Issue 17 by The Meducator

Cancer with Viruses? McMaster’s Medical Research and Health Ethics Student Journal

Global Citizenship Conference Also in this issue: Doctor’s right to refuse patient treatment

Chaperones and protein folding

Special issue in collaboration with Loneliness andthe Global Citizenship Conference cardiovascular

BRIDGING BORDERS THROUGH HEALTH disease

Debate on Canada’s health care

Fortified Foods Peace through Health Counterfeit Drugs Vaccines in the Developing World Overseas Volunteering Issue 17 | March 2010

www.meducator.org

Table of Contents

Issue 17 | March 2010

Research Articles

Presidential Address

Jacqueline Ho

MedBulletin

8, 18, 22

MedWire

MedQuiz

About The McMaster Meducator The McMaster Meducator is an undergraduate medical journal that publishes articles on current topics in health research and medical ethics. We aim to provide an opportunity for undergraduate students to publish their work and share information with their peers. Our protocol strives to maintain the highest standard of academic integrity by having each article edited by a postgraduate in the relevant field. We invite you to offer us your feedback by visting our website: www.meducator.org.

The McMaster Meducator may be contacted via our e-mail address: meducator@gmail.com

Food Fortification in the Philippines Nadira Saleh

From Nigeria to Benin: Combating the Counterfeit Drug Trade Veronica Chan, Iris Lui, Grace Lun, Naushin Nagji

Vaccinations in the Developing World Matthew MacDonald

Crossing Borders and Pushing Boundaries: The Ethics of International Volunteering Rhyanna Cho, Jennifer Edge, Alvin Keng

or our mailing address: B.H.Sc. (Honours) Program Attention: The McMaster Meducator Michael G. DeGroote Centre for Learning and Discovery Room 3308 Faculty of Health Sciences 1200 Main Street West Hamilton, Ontario L8N 3Z5 http://www.meducator.org

Peace Through Health and Its Potential as a Transformative Lens Dr. Nancy Doubleday

March 2010

In recent months, two profound events demanded the attention of the international community, bringing together individuals across the world in a common, global experience. The earthquake in Haiti led to efforts of governments and local communities to help rebuild a demolished country from the ground up. The recent conclusion of the Winter Olympic Games here at home united 82 countries in its celebration of athleticism and global unity, Spectators in Canada and around the world drew collective gasps and screams of joy as the Games unfolded. These events demonstrate the connection we, as global citizens, have with our global family whatever the distance. The plights faced by those of an unfamiliar continent can hit close to home, while festivities experienced within our borders can be felt far and wide. This year, the McMaster Meducator presents this Special Issue in collaboration with the fifth annual Global Citizenship Conference -“The Power to Empower.”In this Special Issue, we explore health issues in various geographical locations in our world. Nadira Saleh investigates the ‘hidden hunger’ of micronutrient malnutrition and the Philippines’ response to this problem. Veronica Chan, Iris Lui, Grace Lun and Naushin Nagji examine widespread counterfeit drug dissemination in Africa and propose an adaptation of Nigeria’s Vendor Awareness Initiative for use in Benin. Matthew MacDonald dives into the delicate business of vaccine use in the developing world, where cultural and social sensitivities affect their effectiveness. Rhyanna Cho, Jennifer Edge and Alvin Keng inspired by personal experiences, reflect on the ethical considerations each international volunteer should explore before departing on such travels. Finally, we are fortunate to have Dr. Nancy Doubleday, the professor of the Peace-building through Health Initiatives course, deliver a commentary on the impact and provision health care in areas of conflict and disaster. This issue is a concerted effort of the McMaster Meducator and the Global Citizenship Conference (GCC) executive committees. It is the goal of the conference to help students recognize their role as socially conscious global citizens, and to inspire their empowerment through learning, discussion, and collaboration towards positive social change. Naturally, today’s most pressing social issues are inextricably linked to global health challenges. Conference presenters will discuss themes consistent with our selection of articles in this issue, including grassroots HIV prevention and aid programs in Northern Ghana, water sanitation engineering technologies, female genital mutilation practices, and traditional aboriginal medicine. Moreover, authors of our Food Fortification, International Volunteering, and Peace Through Health pieces will be sharing their knowledge as workshop leaders. I extend a sincere thank you to those with GCC for their cooperation throughout the process of putting this publication together. To community members and the McMaster Student Union, I would like to express our gratitude for your generosity in helping make this issue a reality. Credit goes to the McMaster Photography Association for the striking images you see on the cover and throughout this publication. Finally, I would like to thank the McMaster Meducator executive for their continued dedication to ensuring the rigor of the publication while constantly striving to better identify with the interests of the McMaster community. Without further ado, The McMaster Meducator and the Global Citizenship Conference jointly present “Bridging Borders Through Health” - we hope you will be inspired and empowered by our selections. Sincerely,

Meducator Staff President Jacqueline Ho Vice-President Veronica Chan Editorial Board Ahmad Al-Khatib Alyssa Cantarutti Randal Desouza Randall Lau Simone Liang Siddhi Mathur Matthew MacDonald Tahseen Rahman Navpreet Rana Sangeeta Sutradhar Fanyu Yang Creative Director Hiten Naik Web Master Keon Maleki Public Relations Shelly Ramsaroop Junior Graphics & Design Daniel Lee Lebei Pi Junior Editors Mohsin Ali Louis Winston Cover Design McMaster Photography Association

Post Graduate Editors Dr. Nancy Doubleday, PhD, LLB, B.Ed Dr. James Dwyer, PhD Dr. Farah Huzair, PhD Dr. Andrew Pinto, MD Dr. Ryan Wiley, PhD

Jacqueline Ho B.H.Sc. IV www.meducator.org

Presidential Address

Dear Reader,

March 2010

Food Fortification in the Philippines Many of the world’s poorest are suffering from what is known as “hidden hunger ”: deficiencies of proper vitamins and minerals. The Philippines is considered a model in its comprehensive interventions, especially in food fortification. Through investigation of this model, its achievements and its shortcomings, other countries may also be able to better nourish their citizens. Nadira Saleh

any of the world’s poorest are suffering not from starvation but from hidden hunger, the glaring deficiency of vitamins and minerals. The consequences of these deficiencies are staggering, especially in vitamin A, iodine and iron. Resulting diseases span from night blindness to impaired cognitive development, weakened immunity and shortened life expectancy (Befeki, 2006). Estimates of the number of people affected by MNM are high, with up to five billion people suffering from iron deficiency and about a quarter of all pre-school children (about 130 million) suffering from vitamin A deficiency (UN, 2005). In 1992, 159 countries endorsed a World Declaration on Nutrition, pledging to make “all efforts to eliminate iodine and vitamin A deficiencies” (FAO, 1992). The need to reduce malnutrition was highlighted in the first Millennium Development Goal “to eradicate extreme poverty and hunger” and underpins several others. Attaining goals in primary education, reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases rely upon good nutrition. The World Health Organisation (WHO) has outlined four main strategies to alleviate MNM. These include increased nutrition education, access to micronutrient-rich foods, micronutrient supplementation, and

food fortification - each strategy with its advantages and disadvantages. Increased diet diversification is an obvious goal, requiring availability and consumption of micronutrient-rich foods. Unfortunately, the intervention is not always feasible for all countries, especially those are constrained in what they can grow and lack purchasing power. Though nutrition education is essential to a sustainable reversal of MNM, it is insufficient. Even with the most widespread nutrition education campaigns, reaching all constituents can be difficult. Nutrition education stipulates changes in purchasing behaviour which may not be possible depending on an individual’s resources. Alternatively, supplementation entails the provision of micronutrients in pills or capsules to supply an optimal amount of nutrients. Unfortunately, supplementation can be expensive and is reliant on strong distribution systems and consumer compliance which may not always be in place. Finally, fortification, the addition of one or more essential nutrients to a food, can be used to combat MNM. Fortification requires appropriate food vehicles that are widely consumed and accessible. It is recognized as an ideal strategy because of its social acceptability and the fact that it requires less change in consumer

behaviours and food habits. As fortified foods can be introduced quickly into markets and reach target populations easily, fortification is the most cost effective mechanism to combat MNM. Unfortunately, fortification is limited to the food vehicles that support certain vitamins and minerals. As well, there are instances in which deficiencies are too severe to correct with fortification (Allen, 2006).

“[...] up to five billion people suffering from iron deficiency [...]” The Philippines Case Study The Philippines is a model in its approach to comprehensive food based interventions, especially in the area of food fortification. Stemming from partnerships in public and private sectors as well as with researchers and policy makers, the Philippines is the only country in Asia to legally mandate fortification of vitamin A and iron (Solon, 2009). The Food and Nutrition Research Institute (FNRI) initiated the nutrition planning program in the 1970s, several motions were ratified throughout this decade to this end (Corazon, 2002; Solon, www.meducator.org

5 2006). Additionally, the issue of proper nutrition entered homes. In 1970, through an initiative called “Operation Weighing”, the weights of preschool children were collected across the country to provide underweight children with immediate assistance. It also served to raise awareness about local nutrition problems. Officials were appointed at municipal levels to ensure that nutrition programs could be mobilised from grassroots. Strong nutrition planning and public-private partnerships is integral in the stability of the Philippine fortification program.

Fortification in the Philippines Fortification has become a large part of the country’s fight against MNM as it is far-reaching and cost effective. The growth of the program was most substantial in the 1990s when sugar and oil were both fortified with vitamin A, salt with iodine, rice with iron and flour double-fortified with both vitamin A and iron (Philippine Food Fortification, 2005). Challenges exist in identifying foodstuffs that are compatible with a desired fortificant. One of the first substances to be considered for fortification was monosodium glutamate (MSG). In the 1970s, researchers discovered that MSG was an excellent vehicle for vitamin A fortification; the results from a field trial demonstrated a decrease in xerophthalmia, the inability to generate tears due to vitamin A deficiency and an increase in serum retinol levels. Unfortunately due to a color change, prominent producers of MSG were reluctant to sacrifice the marketability of their product (Solon, 2000). Fortunately there have been significant developments as well. In 1995, studies were conducted by the NCP to measure the stability of vitamin A alone and combined with iron (double fortification) in flour used to make bread. The results demonstrated that fortificants either alone or in combination were stable in flour and met the required shelf life. This information became vital in passing legislature relating to the requirement of fortifying flour in later years. As of May 2005, 42 brands produced by six different companies fortify flour with vitamin A (Philippine Food Fortification, 2005). Another element that sets the Philippines apart is the use of the “Sangkap Pinoy Seal” (SPS), a type of label identifying fortified foods. The program has been used by the Department of Health (DOH) to “encourage manufacturers to fortify their products with any one, or a combination of Vitamin A, Iron and/or Iodine”, thereby aligning corporate interests with a public health service (Solon 2000). The SPS was introduced in 1996 but gained extensive legal backing in 2000 with the introduction of the Food Fortification Act (FFA). This act enforces that all of the following products be fortified:

Issue 17 -

Rice with Iron Wheat flour with Vitamin A and Iron Refined Sugar with Vitamin A Cooking oil with Vitamin A All imports of these food substances must also be fortified. The packaging of these products is granted the Diamond SPS, demonstrating that the product was mandatorily fortified and complies with standards outlined by the Department of Health. With mandatory fortification as the main objective of the FFA, factors like monetary sanctions for non-compliance were also considered. The Act highlights the support of government agencies in the implementation of fortification programs through various mechanisms including helping manufacturers upgrade their technologies, acquiring loans, as well as implementing programs for the acquisition, design and manufacture of machines and technologies (Congress of the Philippines, 2000). However, the government does not subsidise fortification programs. As outlined in a 2005 report from the Department of Health, “a purely government undertaking on food fortification that involves the donation of fortified products to the affected

“Today, [the Philippines] is the only country in Asia to legally mandate fortification of certain staples with vitamin A and iron” groups is not sustainable and results in waste of time and resources without any impact” (Philippine Food Fortification, 2005). This is reiterated by various experts in the field who report that sustainable programs are those that are multisectoral (Corazon, 2002). Because micronutrient malnutrition is “hidden,” deficiencies are not apparent to those who are deficient, necessitating government action. That is not to say that consumers are excluded from the fortification conversation. Undeniably, the primary factor contributing to long term sustainability of food fortification is consumer awareness of the deficiency and their demand for fortified food (Darton-Hill, 1998). Governments play a pivotal role in setting regulations and making fortification possible, but it is the manufacturer who must be convinced to bear the cost of fortification. Enter academics who supply the scientific proof that fortification is feasible in food vehicles and effective in target populations. These partnerships working together are essential to creating strong fortification strategies.

March 2010

6 significantly affect nutrition and health overall (Pedro, 2006). The results of the most recent NNS are reported in the country’s Medium-Term Philippine Plan of Action for Nutrition (MTPPAN). This is a plan which is revisited every five to ten years by the NNC as new data emerges. The MTPPAN, from 2005 to 2010, has made the Millennium Development Goals its priority to reduce the prevalence of underweight status in children aged zero to five years by 17.2 percent by 2015. It also aims to decrease rates of stunting and micronutrient deficiency, particularly nutritional anaemia and vitamin A deficiency, in children under ten years of age. Finally, MTPPAN also outlines multiple approaches to combat malnutrition including increased food production, nutrition education, micronutrient supplementation, food assistance and micronutrient fortification. The hope is that through tackling malnutrition at different levels, significant achievements can be made for the nation’s population (Pedro, 2006).

Conclusion

Figure 1 “A quarter of all pre-school children suffer from vitamin A deficiency”

The Current Micronutrient Situation in the Philippines Despite all of the efforts by the Philippine Nutrition Program, in 2003, 3.5 million preschool children were still underweight, a prevalence of 27%. The prevalence had been reduced by less than one percent per year for the previous ten years. Additionally, 30 percent of preschool-aged children were stunted. A considerable portion of the Filipino population still suffers from anaemia and vitamin A deficiency. Vitamin A deficiency, a key contributor to mortality and morbidity in children, continues in roughly four out of ten children, despite biannual vitamin A supplementation. Alternatively, notable reductions in iodine deficiency among school children have been noted over the last ten years. These mixed results cannot be attributed to any one part of the program. The Philippines continues to undergo serious political and economic changes as well as natural disasters; the accumulation of which can

Micronutrient malnutrition is a serious problem afflicting developing nations. Dietary diversification is not always an option for poorer populations and government and external programming must be relied upon to remedy these deficiencies. Fortification has been used extensively in the Philippines, a country which has invested heavily in nutrition programming through its various branches. The Philippines has implemented regulations with respect to supplementation, fortification and a variety of other initiatives. It is one of the first countries in Asia to mandate fortification of staple foods, the success of this can largely be attributed to extensive building of vertical infrastructure and partnerships with industry, and various academic agencies. Despite all of the progress the Philippine fortification program has seen, the sustainability of this solution remains in question. Is fortification a mere band-aid solution to alleviate the real issues at hand? Should efforts be pulled from this endeavour and be reallocated to factors that may be predictive of micronutrient malnutrition, such as poverty reduction? Perhaps fortification can evolve into different and newer forms. As biofortification, or genetic modification, gains momentum, plants are being modified to produce various vitamins that they normally would not. Thus, there are many possibilities in which one crop can be modified into a “superfood” that provides daily requirements to address deficiencies in a single bowl of rice. One day, fortification may not be necessary in ensuring stable micronutrient intake but, for now it is here to stay.

www.meducator.org

Issue 17

Postgraduate Editor in Focus Dr. Ryan Wiley is an adjunct professor in the Bachelor of Health Sciences program here at McMaster University, teaching senior seminar courses on Global Health as well as on Science, Culture, and Identity. As Vice-President of SHI Consulting, he has facilitated partnerships between business, health care, public health, and research organizations for economic development and health research strategy initiatives globally, most prominent of which includes helping to coordinate the recent HIV vaccine trial in Thailand. Dr. Wiley holds a PhD in Immunology, and has published extensively in asthma/allergy, immunology, pharmacology and gene therapy.

References Allen L, Benoist B, Dary O, Hurrell R. (2006). Guidelines on food fortification with micronutrients. World Health Organization and Food and Agriculture Organization of the United Nations. World Health Organization, Geneva. Bekefi, T. (2006). Business as a Partner in Tackling Micronutrient Deficiency: Lessons in Multisector Partnership. Business and International Development. Harvard University, Cambridge, Mass. Congress of the Philippines, (2000). Food fortification act 2000 (Republic Act 8976). Metro Manila, Philippines. Darnton-Hill I. (1998). Overview: rationale and elements of a successful food fortification program. Food Nutr Bull, 19:92–100 Food and Agricultural Organization. (1992). International Conference on Nutrition. World Declaration on Nutrition. Food, Nutrition and Agriculture. Retrieved January 2, 2010, from <http://www.fao.org/docrep/u9920t/u9920t00. htm#Contents>. Pedro MRV, Benavides RC, Barba CVC. (2006). Dietary changes and their health implications in the Philippines. From:

The double burden of malnutrition: case studies from six developing countries. FAO Food and Nutrition Paper, 84: 205-243. Philippine Food Fortification Program (2005). History of Food Fortification and Lessons Learned. Department of Health. Accessed on July 19, 2009, from http://www2.doh.gov.ph/ foodfortification/downloads.htm Solon FS. (2006). Good governance for nutrition in the Philippines: elements, experiences, and lessons learned. Food Nutr Bull, 27:343-352. Solon FS, Sanchez-Fermin LE and Wambangco LS. (2000). Strengths and weaknesses of the food fortification programme for the elimination of vitamin A deficiency in the Philippines. Food Nutr Bull, 21 (2): 239–245. United Nations, 2005 United Nations, Standing Committee on Nutrition (2005). Fifth report on the world nutrition situation: nutrition for improved development outcomes. Geneva. Wirakartakusumah MA, Hariyadi P. (1998) Technical aspects of food fortification. Food Nutr Bull, 19: 1–5

March 2010

Breakthrough Heart Scanner in the Making

MedBulletin by Mohsin Ali

A portable magnetometer, an instrument measuring magnetic fields, is currently being developed at the University of Leeds in the United Kingdom. As a result of its unprecedented sensitivity to detect fluctuations in the magnetic field surrounding the heart, it will be able to pick up heart problems at an earlier stage than ultrasounds, electrocardiograms and existing cardiac magnetometers. It will also be smaller, simpler, cheaper, and able to gather more information than the devices in use today. The machine also has the added benefit of being able to be operated by skilled nurses and doctors rather than just specialists, which will help in reducing hospital wait times. The device also functions through clothing, which will also cut down on the amount of time needed to perform the test. Remarkably, by virtue of its portability, it can also be taken out to a patient’s home, helping to reduce the use of hospital facilities. The magnetometer detects the distinct magnetic signature of the heart, while its specialized setup allows all unwanted signals from other magnetic fields to be censored. In such a way, the magnetic field of the heart can be transmitted from the sensor to the detector in a highly shielded passageway. The quantum physics research team, led by Dr. Ben Varcoe, has demonstrated that the magnetometer can reveal clinically-relevant, tiny variations in that signature. The device could be ready for use in a clinical setting in approximately three years. Reference: Engineering and Physical Sciences Research Council (2010, January 29). Breakthrough heart scanner will allow earlier diagnosis. Retrieved from Science Daily: http://www.sciencedaily.com/releases/2010/01/100128101859.htm

DNA Tests After Death

MedBulletin by Louis Winston

Senior doctors are calling for human tissue to be preserved for genetic testing in cases where the cause of death is unknown. The doctors claim that such DNA samples may reveal an unsuspected inherited condition and possibly prevent similar deaths in relatives. Dr Mary Sheppard, of the Royal Society of Medicine’s pathology section and a leading expert on Sudden Cardiac Death (SCD), estimates that every year roughly 800 young people under the age of 35, apparently fit and healthy, die suddenly from unsuspected heart disease or without explanation. Coroners who routinely requested consent at autopsies were able to find out more about how the person died and possibly prevent other deaths in the same family. Though some coroners do ask for permission to obtain DNA sample after death, it is not part of their remit. Currently in Britain and Canada consent is required before tissue samples can be collected from a deceased person. The Human Tissue Authority declared that it was “alarmed” about the public calls for practitioners to break the law. Many people do not wish for tissue samples to be taken from their loved ones for a variety of reasons. This is a concern to some doctors who consider that analysing preserved tissue samples from the deceased could potentially prevent the deaths of others in the same family. Dr. Paul Brennan, a clinical geneticist for the Northern Genetics Service, strongly suggests all pathologists seek permission from the families to take the tissues. He states, “If consent is not given, the tissue must, by law, be destroyed. But if it is not even taken in the first place, a huge potential benefit is lost.” Reference: Call for tests after sudden death. (2009, November 09). Retrieved from BBC News: http://news.bbc.co.uk/2/hi/health/8346901.stm www.meducator.org

MedBulletin

Issue 17

From Nigeria to Benin: Applying a Vendor Awareness Initiative to Combat the Counterfeit Drug Trade

Veronica Chan, Iris Lui, Grace Lun, Naushin Nagji

n 1995, Niger fell victim to a meningitis epidemic and one of the worst reported cases of counterfeit drugs. In an attempt to establish a vaccination campaign, Niger received 88,000 meningococcal vaccine donations from its neighbouring western African country, Nigeria. However, due to suspicious batch numbers and expiration dates that conflicted with those recorded, the vaccines were later identified as counterfeits. 2,500 deaths were reported as a result of this. This problem is widespread globally with severe consequences, yet it remains one of the most underreported global health issues today. A universal definition for the term “counterfeit drug” has not been formally developed. The World Health Organization (WHO) has offered the following as a starting point: ...one which is deliberately and fraudulently mislabelled with respect to identity and/or source. Counterfeiting can apply to both branded and generic products and counterfeit products may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient (inadequate quantities of ) active ingredient(s) or with fake packaging. The vague definition of the term allows it to encompass the many different issues involved with counterfeit drugs, but at the same time, it acts as a hindrance to the formulation of much-needed laws and policies to mitigate the issue.

Nigeria: A Success Story Nigeria is the central hub of drug trade in Sub-Saharan Africa. While drug counterfeiting still exists there, Nigeria’s

Nigeria and Benin are both countries that have faced a widespread epidemic of counterfeit drugs. Nigeria with the use of an awareness programs and the Patent Medicine Vendors protocol was able to control the problem. Benin on the other hand, struggled with the application of this model. This article will provide a brief introduction into the issue of counterfeit drugs and then compare Nigeria and Benin’s strategies in combating this issue. successful attempts to resolve this issue set a solid example for neighbouring countries. Much of this success is due to the newly reformed National Agency for Food and Drug Administration and Control (NAFDAC), initially established to regulate and control quality standards for foods, drugs, and other products imported, manufactured locally, and distributed in Nigeria. Since Dora Akunyili’s induction as president in 2001, many changes have been made to combat the prevalence of corruption and counter the harmful effects of inadequate border surveillance, healthcare, and education system. However, the most effective solution against counterfeit drugs was the public awareness campaigns executed through a variety of media such as posters, radio broadcasts, billboards, fliers, and news articles. These campaigns worked to teach the poorly educated population how to recognize the differences between genuine and fake drugs (Akunyili, 2006). The success of NAFDAC’s efforts became evident and widely acknowledged in 2005 when an estimated 16 million USD worth of counterfeit drugs were voluntarily handed over or confiscated via tip-offs (Raufau, 2006).

B enin: A Work in Progress Benin is another West African country that borders Nigeria to the east (Bernagou, 2008). Benin’s characteristics are similar to those of Nigeria with its low literacy rate, poor healthcare infrastructure, and lack of regulation of the pharmaceutical sector. In its economic capital, Cotonou, is Adjegounle, the notorious “kingdom of street pharmacies” that spans more than 10,000 square feet (Vidjingninou, 2009). This illicit drug market has been linked to at least 250 deaths and 340 cases

March 2010 of chronic illnesses between April 2007 and June 2008 (Vidjingninou, 2009). In a country where many struggle to make ends meet, people turn to the counterfeit drug market to purchase cheaper drugs (Vidjingninou, 2009), because of the opportunity for bargaining (Bernagou, 2008). The counterfeit drug situation is further exacerbated by street vendors who go door-to-door to sell less expensive, unregulated medications (Bernagou, 2008). Since 2003, public awareness campaigns concerning counterfeit drugs have been carried out in Benin, but the primary limitation of these campaigns is that they did not target the vendors along with the rest of the population (Bernagou, 2008). The result was that as the number of visits from travelling vendors decreased, the counterfeit drug situation in the market worsened (Bernagou, 2008). Therefore, awareness campaigns need to extend beyond the general public to target vendors as well.

Design of the Patent Medicine Vendors (PMV) Awareness Campaign: Applying Nigeria’s Interventions to Benin In light of the severity of the counterfeit drug trade in Benin and its similarity to the pre-2001 circumstances in Nigeria, a promising solution would be to borrow elements from one successful awareness campaign targeting PMVs launched in Nigeria and apply it to Benin. While local NAFDAC awareness campaigns have been reported to be more efficacious than improvements in government regulatory control, similar public initiatives in Benin have not been successful in raising awareness among medicine vendors in conjunction with targeting the public (Bernagou, 2008). Furthermore, a cross-sectional survey conducted in Benin regarding citizens’ drug purchase patterns reported geographic and financial barriers to access genuine medications from government-

owned health centres, placing PMVs as a first point of contact for both unofficial primary health care consultation and prescription of medicine (Abdoulaye et al., 2006). The majority of those surveyed do not commonly visit a physician prior to purchasing prescription medications due to high costs (Abdoulaye et al., 2006). Therefore, a novel approach would be to target PMVs in an extensive awareness campaign using peer-directed, participatory education to improve their knowledge of current treatment protocols, as well as to strengthen their commitment to providing quality medicines to their communities. The idea for this initiative primarily stems from a successful 2003 PMV awareness campaign which improved PMV knowledge of malaria symptoms and the responsible prescription of appropriate malaria drugs in the Nigerian communities of Aba North and Aba South (Greer et al., 2004). Given the reported positive outcomes of this intervention - including a three-fold increase in PMV knowledge about malarial prophylactic measures and a nearly sixfold increase in PMVs recommending the correct dose in treatment regimen – there is convincing evidence to support the application of the Nigerian malaria

awareness intervention as a model to combat the counterfeit drug trade in Benin (Greer et al., 2004). This intervention aims to target PMVs practicing in the community health district in which Adjegounle is found. The cascade peer training approach excels in resource-limited settings due to lowered costs and reduced time interval for the intervention to reach all PMVs in the community (Greer et al., 2004). Moreover, the cornerstone of such a model is its intimate small-community setting, which capitalizes on the established relationships of PMVs with neighbouring clients. Furthermore, a comprehensive review of 16 PMV interventions in subSaharan Africa concluded that features of the most efficacious campaigns involved participation of the entire community, material incentives for PMVs, and continued monitoring of performance – all of which are key components in this adapted model (Goodman et al., 2007). From the Nigerian PMV malaria awareness campaign (Greer et al., 2004), we seek to borrow and apply the following elements: 1) partnership coordination and baseline census; 2) peer-directed cascade training model; and 3) supplementary media, materials, and monitoring. www.meducator.org

PHC District/ CAPA Area

Issue 17

-Community Leaders -Community Representatives (from NGOs, associations, etc.)

Community Health District (Cotonou V) Representatives PMV Peer Trainer LGA

PMV 1

STATE Figure 1 Essential components of the community health district committee which would coordinate logistics during the intervention and provide ongoing support to trained patent medicine vendors following the training.

PMV 2

PMV 3

PMV 4...etc

Figure 2 Overview of the PMV cascade training model that will be followed throughout the intervention process

1) Preparation: Partner Coordination and Census Consistent with the Nigerian PMV awareness campaign, coordination of various agencies is crucial to the campaign’s success in Benin. Development agencies - including BASICS (Basic Support for Institutionalizing Child Survival) and the Chirac Anti-Counterfeit Drug Initiative – would provide medical staff to act as master trainers as well as logistical and financial support. Benin’s National PMV Association is another key stakeholder as they would serve to mobilize and persuade PMVs in communities to attend awareness campaign sessions. Furthermore, another important preparatory step instituted in the Nigeria campaign that is also applicable to the Beninese context is the baseline census, assessing geographic distribution, pre-intervention practice patterns, and potential interest in participating in the prescribed awareness campaign.

workshop for the CHD committee (Greer et al., 2004). Each district’s committee - comprised of community leaders, NGO representatives, traditional health practitioners, and physicians, among others - subsequently select four PMVs as a core group of peer trainers for the community, depending on criteria such as literacy, possession of the secondary school certificate, and residence in the community for more than two years (Greer et al., 2004). Master trainers would then deliver an educational workshop to the group of peer trainers, who would each host awareness campaigns in their respective regions to small groups of local PMVs (Greer et al., 2004). This communitybased PMV training aims to teach each PMV to effectively identify genuine versus counterfeit packaging, understand standard treatment regimens for common region-specific diseases in Benin, and to recognize symptoms severe enough to require referral to a physician.

2) Intervention: Peer-Directed Cascade Training As seen in Figure 3, a peer-directed cascade training model was adapted from the original Nigerian campaign. First, master trainers (medical staff ) from partner development agencies would conduct a

3) Supplementation: Materials, Media, and Monitoring One of the primary incentives for PMVs to attend the awareness campaign is the provision of a certificate upon completion. Trained PMVs must sign a pledge of accountability to sell only

genuine medications in their community. Importantly, a key incentive is the provision of logos for PMVs to present on the walls of their shops to identify them as trained professionals, upon completion of the intervention program (Greer et al., 2004). As adapted from the Nigeria PMV intervention model, media promotion is an important adjunct to the central awareness component. Specifically, radio programs can serve to mobilize and encourage local PMVs to attend the peer-lead awareness sessions outlined above. Thus, representatives from all sectors of the healthcare system in the community jointly ensure that each PMV is responsible for guaranteeing the safe provision of medications to local districts.

Underlying Assumptions and Conclusion Careful consideration has been put into re-designing Nigeria’s program for Benin in the hopes of combating the counterfeit drug industry. By applying many of the program’s components to the Benin model including the structure of the training course and the evaluation criteria, the model can be expected to experience similar success. This is based on the assumption that Benin is comparable

March 2010

to Nigeria with regards to a low education level among PMVs and a reliance on PMVs due to poor accessibility to Primary Health Centers (Goodman et al., 2007). The proposed program is also likely to perform well in Benin due to its time and cost efficiency (Greer et al., 2004), thus reducing strain on the nation’s limited budget. In addition, it is believed that this community-centered program will increase the strength and awareness of community groups, leading to a more effective and collective framework in which problems can be dealt with (BASICS II, 2004). Ultimately, if evidence suggests that a vendor-targeted training model such as the one proposed above is effective in reducing

the distribution of counterfeit medications in Benin, there is potential to tailor the program to other countries plagued with counterfeit drugs. It is important to remember that PMVs only comprise a small portion of the counterfeit drug industry. Thus, interventions exclusively targeting PMVs will not completely resolve the problem as they are necessary but insufficient determinants to the suppression of such illicit activities. Moving forward, it would be important to implement regulatory protocols such as anti-corruption and border surveillance initiatives, along with stricter law enforcement, to further the potential progress of this PMV awareness campaign.

Postgraduate Editor in Focus Dr. Ryan Wiley Please refer to page 7 for Dr. Wiley’s biography.

References Abdoulaye, I., Chastanier, H., Azondekon, A., Dansou, A., & Bruneton, C. (2006). Enquête sur le marché illicite des médicaments à Cotonou (Bénin) en mars 2003. Med Trop, 66, 573-576. AfDevInfo Organisation Record, (2008). Retrieved Nov. 27, 2009, from http://www.afdevinfo.com/htmlreports/org/ org_14033.html Akunyili, D. (2005, May). Counterfeit Drugs and Pharmacovigilance. Paper presented at The 10th Pharmacovigilance – The Study of Adverse Drug Reactions Training Course, Sweden. Retrieved from http://www. fug.se/ovrigt/Akunyili.pdf Akunyili, D. (2006). Lessons from Nigeria: The Fight Against Counterfeit Drugs in Africa. Diabetes Voice, 51(3), 41-43. BASICS, (2006). Retrieved Nov. 29, 2009, from http://www. basics.org/about.htm BASICS II, (2004). The CAPA Handbook: A “How-To” Guide for Implementing Catchment Area Planning and Action, a Community-Based Approach to Child Survival. Arlington, VA: State Ministry of Health. BASICS III. (2009). Improving Child Health in Benin: Final Report. Retrieved from http://www.basics.org/reports/ FinalReport/Benin-Final-Report_BASICS.pdf BBC News, (2009, Oct 17). Country profile: Benin. BBC News. Retrieved November 17, 2009, from http://news.bbc. co.uk.libaccess.lib.mcmaster.ca/2/hi/africa/country_ profiles/1064527.stm. Bernagou, P. (2008). La contrefaçon des médicaments et les moyens d’y remédier au Benin. Comptes Rendus Biologies, 331, 986-990.

Bernagou, P., Teyssie, V. (2008). Pierre Fabre Foundation. [Brochure]. Castres: Fondation Pierre Fabre. Centers for Disease Control and Prevention. (2009). Health Information for Travelers to Benin. Retrieved from http:// wwwnc.cdc.gov/travel/destinations/benin.aspx Central Intelligence Agency (CIA), (2009). In The World Factbook: Benin. Retrieved November 15, 2009, from https://www.cia.gov/library/publications/the-worldfactbook/geos/bn.html Central Intelligence Agency (CIA), (2009). In The World Factbook: Nigeria. Retrieved Oct. 25, 2009, from https:// www.cia.gov/library/publications/the-world-factbook/ geos/ni.html Central Intelligence Agency (CIA), (2009). In The World Factbook: Nigeria. Retrieved Nov. 29, 2009, from https:// www.cia.gov/library/publications/the-world factbook/ maps/maptemplate_ni.html Fondation Chirac, (2009). Retrieved Nov. 27, 2009, from http://www.fondationchirac.eu/en/ Gale, J., Loux, S., & Coburn, A. F. (2006, April). Creating Program Logic Models: A toolkit for state Flex Programs. Portland, ME: Flex Monitoring Team. Goodman, C., et al. (2007). Medicine sellers and malaria treatment in Sub-Saharan Africa: What do they do and how can their practice be improved? American Journal of Tropical Medicine and Hygiene, 77, 203-218. Graphic Maps, (n.d.). In Benin Large Color Map. Retrieved Nov. 29, 2009, from http://www.worldatlas.com/webimage/ countrys/africa/lgcolor/bjcolor.htm For a full list of references, please refer to www.meducator.org

www.meducator.org

Issue 17 A study found that individuals taking angiotensin receptor blockers (ARPs) were 50% less likely to develop dementia as compared to other blood pressure drugs. It is known that high blood pressure is a risk factor for Alzheimer’s disease.

Danish scientists proclaim that there has been no substantial change in the number of adult brain tumors since mobile phone usage sharply increased in the mid-1990s.

Dads should not be present in the delivery room, according to French obstetrician Michel Odent. Odent blames the increasing number of Caesarean section births on the increasing number of fathers in the delivery room. He argues that the father’s presence makes the woman more anxious and slows the release of oxytocin, a hormone that stimulates uterine contractions during birth.

MedWire

As a drug that is routinely prescribed for the treatment of severe pain in cancer patients, morphine ironically may promote the spread of cancer. The opiate promotes the growth of new blood vessels which deliver oxygen and nutrients to tumors.

A research team at Harvard University has successfully engineered a plastic implant, which, when placed under the skin of a rat, can kill cancer cells by inducing a systemic immune response. This “cancer vaccine” technology appears promising, but more research is needed before the technique can be used in humans. A major European trial has shown that 1 in 8 men tested positive for prostate cancer using a prostate-specific antigen will, in reality, not develop the disease. Researchers at the University of Chicago found an increased number of proteins in the urine of 90 children diagnosed with ‘dangerous’ snoring, thereby suggesting that the urine test can differentiate dangerous snoring from safe snoring.

Jack Walborn, a six-year-old boy from the United Kingdom, became the first person in the world to have a heart valve opened using a magnetic resonance imaging (MRI) scan rather than X-ray. An MRI involves no radiation exposure, an important consideration for children.

A simple eye test may detect Alzheimer’s and other diseases before symptoms develop, according to UK scientists. The technique uses fluorescent markers that attach to dying cells viewed from the retina, giving an early indication of brain cell death.

Drinking green tea may offer some protection against lung cancer, say experts who studied the disease at a medical university in Taiwan. Recent research involving over 500 people adds to growing evidence point to the beverage’s anti-cancer effects.

Not only does the amount and style of exercise matter, but studies also show that differences in what you eat after exercise produce different effects on the body’s metabolism.

UK experts claim that carrying extra weight on your hips, bum and thighs protects against heart and metabolic problems. Hip fat mops up harmful fatty acids and contains an anti-inflammatory agent that helps prevent arteries from clogging. Neuroscientist Hiroshi Kawabe has recently published a study in the prestigious journal, Neuron, showing that an enzyme, which usually controls the destruction of protein components, has an unexpected function in neurons. Nedd4-1 controls cytoskeleton structure and thus ensures that nerve cells can form the tree-like extensions necessary for signal transmission in the brain.

MED

Patients may have to be prescribed higher doses of antibiotics because of rising rates of obesity. Doctors argue that the standard “onesize fits all” dose may not eliminate an infection in larger adults, which can increase the risk of developing antibiotic resistance.

The Potato Council is trying to reclassify the tuber as a “supercarb” – recognizing its “unique dual identity” as both carbohydrate and vegetable. Spurned by dieters on lowcarbohydrate regimens like Atkins, the vegetable also appeared to score poorly on the Glycaemic Index (GI) which measures how quickly foods are broken down. The slower, the healthier - and the potato breakdown was quick.

Attractive women may have the competitive edge by letting their temper flare more, research suggests. Researchers found women who rated themselves as pretty displayed a war-like streak when fighting battles to get their own way.

Joel Nigg, a scientist at the Oregon Health & Science University postulated that lead, which is sometimes found in paint, may trigger an underlying susceptibility to ADHD and change it into a full-blown disorder.

March 2010

Brain blood vessels point to Multiple Sclerosis (MS): A US study states more than 55% of MS patients have constricted blood vessels in their brains.

Stammering has long been recognized to run in families, but scientists now say they have identified three genes that may cause the problem to occur. They believe that mutations tied to metabolic disorders may also affect the way some parts of the brain function. Professor Ina Weiner of Tel Aviv University recently found that the lateral ventricles and hippocampus were larger in rats that were manipulated prenatally to display schizophrenialike symptoms. Two drugs commonly used to treat schizophrenia, risperidone and clozapine, appeared successful in reducing ventricles and hippocampus size to normal.

A small proportion of extremely overweight people may be missing the same segment of genetic material, claim researchers. The findings, published in Nature, could offer clues to whether obesity can be “inherited”.

Scientists in Cambridge have shown that an “artificial pancreas” can be used to regulate blood sugar in children with Type 1 diabetes. A trial found that combining a “real time” sensor measuring glucose levels with a pump that delivers insulin can improve overnight blood sugar control. Vegetative patients can respond to questions: Scientists have been able to communicate with the thoughts of a brain-damaged man. Awareness was detected in three other patients previously diagnosed as being in a vegetative state.

Scientists are trying to mimic the look, feel, and taste of chicken with soy. Why? It costs less and has many health benefits, including lowering cholesterol levels and maintaining healthy bone structure. The 3D structure of the vesicular stomatis virus (VSV) was recently revealed in a paper published in Science. The bullet-shaped VSV has therapeutic potential in treating cancer and HIV.

A mechanism, which incites sperm swimming when they get near the egg, could one day lead to new forms of male contraception, scientists have said. Tiny pores on the sperm’s surface allow it to change its internal pH, which in turn starts its tail movements.

Scientists at the University of Chicago’s Brain Tumor Center have developed nanomaterials that may help fight cancer. By connecting gold-plated ironnickel microdiscs to braincancer-seeking antibodies, the application of a light magnetic field triggers an oscillation whereby energy transfer induces cell suicide known as apoptosis.

A recent study published Clinical Pediatrics suggested that behaviours relating to how much and what to eat are developed as early as three months to about two years of age. This makes this age period a tipping point in determining the future onset of obesity.

A recent study mapped the effect of acupuncture on brain activity and may allow acupuncture to be more accepted in the scientific community. Researchers found that the sensation produced by acupuncture, termed deqi, deactivates areas within the brain associated with the processing of pain.

MedWire

Swapping a daily glass of wine for another with a slightly lower alcohol content may lower the risk of some cancers. An alcohol content of 10% rather than 14% may be enough to initiate such benefits, says the World Cancer Research Fund.

Researchers at MIT and Harvard University have developed nanoparticles with the capability to cling to the walls of arteries and release medicine. These socalled “nanoburrs” have the added ability to be targeted to specific locations and as a result, introduces an alternative to drug-releasing stents in patients with cardiovascular disease. If you find playing video games a struggle, it could be to do with the size of certain parts of your brain. US researchers found they could predict how well an amateur player might perform on a game by measuring the volume of key sections of the brain.

While most children like sweets, those with an extrasweet tooth may be at higher risk of future depression or alcohol problems. A report in Addiction indicated that children are especially drawn to very sweet tastes had a close relative with an alcohol problem or showed symptoms of depression. www.meducator.org

Issue 17

Vaccinations in the Developing World Vaccines exist for some of the most devastating diseases in the world from typhoid to tuberculosis, with an estimated 3 million children saved by vaccinations in 1991 (Grzybowski, 1991). Logic would suggest that those who encounter these pathogenic organisms on a daily basis would welcome immunity to them; however the question is much more convoluted amongst

those in the developing world. In short, it is accurate to say that achieving satisfactory vaccination rates for any disease in the third world is determined

Matthew MacDonald

onsider tuberculosis (TB) as an exemplar to the vaccination paradox. It is estimated that TB causes three million deaths a year more fatalities than any other bacterial pathogen - with an estimated 1.7 billion people worldwide currently infected. Tuberculosis in the developing world is so prevalent that the UN’s World Health Organization declared it a global health emergency and classified it as one of the three diseases of poverty, which also includes AIDS and malaria (WHO, 2005). Despite having a highly effective vaccine, ninety-five percent of all new TB cases are found in developing nations (Grzybowski, 1991). Most incredulous of all is that the vaccine for TB, Bacillus Calmette-Guérin (BCG) is a relic of the 1920s. The BCG vaccine has proven to be effective in 80% of patients, though its specific biochemical mechanism is not well understood (Soysal et al., 2005). Vaccines are created when scientists create a harmless version of a pathogenic bacteria or virus to be injected into a healthy person. This procedure allows the patient’s immune system to identify the true and dangerous disease by virtue of having an antigenic memory stored in B-cells (CDC, 2009). Through trial and error, Calmette and Guérin discovered that subculturing virulent strains of Mycobacterium bovis in a media of glycerine, bile and potato created a less

by supply, social, and cultural factors.

virulent strain of TB. After painstakingly reculturing the bacteria for nearly a decade, they created a non-pathogenic version of TB (Fine, 1989). By 1921 the first inoculation was performed on a child; 90 years later, it is predicted

that 3x109 BCG vaccines have been administered worldwide. After almost a century of possessing an effective vaccine against TB, the developing world continues to suffer tuberculosis at pandemic levels (BarretoI et al., 2006). Much of the aforementioned statistics seem contradictory; despite having a viable and proven vaccine, TB continues to be a scourge to one out of every six human beings – “why?” is the question this essay will attempt to answer.

hours they operate during the day; mothers will not take their children to be vaccinated if they must be working from 9 to 5. Therefore, vaccination planners must collaborate with the community in question in order to align their resources for maximum effect (Boniar et al, 1989). We also see a drop in vaccination rates when clinic workers are pressured to focus exclusively on the quantity of individuals they vaccinate to the detriment of the quality of service. In the same vein we observe a decrease in the population’s willingness to be vaccinated when organizational policy avoids any risk-taking even when it is in the best interest of the patient or the community. For example, clinic doctors refer critically ill patients to distant hospitals simply in order to avoid responsibility (Grzybowski, 1991). It is important to have both a readily available supply of vaccines and staff who are trusted to administer it, but this factor eclipses an even more intractable issue: does the public want the vaccine?

Supply S ervice Factors

S ocial Factors

Before discussing underlying cultural and social resistances to vaccinations, the rate-limiting step of supply and service must be examined. One major consideration is the physical location of vaccination clinics as well as the

Recent trends in establishing effective vaccination programs have moved towards a ‘social marketing’ approach to encourage compliance and self-motivated behaviour. Instead of focusing on factors that predict the

“[...] vaccine planners must collaborate with the community in question”

March 2010

16 they have forsaken when they abandon their heritage in favour of “Christian values, tastes, and desires.” In the most extreme cases, there are fears that vaccination programs are nothing more than a western attempt to gather biological data about immunodeficiencies in the developing world’s population in order to produce biological weapons against them, as was a heated controversy in India’s national press in 1987 (Scheper-Hughes & Lock, 1987). A comprehensive list of social anxieties and variables that inhibit vaccination programs is essentially impossible due to the complex and ever changing geopolitical and social landscape. An effort, however, must be made to compensate for concerns and fears that cultures produce when an external agent attempts to influence them even if it is with benevolent intentions.

Figure 1 Implementing vaccine programs in developing countries involves overcoming several challenges.

non-compliance with vaccination programs, the model of social marketing works similarly to its consumer-marketing cousin in finding predictors of demand (adherence) and self regulation. Examples of such studies in North India and Nepal have shown that there is gender disparity: males are more often vaccinated than females and a positive correlation exists between the mother’s education level and her compliance in a vaccination program (Grzybowski, 1991). It is important to remember that vaccination programs do not operate in a vacuum; compliance is a function of a complex interplay of regional history as well as how individuals perceive western influences and even their own government. A powerful example is in India; conspiracy theories have emerged among conservative Hindu and Muslim groups linking vaccination programs to hidden political agendas. Mahadevan’s 1986 study suggested that Indian Muslims feared that vaccines are not medicinal but are in fact a sterilizing agent designed to enforce family planning, thus curbing their population growth and limiting the number of Muslim voters. These fears stem from past events such as when, in the 1970s, the Indian government exercised ‘emergency’ state power in the name of population control. Then, in 1990 during heightened Muslim-Hindu tensions, vaccination programs that specifically targeted women and children were coincidentally intensified (Bastien, 1989). Such tensions also include Western influences, as many in India believe that vaccination programs are simply a modern day adaption of the techniques used by Christian missionaries who built hospitals and schools in order to convert Hindus. One leader of a prominent Hindu group in a South Indian city, as interviewed by Grzybowski, pointed out the visual similarities between a hypodermic needle and the Christian cross. He also believed that youths vaccinated against diseases would feel immune to the wrath of the gods

Cultural Factors While less appreciated for its importance than social factors (Grzybowski, 1991), cultural influences regarding the perception of vaccinations and illnesses in general as well as the idiosyncratically held role of medicine in producing and protecting health is just as pivotal in the success of any vaccination campaign.

“[...] cultural factors such as a lack of education can lead to reduced compliance rates as patients develop unreasonable expectations of vaccines” One of the major stumbling blocks in creating a sustainable, wide-scale vaccination program is a poor understanding of what vaccinations do and what diseases they protect against which leads to unrealistic expectations. Grzybowski found that mothers either believe that vaccines are good for a child’s health in a general sense akin to a balanced diet or that vaccines are designed to protect against serious diseases but nothing specifically. While 40-50% of mothers thought vaccinations protect against specific illnesses, only 25% could name a local disease that is vaccinable. Another major folly is that mothers often see vaccines as a treatment instead of a preventive measure, and thus do not vaccinate their children on the reasoning that the child is healthy (Raharyo & Corner, 1990). These misconceptions are often caused by rapid explanations given by health care workers for why mothers should comply with vaccination directives www.meducator.org

Issue 17

or why a more sophisticated explanation is outside of an uneducated mothers’ understanding. Another cultural aspect to consider is the general view a population holds about medicine and the ethical dilemma of either attempting to explain vaccination in rational terms, or instead introduce the concept using existing cultural frameworks – essentially explaining vaccinations as “magic”. Should the significance of the raised skin of a TB test be described in terms of an immune response or that its purpose is akin to a mystic’s divination procedure? In this precarious line of reasoning, one must remember the distinction between attributing the effects of a vaccine to magic, which is indefensible, and simply elucidating expectable results using terms familiar to the target population. While one’s first instinct may be to favour the option that does not appear to involve the intentional spread of superstition, consider which is less truthful: using existing cultural frameworks to explain that BCG will protect against TB for some time like an amulet would protect against a malevolent spirit, or giving a vague explanation that ultimately leads to a mother who draws false conclusions about the purpose and ability of a vaccine (Grzybowski, 1991)?

Conclusion Failure to vaccinate is sometimes thought as a kind of parental neglect, that the parent does not care enough for the child’s health to have him or her vaccinated; indeed this is the opposite of the truth. Mothers who refuse to vaccinate often do so for fear of the child’s health, even if that fear is misplaced. When you subtract the supply issues involved and imagine a best-case scenario in which vaccines are available to all those who seek it, we are still hindered by the social environment that the vaccination program finds itself in as it must contend with non-health related issues such as racial tension. In addition to social factors, cultural factors such as a lack of education can lead to reduced compliance rates as patients develop unreasonable expectations of vaccines. Any successful vaccination regiment must contend with these three factors while never losing sight of that our efforts are humanitarian; forced vaccination compliance gained through a government’s directive is unsustainable and morally grey at best, so we must endeavour to educate and win the hearts and minds of those we are trying to help so that they seek vaccination of their own volition.

Postgraduate Editor in Focus Dr Farah Huzair is currently a part of the Technoscience and Regulation Research Unit (TRRU) at Dalhousie University. Her research interests include the evolution of science and biotechnology, and most recently she is a co-investigator for TRRU’s “Vaccines of the 21st Century” project.

References BarretoI, M., PereiraII, S., Ferreira, A. (2006). BCG vaccine: efficacy and indications for vaccination and revaccination. Jornal de Pediatria, 82(3), 45-54. Boniar A., Rosenfield P., Tengvald K. (1989). Medical technologies in developing countries: issues of technology development, transfer, diffusion and use. Soc. Sci. Med. 28, 769. Bastien, J. (1989). Cultural perception of neonatal tetanus and program implications. Applied Anthropology meetings, Santa Fe, New Mexico. Centers for Disease Control and Prevention. (2009). How Vaccines Prevent Disease. Retrieved from http://www.cdc. gov/vaccines/vac-gen/howvpd.htm Fine, P. (1989). The BCG Story: Lessons from the Past and Implications for the Future. Reviews of Infectious Diseases, 11(2), 353-359. Grzybowski, S. (1991) Tuberculosis in the third world. Thorax, 46, 689-691.

Mahadevan K. (1986). On Muslim culture as pronatalist in ideology and politics. Fertility and Morality: Theory, Methology and Empirical Issues, Chapter 8. Sage, Beverly Hills. Raharyo Y., Corner L. (1990). Cultural attitudes to health and sickness in public health programs: a demand-creation approach. Health Transition, 2, 522. Scheper-Hughes, N., Lock, M. (1987). The mindful body: a prolegomenon to future work in medical anthropology. Medical Anthropology, 1, 6. Soysal, A., Millington, K.A., Bakir; M., Dosanjh D., Aslan Y., Deeks, J.J., Efe S., Staveley, I., Ewer K., Lalvani, A. (2005). Effect of BCG vaccination on risk of Mycobacterium tuberculosis infection in children with household tuberculosis contact: a prospective community-based study. The Lancet, 366 (9495), 1443-1451 World Health Organization. (2005). Poverty Issues Dominate WHO Regional Meeting. Retrieved from http://www.wpro. who.int/media_centre/press_releases/pr_20020916.htm.

March 2010

MedBulletin by Louis Winston

170,000 doses of the swine flu vaccine Arepanrix have been put on voluntary hold because of an above average report of anaphylactic reactions; this includes symptoms of difficulty breathing, skin rashes and an increased heart rate. It has been reported that one in 20,000 people suffered such adverse reactions to the batch. This is five times the expected number, although none of these patients suffered long term or fatal illness from the drug. The manufacturers of Arepanrix, GlaxoSmithKline (GSK), said that the vaccine was being put on hold because “of a higher than expected rate of serious allergic reactions”. GSK also added that similar anaphylactic reactions were not seen in other lots. To date some 15 million doses of Arepanrix have been distributed across Canada. The overall frequency of severe allergic reaction following immunization has been normal, with one case per 100,000 being reported.

Reference: Canada’s doctors told to halt swine flu vaccine batch. (2009, November 25). Retrieved from BBC News: http://news.bbc. co.uk/2/hi/8376534.stm

Heart Damage: A Sexist Phenomenon?

MedBulletin by Mohsin Ali

Recently, Australian researchers have suggested that male sex hormones, collectively known as androgens, may play a role in helping the vasculature around the heart regenerate, thereby preventing heart damage. Men tend to suffer heart attacks that are more frequent, worse, and earlier in life than those compared to women. As estrogen is known to help blood vessels regenerate, it was assumed that the lack of the female hormones in men resulted in the heart attacks. However, recent work done by Sieveking and collegues have found that the heart attacks among men may be due to the drop in androgens as men age. Exposure to androgens caused cells derived from the umbilical cord of a male fetus to move and multiply, which are activities associated with new vessel growth. Moreover, when researchers inflicted blood vessel damage on castrated mice lacking androgens, the mice responded poorly. But when treated with androgens, the recovery rate of the castrate mice was increased. Taking all this evidence together, the authors suggested that androgen replacement therapy might possibly be a treatment for heart disease for men in the future. It will also be accompanied by increased energy and muscle mass, among other benefits. The dark side? Androgens have also shown to play a part in helping tumour growth in prostate cancer, perhaps by the same mechanism: stimulating vessel growth. Reference: Rockefeller University Press (2010, January 16). Gender-biased heart damage. Retrieved from Science Daily: http://www. sciencedaily.com/releases/2010/01/100113172304.htm www.meducator.org

MedBulletin

Canada’s Doctors Told to Halt Swine Flu Vaccine Batch

Issue 17

Crossing Borders and Pushing Boundaries: The Ethics of International Volunteering There

are many ethical challenges and implications of volunteer work in

a global health setting undertaken by students.

Therefore,

substantial

reflection regarding humanitarian motivations, morality and self- awareness must be carried out by the volunteer. Inspired by the authors’

Embedded the Global

Learning Experiences overseas as Health Sciences students in Health Specialization, this article will shed light on the current surrounding ethical dimensions of overseas volunteering.

evidence

Rhyanna Cho, Jennifer Edge, Alvin Keng

hat does it mean to volunteer in a global health setting? As students of the Global Health stream in the Bachelor of Health Sciences (Honours) program, we have discovered the vast amounts of ethical and personal challenges encountered when going abroad as foreign volunteers. Despite travelling to different locations for our Embedded Learning Experience placements (South Korea, Ghana, Philippines), several common themes have emerged from our dynamic experiences. As such, we emphasize the importance of developing a strong ethical foundation in preparation for the emotionally challenging situations encountered during a volunteer experience. Every year, many students consider volunteering abroad in a global health setting. But what does ‘global health’ and ‘volunteering abroad’ encompass? Kaplan et al. (2009) propose a general definition of global health as, “an interdisciplinary and multidisciplinary field of study, research, and practice aiming to improve health and health equity worldwide”. The term ‘global’ signifies a focus on the scope of health issues versus the location, emphasizing a “two way flow between developed and developing countries” (Kaplan et

al., 2009). Palmer (2002) describes a volunteer abroad as “…someone who willingly works overseas [most often in ‘developing’ countries] for a package that amounts to less than what he or she would be earning in the same capacity in his/her country of origin” (p. 637). This gives rise to a pressing question: Why volunteer in a foreign country instead of at home? Palmer (2002) outlines two underlying motivations: altruistic and self-centric. Altruistic motivation is the desire to make a difference to those less privileged. However, the prospect of contributing to a developing country versus a developed one may seem more appealing because a more ‘valuable’ contribution may be made by diminishing the gap between the two worlds. Self-centric motivation refers to the desire to learn more about a culture, or to enhance career prospects. These motivations, amongst other objectives are likely to cross an individual’s mind at some point when planning to engage in an overseas volunteer experience. In the emerging trend of ‘volunteer tourism’, students must be mindful of the objectives of global health. Preliminary research findings by Brown & Morrison (2003) propose that volunteer tourism

encompasses two distinct participant outlooks: volunteer-minded vs. vacation-minded (or ‘voluntourism’ as cited in Brown, 2005). Regardless of how one ultimately chooses to sculpt their volunteer experience, as a student or a health care professional seeking global health related clinical or research experience, it is imperative to recognize that there are ethical dilemmas to be faced when interacting with highly vulnerable or marginalized groups, especially in a developing country. Without adequate preparation before departure, there is the risk of causing harm not only to oneself, but to the individuals and communities that one hopes to help.

S elf-Awareness Self-awareness is essential because decisions while volunteering may result in harmful consequences. The act of volunteering is rooted in humanitarianism, and the fundamental principle behind humanitarianism is humanity, defined by Vaux (2001) as “the capacity to listen to the person in need” (as cited in Gilbert, 2005). This is easier said than done – and while attempting to fulfill this task, one may experience emotionally demanding situations.

March 2010 Thus, it is argued that self-awareness is essential because the presence or absence of self-awareness can directly influence the impartial response to the benefactor (as cited in Gilbert, 2005). Emphasis on experiential group learning may help facilitate this process, with focus on relevant tasks that are emotionally stimulating, leaving individuals feeling vulnerable as they engage in critical self-reflection. One such example of an experiential group learning activity is active listening. Gilbert (2005) deems this appropriate as “one’s own judgmental feelings about others, one’s own value system, issues of cultural relativity, and many other disturbing feelings can be engendered” (p. 67). A crucial aspect is that trust be established within the group allowing individuals to be comfortable enough to reflect frankly on their experiences. Although this type of self-reflective process is challenging, it facilitates personal growth, strength, and awareness, which will equip the individual with the capacity to make decisions and respond appropriately with the principle of humanity in mind (Gilbert, 2005).

Ethics: The G ood, Bad, and Ugly As a foreign volunteer, one’s impact on the host community can be positive or negative, depending on how volunteers engage the community. Social developments can result on both sides wherein residents gain improvements in health, nutrition, education, or welfare service due to the work commissioned by foreign volunteers (Sherraden et al, 2008). New markets and businesses can be stimulated by the entrance of volunteers, which overlaps with the tourism market. However, this can also have adverse effects on the community. Any efforts to create an empowered selfsufficient community can be hindered by local dependency on foreign volunteers (Sherraden et al, 2008). Such an overreliance can create a skewed image of all incoming volunteers to the communities. For example, undergraduate students with no medical training may be assumed to be doctors in developing countries as part of an organization that provides medical excursions. If such volunteers give medical care, there is a higher likelihood of harm presented to the community. Such a scenario would also violate two key principles of medical bioethics, beneficience and non-maleficence, which is the duty to improve the condition of others and do no harm (Boetzkes & Waluchow, 2002). Therefore, volunteers lacking relevant skills are potential security, health, and political hazards for their host community (Pinto & Upshur, 2009). Volunteers can also drain the community’s already scarce resources without providing much added value in terms of service work. Despite the potential harm, such

20 humanitarian work can be both beneficial and life-changing for both volunteers and host communities. The cross-cultural component exposes both sides to new perspectives thereby aiding mutual global understanding (Sherraden et al, 2008). One of the foundations of service-learning is to incorporate some form of personal values and ethics training for the participants (Hales, 1997). In the healthcare field, service is intertwined with the work and learning of the students. As the trend for globalization continues to surge, the demand for such experiences amongst health professionals continues to rise. Solving problems pertaining to global health requires an understanding of ethics and the moral responsibility for upholding basic human rights to healthcare (Ruger, 2006). A prime example is the growing interest in global health electives among medical students (Brewer et al, 2008). Before such international immersion work is allowed, students should undergo social preparation for the culture shock and challenging ethical situations they will face (Brewer et al, 2008). Pinto & Upshur (2009) discuss certain key principles of global health ethics, including: humility, introspection, solidarity, and social justice. Institutions that send their students on global health experiences have a responsibility to prepare them in this manner before their departure (Pinto & Upshur, 2009). From personal experiences, students should also bring a mindset to bring about sustainable change that is desired by the community. This attitude is critical to prevent further inequalities between the developing and developed worlds. The lack of this viewpoint among international volunteers has been identified as a problem by Sherraden et al. (2008). From both a developmental and ethical standpoint, students must question whether local communities can sustain particular initiatives on their own. If a project cannot be maintained, are contributions, however substantial, making a negative impact if they become unsustainable after the volunteers leave the host community? A volunteer’s success, either clinical or research-based, cannot be solely based on publication turnouts, number of treated patients, or knowledge acquisition, but based on how the priorities of the host community are met (Pinto & Upshur, 2009). Overall, it is essential to establish one’s ethical foundation prior to going abroad in order to overcome the personal challenges that will be faced. The desire to volunteer must be self-motivated and derived from a genuine sincerity to contribute in a sustainable manner. These two factors become paramount when considering that one’s morals and ethics will, at times, be the only tools available to assist in withstanding and overcoming harsh obstacles such as racial discrimination, language alienation and gender inequality

www.meducator.org

Issue 17

that can be associated with volunteering in a foreign country. In addition, individuals should be prepared to embrace and acknowledge the influence of culture on daily aspects of working and living abroad. If an individual is not ready to respect the beliefs and customs of others, he or she will burden the local community with intolerance and emotional unpreparedness. It is essential to arrive ready to tolerate any cultural differences from one’s own society and willingly demonstrate appreciation and patience when adapting to cultural norms. While it is important to harbour the “humanitarian” mindset of making a difference in the community, one must be realistic about how much they can accomplish

given the limited skills and time constraints. Irrespective of the size of the contribution, it is important to ensure that all implementations can be sustained by the community. Though cultural appreciation and career resumé padding may be important considerations on a personal level, these should not be the primary reasons for undertaking a volunteer experience abroad. Individuals should organize their experience to be centralized around making a sustainable contribution to the community. Despite the uncertainties or fears of volunteering overseas, it is important to establish morality and self-awareness. Once these ethical roots are established, emotional aptitude and ability to work towards making an impact overseas can be ensured.

Postgraduate Editors in Focus Dr. Andrew Pinto is a family physician who underwent specialty training in Public Health at the University of Toronto, working frequently with the impoverished urban, rural Ontario, and First Nations populations. He is currently pursuing a Master’s degree in Community Medicine at the London School of Hygeine and Tropical Medicine. He conducts international research regarding injuries associated with gun violence and the arms trade as a member of Physicians for Global Survival. Dr. James Dwyer is Assistant Professor of Bioethics and Humanities at the State University of New York Upstate Medical School, and a member of the University Hospital Ethics Commmittee. He also serves as a board member of the International Association of Bioethics. Dr. Dwyer’s research involves the fields of justice and democracy in relation to global health, and more recently, global migration of health care workers as well as health care professionals’ obligations in epidemics. He has written for the Bioethics journal as well as the Bulletin for the World Health Organization.

References Boetzkes, E. A., & Waluchow, W. J. (2002). Readings in health care ethics. Peterborough, Ont.: Broadview Press. Brown, S. (2005). Travelling with a purpose: Understanding the motives and benefits of volunteer vacationers. Current Issues in Tourism , 8 (6), 479-496. Gilbert, J. (2005). ‘Self-knowledge is the prerequisite of humanity’: personal development and self-awareness for aid workers. Development in Practice , 15 (1), 64-69. Hales, A. (1997). Service-learning within the nursing curriculum. Nurse Educator , 22 (2), 15-18. Kaplan, J., Bond, C., Merson, M., Srinath Reddy, K., Rodriguez, M., Sewankambo, N., Wasserheit, J. (2009). Towards a common definition of global health. Lancet, 373, 1993-1995. Izadnegahdar, R., Correia, S., Ohata, B., Kittler, A., ter Kuile, S.,

Vaillancourt, S., et al. (2008). Global health in Canadian medical education: Current practices and opportunities. Academic Medicine , 83 (2), 192-198. Palmer, M. (2002). On the pros and cons of volunteering abroad. Development in Practice , 12 (5), 637-643. Pinto, A., Upshur, R. (2009). Global health ethics for students. Developing World Bioethics, 9 (1), 1-10. Ruger, J. P. (2006). Ethics and governance of global health inequalities. Journal of Epidemiology and Community Health , 60 (11), 998-1002. Sherraden, M. S., Lough, B. J., & McBride, A. M. (2008). Impacts of international volunteering and service: Individual and institutional predictors. St. Louis, MO: Center for Social Development Working Papers.

March 2010

MedBulletin by Louis Winston

DNA differences which appear to affect the risk of giving birth early have been found by US scientists. The US National Institutes of Health study found the variants in both babies and mothers. It is thought they may play a role in controlling immune responses which could theoretically trigger labour if they become too powerful. The causes of premature birth are poorly understood, although infections and other medical complications are blamed in some cases. The study looked at 700 DNA variants in 190 genes in women who delivered early, and those who carried their baby to term. They narrowed the search down to a handful of gene variations found more often in the women who gave birth prematurely, and their babies. In particular, babies who carried the gene for the â&#x20AC;&#x153;Interleukin 6 receptorâ&#x20AC;? were more likely to be born early. This was a good candidate gene because Interleukin 6 is produced by cells in response to infection and is involved in inflammation. High levels of Interleukin 6 in the amniotic fluid and foetal blood have been linked to the onset of premature labour.

Reference: Premature birth gene clue found. (2010, February 5). Retrieved from BBC News: http://news.bbc.co.uk/2/hi/health/8498712.stm

Use of Infrared Screening for Skin Cancer

MedBulletin by Mohsin Ali

Researchers at Johns Hopkins University have designed a novel technique aiming to help health care professionals ascertain whether any given pigmented skin growth is a benign mole or alternatively, a melanoma, a dangerous form of skin cancer. The research team consisting of Rhoda Alani, professor and chair of dermatology at the Boston University School of Medicine, Cila Herman, a professor of mechanical engineering at Johns Hopkins, and Muge Pirtini, a mechanical engineering doctoral student at Johns Hopkins, hopes that infrared images will provide an objective measure for identifying melanomas at an earlier, more treatable stage. Their work focuses on differentiating cancer cells from others based on the premise that since cancer cells divide more rapidly than normal cells, they typically generate more metabolic activity and release more energy as heat. Though the temperature difference is very small, the researchers have devised a clever way to make the difference more noticeable. They initially cool a patients skin for one minute. Immediately after, they record infrared images of the skin for an additional two to three minutes. Since cancer cells reheat more quickly than the surrounding healthy tissue, the difference can then be captured. Though the technology is still in its testing stages, the researchers envision a hand-held scanning system which will be available for dermatologists in order to evaluate suspicious moles. Reference: Scanning for Skin Cancer: Infrared System Looks for Deadly Melanoma. (2010, February 26). Retrieved from Science Daily: http://www.sciencedaily.com/releases/2010/02/100226093209.htm www.meducator.org

MedBulletin

Gene for Premature Birth Found

Issue 17

Professor Commentary Peace Through Health and Its Potential as a Transformative Lens Nancy Colleen Weeks Doubleday, PhD, is the HOPE Chair in Peace and Health at McMaster University, Centre for Peace Studies, and Associate Professor, Department of Philosophy. She holds B.Sc. (Hons.) and Ph.D. degrees in biology from Brock and Queen’s Universities respectively, degrees in Law (Osgoode Hall Law School) and in Environmental Studies (with a Specialization in International Law and Aboriginal Rights) from York University, and a degree in education from the University of Toronto. Dr. Nancy Doubleday

“P

eace Through Health” is a courageous idea advanced by health practitioners at McMaster and elsewhere to bring forward a consideration of “alternative” means to promote peace even in zones of active conflict. The word “alternative” is used to emphasize a contrast drawn between the approaches that have been used in peace through health and more traditional methods of addressing warfare and resolving conflict. In the recent book “Peace Through Health”, edited by Neil Arya and Joanna Santa Barbara, the case is made that health professionals have a clear duty to honour their Hippocratic Oath, and yet too often find themselves caught between the duties of ethics and politics all too often. The principled approach articulated under the rubric of peace through health urges the recognition and respect for human rights as a primary obligation and the fulfilling of higher moral commitments such as “to do no harm” as essential elements. Much of the early peace through health effort has addressed the processes of peace and situations of those in the most dire circumstances such as wars in zones of conflict or state oppression. In

turn, we have begun to recognize that there are forces operating in the world that create inequitable conditions prejudicial to health and well-being on a global scale. Some of these forces are direct in their action and identifiable as to cause, while some are indirect and elusive in both actions and origins. Violence can adversely affect health and well-being through direct and bloody means such as armed conflicts.

“[...] it is still violence that adversely affects the health and well-being of humanity.” Additionally, indirect forms of violence can include the action of multinationals which are unconstrained by standards governing labour or environment, leading to slow death by malnutrition or toxic contamination. In either case, it is still violence that adversely affects the health and well-being of humanity. In order to go beyond short-term interventions to reach the roots of violent confrontation and the resulting spread of ill health, we need to employ a very broad scope in our inquiry. It is here that peace through health

has enormous potential to make a revolutionary contribution. Speaking at the Canadian International Council conference on “The World in 2015: Implications for Canada” held recently in Ottawa, Ramesh Thakur remarked that increasingly intra-national or civil unrest of an ethnic character is replacing inter-national conflict (CPAC 7 February 2010). Thakur is perhaps best known for his contributions to advancing recognition of “the duty to protect” or as it has become more widely known “the responsibility to protect” within the United Nations system. If we are to be effective in promoting peace through health under conditions forecasting increasing civil violence in the future, then we need to adopt a proactive stance to the elimination of the root causes underlying what Haile Menkerios of the United Nations has described terrorist actions as increasingly desperate responses of desperate peoples (CPAC 7 February 2010). Menkerios goes on to say that we need to ask how this desperation came about, and speculated that terrorism and extremism are fostered by frustration with existing conditions, particularly in the Middle East. Here we clearly move across scales to pinpoint

March 2010

Figure 1 A boy was wounded amid the chaos of Port-au-Prince’s commercial district (courtesy of Ramon Espinosa/Associated Press)

the direct causes of these impacts on health and well-being - from the level of individuals who suffer the traumas of injury and mortality, to the levels of larger organizations and affinities that are driving the conflicts occurring at regional, national and international scales. Haiti provides us with a very significant lesson about violence and recovery partly because the world media are free to focus on the daily struggles of the Haitian people following the recent earthquake. The reason they are able to do this so effectively is due in part to the fact that the violence Haiti has experienced recently is non-partisan – there is no political edge to the death and destruction and therefore no censorship or contested meanings are attributed to the destruction of people’s lives on the ground. In fact the destruction itself becomes the focus, and the impacts on the health and well-being of Haitians of all ages are key themes. For instance, issues of physical rescue and burial were prevalent in the media in the early days and needs for water, food, sanitation, and shelter has emerged and becomes increasingly urgent as time passes. It is very obvious that basic needs must be met or violence, injury and health impacts arise. It is not difficult to transpose the lessons to other scales and to other situations where destruction has begun with human actions instead of with natural causes. With this in mind, it is important to understand that Galtung’s list of needs is entwined with the ladder of needs that

Figure 2 Courtesy of Ruth Fremson/The New York Times

constitute the biological and sociological basis of human survival identified by Maslow. The health of the individual is also entwined with the health of the body politic – as well as the body economic. In order to depolarize intra-national, inter-ethnic tensions that are seen as increasingly important sites of conflict and violence, some scholars flag the necessity of avoiding inappropriate concepts of justice, democracy and civil society (e.g. Cervan, February 5, 2010). Such ill-conceived interventions can exacerbate conflict, where what is needed are culturally appropriate and locally grounded solutions. Potential interveners and external forces need to listen – long and hard – before taking unilateral action. In any event, respect for all involved must be felt and shown. Rather than seeking to impose solutions as has been the case in colonial and neo-colonial relations to date, what is needed is a supportive, respectful and enabling approach. In short, we need a healing approach to the violated rights and relationships experienced at the level of ethnic and social groups; remedies for the indirect, structural violence embedded in colonial practices; as well as for the physical and psychological traumas experienced by individuals involved in direct conflicts. It is only by taking such a broad view, that we can seek to reduce present trends toward exponential growth in conflicts and casualties experienced in recent decades.

References Neil Arya and Joanna Santa Barbara, Peace Through Health: How Health Professionals Can Work for a Less Violent World. Kumarian Press, 2008. Daniel Cervan – “Transitional or restorative justice in Lebanon? The Arabic concept of Adl in the Islamic & the Maronite Christian traditions and its contribution to reconciliation” Oral Presentation at the 19th ANNUAL SYMPOSIUM ON CONFLICT RESOLUTION Thinking,

Knowing & Doing: Linking theory, Knowledge & Practice in Conflict Resolution? Friday, February 5, 2010 R.A. Centre, 2451 Riverside Drive, Ottawa, ON Canada CPAC “The World in 2015: Implications for Canada”, Rebroadcast 7 February 2015. See: http://www.cpac.ca/ forms/index.asp?dsp=template&act=view3&templat e_id=46&lang=e

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March 2010

MedQuiz

MedQuiz Have you read all the articles? Test yourself and see how well you understood the articles by answering the questions below. 1. The leading example of fortified food programs was championed by: a) South Africa b) Phillippines c) China d) USA 2. PMVs in the Counterfeit Drugs article refers to: a) Personal medical veterans b) Personal medicine vendors c) Patent medicine vendors d) Patent medicine veterans 3. The three main components of the PMV awareness campaign (in sequential order) are: a) Intervention, preparation, implementation b) Advertisments, positioning, training c) Implentation, training, delivering d) Preparation, intervention, supplementation 4. Students considering volunteer work overseas should undergo preparation for: A) Culture shock B) Adopting a mindset for contributing to sustainable change C) Ethical challenges D) All of the above

5. Placing emphasis on the following factors in dealing with conflict and violence resolution is ineffective and inconsistent with principles of the peace through health movement: a) Justice b) Beneficence/non-maleficence c) Democracy d) a and c 6. The predominant force creating inequitable conditions, according to the peace through health principles, is: a) Lack of access to clean water b) Violence c) Malnutrition d) Lack of access to medical technology 7. ‘Social marketing’ approaches in the establishment of vaccination programs encourage: a) Local community solidarity b) Compliance c) Racism d) Medical innovation

Answers: b, c, d, d, d, b, b

Meducator Staff

Cancer with Viruses? McMaster’s Medical

Research and Health

Global Citizenship

Ethics Student Journal

Conference Also in this issue: Doctor’s right to refuse patient treatment Chaperones and protein folding

Special issue in collaboration with Loneliness andthe Global Citizenship Conference cardiovascular

BRIDGING BORDERS disease

Debate on Canada’s health care

THROUGH HEALTH

Issue 17 | March 2010

Fortified Foods Peace through Health Counterfeit Drugs Vaccines in the Developing World Overseas Volunteering www.meducator.org

Back Row (Left to Right): Hiten Naik, Matthew MacDonald, Daniel Lee, Keon Maleki, Mohsin Ali, Ahmad Al-Khatib, Tahseen Rahman Second Row: Navpreet Rana , Randal Desouza, Shelly Ramsaroop, Alyssa Cantarutti, Fanyu Yang, Simone Liang, Sangeeta Sutradhar, Lebei Pi, Siddhi Mathur Front Row: Veronica Chan, Jacqueline Ho Absent: Louis Winston, Randall Lau

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From Nigeria to Benin

Crossing Borders and Pushing Boundaries