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Flashcards in final Deck (115):

Being mortal reading

- 1991, Bill Thomas working as medical director at Chase Memorial Nursing Home
• Bill Thomas had oppositional defiant disorder
• Went to SUNY Cortland (state college) for the good times → did well, ended up being their first student to go to Harvard med
• Had ideal of self-sufficiency and conditions at nursing home contradicted his ideals → believed good life is independent
• 80 severely disable residents; Half were physically disabled; 4/5 had Alzheimer’s or other cognitive disability
- Found nursing home depressing → resident devoid of spirit and energy


Thomas’ proposal attacked the 3 plagues of nursing home existence:

1) Boredom
2) Loneliness
3) Helplessness
- 3 plagues are social, not very measurable
- Proposal included 2 dogs (1/ floor), 4 cats (2/floor), 100 birds, changing all fake plants with real ones, a garden
• Program called “Eden Alternative”
- Thomas wanted “Big Bang” → bring in everything at once
• Pandemonium → birds came before cages, then cages came, but were not assembled


Complications with Eden alternative

• Nurses did not want to clean up after the animals
• Eventually everyone decided to work together on the task of bringing life into Chase → worked, noticed difference in residents


Results of Eden alternative

• Number of prescriptions required per resident fell to half of control
o Psychotropic drugs for agitation decreased
• Total drug costs fell to 38% of comparison facility
• Deaths fell 15% percent
o Thomas believes difference in death rates is due to fundamental human need for a reason to live
- Story of Mr. L - Doesn’t want to eat or get out of his chair, arrives at same time as birds, eventually starts talking to staff telling them about what the birds like, offered to walk dogs, 3 months later he went home
o He came out of depression


Conneticut nursing home - 1970s

nursing home gave each resident a plant
• Half told water it, other half told it was staff duty to water it
• Half with responsibility → more alert, active, appeared to live longer

- Mr. L lost wife and home, sent to Chase, depressed, then started caring for his bird, program helped him → he was discharged 3 months later
• Boredom → offers spontaneity
• Loneliness → offers companionship
• Helplessness → offer chance to take care of another being


- 1908 – Josiah Royce, Harvard philosopher wrote book “The Philosophy of Loyalty”

• We all seek a cause beyond ourselves → was an intrinsic need; gave life meaning
• Transcendence → above self-actualization in Maslow’s hierarchy → transcendent desire to see and help others achieve their potential


Newbridge on the Charles → old home in Boston suburbs

• Divided into pods (called households) with no more than 16 people
o Less than 20 people = less anxiety/depression, more socialization, increased sense of safety
• Shared grounds with private school kindergarten – 8th grade


3 concepts of autonomy

1) Free action – living independently, free of coercion and limitation
2) Freedom to be authors of our lives – Ronald Dworkin
o Want to retain freedom to shape our lives in ways consistent with our character and loyalties


Pain vs suffering (social determinants)

- Pain: - can measure/ evaluate to a degree
1) Highly unpleasant physical sensation caused by illness or injury
2) Mental suffering or distress
- Suffering: - state of undergoing pain, distress, or hardship
- Suffering is broader
 socially different; has a more social origin, pain is more medical term
 shaped by what is considered a hardship
 emphasis on experience and perception of pain


Loneliness and social isolation

 Loneliness – subjective perception of isolation – the discrepancy between one’s desired and actual level of social connection; quality over quantity for relationships
 Social isolation – few social connections or interactions; objective
 More of us living alone and growing old alone
 We value our privacy and independence
 In Guinea, no one is homeless, unless they have a severe mental illness
o Anyone that is distressed will be taken in
o Muslim ethic to take people in, take care of them and make sure no one sleeps on the street


Social isolation: an objective risk factor - Impacts?

 Impacts on ability to self-regulate
o Comfort foods (sugar, fatty foods) can access the pleasure centers of the brain, which can help people who are suffering from social isolation
o Alcohol can make you feel better, and self-harm can dull the pain
 Impacts on biomarkers
o Stress hormones, inflammation, blood pressure
o Chronic inflammation = Increased RISK heart disease, stroke, type 2 diabetes, suicidality


Loneliness - subjective - Impacts?

- Impacts autonomy by eroding ability to perform basic tasks of living – results of study over 6 years with 1604 adults
o Correlation between self-isolating and stress hormones and blood pressure increasing and chronic inflammation – can lead to chronic heart disease, type 2 diabetes
o Compared those who identified as lonely and those who did not
- Those who identified as lonely had more impacts and were usually the elderly
- Elderly of 65+
- Harder to get out of bed, other basic tasks of living harder
- Sleep disruption leads to inflammation and increases risk of heart disease and immune response
- Autoimmune disease and feeling lonely = disease can get worse


3 wishes project - Debra Cook - ~6 yrs ago

- Objective: bring peace to the final days of a patient’s life and ease the grieving process
- ICU introduced in 1980s – ideally brought into ICU to treat you until you move to a different section
 Not created for dying
 Suffering of surviving family members higher after death in ICU versus hospice care
 Intensive care specialists increasingly involved in dying
- 65% Canadians will die in hospitals
- Patients state their 3 wishes before they die so they get a say and eases the grieving process
- Personalized approach to care


Indian horse - reading

story of boy who's brother is kidnapped and taken to a residential school, comes back with TB, dies
- more details in your notes
- Richard Wagamese; Oct 14, 1955 – March 10, 2017
• Ripping apart of family → symbolic of ripping away from family structures and culture that is due to colonialism



- Sum of total habits and expectations
- Shared, symbolic, learned, dynamic (not static)
• Constantly changing; reproduced in day-to-day interactions
• Intergenerational – passed on from parent to children
- Culture is system/ collection of values, practices, norms, and ways of being and experiencing the world
• Shared amongst group of individuals


Culture is learned implicitly and explicitly

• Told what success/ failure is, good/ bad
• Certain foods are cultural
• May react differently to certain things (e.g. how women dress, what is normal)


Iceberg theory of culture

- proposes that 9/10 of culture is not seen
o Most of what we think of culture is at top of brain, but a lot of things we don’t realize about what we’re doing that are based off of what we learned and our culture
o Don’t learn them, but acquire them as we grow up; learn what we think is fair and what is not fair
o Tip of iceberg: clothing, food, language, rituals
o Rest of iceberg: unconscious rules, assumptions, fairness, ethics, conception of justice, definition of sin
- Culture shapes experiences of illness, healing, death, dying, and care


2 main reasons to pay attention to culture in healthcare

1) Understand distribution of disease
o People grow up and learn certain behaviors and practices that they view as normal or not harmful (e.g. smoking, teen pregnancy)
o Understand values, practices, and family structures that are acting as barriers to improved health outcomes
2) If do not pay attention in multicultural Canadian society, will not provide good care → suboptimal care
o Respect people’s rights to cultural beliefs _________________
o Affects how people report and express their symptoms
 E.g. Latinos express pain symptoms in stomach cancer differently
o Women will say they have an “ache”, which delays testing and diagnosis
o Men say pain feels like dying
o They experience the pain differently
o Maybe social norms where women are not used to talking about their pain and suffering; women maybe more used to getting cramps
o Hindus don’t want to take pain relief because they believe that they are supposed to experience them → because of something in their past life, or a test resulting in a better outcome in their next life


How culture impacts patient/ family

- Responses to symptoms, naming of symptoms
- Meanings attributed to illness, treatment, dying
- Communication styles:
• Emotional expression
• Deference vs active engagement
• Difficult family → maybe family is grieving loudly, but that may be how they think they are expected to act because of their culture
- Decision-making processes, treatment decisions
• Telling the truth → patient may not want to tell family to protect them and decrease stress → encouraging them to tell family
• Patient decides who gets a say in their treatment
- Medical info preferences
- Culturally competent care means patient-centred care
- Case with Jehovah’s witness where parents denied their child a blood transfusion after an accident and killed child


How we as a culture perceive aging and dying = a social determinant of health

- Different diseases/ illnesses are not seen the same way around the world
- Breast augmentation/ reduction more common because of our society, not the boom of cosmetic surgery
- Sex realignment surgeries are possible and paid for by Canadian government


Social suffering

- Geographies of suffering are uneven and connected to inequalities
- Structural violence – violence that is not acutely experienced as physical; structural violence is systematic inequalities that harm people’s sense of well-being
• Back and forth between how you feel psychologically and what happens physiologically
• Lots of impacts from chronic stress from daily life
• Social suffering term introduced 30-ish years ago by anthropologists
o Perceptions of pain is never equally distributed in society
- Feelings of suffering are experienced disproportionately → people who are economically marginalized feel it more

- Suffering that is lived as a collective rather than individual reality
- Linked to living conditions and/or socially entrenched
- Wounds individual and social body at once


Social stresses somatized = written on body

- Sickness as a “language of the organs through which nature, society, and culture speak”
• Anthropologists Margaret Lock and N. Scheper-Hughes 1991
- Soma – Greek for body
- Social stresses are written into and onto the body
• Do not just embody your culture, also embody stressors in your life
- Illness does not reside in your body → also impacts people close to you
• Someone in household with depression = affects others in household and close ones
- Distribution of fear, pain → all are forms of suffering; reflects inequalities in access to resources, socials status, and burdens of work
• Less time to relax, restore your body, sleep → layers of problem take bigger toll on your body


Suicide and first nations

- Suicide and self-inflicted injuries are the leading causes of death for First Nations youth and adults up to 44 years of age
• 2nd cause of death in Ontario for this age group with car accidents being first
- Rate of suicide for First Nations male → 126/ 100 000
• 5 x national average
- Rate of suicide for First Nations female → 35/ 100 000
• 7 x national average
- Rates can be up to 12x higher in the North and Nunavut
- Called a health crisis/ emergency in the North
- Social determinants approach to suicide in indigenous communities requires attending to:
• Historical significance
• Food insecurity → has psychological impact and has link to colonialism
• On reserves → social separation and segregation as well as sense of being other; discrimination and loneliness → get internalized and can add to suffering


social determinants approach to suicide in indigenous communities

- Direct and indirect trauma of colonialism
- Suicide as a means a form of communication and connection in the face of limited other opportunities



- Policy or practice of political control over a territory, occupying it, and imposing control over its native population through cultural, economic, and political domination



- Like 2-3 suicides per month in Nunavut → started tracking suicides in 1980s
• Do have to do with colonial history of various practices _______
• Canada’s North → Mid 1800s to early 1900s – “first contact”
o Trading and stuff began, Canadian dominion claiming ground
o People continued living in nomadic groups
• 1940s → some resettlements started by Hudson Bay companies for → people would get houses for people who were able to trap animals that they wanted the fur of
- Nunavut population → 35 944
- Western population → 28 828


Canada’s North & Government Era (1950s – 60s)

- Forced relocations to white-run settlements: from Northern Quebec to High Arctic
• Inuit people lost their rights to occupy lands in Quebec and told to resettle in the North
• Only 50-60 yrs ago had to relocate because no longer had rights to their land and traditional fishing and hunting grounds
o Moved to places that were colder and darker; not adapted to it as well; given homes in government run towns
 Important to government for 2 reasons:
1) Because govt had growing service in north
2) Important for them to colonize a bit of the north
• Inuit also part of the colonization of the north because they settled into areas that were not settled


Impacts of government era

- Housing changes and traditional family changes
- Hunting and trapping impacted:
• Dependency on selling to fur traders for goods
• Impact on nutrition
• Rise of alcoholism
• Loss of traditional status & authority
• Loss of connecting cultural knowledge


Residential schools

1879 - 1996
- Forced them to go to residential schools; tried to avoid them, but sent to the settlements and if they wanted to work with HBC, they had to stay in settlements and go to residential schools
- One of the most destructive tools fashioned by the federal government in its attempts to forcibly assimilate Aboriginal people
- Food and nutrition is changing
- Biggest loss → loss of intergenerational transference of cultural knowledge
• Children taken away from 4+, taken away from family, not allowed to speak traditional language or learn family practices → when emerge (sometimes 20 yrs later), don’t feel like they belong in their communities
- Residential schools mostly catholic or protestant → taught Christian god
- Control population and try to socialize them into Canadian values
- Get home → don’t identify with their parents; happens for multiple generations
- No choice in attendance; law that children had to attend
- Inuit children who lived too far away had to stay at school during the summer
- Using children to undo the “savageness”


Civilizing mission

- Language
- Religion
- Dress
- Survival off land is lost


Big impact: family

- Separations – intergenerational segregation
- Loss of ungayuq – affection/closeness
- Loss of Naalaqtuq – respect/obedience (trad. age-based)
- No clear belonging


Fractured worlds
and anomie

= Equals stigma, poverty, loneliness, depression
= (in some cases leads to) depression and suicide

- Anomie - a condition of instability resulting from a breakdown of standards and values or from a lack of purpose or ideals
• Colonialism produces Anomie


Widespread social suffering made visible through youth suicide

- Unlike diagnostic psychiatry, social perspective considers how symptoms might be response to difficult situations and circumstances
- Suicide can be used to express anger, helplessness, hopelessness
• Also a way for youth to connect to each other → many lose friends/ siblings to suicide; get to reunite with friends when you commit suicide (act of solidarity)
• Grant meaning to life that feels meaningless
- Improve by
• Try to find another way for them to feel connected to their friends
• Residential schools → sense of loneliness in their age group
o Youth considering suicide, would isolate themselves → no connection/ cannot identify to their family
o Work with this need for belonging across generations and age groups

- Suicide in Inuit is not solitary act, not psychoses
• People are suffering from depression, but issue of suicide is more complex → rooted social environment that is historically specific to Canadian North


Causes of social suffering in first nations runs deep

- Forbidden traditions, language, clothing
- Shame, inter-generational segregation, lost sense of
belonging and self
- Feeling misunderstood and disposable
- 1181 documented cases of missing or murdered Aboriginal women in Canada from over the last three decades
- Lost ways of life and self-sufficiency
- Poor living conditions
- Widespread health problems: Addiction, violence,
suicide, depression


Importance of communication for healing

If illness can be narrated or given a place in a story bigger than oneself, it may feel less of a burden to the individual and easier for others to recognize and
respond to distress


Importance of symbols in illness and healing

The meaning of a symbol is not inherent to any object or practice - it is culturally specific

- Actions or objects that are experienced as meaningful can support healing as social actors and our bodies respond to
symbols and the meanings they carry for us: comfort, connection
to an ethnic or national identity, connection to the sacred,
power to heal


What is it about dance competition in Nunavut that is healing?

- Building pride in community
- Sense of belonging and contribution to the life of the
community (counters social isolation/loneliness)
- Physical activity=improved mental health
- Awareness / education


Importance of symbols in illness and healing

The meaning of a symbol is not inherent to any object or practice: it is culturally specific

- Actions or objects that are experienced as meaningful can support healing as social actors and our bodies respond to symbols and the meanings they carry for us: comfort, connection to an ethnic or national identity, connection to the sacred, power to heal


Social suffering runs deep

Internal +
inter-personal within a group+
relation of group to wider society+
structural/institutionalized norms

Requires change at all levels


Loss of health through pesticide exposure

- Health as a resource that impacts on one’s abilities to adapt to and respond to life’s challenges
- Health as one determinant of personal potential: impacts on one’s ability to pursue goals, education, and control one’s life
- Health as capacity to fulfill social roles


Circle of poison

“refers to the export of domestically banned
pesticides for use on foods elsewhere, some of which
returns by way of import.”

- The "circle" is complete when the toxic chemicals that
were exported are then used to grow fruit, meat, and
produce that are imported and available for domestic
consumption. This circle was first identified relative to
the United States but the relationship also exists
between other nations of the Global North and South



a course of action that guides decision-making in an area of government
- Origins Old French – policie: “study or practice of government; good government”
- structures social relations and/or the distribution of resources in a given society
- reflects and reproduces dominant values


Historic control of toxic chemical policies in Global North

None until late 1960s
- Circle of Poison Prevention Act (1991) did not pass in the U.S


Chemical bans in GLOBAL NORTH not
extended to GLOBAL SOUTH include

- Endosulfan - organochlorine insecticide and acaricide
- Nemagon (DBCP) – soil fumigant banned in the U.S. 1979, exported until late 1980s until lawsuits emerged
- DDT – banned in U.S. in late 1960s while used worldwide


Structural inequalities

are reproduced intentionally or unintentionally in society, through the routine under-representation of certain groups in positions of power and decisionmaking,
as well as through historically entrenched patterns of unequal distribution of and access to resources (health, economic, education, land, rights)


Friedrich Engels

- political economist studied how poor housing, clothing, diet, and lack of sanitation led directly to infections and diseases associated with early death amount working people in England


Rudolf Virchow

identified how health-threatening living conditions were rooted in public policy-making and emphasized role that politics played in promoting health and preventing disease
• Known as father of modern pathology


1980 publication of Black Report and 1992 publication of Health Divide

• Described how lowest employment-level groups showed greater likelihood of suffering from wide range of diseases and dying prematurely from illness or injury at every stage of life cycle
• Health differences emerged at end of WW2, even though UK has universally accessible health care system
• UK is source of many ideas on how to apply these findings to promote health


Social determinants of Health

– economic and social conditions that shape the health of individuals, communities, and jurisdictions as a whole
• Quantity and quality of resources society makes available to its members
• Health how society organizes and distributes economic and social resources → improve it by directing attention to economic and social policies
- Term “social determinants of health” debuted in 1996 in Health and Social Organization: Towards a Health Policy for the 21st century


Health of americans vs other industrialized nations

- Health of Americans compares poorly to the health of citizens in most other industrialized nations
• This is case for life expectancy, infant mortality, and death by childhood injury despite US’s overall greater health


Prereqs for health

- Ottawa Charter of Health Promotion identifies “prerequisites of health” as peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice, and equity
• Prereqs are concerned with structural aspects of society and organization and distribution of economic and social resources
- British working group defines social determinants as social (class health) gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transport
• More grounded in everyday experience of people’s lives and policy making structures


Drones to provide healthcare in rural areas

provide healthcare to those who live in off-grid, remote parts of the world
- Flew blood samples from rural Madagascar to a central lab
- Made by Vayu – company founded by Daniel Pepper
Aim → bridge gap between far villages and
healthcare that is available, but out of reach for local
inhabitants → prevent unnecessary deaths and
o Took 2 years to develop drones
o Came up with idea when working as journalist in India → saw it was difficult for people to get to hospitals because of weather/ terrain/ etc.
- Company called "ZIPLINE" doing soemthing similar - first remote delivery of drone blood products in Rwanda


Issues with using drones in healthcare

- Difficult because countries have bans for drones → Vayu has to work with national governments to overcome bans
- Drones are more efficient when flying forwards than when hovering, however because no landing/ take-off strips, must hover
- Vaccines only useful if village health workers can administer them, and diagnoses only made if samples are taken in sterile conditions and packaged correctly
• Village health workers are trained to identify prolonged coughs and send for drones to deliver TB testing kits
• At lab, drone will fly back with meds if the sample comes out as positive; will also have video to give people instructions so untrained individuals can give the treatment


Tuberculosis (TB)

- greatest killer amongst Infectious Diseases (ID)
* used to be HIV; now many who die of TB have HIV
• > 10 million active cases 2016
• >1.4 million deaths
• India 27% of TB caseload globally; highest in India
• Pulmonary or extra-pulmonary


Recommended treatment of TB

• 4-9 months for standard TB
• Pill or injection of minimum 2 anti-biotics usually once a week
• Directly Observed Therapy (DOT) - WHO put forward if you want to tackle TB → ensure people are taking meds on time → otherwise completely ineffective – very sensitive to being derailed
• Rest and healthy food
• GO to healthcare professional that watches them take it → helps if they need it


Commonly cited barriers to TB control

• Hard to control
1) Stigma → low knowledge; believed if you get TB, you will die → because that is all they see
- Associated w HIV so stigma → HIV w promiscuity
2) Access - Geography → many communities live far away from health care centre
- Need to diagnosis – not obvious to take TB test, or not available in their community
- Given one month of treatment at a time → need access to place that will give treatment
3) Access - Cost
4) Diagnosis and care expertise
5) MDRTB (multi-drug resistant TB)


End TB strategy

Adopted by World Health Assembly in May 2014
• 2035 target: 90% decline in TB incidence
• Tb incidence going down 2% a year → prob because free meds and follow up
• Need 5% decline a year to meet the 2035 target

• Funding: World Bank, Bill & Melinda Gates Foundation (BMGF), the Global Fund to fight HIV/AIDS, TB, and Malaria
- Bill & Miranda Gates → now TB meds is available free in many countries
• Because public health threat → want your people to have access to these meds


3 Pillars - TB

1) Integrated patient-centred care and prevention
2) Bold policies and supportive systems
3) Intensified research and innovation



• Far from African mainland → lots of diverse and cool ecosystems
• 5th biggest island
• 4th poorest nation in the world
• Average Malagasy lives on $1.90 USD/day
• Subsistence agriculture
• 3rd lowest health expenditures per capita in world in 2014
• Estimated 50% do not have access to healthcare
• Coup in 2009 fucked up health care systems even more
• ~ 40% live 5+km from healthcare
• Geography a massive barrier: In some districts, 70% live far (up to 2 days’ walk) from nearest health facility


DrOTS – Drone Observed Therapy System in
remote Madagascar

• Trained Community Health Worker in every village
• Drones: called to collect sputum sample and
deliver monthly treatments
• Medical Event Monitoring Systems (MEMS) :
medication bottles with microelectronic chip
registers date/time of every bottle opening


Issues + potential issues with DrOTS

- rely on self-reporting of community health workers on whether they believe if they taking med on time
- People still have to get their drugs so geography still a problem
- Was supposed to be last October → didn’t work → was supposed to be community worker can press a red button and be like yo he’s got a problem, but not enough signal so didn’t work
- Now drones come once a month → lil complicated

- sustainability and prevention under-addressed

• Identifying visibly sick and contagious
• Sustainability - when funding ends, who takes it over? Bc government already spends so little on healthcare
• Focus on cure rather than prevention
• TB is a disease of poverty and inequality (e.g. wood burning stoves produce dust)
- 95% TB deaths in low- and middle-income countries


Limits of drones

• Big weather event – storm? Cannot fly → messing up schedule. Crashes?
• Having only healthcare provider is a limited person → is person does not do shit properly, cross contamination
• Areas where drones are used as military shit, but now there is a dual usage so now people have difficulty differentiating → painted florescent orange for humanitarian help?


All these deaths, but heard only about Ebola

- >1 million deaths from TB per year
- In 2015 there were an estimated 438 000
deaths from malaria
- Yellow fever causes 60 000 deaths/year, most in Sub-Saharan Africa


Ebola - disease profile

• First identified 1976, near Ebola river in present day Democratic Republic of Congo
• Approximately 27 outbreaks to date
• Human to human transmission via bodily fluids
• 2-21 day incubation
• Very contagious and up to 90% mortality
- before Ebola hit, Sierra Leone and Liberia were recovering from wars


Ebola symptoms

-muscle pain, severe headaches, disorientation, vomiting, diarrhea, rashes, impaired kidney and liver
-in 50% hemorraghic symptoms


Ebola outbreak timeline

- December 2013: first case in Guinea
- March 2014: WHO recognizes outbreak and mobilizes experts and lab support, isolation unit set-up with Doctors without Borders
- May 19: Guinea’s Ministry of Health says under control
- June 2014: First cases appear in Sierra Leone
- August 8 WHO declares the Ebola outbreak a Public Health Event of International Concern (PHEIC) :
* Event that is extraordinary, public health risk to
other countries, and required international
- Early September - 500 new cases a week


Structural violence - Ebola

“refers to the way institutions and practices inflict avoidable harm by impairing basic human needs”
• Involves inter-connected long-term economic, social, political injustices and inequalities


Weak health systems - lack stuff and staff

Structural adjustment plans (late 1970s -):
-conditions imposed on low- and middle-income countries by loan agencies (World Bank, International Monetary Fund)
= starved social and health systems


What in the social organization of these countries’
societies contributed to Ebola outbreak?

-Horizontal as well as vertical inequalities
-Uneven development
-Patriarchal and gerontocratic (status based on age) societies


How did history of conflict and political
corruption contribute to Ebola?

- Mass migration
- No trust – no “inclusive security”
- September 8, 2014 U.S. and UK commit to constructing treatment centres
- UN approves first-ever UN public health mission: creates air corridor for staff andsupplies
- WHO with NGOs provide training to 1000s of
government health workers in Infection Prevention and Control


Influx of $$$ and volunteers

• 1000s of foreigners
• 4.6 billion spent on response
• Training and treatment centers provided


Main criticism - Ebola

- "too little too late"
- WHO (World Health Organization) TOO slow and
- When international responders arrived, chaos
- Clinical trials started too late


Possible reasons for Ebola epidemic

1) Zoonotic spillover event in a poor, out of the way place in an uncertain and environmentally degrading world → that rapid deforestation combined with poverty is newly bringing people, virus-carrying bats and infected wildlife
2) Local ‘cultural’ beliefs and practices, including those contributing to transmission—burials and funerals, especially of high-ranking officials of the region’s initiation societies, are held to account for a high proportion of those cases occurring in community settings
3) Classic ‘global outbreak narrative’, seen around so many other emerging infectious diseases, in which a disease ‘out of Africa’ threatens a world of mobile people and microbes, reaching its tentacles out to affect the powerful global North


United Nations Secretary General proposed six cross-cutting ‘essential elements’ to the post-2015 agenda:

1) Dignity: to end poverty and fight inequality
2) People: to ensure healthy lives, knowledge and the inclusion of women and children
3) Prosperity: to grow a strong, inclusive and transformative economy
4) Planet: to protect our ecosystems for all societies and our children
5) Justice: to promote safe and peaceful societies and strong institutions
6) Partnership: to catalyse global solidarity for sustainable development


Ebola beliefs and fears

- In some areas of Guinea, people believe Ebola to have been introduced by White people who have mineral resource interests, with the complicity of the government, for the sole purpose of destroying their communities
- Fears have also applied to foreign outbreak control teams, who—with their alienness magnified by spacesuit-like protective suits—have been interpreted as extractors of human resources—body parts, blood and lives—to serve mysterious but assumed-powerful international markets


Cape Town, South Africa

City of 4 million
2013 – one of wettest years on record
since 1970s
2015 – lowest rainfall in over 100 years
- Dams flooded
- 2014 – 7 inches less of rain, and 7 less again in 2015
- Drought declared in 2015 because of condition of reservoir
• 6 dams – 13.5% capacity in reservoir is emergency –
cape town about to hit it soon
- First city in world to run out of water (in few months or next year) – will have to turn off taps and do something
• Consumption exceeds keeping up with population
increase and climate change
- City opened disaster operations centre – so on day 0 when water runs out they have something
- Reduced amount of water consumption – 40L a day
- They track households water consumption
- activated their Disaster Operations Centre (DOC) to execute the City's water disaster plan, which will start day 0


Climate change is the biggest global health
threat of the 21st century

- 2009 commissioned investigation into climate change
- 2-5 degrees Celsius increase in the next 70 yrs
- North Canada have 5% increase because of thin ozone


Globally aging population

- By 2050, over 20% of the global population will be over 60
- 2/3 of those over 60 today live in low and middle income countries (LMICs)
- Many LMICs harbor high rates of extreme poverty
(under $2/day)
- die on $2 a day” – elders in latin America
- Majority of Canada will be elderly
-If govt has small budget – not proper disaster relief program
•If no resources to coordinate recovery process makes it difficult


DIRECT climate-related risks to health

Changing Disease Patterns
- Rise in mosquitos (up to 10x increase with every 1
degree Celsisus increase!)
- Climate warms so mosquitos can move there
because now warm (e.g. dengue)
- Increased reach and peak periods for deadly
diseases: malaria, dengue, tick-borne encephalitis
↑ respiratory problems + dehydration – shared risk
with young children ↑stroke, heart attack ↑dizziness,
exhaustion, falls
- 2003 – 70 000 deaths due to extreme heat wave
in Europe – consequence of climate change
- Children and elders become dehydrated quickly

- Floods, droughts, extreme weather events
- Leave life-long disabilities, affects health a lot
- Affects infrastructure – no electricity, cannot clean
• Bridge broken/ blocked – cannot get medical
• Food source fucked – price of food is up
- 25% of death in children in Bangladesh is due to
drowning because Bangladesh has a lot of flood
• Floods is most predicted disaster due to climate change


Urban Heat Island Effect (UHI)

- Informal settlements, housing precarious, home is not on legal land – slum
- 1-5 degrees higher in slums – heat trapped because not high roofs, concrete floors make it warmer than dirt floors, but concrete cleaner
- can increase temperatures by 1–5 °C above nearby rural areas and/or raise night-time temperatures by several degrees above surrounding rural areas
• Risks will increase as climate change amplifies UHI
• Adapting to heatwaves requires several strategies, ranging from modifying the built environment to improving housing and building standards


INDIRECT climate-related risk to health

1. Disasters
- Floods, droughts, extreme weather events
- E.g. drought – food crops compromised if living of

2. Food and water insecurity
- Rising food prices
- Less food in country (pest/ failed crops/ etc) – prices
of food increase, people on smaller budgets can’t
afford it
-1/5 of world depends on glacial outfeed
-Increase waterborne infections SUCH AS diarrhea
- WHO by 2020 will be 5% increase in diarrheal
• 2nd killer of kids
• Causes malnutrition and is also caused by
• Kills through dehydration
• Happens through pests
• Flooding interrupts water supply, water goes
through slums
• Risk through not pure water or safely stored water


Destruction and displacement

- More pressure on informal settlements (slums)
- Will come to cities, need to be prepared for expansion
- CNN peru mudslide article video
• Not everyone is physically able to escape the
• Same goes for disasters – not everyone physically
prepared, may be left behind because they can’t
• Lots of sexual assault in migration – so women
don’t, elders can’t, so most people coming in are
young men


Disaster response often ill-equipped for
needs of elderly

- Age-related health conditions exacerbated in disasters
- Normal health services may be diverted
- Disaster response often inadequately prepared for responding to older residents’ needs and disabilities

- Elders have experience with shit, want to be involved, not call them victims,
- They are wise have experience know what to do



- Informal settlements
- often in flood prone or landslide prone areas
- limited/no sanitation increases risks when flooded
- precarious structures vulnerable to extreme weather
- poor insulation = use of “dirty” fuel (wood and coal)
- poor ventilation + heat increases pollution
- Will house majority of world
- Most vulnerable area
- Lots of mosquitos – little puddles
- In areas prone to natural disasters
- Can only afford wood to cook, and creates a smog –
aggravates respiratory disease (pneumonia, asthma)
• Get richer –> natural gas, electricity to cook


”Resilience” linked to access to resources

-to absorb rising food and commodity prices
-to move
-to rebuild or improve housing
-to miss work
-to access healthcare


What could help climate change (technical and political)

- green technologies for the poor as well as the rich
- more efficient ways to keep buildings cool
- better planning for expanding cities

- reduce fossil fuels to stabilize temperature rise
- improve health systems
- social justice

- Often resilience is about making cities and health systems smarter so when derailed for disasters
• Technical solutions, having good disaster plans,
affordable renewable shit
- Nothing will have substantial\
• So many spinoff effects of global warming, so need
to fix the fossil fuel shit
• Inequalities root of why people are – will be
worsened with climate change


Sub-concussive impacts

• The “Big Hit”
•Canadian CIS football game = average of 24
• Effect of sub-concussive impacts on brain are not well
•Accumulate over time without clinical presentation



•“A complex pathophysiological process affecting the
brain, induced by biomechanical forces”- BJSM
•Linear or rotational forces
•Physical, cognitive, emotional or sleep related
•No exact threshold for concussion


Concussion testing

•King Devick



• 3 main components
1) Symptom Evaluation
2) Cognitive and Physical Evaluation
- Orientation
- Immediate recall
- Concentration
- Delayed recall
3) Modified Balance Error Scoring System (mBESS)
• Current clinical standard for NFL, NHL, FIFA, IRB and all Western University Varsity Athletics



• Post Concussive Symptoms
- Athletes rate 22 post concussion symptoms
• Word Memory
- Athletes are shown a list of words.
- After, a new list of words are shown and athlete
response to original words
• X’s and O’s
- Athletes are shown two shapes with corresponding
keyboard keys “Q” and “P”.
• Design Memory
- Athletes are shown complex shapes, they are later
shown similar shapes but must react via button press
to only the exact same shape
• Symbol Search
- Athletes are shown 9 shapes with a corresponding
number. Later these shapes will be shown on the
screen and must press the corresponding number
• Grid Search
- Athletes are shown a 5 x 5 grid of numbers ranging
from 1-25. They must click the numbers in reverse


King Devick (K-D test)


Chronic Traumatic Encephalopathy (CNE)

• Stage I
- No symptoms
- Isolated spots of TAU build up in frontal lobe
• Stage II
- Symptoms include- Rage Impulsivity, Depression
- TAU protein effects more cells within frontal lobes
• Stage III
- Symptoms include- Confusion and Memory Loss
- Tau can be found in the frontal and temporal lobes
- Hippocampus and amygdala are effected
• Stage IV
- Symptoms- Advanced Dementia
- Tau has overwhelmed the entire brain, killing many
- Brain may shrink to half normal size


Classic rule changes (football)

•45 players died between 1900 and 1905
•1905 football season
- 18 people died
- 150 were injured
1. The two teams would be separated by a neutral zone (the length of the ball) at the line of scrimmage.
2. Hurdling was penalized.
3. Offensive linemen had to drop back five yards behind
scrimmage if not moving forward.


Recent rule changes in sport

•Using a centralized, unaffiliated neurotrauma consultant
at the league office to monitor feeds of all games
•All players who are evaluated for concussions on game
day must have a follow-up evaluation the next day
• Extend the rule changing the spot of the next snap after a touchback resulting from a free kick to the 25-yard line


Rowan's law

• May 2013 Rowan Singer died due to second impact syndrome
• Ontario government passed regulations in 2017 to protect amateur athletes in her honour
• Providing education on sport-related concussions to athletes, coaches and parents
• Removing a child or youth athlete from play if a concussion is suspected;
• Ensuring the child or youth does not return to play until he or she has received medical clearance
• Ensuring appropriate return to learn and return to play strategy is in place


Socioeconomic impacts - concussions

• Socioeconomic Status and Race Outperform Concussion History and Sport Participation in Predicting Collegiate Athlete Baseline Neurocognitive Scores.
- Players of Lower SES and Black/African-American
race scored lower baseline levels
• Clinical and demographic predictors of concussion resolution in adolescents: A retrospective study
- Athletes with lower SES may strongly identify
with their athletic role because their athletic
career may lead to future financial opportunities
such as athletic scholarships and professional
sport careers; hence, they may be more
motivated to follow concussion management


Mild traumatic brain injury (mTBI)

- Washington State data revealed that the greatest number of TBI cases occurred from truck driving, construction work, and farm work
- Cross-sectional study from Ontario revealed that nearly 60% of injuries occurred in men who were, on average, 38 years of age
- Men comprise a greater percentage of mTBI cases
- Compared with a similar cohort of men, women with mTBI seen in the ED were older, less likely to be injured while participating in a sport, and more likely to be injured in an MVA
• In addition, female gender was associated with
higher postconcussion symptom scores 3 months
after the injury


Brain injury and military

- Brain injury in the military is increasingly recognized and has been referred to as the “signature” injury of the present generation of service members
• Soldiers with mTBI were significantly younger, more
junior in rank, and more likely to be male than were
soldiers reporting other injuries
• Soldiers with concomitant post-traumatic stress
disorder (PTSD) and mTBI were more likely to have
postconcussion symptoms than were those with
mTBI or PTSD in isolation


Concussions and sports

- More than 75% of the concussions reported were attributed to player-to-player contact, followed by 15.5% from contact with the playing surface, and nearly 78.5% occurred during competition rather than practice
- Boy’s football accounted for 56.8% of injuries and girl’s soccer for 11.9%
- Athletes consistently have been shown to have higher rates of concussion during games and competitions than during practices, although the degree of differences varies by sport
- Majority of injuries occur from player to player contact, and certain positions have higher rates of concussion than do others
- Currently, the only way to prevent concussion in sport is to control risk (ie, limit exposure)


Gender and sports-related concussions

- Gender appears to play a role in the sports-related concussion, and rates tend to be higher for women and girls in comparable sports
- High school boys and girls also self-report different symptoms
• Girls reported more drowsiness and sensitivity to
noise and boys reported more confusion/
disorientation and amnesia
- Overdiagnosis in female athletes, or it may simply reveal under-diagnosis in male athletes
• Tendencies to “protect” female athletes →
physicians may be more likely to diagnose
concussion in women to “protect” them from
premature RTP


Rational choice theory

• people value the present more than the future
• we don’t evaluate benefits of an action on the present and the future in the same way
• we experience benefits we can access immediately in an exaggerated form


Scottish health survey

- As girls went through age of puberty:
• Smoking rates increased
• Exercise went down
• Started to experiment with alcohol

- “Harmful health behaviors” ↑ as social class ↓
- People may not have access to healthier choices
•“People with little control over their lives do not
feel able to make healthy choices”


Health inequities

“the unjust and avoidable differences in health and well-being between and within groups of people” (WHO)

• Systematic: produced by social norms, policies, practices and institutions that reproduce unequal access to resources and opportunities

• Connected to social stratification (gender, education, class, geography, ethnicity)

• So embedded, often taken for granted: appear inevitable and normal


Nunavut and TB

• 14 of 25 communities in Nunavut had TB outbreaks
• Rate of active TB infection 260x higher in Nunavut than any level of TB amongst non-indigenous Canadians
• This is in 2017


Visible and intangible social determinants

• Terrible overcrowding, poor living conditions, food prices
• Lack of doctors, nurses, and other healthcare workers
• No genex machine best diagnosis
• Legacy of racism and neglect
• Norms of abandonment


2 Lists in book - Apr 5 reading

1) 1999 by England’s Chief Medical Officer focuses on personal determinants and your actions (e.g. limit smoking and alcohol use)
o Aspects in person’s control
2) David Gordon at University of Bristol focuses on social determinants (e.g. “don’t be poor. If you are – stop.)
o Aspects that person cannot control


Rational addiction

addiction can be explained by rational choice theory; more people discount the future, the more can rational choice account for addiction
• “Utility of doing so is greater than utility of
• E.g. value health, but that is in future; value piece of
cake more
• Becker & Kevin Murphy, University of Chicago


Status/ income and behaviour

- Among women in middle-income and high-income countries, lower status = greater obesity
- Lower status = more unhealthy behaviour
- In Britain, 9% of adults in higher income households smoke; 31% of adults in manual households smoke
- In high-income countries noticed with women
particularly → lower education = greater
prevalence of overweight and obesity
- In low-income countries women → more education
= more likely to be overweight
• Women with low education in low-income countries
too close to poverty line to have sufficient calorie
intake to get fat


Obesity shows interaction of individual and social determinants

• Make choices → how much to eat, what to eat,
exercise and how much
• Choices influenced by environment
• Twin studies show obesity is 50-90% heritable
• Migrant studies show obesity is environmental
o Average of Punjabi men in Punjab is underweight
(BMI – 18) vs Average of Punjabi men in London is
overweight (BMI – 28) → have similar genetics, so
environment must play a role
- If restricted range of environmental exposure, all variation will be genetic


Alcohol use and social conditions

- Alcohol is obvious example of health behaviour influenced by social conditions
- In Britain, average alcohol consumption is higher in people of higher socio-economic position, especially women
• Women with more education and higher-status jobs
drink more on average
• Same in US → higher education = more likely to be
- As price of alcohol dropped → consumption increased


American health vs British health

• Overall Americans sicker than English
• Richer Americans were sicker than richer English
• In 1 or 2 cases, richer Americans were sicker than poor English


There was a proposal that poor people should be held liable for cost of diabetes treatment – 3 reasons:

1) Disincentive – forcing them to pay would
encourage lifestyle changes → not get obese →
not get diabetes
2) Punishment – behave badly → incur a cost as penalty
3) Cost saving – lower costs to the health service by
offloading the cost onto the irresponsible person


Healthcare and health

- Common to equate healthcare and health – but are different
• Lack of healthcare is no more a cause of ill-health than aspirin deficiency is the cause of headache


2 approaches to promoting healthy behaviours:

1) Make healthy choices the easy choices
- Make healthy food more readily available than
unhealthy food
2) Empower people to take decision that positively influence their health and well-being
- Create conditions for people to have freedom to
lead lives they have reason to value