases, and feeling unfamiliar with medical terms. The especially when there are many local healthcare issues that could importance of establishing a trusting physician-patient relationship benefit from further study. However, we argue that global health has been emphasized throughout our medical education, and we research, when conducted within ethical boundaries, contributes are grateful to have had the opportunity to develop these skills in a to improvements in healthcare at population and systems levels. more challenging setting. In the future, we will apply the techniques Through collaboration, global health research allows for the that we learned on our global health placement when trying to exchange of medical knowledge, resources, and expertise leading establish trusting relationships with our patients. to sustainable improvements in healthcare worldwide. Ethical guidelines suggest that global health research should 4. Allow your patients to guide you, because each only be conducted in a population that would stand to benefit one is the expert of their own story from the research, and that it should respond to the needs of the Our placement in Malaysia highlighted the importance of communities being studied.9 As a team, we felt that our project taking a patient-centred approach to care. During one of our was culturally informed, resource-efficient, and can be carried clinical encounters, a man expressed strong dissatisfaction with forward by the healthcare providers at UKMMC. By collaborating

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How our global health experience contributed to our developing identities as physicians: four lessons learned while working abroad

with members of the Malaysian community, we helped address unanswered questions about mental health in the context of References diabetes. The information gathered from the study can inform 1. The World Factbook [Internet].Washington: Central Intelligence Agency; 2018 [cited 2019 Nov 15]. Available from: www.cia.gov/library/publications/the- future patient care at UKMMC and improve already existing world-factbook/docs/faqs.html. programs, like the Diabetes Education Centre. 2. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic re- view. BMC Med Ethics. 2017;18(1):19. We are humbled by the realization that this experience has 3. Burgess D, Van Ryn M, Dovidio J, et al. Reducing racial bias among health significantly shaped our identities as future physicians. Although care providers: Lessons from social-cognitive psychology. J Gen Intern Med. these lessons were learned in the context of global health research, 2007;22(6):882-7. 4. Boscardin CK. Reducing implicit bias through curricular interventions. J Gen they will inform our work with diverse populations in Canada. To Intern Med. 2015;20(12):1726-28. students who are thinking about doing a global health research 5. Schoenthaler A, Montague E, Baier Manwell L, et al. Patient–physician racial/ placement, we say this: with a goal of personal growth and learning, ethnic concordance and blood pressure control: the role of trust and medication adherence. Ethn Health. 2014;19(5):565-78. be flexible as you conduct research and be open to all that your host 6. Nguyen GC, LaVeist TA, Harris ML, et al. Patient trust-in-physician and race are community has to teach you. predictors of adherence to medical management in inflammatory bowel disease. Inflamm Bowel Dis. 2009;15(8):1233-9. 7. Kerse N, Buetow S, Mainous AG, et al. Physician-patient relationship and medi- Acknowledgments cation compliance: a primary care investigation. Ann Fam Med. 2004;2(5):455- We would like to thank the people who made this experience 61. 8. Bonds DE, Camacho F, Bell RA, et al. The association of patient trust and self- possible. We are grateful to the MAA & CREMS for creating and care among patients with diabetes mellitus. BMC Fam Pract. 2004;5(1):26. funding this opportunity, as well as Dr. Ravindran and Dr. Asrar for 9. Grady C. Ethics of international research: what does responsiveness mean?. AMA organizing and guiding the project. We would also like to thank our J Ethics. 2006;8(4):235-40. colleagues in Malaysia who made the summer so memorable: Dr. Hatta Sidi and his family, Dr. Luke Woon Sy-Cherng, Dr. Wani, Dr. Puteri, and Dr. Amelia.

UTMJ • Volume 97, Number 2, March 2020 39 Commentaries 

Comprehensive sexuality education in Rwanda and Ontario: an important public health intervention

Hilary Stone, MESc1

1MD Program, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario

that CSE needs to be age-appropriate, scientifically accurate, and Abstract culturally relevant; it should span several years so the content I participated in a medical student exchange program can be more comprehensive as the recipients get older. It should discuss anatomy, contraception, pregnancy, and STIs including in Rwanda on sexual and reproductive health this past HIV, as well as culture, values, human rights, gender roles, and summer. One of the key topics during the exchange sexual abuse among other topics. In order to be effective, CSE was on comprehensive sexuality education and its role should have interactive (ex. role-playing) components with properly in prevention of teenage pregnancy and promotion trained and supported teachers, and should engage the parents and of sexual and reproductive health. I learned about the communities.3 controversies surrounding comprehensive sexuality We were given the opportunity during the exchange to extend our understanding of CSE by co-planning and delivering a CSE education in Rwanda, as well as the public health and lesson to two secondary schools with our Rwandan medical student development impacts, and compared it to the discourse on hosts. The Rwandan medical students regularly go into schools comprehensive sexuality education in Ontario, Canada. to provide these CSE programs because many schools are not Comprehensive sexuality education does not result in delivering the curriculum, despite the fact that CSE was integrated risky sexual behaviours and is an essential tool for public into the curriculum in 2016. One of the challenges shared by the medical students is that many people think that CSE undermines health in any community. parental authority and encourages young people to have sex; this is one element of controversy surrounding CSE in Rwanda. In Ontario, Canada, there has been a similar controversy and politicization of CSE in schools, and changes in political power resulted in changes of curriculum.4 The Liberal government his past summer I had the opportunity to participate in updated the CSE curriculum in 2015, and in 2018, the an IFMSA-SCORA exchange in Rwanda. IFMSA is the Conservative government reversed the changes temporarily until International Federation of Medical Students, and one they re-updated the curriculum in 2019. They effectively brought ofT their subcommittees is SCORA, the Standing Committee on back the Liberal 2015 version, with some changes that delayed Reproductive health and AIDS. Rwandan medical students hosted the introduction of certain topics. The Conservative party also eight participants from various countries including Canada. One added that school boards must create a policy to allow parents key focus of this exchange was on youth awareness of sexual to exempt their children from this curriculum. Exemptions were and reproductive health and access to contraception, as 20% of allowed previously with the Liberal curriculum, but only on a Rwanda’s population is between 15-24 years old. As well, teenage case-by-case basis and school boards were not required to have a pregnancy has been on the rise, increasing from 6.3% in 2010 to policy on the issue. There is dispute regarding these exemptions, 7.3% in 2015.1 with supporters arguing for parental autonomy and authority over One of our visits was to the UN Population Fund (UNFPA) – their children’s learning, and critics arguing for the human rights the UN’s sexual and reproductive health agency – whose mission and the importance for all children to be exposed to CSE.4 Clearly, is to “deliver a world where every pregnancy is wanted, every similar themes in support of and in critique of CSE exist in both childbirth is safe and every young person’s potential is fulfilled.”2 Rwanda and Ontario. Their presentation focused on the role of comprehensive sexuality A lot of the backlash against CSE relates to the fear that CSE education in the work that they do with youth, specifically in will encourage earlier and/or riskier sexual behaviour, but research Rwanda to reduce teenage pregnancy. As defined by UNFPA, has shown this not to be the case. Abstinence-plus programs, for comprehensive sexuality education (CSE) is a rights-based, gender- instance, are a form of CSE where abstinence is preferred but focused approach to sexual education that can be used in both condom use and other safe sex practices are also encouraged as an the education system and the community. The UNFPA argues alternative.5 Underhill et. al.’s review found that abstinence-plus programs are likely to have a protective effect against risky sexual Corresponding Author: behaviours, in comparison to abstinence-only programs which did Hilary Stone not have a significant effect. This meant increased condom use and [email protected] some studies showed a delay in sexual initiation for example, with

40 UTMJ • Volume 97, Number 2, March 2020  Commentaries

Comprehensive sexuality education in Rwanda and Ontario: an important public health intervention

the abstinence-plus programs. Abstinence-plus programs were not One of my greatest takeaways from the exchange was the found to confuse participants and did not result in any adverse importance of advocating for the integration of CSE into the effect in risky sexual behaviours. This study looked at school and curriculum. I understand that there are many controversies around community-based programs in high-income countries where HIV CSE that exist around the world, but I think that a lot of the education was the focus, but pregnancy prevention was also included controversy stems from misunderstanding. I also recognize that in some programs. It highlighted the impact on public health and there are many challenges in appropriate implementation in a way health equity, especially related to higher risk groups in terms of that honours cultural differences and community voice. However, their social determinants of health.5 Kirby et. al’s review found through my experiences I have learned that when comprehensive similar findings with programs in both developing and developed sexuality education incorporates scientific accuracy, human rights countries, rural and urban settings, school and community settings, and cultural values, it is an essential tool for public health and with CSE programs more likely to have a positive impact than a development in any community. negative impact.6 Haberland and Rogow’s review also highlights the value of CSE, with an additional finding that incorporating References a gender and rights perspective is empowering and particularly 1. UNFPA Rwanda. Adolescent pregnancy [Internet]. [cited 2019 Nov 14]. Avail- 7 able from: https://rwanda.unfpa.org/en/topics/adolescent-pregnancy-3. effective at improving reproductive health outcomes. 2. UNFPA. United Nations Population Fund: About us [Internet]. [cited 2019 Nov This reduction in risky sexual behaviours through CSE 10]. Available from: https://www.unfpa.org/about-us. 3. UNFPA. Comprehensive sexuality education: Advancing human rights, gender has important individual and public health impacts, including equality and improved sexual and reproductive health. 2010. reduction of sexually transmitted infections including HIV, and 4. CBC News. Parents will be able to exempt children from some of Ontario’s new teenage pregnancy. By preventing pregnancy in adolescents, sex-ed curriculum. 2019 Aug 21; Available from: https://www.cbc.ca/news/ canada/toronto/ontario-new-sex-ed-curriculum-1.5254327. there is a risk reduction of obstetric complications that are more 5. Underhill K, Operario D, Montgomery P. Systematic review of abstinence-plus common in adolescents compared with adults. These obstetric HIV prevention programs in high-income countries. PLoS Med. 2007;4(9):1471– complications include death and obstetric fistula, which has life- 85. 3 6. Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: Their im- long consequences. Teenage pregnancy also often prevents girls pact on sexual behaviors of young people throughout the world. J Adolesc Heal. from going to school, impeding their right to education and social 2007;40(3):206-17. 7. Haberland N, Rogow D. Sexuality education: Emerging trends in evidence and supports and impacting their development as they transition into practice. J Adolesc Heal [Internet]. 2015;56(1):S15–21. Available from: http:// adulthood. This lack of education can impact their financial dx.doi.org/10.1016/j.jadohealth.2014.08.013. security and other social determinants of health, which leads to 8. UNFPA. Girlhood, not motherhood [Internet]. United Nations Population Fund. 8 2015. 1–62 p. Available from: https://www.unfpa.org/sites/default/files/pub- negative health outcomes throughout their lives. The impact is so pdf/Girlhood_not_motherhood_final_web.pdf. great that UNFPA considers CSE to be seen as a human right in itself, along with enabling other human rights.3

UTMJ • Volume 97, Number 2, March 2020 41 Commentaries 

Mobile applications to improve antiretroviral therapy adherence: quality over quantity

Calvin Diep, BMSc1,2; Majd Abdullah, BSc, MSc1,2; Soo Chan Carusone, PhD1

1Casey House, Toronto, Ontario 2Faculty of Medicine, University of Toronto

hile remarkable progress has been made working Applications that have no associated download cost and that are towards the 90-90-90 targets outlined by the Joint password-protected are also preferable. United Nations Programme on HIV/AIDS (UNAIDS), To illustrate how commonly these features are incorporated thereW still exist significant obstacles in the way of achieving these into MRAs, we compared three different MRAs in Table 1. The goals.1,2 Medication nonadherence in people living with HIV first, Life4Me+, is an application designed specifically for PLWH (PLWH) remains one of the greatest problems in the successful that was featured on the UNAIDS website recently.12 The other administration of antiretroviral therapies (ARTs) and viral load two, MediSafe and Dosecast, are popularly downloaded MRAs in control.3,4 A large meta-analysis in 2011 reported that, globally, the Apple and Google application stores. In addition to considering 62% of PLWH are adherent to ≥90% of their ART doses.5 the features mentioned above, we also used the Mobile Application Forgetfulness, or “unintentional nonadherence”, is often cited Rating Scale (MARS) to compare the applications.13 The MARS as the most common reason (35%) for missing ART doses.6,7 is a validated tool developed to assess the quality of mobile health Medication adherence for PLWH could thus be improved with applications based on 23 criteria across domains of engagement, regular and reliable reminders. functionality, aesthetics, information quality, and subjective The need for effective reminder systems, coupled with advances qualities such as likelihood to recommend the application to others in technology, has led to experimentation with mobile-based and reusability. For full details about the criteria, a PDF version health interventions over the past few decades. These reminders of the MARS can be accessed online. Two authors (CD, MA) have primarily taken the form of mobile phone text messages, for downloaded the three applications and independently used the which there exists strong evidence demonstrating improvements in MARS to compute objective and subjective quality scores for each. adherence for many chronic disease populations such as patients Average scores are included (Table 1). with hypertension, diabetes, asthma, smoking, as well as PLWH.8,9 More recently, the development and use of mobile health Table 1. Comparison of Medication Reminder Applications. applications for smartphones has become a popular supplement Life4Me+ MediSafe Dosecast to patient health education and medication adherence. With no MARS Objective /5 4.50 4.03 3.41 clinically relevant risk assessment framework for these, healthcare MARS Subjective /5 4.75 3.25 2.75 providers and patients alike are challenged with assessing medication Cost Free “Free” “Free” 10 reminder applications (MRAs) themselves. Furthermore, an Security Yes -- -- overwhelming number of MRAs now exist, fueling uncertainty Peer Support -- Yes Yes* about their quality. No evidence currently exists in support of any one application over another. In fact, our scoping review did HCP Viewing Yes Yes Yes* not retrieve any controlled trials or cohort studies evaluating the Local Resources Yes -- -- effectiveness of MRAs to improve ART adherence in PLWH. Medical Charting Yes Yes -- Despite the lack of evidence for or against the use of mobile News Updates Yes -- -- applications as reminder systems, reports and reviews continue MARS = Mobile Application Rating Scale, HCP = healthcare provider, “Free” = free to endorse MRAs as “promising”. As such, numerous qualitative version with less features, * = features unlocked if upgraded to paid version studies have investigated and reported on specific features of MRAs that PLWH would benefit from.11 For instance, allowing Life4Me+ attained higher MARS objective and subjective users to connect with their healthcare providers, facilitating quality scores than both MediSafe and Dosecast. Furthermore, networking with peers, providing information about local health or the latter two applications had marked discrepancies between their social resources, and offering updates about relevant local or global objective and subjective scores. Discrepancies such as these are to news and research are consistently considered valuable features. be expected with the MARS, as interpretation of the criteria is heavily user-dependent, especially in the subjective domain. Whilst MediSafe and Dosecast have but a few of the features deemed favourable for PLWH, Life4Me+ has nearly all of them. Life4Me+ also incorporates an interactive map that displays Corresponding Author: Calvin Diep the location and contact information of relevant social and [email protected] medical resources for PLWH. This feature is updated for nearly

42 UTMJ • Volume 97, Number 2, March 2020  Commentaries

Mobile applications to improve antiretroviral therapy adherence: quality over quantity

150 countries, with North America being the one major region References 1. UNAIDS. Accelerating towards 90–90–90 [Internet]. 2018 [cited 2019 January]. excluded for the time being. Available from: http://www.unaids.org/en/resources/presscentre/featuresto- While Life4Me+ may be considered a high-quality application, ries/2018/july/90-90-90-targets-workshop. it represents a tiny sample of all MRAs. A recent review of 5881 2. UNAIDS. 90-90-90. An ambitious treatment target to help end the AIDS epi- demic. [Internet]. 2014 [cited 2019 January]. Available from: http://www.unaids. MRAs found only 420 were accessible and free. Of these, only 57 org/sites/default/files/media_asset/90-90-90_en_0.pdf. were developed with healthcare provider involvement and only 3. Kranzer K, Ford N. Unstructured treatment interruption of antiretroviral therapy 4 had some evidence for their use, typically in the form of case in clinical practice: a systematic review. Trop Med Int Heal. 2011;16(10):1297– 14 313. reports. 4. Mussini C, Touloumi G, Bakoyannis G, et al. Magnitude and determinants of According to recent industry estimates, there are currently CD4 recovery after haart resumption after 1 cycle of treatment interruption. J Acquir Immune Defic Syndr. 2009;52(5):588-94. over 300,000 mobile medical applications available across all 5. Ortego C, Huedo-Medina TB, Llorca J, et al. Adherence to highly active antiret- 15,16 major application stores, with no formal quality control system. roviral therapy (HAART): A meta-analysis. AIDS Behav. 2011;15(7):1381-96. Recognizing this as an important concern in the age of mobile 6. Walsh JC, Horne R, Dalton M, et al. Reasons for non-adherence to antiretroviral therapy: patients’ perspectives provide evidence of multiple causes. AIDS Care. health, the FDA recently launched the Digital Health Software 2001;13(6):709-20. Pre-Certification Pilot Program to regulate and monitor software 7. Chesney MA. Factors Affecting Adherence to Antiretroviral Therapy. Clin Infect classified as medical devices, which includes mobile medical Dis. 2000;30(S2):171-6. 17 8. Mbuagbaw L, Mursleen S, Lytvyn L, et al. Mobile phone text messaging interven- applications. This regulatory system is expected to function tions for HIV and other chronic diseases: an overview of systematic reviews and similarly to how the quality of drugs is monitored when they are framework for evidence transfer. BMC Health Serv Res. 2015;15:33. 9. Thakkar J, Kurup R, Laba TL, Santo K, Thiagalingam A, Rodgers A, et al. Mo- marketed. bile telephone text messaging for medication adherence in chronic disease a meta- Future efforts in this field should emphasize quality over quantity analysis. JAMA Intern Med. 2016;176(3):340-9. of mobile health applications. This, first and foremost, involves 10. Lewis TL, Wyatt JC. MHealth and mobile medical apps: a framework to assess risk and promote safer use. J Med Internet Res. 2014;16(9):e210. advocating for inclusion of healthcare providers and patients in 11. Saberi P, Siedle-Khan R, Sheon N, Lightfoot M. The use of mobile health ap- application development. While this will not guarantee application plications among youth and young adults living with HIV: focus group findings. efficacy, it may provide more valid clinical insights pertaining to AIDS Patient Care STDS. 2016;30(6):254-60. 12. UNAIDS. New app helps treatment adherence for people living with HIV [In- user needs. Even indirect inclusion, such as incorporating desired ternet]. 2017 [cited 2019 January]. Available from: http://www.unaids.org/en/ features that are reported in qualitative studies, will produce higher resources/presscentre/featurestories/2017/october/20171030_life4me. 13. Stoyanov SR, Hides L, Kavanagh DJ, et al. Mobile app rating scale: a new quality applications, such as with Life4Me+. Simultaneously, tool for assessing the quality of health mobile apps. JMIR mHealth uHealth. robust RCTs or cohort studies must investigate the effect of 2015;3(1):e27. MRAs on helping PLWH improve ART adherence and viral 14. Ahmed I, Ahmad NS, Ali S, et al. Medication adherence apps: review and content analysis. J Med Internet Res. 2018;6(3):e62. load suppression. Developing an evidence base to cite would lend 15. Research2Guidance. mHealth Economics 2017 – Current Status and Future healthcare providers more clinical confidence when counseling Trends in Mobile Health. 2017. patients or making recommendations about MRAs. 16. FDA. Device software functions including mobile medical applications [Internet]. 2019 [cited 2019 October]. Available from: https://www.fda.gov/medical-devic- Based on evidence of improved medication adherence with es/digital-health/device-software-functions-including-mobile-medical-applica- populations living with other chronic diseases, MRAs are likely to tions. 18-21 17. FDA. Digital health software precertification (pre-cert) program [Internet]. 2018 also be effective for PLWH. While their use to improve ART [cited 2019 January]. Available from: https://www.fda.gov/MedicalDevices/ adherence is presently experimental, the potential benefits of high- DigitalHealth/DigitalHealthPreCertProgram/default.htm. quality MRAs may result in accelerated progress towards achieving 18. Gandhi S, Chen S, Hong L, et al. Effect of mobile health interventions on the sec- ondary prevention of cardiovascular disease: systematic review and meta-analysis. the goals of having 90% of PLWH receive sustained ART and Can J Cardiol. 2017;33(2):219-31. suppressing their viral loads to ultimately improve their health and 19. Park LG, Howie-Esquivel J, Dracup K. A quantitative systematic review of the quality of life. efficacy of mobile phone interventions to improve medication adherence. J Adv Nurs. 2014;70(9):1932-53. 20. Quinn CC, Clough SS, Minor JM, et al. WellDoc TM mobile diabetes manage- Acknowledgements ment randomized controlled trial: change in clinical and behavioral outcomes and patient and physician satisfaction. Diabetes Technol Ther. 2008;10(3):160-8. This Commentary was conceived from a community-based 21. Firth J, Torous J. Smartphone apps for schizophrenia: a systematic review. JMIR learning experience at Casey House through the University of mHealth uHealth. 2015;3(4):e102. Toronto Faculty of Medicine.

List of abbreviations ART – anti-retroviral therapy FDA – Food and Drug Administration HCP – healthcare provider MARS – Mobile Application Rating Scale MRA – medication reminder application PLWH – people living with HIV RCT – randomized controlled trial UNAIDS – Joint United Nations Programme on HIV/AIDS

UTMJ • Volume 97, Number 2, March 2020 43 Case Studies 

Recurrent back pain in a five-year old boy: a harbinger of tempest

Salwa Hasan, BSc, MPH1; Fizza Manzoor, BHSc1; Rosemary G. Moodie, MBBS, MBA, FRCPC2; Yousef Etoom, MD, MHSc, FRCPC2,3; Ibrahim Al-Hashmi, MBBS, FRCPC2,3; Ivor Margolis, MD, FRCPC4; Peter D. Wong, MBBS, PhD, FRCPC2,4,5

1Faculty of Medicine, University of Toronto 2Department of Paediatrics, Hospital for Sick Children, Faculty of Medicine, University of Toronto 3Department of Paediatrics, St. Joseph’s Health Centre, Toronto 4Department of Paediatrics, William Osler Health Centre, Toronto 5SickKids Research Institute, Toronto

Abstract mild bone pain. More than half of children with ALL Introduction: We describe a boy with back pain who present with musculoskeletal symptoms have no accompanied by normal physical, hematological, radiological findings. and radiological findings prior to diagnosis of acute Conclusions: Given that the clinical presentation of lymphocytic leukemia (ALL). ALL is non-specific and may precede hematological Case: A previously healthy, 5-year-old boy presented on changes, a high index of suspicion for bone pain in young 2 occasions to the emergency department with isolated children may contribute to the early diagnosis of ALL. nocturnal lower back pain. His back and neurologic exams were normal. The child’s investigations only showed low haemoglobin (99 g/L). Spine and chest x-rays were normal. The child’s third presentation with back Case pain occurred two months later, accompanied by fatigue previously healthy, five-year-old boy presented to the and episodic fever. His investigations showed an anemia emergency department with a two-day history of fever and (haemoglobin 37 g/L), thrombocytopenia (platelet count lower back pain which awoke him from sleep. However, he Awas not able to describe the characteristics or pinpoint the location 200 X 109/L), and leukocytosis (leukocyte count 16.6 X of the pain. There was no history of trauma, skin rash, or joint 9 9 10 /L) with neutropenia (neutrophil count 0.50 X 10 /L). swelling. His blood smear showed 43% of circulating blasts. His The child was well-appearing. His temperature was 38.5 bone marrow biopsy confirmed the diagnosis of early degrees Celsius, heart rate 132 beats per minute, blood pressure precursor B-ALL. 88/60 mmHg, and respiratory rate 18 breaths per minute. His back exam was normal, with full range of motion and no swelling, Discussion: Clinical findings of ALL at diagnosis erythema, or tenderness of the spine or paraspinal areas. His tend to be non-specific and include fever and infection neurologic examination of the lower limbs was normal. He had caused by neutropenia, bruising and bleeding from small bilateral cervical lymph nodes. There was no evidence of thrombocytopenia, and fatigue and pallor from anemia. petechiae, bruising or hepatosplenomegaly. The remainder of his Isolated bone pain as the initial presentation of ALL physical examination was normal. is uncommon. Children with ALL who present with The child’s investigations showed a normal complete blood count (haemoglobin 107 G/L, white blood cell count 5.0 X prominent bone pain have hematological values that 109/L, and platelet count 189 X 109/L). Except for erythrocyte are closer to normal, as compared to those with no or microcytosis, his peripheral blood cell morphology was normal. His inflammatory markers were elevated (C-reactive protein (CRP) 18.4 mg/L and erythrocyte sedimentation rate (ESR) 73 mm/hr). His other laboratory investigations were normal, including blood glucose, bilirubin, electrolytes, alkaline phosphatase, aspartate transaminase, alanine transaminase, amylase, and creatine kinase. Subsequently, his throat swab was positive for Group A Corresponding Author: Peter Wong streptococcus. His blood and urine cultures were negative. The [email protected] child was treated with a course of oral amoxicillin.

44 UTMJ • Volume 97, Number 2, March 2020  Case Studies

Recurrent back pain in a five-year old boy: a harbinger of tempest

The child’s second presentation occurred two weeks later. young children. Accompanying symptoms of fever, weight loss, or He continued to complain of lower back pain. Although he malaise will heighten the need for diagnostic evaluation. Bone pain appeared pale, he was afebrile and energetic. His abdominal, in children with ALL may be the result of massive proliferation musculoskeletal, and neurological examinations were normal. of hematopoietic tissue. The prevalence of bone pain alone as The child’s investigations showed a low haemoglobin (99 g/L) and the first presentation of childhood hematological malignancy normal white cell (5.7 X 109/L) and platelet (213 X 109/L) counts. is low, the spine being less common than the long bones.3 More His inflammatory markers remained elevated (CRP 35.3 mg/L frequently, bone pain occurs in combination with other symptoms. and ESR 52 mm/hr). His spine and chest x-rays were normal. A Children with ALL who present with prominent bone pain have presumed diagnosis of viral myositis was made. hematological values that are closer to normal, as compared The child’s third presentation occurred two months later. Again, to those with no or mild bone pain.4 Further, more than half of he complained of lower back pain. In addition, the pain was now children with ALL who present with musculoskeletal symptoms, accompanied by fatigue and episodes of self-resolving fever. His including bone pain, limp or joint swelling, have no x-ray findings.5 physical findings and investigations revealed the diagnosis. MRI may be considered in the early workup of children presenting with ongoing bone pain without the classic laboratory findings or Discussion physical signs of ALL to avoid delays in diagnosis.6 The child’s physical examination revealed pallor and bilateral Clinical disease presentation of ALL is protean, and may cervical lymphadenopathy. He had petechiae and bruises on precede hematological changes. We report a boy with the his face, abdomen, and legs. However, his back and lower limb uncommon symptom of back pain with normal physical, neurological examinations were normal. His investigations showed hematological, and x-ray findings, prior to diagnosis. A high index a worsening anemia (haemoglobin 37 g/L), normal platelet count of suspicion for recurrent bone pain in young children with normal (200 X 109/L), and leukocytosis (leukocyte count 16.6 0 X 109/L) investigations may contribute to the early diagnosis of ALL and with a neutropenia (neutrophil count 0.50 X 109/L). Further, his complement existing protocols for pediatric back pain. blood smear showed 43% of circulating blasts. His bone marrow aspirate confirmed the diagnosis of an early precursor B acute Conclusions lymphoblastic leukemia (ALL). No further radiological tests were In conclusion, the following clinical pearls may be presented: done. 1. The clinical presentation of acute lymphoblastic leukemia ALL is the most common cancer in children, and a frequent (ALL) is protean, and may include fever and infection cause of death.1 Its peak incidence occurs at 3 to 5 years of age. caused by neutropenia, bruising and bleeding from The current 5-year overall survival rate in children with ALL thrombocytopenia, and fatigue and pallor from anemia. exceeds 85%. Clinical findings of ALL at diagnosis (Table 1) 2. Bone pain as the earliest presentation of childhood ALL is tend to be non-specific and include fever and infection caused by uncommon, but important to consider among differential neutropenia, bruising and bleeding from thrombocytopenia, and diagnoses. Back pain is less frequent than long bone fatigue and pallor from anemia. Extramedullary manifestations involvement. may occur from tumor infiltration into lymph nodes, spleen, 3. Back pain as the initial presentation of childhood ALL testicles, and the central nervous system. Less commonly, the may have normal physical, hematological, and plain film disease may present with vague complaints of bone pain, limp, or findings, which creates a diagnostic conundrum. MRI may abdominal symptoms that mimic other childhood diseases. be considered in the early work up of undiagnosed bone pain in children to avoid diagnostic delays. Table 1. Acute lymphoblastic leukemia: clinical findings at diagnosis.

Frequency Clinical finding Acknowledgements

More common Hepatosplenomegaly The authors thank the patient’s family for allowing them to Pallor share this case. Fever Lymphadenopathy Bruising References Common Malaise/fatigue 1. Hunger SP, Mullighan CG. Acute lymphoblastic leukemia in children. NEJM, Anorexia/weight loss 2015;373(16):1541-52. Petechiae/purpura 2. Clarke RT, Van den Bruel A, Bankhead C, et al. Clinical presentation of childhood leukaemia: a systematic review and meta-analysis. Arch Dis Child. Less common Bone pain Limp/joint swelling 2016;101(10):894-901. Abdominal symptoms 3. Teo WY, Chan MY, Ng KC, et al. Bony presentations of childhood haematologi- cal malignancy to the emergency room. J Paediatr Child Health. 2012;48(4):311-6 Note: Adapted from Clarke et al. 20162 4. Jonsson OG, Sartain P, Ducore JM, et al. Bone pain as an initial symptom of childhood acute lymphoblastic leukemia: association with nearly normal hemato- logic indexes. J Pediatr. 1990;117(2):233-237. Bone pain as an early presentation of childhood disease has a 5. Sinigaglia R, Gigante C, Bisinella G, et al. Musculoskeletal manifestations in pe- broad differential diagnosis, including trauma, congenital defect, diatric acute leukemia. J Pediatr Orthop. 2008;28(1):20-28. infection, rheumatologic disease, and malignancy. Red flags 6. Lu CS, Huang IA, Wang CJ, et al. Magnetic resonance abnormalities of bone marrow in a case of acute lymphoblastic leukemia. Acta paediatrica Taiwanica = are pain that is constant, prolonged, or nocturnal and occurs in Taiwan er ke yi xue hui za zhi. 2003;44(2):109-11.

UTMJ • Volume 97, Number 2, March 2020 45 Interviews 

Interview with Dr. Errett

UTMJ Interview Team (Annie Yu and Ryan Daniel)

r. Lee Errett is the first I am also the president of the Bethune Medical Develop- Professor of Global Surgery ment Association of Canada that has done an enormous at the University of Toronto amount of work in China. Dand the President of the Bethune Medical Development Association of UTMJ: What instigated your passion for global surgery? Canada. Throughout his career, he has dedicated himself to advancing LE: One instigating factor was my time working on the trans- cardiac surgery in areas of research, plant team while doing research at Oxford. I got to travel innovation, and clinical care. With to various places in Europe to pick up donor organs and regards to his efforts abroad, Dr. Errett I was amazed by the vast differences in healthcare from has taught, mentored, and performed country to country. Another instigating factor was when I Dr. Lee Errett cardiac surgery in all six continents. He got involved with project HOPE, which is a humanitarian was also the recipient of the 2006 Norman Bethune Award for his healthcare organization with the goal of creating sustain- work in restructuring surgical training programs in China. able global health improvements. With this organization, I travelled on a boat equipped with healthcare services from port to port identifying and treating individuals who need- UTMJ: Hi Dr. Errett, thank you very much for allowing us to ed operations and healthcare most urgently. And finally, I interview you today. Do you want to start by telling our have always been interested in equity. Unfortunately, the readers a bit about your journey from undergraduate type of healthcare you receive is all dependent on where studies to medical school to your current clinical and aca- you’re born. If we can smooth that inequity out a little demic appointments? that would be a good thing. We're not going to solve this problem anytime soon but if we all take on a little bit we LE: Well, when I was in my undergraduate studies, I actually will start to make some progress on the issue. I recognize wanted to be a lawyer. At that time, a good friend of mine, we won’t change the world, I just want to make a little bit Mr. Terrence Donnelly, a lawyer, questioned my true in- of a dent. terest in law and pointed me in the direction of medicine. After a lot of thinking and conversations with many men- UTMJ: As you mentioned, in 2015 you were appointed as the first tors, I decided to apply to medical school and ended up professor of global surgery at the University of Toronto. at Memorial University in Newfoundland. After medical What is your vision for the University of Toronto's in- school, I moved on to Queen's University in Kingston volvement in this initiative? for my residency training in general surgery. They have an excellent program with extremely good surgeons and LE: Along with Dr. Rutka, the chair of the department of sur- teachers, who ultimately guided me towards cardiac sur- gery, we’re continuing to develop University of Toronto’s gery. But before I went in clinical practice, I wanted to involvement in global surgery and provide more organiza- have some research skills, so I went to Oxford in England, tion and direction to this division. First and foremost, the to conduct research with Sir Peter Morris, who was a tre- University of Toronto has a wealth of talent that can be mendous mentor. From there I received additional train- harnessed to tackle global surgery through collaboration, ing at McGill University in cardiac surgery and then at teaching and innovation. My vision is for medical special- Duke University in electrophysiology before landing my ties to join forces to take on the different issues that present first job as faculty at McGill. I then worked at Yale Univer- in resource limited settings. For example, on my next trip, sity before being recruited to become the chief of cardiac I’m going to Jamaica, and I am taking a cardiologist with surgery at St. Michael's Hospital. I had the opportunity me so that comprehensive cardiology assessments can be to build the program there, hiring all the surgeons and performed prior to cardiac surgery operations to ensure creating a good team of excellent clinicians, teachers the best outcomes. Anesthesia is also another key specialty and researchers. After twenty years, I left fulltime clinical to any surgical operation and other surgical specialties, practice to become the first Professor of Global Surgery. such as general surgery, obstetrics, and ophthalmology,

46 UTMJ • Volume 97, Number 2, March 2020  Interviews

Interview with Dr. Errett

etc., are also widely needed in these settings. When go- a language barrier. In Jamaica poverty is behind all the ing abroad, you need to identify the problem, determine a shortcomings. Another consideration specifically in global reasonable way of addressing it and develop ways to teach surgery is that in some cultures it is considered a bad thing the local people or leave medical technologies behind that to have your skin opened and operated on. One of the will lead to sustainable solutions. My ultimate vision is to hardest things that I deal will is deciding who gets an op- inspire all Canadian Universities to play a part in global eration and who doesn’t. When going abroad there is only surgery and global health and encourage their trainees to so much time and resources and thus difficult decisions become leaders in these initiatives. about which patient needs the operation most occur all the time. Another challenge is knowing when operating UTMJ: How do you think that your involvement in global surgery is not the best course of treatment for the patient due to has impacted your regular clinical practice as a cardiac many different factors. To overcome these barriers and surgeon? challenges I believe you must develop good relationships with your medical team and more importantly with the LE: It has made me more aware than ever that Canada has its local government and healthcare workers. You need to challenges like every other place. Canada can't be smug make sure that you’re going into a situation where your about global health because the same problems that exist help is wanted and that you’re not impinging on the local in places like Jamaica exist in Nunavut with regards to lack populations wishes. of access to timely care. It has also changed my attitude to realize that you don’t always need the latest and great- UTMJ: What advice do you have for healthcare professionals that est of everything in order to get good patient outcomes. I are interested in global health initiatives, such as global believe most students would be amazed to see how people surgery? can deal with lack of facilities, lack of care, lack of sup- plies, and still do a pretty good job. Overall, it has made LE: Whatever type of medical specialty you choose or health- me a more resourceful and humbler doctor and realize care profession you’re in make sure to be good at what you that having the right mindset when approaching patient do first. Your main focus should always be on being the care is key. best professional that you can be so that you can be more valuable wherever you go. In Canada, we have rigorous UTMJ: It may be difficult to pick one, but can you talk about one training standards, but students should try to appreciate global surgery venture that was really impactful? this opportunity and make the most of it. The other piece of advice I have is to not be in a rush. You can take part in LE: I have had so many impactful moments through global global health initiatives during your training from medical surgery but one that stands out was during a project with school to staff positions, but you don’t need to rush it. It a group of ophthalmologists in Jamaica. We set up an eye may start as one week a year and then it might blossom clinic and a little boy around eight or nine years old came into two weeks and then you may end up doing it full time. in with his grandfather. The boy was holding the grandfa- Finally, make sure that when taking part in these initiatives ther’s hand to prevent the grandfather from running into that you find likeminded people who have the right atti- things, almost like a guide dog. The ophthalmologist then tude and are doing it for the right reasons. Not all physi- did a cataract operation to fix the grandfather’s sight and cians have the temperament to do this work just like the after a couple of days of recovery the grandfather was differences that exist between all specialties. In operations able to see his grandson for the first time. You can imagine abroad, sometimes the lights go off or there are limited that that moment was very moving, and a lot of positivity supplies and you need to be able to go with the flow and came out of it. The boy can now play and enjoy life with- find solutions. So, make sure that you have the right at- out guiding his grandfather around, and the grandfather titude to be able to deal with these barriers and work with can finally see. It is crazy that the wait list is around eight others. The fact that someone will get treatment that they years for a cataract operation in Jamaica, when it is such a otherwise may not have had is the reward. fixable and impactful issue. This is a great example of one area that global surgery can make a huge impact. UTMJ: Why is global surgery such an important global health is- sue right now? UTMJ: What are some of the barriers and challenges when work- ing abroad and how do you overcome them? LE: Global surgery is one part of a larger subset of global health issues. And global health issues are an enormous LE: There are many barriers to working abroad, including problem in the world right now, and the inequity is grow- language, culture, politics etc. In China, there is obviously ing. While resolving public health and social issues such as

UTMJ • Volume 97, Number 2, March 2020 47 Interviews 

Interview with Dr. Errett

poverty, clean water, smoking, physical activity and diet, be far better if they focused on teaching young surgeons have tremendous impacts long-term, surgery is an indis- and allowing them to perform more operations on their pensable way of resolving issues immediately. Resolving own. Ultimately, this led to the development of a cardiac surgical issues in a timely and proper manner, such as a surgery training program similar to the residency train- broken arm or a hernia, can get rid of so much hardship ing programs offered in North America. At one hospital, and issues for not only the patient but also their family. For this led to an increase in the number of successful cardiac example, if a man who works as a manual laborer breaks surgeries from 180 to 2000 per year. It started off with his arm and it is not set properly, he could be unable to just cardiac surgery, but now we have progressed to create work for the rest of his life. This will lead to poverty for more structured training programs in related fields, such himself and his family and ultimately more health issues as anesthesia and cardiology. Myself and two perfusionists down the line. started the organization in 2010 and now we have over 400 members across all different specialities. We've been UTMJ: You mentioned previously that you’re the founder and to over 160 cities in China and have established all kinds president of the Norman Bethune Medical Development of training programs. In addition, almost 150 Chinese Association of Canada (NBMDAC). Do you want to talk physicians have come here to learn and then return to a little bit about what this organization does? China with new knowledge and skills that they can dis- seminate. LE: In the spirit of Norman Bethune, this organization has the goal of facilitating positive relations between Canadi- UTMJ: Do you have any additional general advice for medical an and Chinese universities and hospitals and developing students in training? long-lasting connections between these facilities. I have been going to China for 20 years now and the main thing LE: I think it is really important for medical students to stay we have done is try to help restructure the medical train- up to date on the world around them. This allows them to ing programs in the Chinese hospitals and universities. In make informed decisions about the care they provide and China, the conventional surgical training system functions makes them more culturally and socially aware. And once like a pyramid system, where the head surgeon performs again I would counsel students to not be in a rush to get to all the operations and the trainees simply watch. With the the destination. Enjoy the journey, work hard and focus on BMDAC, I have convinced head surgeons across China your path and the accolades and success will come as you that their legacy, which is important to the culture, would go.

48 UTMJ • Volume 97, Number 2, March 2020  Interviews

Interview with Prabha Sati

UTMJ Interview Team (Happy Inibhunu and Jeff Park)

rabha Sati is an Associate literacy rate was really low. Health was not a priority for Director for Africa at Centre people in general, particularly the women, who would for Global Health Research only seek medical help when deemed severely necessary. P(CGHR). She works extensively This was an integrated development project which managing and coordinating global had various components, including a focus on health. health projects in India and more The project looked at improving the water and sanitation recently, Africa. Prior to joining situation in the area, improving health, and also worked CGHR, she led numerous projects towards improving pre-school education and providing for organizations like UNICEF, opportunities for women to generate income. Health European Commission, the Institute awareness camps and mother’s regular check-up camps for International Cooperation and were organized. There were programs for HIV/AIDS Prabha Sati Development, Humana People awareness in schools and communities, as well as for to People and Alliance for South Asian AIDS Prevention. At truckers. Pre-schools were established and school health CGHR, she has managed large nationwide randomized control and sanitation programs were implemented. Many low- trials like the District Evaluation Study for Health and a Catalytic cost toilets were constructed, handpumps were repaired, National Programme to Reduce Tobacco Deaths in India. Her and new ones were installed. As we continued to inte- current role at CGHR now includes implementing and managing grate ourselves more in the day-to-day workings of the cause of death studies in Africa. state, we implemented income generating activities to help promote and foster the local talent already present among the women. One example included connecting UTMJ: How did you get involved in Global Health? women who could make handwoven carpets to businesses that employed these types of craftspeople. This work took PS: My education took place in India, and my educational place in approximately 200 villages, with the help of many background is in psychology. I coincidently got involved in dedicated local workers. global health and I enjoyed the work so much that I chose this as my field of work and have continued since then. UTMJ: Besides women’s health, what other projects have you One of the first projects I was involved in, in terms of worked in and what Global Health projects can someone international work, was with a Danish organization, Hu- become involved in? mana People to People. It had work centered on health, rural development, and programs specific to women, such PS: There are many global health projects that one can get as women's empowerment, education, health, HIV/AIDS involved in depending on what one passionately feels for. awareness programs, and income generating activities. A There are projects centered around maternal health, ado- big component of this work was also geared towards clean lescent and children’s health, water and sanitation, health water and sanitation. I started my first project for the or- system strengthening, HIV/AIDS, malaria, nutrition, etc. ganization which was a very satisfying experience and one Based on the landscape of each country or region you of my most cherished projects. partake in, different themes or issues come to light that can be addressed either through research, awareness, or UTMJ: What did your first project in Global Health entail, specifi- established programs to improve the livelihood and well- cally on the ground level? What was required of you as being of their citizens. you worked in this stream of international health? I have worked for the European Commission Techni- cal Advisory Group and the mandate of my project was PS: My first project in India was in the state of Rajasthan, to create a database of health sector policy reforms. My which was at that time one of the most economically and work entailed meeting the health secretaries of the states socially backward states in the country – for example, it across the country and learning of the successful health had one of the worst sex ratios. The condition of women initiatives running in that state. These initiatives were then was pitiable, child marriages were rampant, and female documented and put up on the national website of Min-

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Interview with Prabha Sati

istry of Health and Family Welfare so states could learn nerships, achieving targets, controlling costs, managing from each other and replicate feasible initiatives in their risk, and improving project outcomes. state. I am also currently working on studies in India, Sierra UTMJ: As a project manager, like yourself, working on the ground Leone, and Ethiopia, where causes of deaths are being in various countries to implement Global Health initia- measured using electronic verbal autopsy. tives, how is your or your organization's relationship with the citizens and/or the governments? Is there any interfer- UTMJ: Of the many different projects taking place in various ence or limitations to the work that you or your colleagues countries around the world, as to date, which initiatives are trying to put in place? were you the proudest of ? Why? PS: As far as communities are concerned, there have been no PS: There are several projects that come to mind that I am issues within the region where we are working. In fact, I do very proud of but my most cherished project was the in- love working with the communities and find it very easy to tegrated rural development project in Rajasthan. It was build rapport with the community. We also ensure that the a very fulfilling experience because within a span of two field teams we hire have good communication and com- years one could see the overall development in the villages munity mobilization skills and are respectful while inter- where the work was carried out. It was a multifaceted acting with community members. project which addressed the social, medical, educational, However, different challenges may emerge while work- and economical issues of the community and the impact ing with governments of different countries. Some govern- of our work could be felt within 1-2 years. The project ments are very welcoming and receptive to new research had a very vibrant and energetic team of employees and studies or projects. Others may take time and need a lot international volunteers. As someone who thrives on hu- of follow-up. I have been associated with well-known or- man interactions, this project gave me plenty of opportu- ganizations who have had very good working relationships nities to interact with communities, make an impact, and with federal governments, so it has been comparatively partake in their social festivities. I got local district officials easy to work in different countries. We also work with local involved in all these activities which helped the work move country partners who have strong local networks with the ahead quickly. government and other organizations, so that contributes My work with UNICEF, focused on water and sanita- to the ease in working in new countries. tion, was also one of my favorites. Specifically, we utilized One of my most interesting experiences was when I im- local theatrical teams to create awareness on importance plemented the very first project of a Danish organization of potable water and improved sanitation, which was was in one of the under privileged states of India many years one of the highlights of the project. This led to construc- back. The project had international staff and volunteers tions of many toilets which significantly increased the and we were working in the communities of Rajasthan. sanitation coverage in the area. There was doubt as to why foreigners' policies and views Finally, I also find my current projects on causes of were being imposed on a country or region that does not death surveys in Sierra Leone and Ethiopia to be very belong to them. This stemmed from the fact that in the exciting and challenging. In India, I was involved in the past, British colonialists had captured India and made implementation of the cause of death study in two states them slaves. Unfortunately, community leaders and mem- – and within a span of 7 months, 10,000 deaths were col- bers assumed this was the same strategy being deployed lected. Furthermore, the project adhered to the timelines again. I was contacted by the community leaders who ad- and was well with the budget, which I deem a great suc- vised me to disassociate myself from this organization. I cess. was really amused that the locals thought this way in the modern day. However, it gave me the chance to speak to UTMJ: Can you describe what is the required role of a project the village leaders and explain to them the intentions of manager in Global Health initiatives? the organization and convince them that the work being carried out was solely for the benefit of the people in the PS: Project Managers have an important role to play in any region, and that it had the approval of the government. project, including any global health initiatives. If proj- One important lesson from this experience is that when ects are not managed well, no matter how innovative and you start working in new community, you should contact impactful a health initiative is, it will fail. There are also the community's leaders and explain the purpose of your many other important elements that contribute to the suc- project. After we explained our intentions, we managed to cess of any initiative, but the role of the project manager carry out a lot of social mobilization activities. In no time, cannot be understated. Managers help in building part- we got the full support of the people in that region. In fact,

50 UTMJ • Volume 97, Number 2, March 2020  Interviews

Interview with Prabha Sati

we had many village leaders asking us to start work in their We work with local partners who hire local staff for im- area as well. I was also contacted by a political party who plementing the projects. The first project where we inte- asked me to join their party as their youth leader, which I grated foreigners with locals happened many years back politely refused. when I worked for Humana People to People. For the first ten years in my work, I worked on site with the local UTMJ: How do you find the experience of working with unfa- people. Now, my work no longer entails living or directly miliar governments and local community members that working within communities. The implementation of our might either lend their support or pose challenges? projects is carried out by local partners, but I do not miss the chance to interact with communities whenever I can. PS: I thrive with interpersonal interactions and these types of My responsibility now involves managing the projects and challenges do not deter me, but rather enthuse me. I find building partnerships with governments and other part- working in different countries and settings pleasurable. ners for the smooth and effective implementation of proj- Sometimes when people have differences of opinions, I ects. like to clarify my organization’s position and objectives My on-site stay on the project depends on the need patiently and help resolve their doubts. Throughout the and nature of the project. One of CGHR’s projects in years, I have managed to convince many governments of- India was a randomized control trial called the District ficials to see my view and I’ve gotten quite good at it. Evaluation Study of Health where we were sending out One has to understand that there is a difference be- information packages to the senior government officials tween governmental styles in Africa and India, and even and politicians. It was a national level trial and we were within countries in Africa such as Sierra Leone and Ethio- directly involved in the implementation. The whole trial pia. In Sierra Leone, I found the people there very verbal had to be set up, which included getting governmental ap- and expressive. If they do not like something, they will talk proval. As a result, I ended up staying on site for 9 months. about it. They are not afraid to say it. In contrast, in India, Now when I go to Sierra Leone or Ethiopia, the dura- people will say “yes” to everything, but you don't know if tion of stay varies. The longest I stayed in Sierra Leone is they actually mean yes or a no. You eventually develop the a 21 day stretch, whereas in Ethiopia, it was for 12 days. ability to manage them. You say, “Okay let’s sit down and Basically, I would go for short durations from time to time talk about the issue.” Eventually, you decide on things that for purposes such as training, building partnerships and have the consensus of both the parties. Sometimes you meetings, and so forth. have to make decisions which are in the interest of the organization even if the parties are not quite in agreement UTMJ: What are some of the major issues in the healthcare sys- with it. tem in the countries you have visited and what should However, yes, there is some satisfaction in coping with healthcare professionals aspiring to partake in global the challenges in the work that I do. Sometimes you can’t health projects expect when visiting these countries? convince people no matter how much you try. Sometimes people are motivated by political reasons. They could be PS: What I feel is the most lacking is weak health infrastruc- saying no to whatever you are trying to achieve because ture, inadequate human resources, and limited health there is already another organization they are supporting budgets. In India, for instance, there are many public and there is a conflict. There are many different reasons healthcare facilities that even the poor do not like to go why some community leaders and government officials to because of inadequate infrastructure or the absence of would not want to support your organization. It’s impos- doctors in these facilities. Instead, they will go to a private sible to always know. Once you realize that it is not going doctor. Out of pocket expenses for health care are very to work, you have to find an alternative strategy or simply high in these countries. Health facilities are supposed to give up. Fortunately, we haven’t experienced enough resis- have certain essential medical resources in stock, but of- tance to any of our projects to completely stop the work. ten due to mismanagement they are not there. Occasional shortages in medicines are not a problem, but health staff UTMJ: It sounds like you were responsible for many different op- negligence and lack of accountability is. One example I’ve erations within a project. We are curious as to who is usu- seen was an incident where a patient who had been bitten ally involved in these tasks—local volunteers, foreigners, by a snake presented to a health facility with anti-venom or both? Also, how long do you stay on site when imple- that could have saved the patient. However, the medica- menting projects? tions were locked away in storage and the keys were miss- ing. The patient ended up dying. This happened in one PS: The current projects I am working on with the Centre of the areas I had worked in. Such cases of neglect are for Global Health Research do not involve volunteers. rampant in the country.

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Interview with Prabha Sati

Another thing to understand when working in these immediately. They have to remember that the work has countries is that you shouldn’t go in with too high of an been done but the results do not appear immediately. expectation. Things move at a very different pace there. That being said, I think if you were to work abroad as I have seen US trained volunteers that come to Africa or doctors, you will find the work very rewarding. Reception India for a period of 6 months, whether it is for HIV/ for foreign doctors is great and people get excited by the AIDS prevention or sanitation or any other program. news of doctors visiting their community. There is a big They come to the communities thinking they will make demand for doctors in places like India and Africa and and see a lot of difference during their stay. many people think that North America produces the best What I can tell you from my experience is that many of doctors in the world. I would definitely recommend going them go back after 6 months feeling very dissatisfied with abroad. It is good to have doctors with kind hearts going how much they were able to contribute. They thought there and helping the locals. Practicing the skills you learn they would be able to see the effects of their work almost in Canada can be a great contribution for the local people.

52 UTMJ • Volume 97, Number 2, March 2020 Interviews 

Interview with Dr. Kamran Khan

UTMJ Interview Team (Kathleen O'Brien and Alexandra Florescu)

r. Kamran Khan is an were billions of economic implications to the city as well infectious disease physician as social impacts it had on people from a psychological and scientist at St. Michael’s standpoint. So for me, this was sort of a realization of DHospital in Toronto and a Professor course that the world I would practice medicine in was go- of Medicine and Public Health at ing to look very different than perhaps a generation earlier the University of Toronto. Motivated simply because the world was going through some pretty by his experiences as a frontline rapid and profound changes–population growth, urban- healthcare worker during the 2003 ization, climate change, commercial air travel, industrial- Toronto SARS outbreak, Dr. Khan has ization of agriculture, disruption of wildlife ecosystems. been studying outbreaks over the past These are all driving the emergence and spread of hu- 15 years to lay the scientific foundation man pathogens, novel pathogens, and then even the old Dr. Kamran Khan for a global early warning system for diseases, so vaccine hesitancy, measles etc., we’re seeing infectious diseases. His research has been published in scientific more and more activity and more dispersion. So I spent journals including the New England Journal of Medicine, the the next ten years as an academic studying this type of Lancet, Science, and Nature. To translate and disseminate scientific work; work in the area with the commercial airline indus- knowledge into timely action, Dr. Khan founded BlueDot, a digital try studying data from the private sector on transportation health company that uses human and artificial intelligence to help through the global commercial airline network, published governments protect their citizens, hospitals protect their staff and research related to the H1N1 pandemic, things like the patients, and businesses protect their employees and customers from MERS outbreak, the spread of chikungunya across the dangerous infectious diseases. His research during public health Americas, the Ebola outbreak, Zika, yellow fever, and so emergencies has led him into numerous advisory roles from the forth. But I think one of the things that I realized was World Health Organization to the White House. Dr. Khan recently that the academic environment is really great for discovery received a Governor General’s Award for his work transcending but it’s not always timely. The ability to get information clinical medicine, public health, big data, and artificial intelligence. out and disseminate it and so forth can be slow, and can take months, and when you’re dealing with an emergency like the one we are currently dealing with you don’t have UTMJ: We’re wondering if you could take us through a bit of months, you really have maybe hours or days to make de- your journey of how you came to do research in infectious cisions, and so it led me down the path to take a leap of disease and human migration. faith and to actually create a digital health company. I am not a serial entrepreneur. I don’t have an MBA. I did not KK: I’m a U of T grad and I did my specialty training in in- go to business school. But I am a pragmatist and I really fectious diseases and in preventive medicine and public wanted to tackle and solve a problem. And so in this case health, so I trained on both those two fronts. I have always making use of big data and advanced analytics and digital been interested in the issue of human migration and travel technologies and really driving innovation both in public as it relates to infectious diseases... As a scientist, I have health and healthcare was something I thought was really been studying and practicing clinically managing diseases very important, and I wasn’t convinced that it was going like tuberculosis for the last 20 years almost, and that has to happen through the public sector or the academic sec- been kind of an ongoing area of interest. But I will say tor in a way that was really moving quickly and that was that after starting my career in Toronto at St. Mike’s back scalable. So, MARS supported me with some seed money in 2003, we had the SARS outbreak back then. That was to get things started, helped me get the company founded a pretty eye opening experience seeing some of our fel- back in 2013. It was just me back then, [but] we’re over 40 low health care workers get infected... one member of our people now and a mix of physicians, vets, ecologists, engi- division got infected, and so seeing it through that lens, neers, data scientists, software developers, designers, and having it hit close to home, seeing our hospitals over- we’re really just an eclectic mix of people that are mixing whelmed, our public health system overwhelmed – there our skill sets to tackle some of these challenges. We have

UTMJ • Volume 97, Number 2, March 2020 53 Interviews

Interview with Dr. Kamran Khan

been working in this domain for the last 6 years and have a typical path. I think what is really important is that one, built and are continuing to build a digital platform that we academics and scientists and others at the university un- sort of dub a ‘global early warning system for infectious derstand that this is an option and two, that the hospitals diseases’ that is using artificial intelligence to help us con- and the universities really accommodate. And I wouldn’t duct surveillance of infectious diseases around the world even say accommodate is the right word here! When we and doing it in a very scalable and timely manner. We are talk about innovation, well what does it mean? It is ulti- connecting data sources from the entire world’s air travel mately about doing things better, and sometimes the struc- and not only picking up where diseases are but trying to tures and mechanisms that are in place just don’t fit. And anticipate where they may disperse to different parts of so I think it is important for the university and for institu- the globe. We are doing this not within months but re- tions to be able to recognize that we cannot operate in a ally within minutes. That’s a little bit of the journey from square peg round hole mindset. We have to be able to first being a clinician and scientist to a somewhat accidental ask ‘what is the mission?’ and then enable the mechanics entrepreneur, or somewhat serendipitous entrepreneur, to facilitate and enable the mission, rather than the other certainly not by design but more just by necessity, solving way around. It’s the opposite from someone saying: here a problem. are the mechanics, fit within the mechanics and try to make something happen just because that’s how we have UTMJ: We’re wondering how your roles as a clinician, researcher, always done things. That is ultimately about innovation, and entrepreneur intersect. And you mentioned you don’t not only from a scientific, health and medical standpoint, have a business background, you aren’t a serial entrepre- but it requires innovation from the university and hospitals neur, so have there been challenges with becoming an en- as well. trepreneur having a medicine background? UTMJ: That is a really interesting perspective. I feel like we should KK: No, I don’t think so but I will say the following. I’ll share a ask you at least one question about the coronavirus since cheeky little story that’s in our household which is, I’ve got it’s timely! We were wondering what your thoughts are twin boys who’ve just turned 11 and a year ago they asked about the current situation - do you think that we are me “Hey dad who’s the smartest person at BlueDot?”, and more prepared if it escalates to the level of SARS than we I said, “You know, it’s not how smart you are, it’s how you were 17 years ago? are smart.” And so, I added, “I don’t know the answer to that,'' I mean because you know our designers are bril- KK: I am going to say we are definitely better prepared. The liant, and our clinicians are brilliant, and so I don’t even difference between where we were 17 years ago is we think that that makes sense. And it’s the diversity of skills didn’t even know what SARS was until it showed up in our that become important. What I think is important as an hospitals and in our cities. Today, the difference is we are entrepreneur is to be self-aware of what your limitations waiting for its arrival. We have been waiting. And that’s a are, what your strengths are, and play to your strengths big difference between being caught flat footed and antici- and surround yourself with a team that has a diversity. pating and being ready. We have clearly come a long way And I don’t mean it just in terms of racial or ethnic diver- in that regard, with better systems to detect outbreaks and sity but really a diversity of skills and diversity of perspec- threats and to communicate information, so there have tives and ideas, and to bring those together so that you can been some improvements in that regard. But we have a tackle problems that are complex, that you yourself can- formidable virus and we are going to have to see how this not tackle. I have something to contribute as a physician plays out in terms of our ability to control and contain it. and as a scientist, but I can’t contribute everything. And then the other is to surround yourself with people who can UTMJ: When you say that we are more prepared for it, what kinds really make smart decisions, who have expertise in com- of things make a hospital or health care team more pre- mercialization, who have expertise in business. Ultimately, pared aside from anticipating the arrival of a pathogen? for me this is about creating an entity and a company where I can infuse my values about why the company was KK: From the lessons from SARS, there are lots of operat- created, what is its mission, how it is trying to not just do ing procedures that have been developed to basically well, but do good – not lose sight of that, and then bring run through these types of exercises. We have had other the diversity of skills around to make sure that we can instances like the Ebola outbreak where we have had to achieve that goal. think about personal protective equipment and infection Perhaps what I would say is that I think within the aca- control precautions. I think in many ways the infection demic environment, being an academic clinician, a pro- control precautions and procedures have evolved and im- fessor, and an entrepreneur is a little bit unusual–it’s not proved because the real key when we are dealing with this

54 UTMJ • Volume 97, Number 2, March 2020 Interviews 

Interview with Dr. Kamran Khan

type of spread of infection is preventing one case from be- they can protect themselves, their patients, and prevent an coming ten or a hundred cases. And that means quick de- outbreak in their hospital. This is ultimately what we are tection and recognition of a disease, and then appropriate trying to do at BlueDot. We are better prepared, but we isolation precautions to prevent its spread. This is what we have a lot of work still to do, because the problem is not are doing at BlueDot and I feel like I would need another going away. The problem is only becoming more signifi- 20 minutes to explain what we are doing, but we are basi- cant over time. cally trying to create more astute clinicians. It is impos- sible for a clinician today – whether a doctor or nurse or UTMJ: Following up on that, what is the future direction and next someone else – to have a global understanding of diseases. goal for BlueDot? When I was at U of T [medical school] I think I got a day or two of tropical medicine maybe in my entire four years. KK: I would say in the near term, our next big goal is to em- With this, would someone be able to answer a question bed our technology into hospitals and to front line health like “tell me the map of dengue fever and chikungunya care workers for the reasons that I described because they and typhoid and malaria and yellow fever and on and on, need to be able to protect themselves, and they need to what do those maps look like?” Someone couldn’t possibly be able to better protect patients, our hospitals, and our do that. If I were to ask someone to tell me about every communities. Up until now, we have been working largely outbreak that is happening around the world, whether it’s in the public health areas, but we think that these insights an outbreak of Lassa fever right now in Nigeria or the and this intelligence now needs to be reaching the clini- Ebola activity in Uganda or hemorrhagic fever also in cians. This is because a sick patient does not go to the Uganda – someone would not be able to remember all public health department, they go to the emergency de- of that. Neither can they remember the incubation pe- partment. And the question is, will that clinician on the riod for every one of these pathogens. It is impossible. So front lines recognize that first case? Or will they end up we need to be using data technology to be creating more getting infected in the process leading to all of the things astute clinicians and empowering our front line clinicians that I just mentioned. That is our next big goal and what because they are a big part of the difference between one we are doubling down on – bringing this intelligence from case of the disease in a traveler and an outbreak that can that panoramic view in the public health arena, down to affect an entire city. It also is important that we do that so empowering the clinician right on the front line.

UTMJ • Volume 97, Number 2, March 2020 55 Interviews

Interview with Dr. Eileen de Villa

UTMJ Interview Team (Imindu Liyanage and Kathleen Simms)

r. Eileen de Villa is the and foremost. The second objective is that in improving City of Toronto’s Medical the health status of the population, it’s our job also to Officer of Health. She leads reduce disparities in the health of that population. DCanada’s largest Public Health agency, Finally, and this is the one that I think most people are serving nearly 3 million Torontonians familiar with, public health prepares for, and responds to with essential health and preventative outbreaks and emergencies. So, improving health status, medicine programs. Dr. de Villa reducing disparities in health status, preparing for and further serves as an Adjunct Professor responding to outbreaks and emergencies; those are the with the Dalla Lana School of Health three major objectives of public health. at the University of Toronto, where she previously graduated with both UTMJ: From your expertise in working with public health, how Dr. Eileen de Villa her Doctor of Medicine (MD) and does it work to achieve those objectives? Master of Health Science (MHSc) degrees. She also holds a Master of Business Administration (MBA) from the Schulich DV: In many and mysterious ways. I think we work in a School of Business. wide variety of areas, but I think that when we look at Dr. de Villa is a tireless advocate and practitioner of public those objectives, it becomes very clear that we have to health. She has presented and published research on diverse know what is actually driving health in the population, topics in the field – ranging from infection control to city planning. what are the factors that are influencing the health She has also earned numerous commendations for her leadership status of the population, and what might actually be and educational roles – including the honorific: ‘the people’s driving disparities in health status. So, there is clearly doctor’ by a major Toronto news agency. a surveillance and epidemiology component to public health - we have to understand what is the health status of our population, and what’s actually contributing to it. UTMJ: Dr. De Villa, what is public health? I think the other part of public health is that because we’re talking about what drives health, and we know that DV: Well that’s a great question. Public health is, first and the vast majority of that which determines health status foremost, the most fascinating branch of medicine there has to do with the social determinants of health, we have is; and I don’t say that just because I happen to practice to assess and evaluate these factors on an ongoing basis. in public health and preventative medicine. I say that, As important as healthcare is, and as important as access because it covers this broad range of subjects that have to healthcare is, even more important are the social direct impact on everybody’s, everyday lives. If you determinants of health. look at a textbook definition of what public health is, When we look at what creates and maintains health. you’ll probably see something like, ‘public health is the We know that healthcare accounts for 20-25% of art and science of promoting health, preventing disease health status, biology and genetics accounts for 10-15% and prolonging life through the combined efforts of (something in that range) - but it’s something in the range society’. I’ve always been fascinated by that definition of 60-65% that is actually determined by the social because it’s interesting, but I’m never really sure that it determinants of health. Things like income, housing, actually answers the question in a meaningful way for employment, education, social connections, sense of most people. belonging, and all the elements that go into civic and So, when I think about public health, and when people municipal infrastructure (air quality and environment ask me what it is we do in public health, I find it’s better for example). All these kinds of factors are really what to talk about our objectives. What is it that public health determines and give an individual’s health status – and is meant to do? What is it that we’re seeking to achieve? more importantly from a public health perspective, a And when I think about public health in that way, I population’s health status. actually think about three major objectives. The first is So, with all those drivers and factors as the areas in to improve the health status of the population, that’s first which public health needs to work on, you could well

56 UTMJ • Volume 97, Number 2, March 2020 Interviews

Interview with Dr. Eileen de Villa

imagine that what it is that we do varies depends on and affordability have just gotten worse. So I anticipate, what the subject is. Sometimes, it’s about delivering unfortunately, that this number has increased in the last immunization, sometimes it’s about case management year and a half or so. in instances of communicable disease and sometimes it’s We know that there are chronic disease issues, major about sitting in front of legislatures or decision makers to chronic disease issues, whether it’s diabetes, obesity, try to advance policy (smoke-free policy, housing policy, heart disease, these are certainly issues that we need income policy – those kinds of things). It’s an endless to be mindful of; but I would be remiss if I didn’t talk variety of areas of practice that public health ultimately about the impact of two more things;1 mental health. We gets into. know that there are significant mental health challenges I think that’s what makes public health so fascinating; experienced by large swaths of our populations. We’re we’re working in different realms, and that the results of alarmed to see what is happening amongst young our work are visible in the everyday lives of the people people’s stress levels, manifesting themselves in such who live in the jurisdiction that you serve. actions as suicide and self-harm; and these are important discussions to be had.2 I think we need to think very UTMJ: You mentioned a couple of different components of seriously, and act on issues relating to climate change public health, but what are the greatest challenges that and their impact on health. So these are just a few of the you see facing public health right now? items, if you allowed me more time, I could probably go on for much longer, but just to give you a sense, those are, DV: What I find fascinating is that our population is changing I think, some of the greatest challenges that are in front so quickly, and as a result, its needs and its health needs of us right now. are changing rapidly as well. But if you’ve had any opportunity to spend any time in Toronto, and have UTMJ: So, it seems public health is a very upstream intervention. had the chance to look through the news and to observe what’s happening out on the streets, there are clearly a DV: The dark side of public health is that we want to be number of issues that are influencing and impacting on upstream, we wish to be upstream, but frankly there is so the health of the population. Certainly, in the talks that much that is going on right now that I do feel that we get I’ve given, I’ve spent quite a bit of time in the last two pulled downstream more than we would like to. to three years on the issue of the opioid overdose crisis. I will tell you this, I think the other very interesting I have given many talks on how that may very well be thing is that because we are health professionals, and that the defining health crisis of our time. It is a significant because we work in an environment with a lot of other issue [and] continues to be a very significant issue here health professionals, we have to recognize that there is in our city and in fact, throughout Canada. We know a certain satisfaction out of actually doing downstream that in Canada, we’re losing one person every 2 hours activities. There is something extremely satisfying, from to preventable death as a result of the opioid overdose a professional perspective, to see somebody who has a crisis. So, this certainly is an important issue in my mind. particular challenge and offer some kind of individual Also looking out on our city, particularly over the solution, in the context of a one-on-one relationship. last two years or so, not that it wasn’t an issue before, At a human level, that’s profound. We’re just as human but we’re certainly seeing some acceleration in the last as any other healthcare practitioner of any kind, so we few years: homelessness and under housing. Housing sometimes want to do that – and most of us come from a is a major determinant of health. We’re seeing huge clinical background. numbers and huge increases in the numbers of those Remember, public health and preventative health who are experiencing challenges with housing, and who specialists are physicians. You go to medical school first, are outright homeless. When we look at the data here where all your training is within the context of a clinical in Toronto, the last Street Needs Assessment reported setting – to start of with anyway. Then you start to move on one given night, in the Spring of 2018, the count on to the realm of public health. The largest group of homeless people and under housed individuals in the professionals we have here, as in most local public health city of Toronto was in the range of about 8,500. Those units, are nurses. They also train within the context of a counts include those who are within the shelter system or clinical environment and in a school where most people were countable within the downtown core. I’m sure there go on to do individual level care. So we get steeped in were others who were not accounted for, so my sense is, this environment where we get our sense of self efficacy and I’m quite certain that this is correct, that count is and our sense of value as a professional from largely an underestimate of that which existed at that time, and individual interactions. It takes a different kind of mind I know that the circumstances with respect to housing set and an ability to sort of step away from that to say,

UTMJ • Volume 97, Number 2, March 2020 57 Interviews

Interview with Dr. Eileen de Villa

actually we’re going to work at the population level, and health. So one has to wonder about why there is such a our benefit may not be seen today and it may not be maldistribution of the resources available; if we know seen tomorrow, and it may not even be seen next year. what really contributes to health, why are we putting so We have to wait 10 years on the short end, and 40 – 50 much in those areas of health that we know can’t possibly years sometimes on the long end, before we really see attribute for that much, in respect of total health? That’s the results of our work; particularly if you’re focusing on not to take away, by any stretch of the imagination, prevention. from the importance of healthcare. Healthcare is Also, what happens when prevention works? Looks important, access to healthcare is significant; it’s just not like nothing, nothing happens – because happy, healthy, as significant to overall populational health as the social thriving people don’t look like a ‘something’. It looks determinants of health. like nothing is happening, but as I’ve told many people, it’s probably the most valuable nothing there is. No UTMJ: How can medical students can get involved in this larger outbreaks, no disease or delayed disease, it kind of looks conversation? like nothing, so it’s not always an easy sell to make, either to decision makers or to professionals. DV: There are many ways that medical students can get involved. I think being engaged citizens, first and UTMJ: In the context of discussing the challenges to public foremost, is probably the chief way that medical students health, could you share why you think that cuts to public can get engaged. My sense though is that as a medical health are detrimental, and could be dangerous? student, your primary goal right now should be focused on the studies to become a medical doctor, and for the DV: I think the issue is fundamentally related to what vast majority of students in medical school, that means actually determines health. So we go back to what we practicing within the realm of clinical medicine. But were talking about earlier, and it is around the social there is also a role and a value, in terms of understanding determinants of health. While those social determinants how the experience of an individual patient actually of health are not exclusively the purview of public rests in a broader context. So yes, it’s a little bit about health, we do have a significant role to play in terms of the medicine, yes, it’s a little bit about the interpersonal influencing and informing decision makers and actors. relationship and the nature of the care that is provided; Take the provision of housing. We have the opportunity but in order to actually deliver the best healthcare, one to work with city planners and to work with housing has to be cognisant of the social circumstances – the real providers, and with housing officials within the context life circumstances, not just what we see in the clinical of municipal government. So we have some role to play setting, but what it means when that patient goes home. there, here at Toronto Public Health, we also have the Absolutely, you need to learn the medicine, because that opportunity to interact with people who have purview will be the focus of the vast majority of evaluations, over income, so we have the opportunity to speak to the but what makes a great physician is somebody who need for sufficient income – whether it’s through Ontario understands the context of the individual patient that Works, or whether it’s through the Ontario Disability they see in front of them, and then goes a little bit Support Programs. beyond. I think that if we agree and believe and know, that So, ask yourself, what can we do as a profession to those are the elements that actually provide for better change those circumstances more broadly, not just health for populations, then taking away funding from for that individual patient, but perhaps for the entire public health impedes the capacity of public health to patient population? So a little understanding of what’s do that which it needs to do in each of those arenas. happening at the individual level, and where possible, I think that another interesting thing, from an Ontario thinking about what can be done at a broader level so context in particular, is that when we look at the Ministry that it’s better, not only for that individual patient that of Health’s budget, it is in the range of $60 billion, that’s you have in front of you, but for the next several patients, ‘B’ billion dollars. As it turns out, the proportion that whether their yours or whether their somebody else’s, in actually goes to the entirety of public health, including another clinical setting. provincial public health, actually eats up a very small proportion of that. At times, it has been as high (I UTMJ: Thank you for sharing your expertise about public health, believe) as three-ish percent. At this current point in and thank you from the University of Toronto Medical time, last I checked, we’re roughly two percent of the Journal for sitting down and sharing your experience. entire ministry budget. But we’re the actors that have the potential to influence on that 65% that influences DV: Thank You.

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