New health problems

If concern of the health of people living in the cities is not new, the issues of today are not the same as they were in the past. Some decades ago, health problems in the city were related to industries and pollution. The cities were overpopulated and did not have proper infrastructures, particularly in sanitation and running water supplies. Because of bad hygiene, epidemics such a cholera, tuberculosis or yellow fever were common. Today, pollution is still responsible for respiratory diseases but so is our modern way of living. The use of the car led people to adopt a sedentary lifestyle which increased the risk of obesity and chronic diseases such as hypertension and type 2 diabetes.

According to the World Health Organization (WHO), more than five persons in ten live today in urban areas. By 2030, there will be six persons in ten living in towns and around seven persons in ten by 2050. If nothing is done by that time, we will have to face important costs in health, social inequalities and security due to this rapid urbanization. Given that these problems concern developed countries as well as the others, the WHO chose the issue of urban health for the World Health Day of 2010.

What characterizes a healthy city?

The urban environment can have positive or negative outcomes on health and researchers in public health and urban planning agree that our decision makers from both areas should collaborate when setting up public policies.

To develop sustainable communities and affect the health of people, various measures seem essential. It is important to have a low air pollution rate and to have access to quality water supply. Diversified neighbourhoods where we can find housing, shops, proximity of services (health centres, schools…) and infrastructures for practicing sports are to be encouraged.

A healthy city is also a place where its residents feel good and safe. Indeed, safe urban developments are necessary to encourage active transit. This can be done by simply installing more efficient street lighting. The town can also impose traffic measures where the riders of bicycles, cars and pedestrians can share the road, reducing the risks of accidents.

The role of design in promoting healthy living

Big cities like Paris and New York already have some characteristics of healthy cities (easiness to transit without using a car) and other measures have been taken to favour an active living (public bicycle share programs, creation of green pathways…). But these measures are not enough and to limit an epidemic of obesity, the City of New York published at the beginning of 2010 a guide meant for architects and urban designers. This guide describes best practices already developed and recommends measures to be taken.

When studying what has already been done, the authors of this document realized that an important variable was missing to make the urban environment more pleasant: the design. A recent study identified various design characteristics that should favour walking and physical activity. They include physical arrangements that capture attention, evoke feelings and that are built to match the size and proportions of humans.

The Hinnovic team presents a dossier on healthy places. With three interviews and a text, we invite you to discover what is being done in healthy cities and what the challenges we still need to face are.

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Who did not have to wear it at least once until now? Raise your hand if you enjoyed the experience? Not only does the hospital gown transform us into a patient, a role that none of us like to endorse, but it is ugly, hard to tie and it exposes to everyone’s view our most intimate parts, regardless of the size of our body. Is this the only solution? No! And this is what Noémi Marquis – who graduated in industrial design from the University of Montreal –demonstrated with her supervisor, Denyse Roy.

Their adventure began five years ago and is far from over yet. Five years to redesign an object that seems a priori so simple! Why did it take so long? Because it involved many actors with specific constraints and needs: patients, health care providers and launderers. The gown had to fit patients of all size and ages, and be easy to put on. While preserving the intimacy and dignity of patients, it had to secure an easy access to the body for health care providers. As the hospital gown spends more time at the laundry than on the patient, it should not raise maintenance costs: no metal or plastic clips, lightweight fabrics, a minimum of seams. The final result: “The Duo”, that is, two half gowns, one that covers the front of the body, and the second that covers the back or vice versa, no mistake possible.

Everybody is delighted! At last, an alternative that fulfils its functions while preserving patients’ dignity! Yet, our designers estimate it will take at least five to ten years to implement the new hospital gown in health institutions in Quebec. Why will it take so long? Because each supply contract between launderers and health institutions will have to be changed, and each department within hospitals will have to be persuaded of its relevance. Once their participation will have been secured, healthcare providers will have to be trained and patients informed. (Reference: La révolution de la chemise d’hôpital). Under these circumstances, it is not surprising that the “familiar objects surrounding us”, despite the fact that they are far from the optimal solution, often remain the way they are…

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This documentary, to which the Canadian International Development Agency and other partners brought their support, shows how the Rescue Foundation located in Mumbai, India, rescues, rehabilitates and repatriates girls who have been sold for forced prostitution.

The documentary tells us just enough about how child trafficking is organized, how these young women are being manipulated and how traffickers and the women who operate the brothels work together. According to the Rescue Foundation, a 14 or 15-year old Nepali girl can be sold for as much as 150 000 rupees (approx CAD $3600) in Mumbai’s largest brothel networks. The documentary also explains how these young women are led to believe that they will remain for the rest of their lives in brothels. One key argument is that going back to their home is impossible since their soul and body have been spoiled forever and that would only bring shame to their parents and relatives.

What the documentary does very effectively thanks to its Writer, Director and Producer, Wendy Champagne, is to show how another version of this story can be told. And I would be tempted to say, must be told for these young women to face a brighter future. Wendy Champagne spent a lot of time observing and filming how Nancy Leduc, a Canadian choreographer, gradually helped these young women to let light shine again out of their souls and bodies. Dance is here used as a medium for these women to communicate feelings, to establish new bonds with their peers and to also draw their own personal boundaries against potential abuse. This process of regaining a sense of control over one’s life is simply beautiful to watch unfold, even if the process remains fragile and reminiscent of painful memories at times.

I got however increasingly puzzled by, and somewhat uncomfortable with the notion that getting married represented for most of these young women the only way out. At one point or another, they have to leave the Rescue Foundation behind and pursue a “normal” life. Both Wendy Champagne and Denis McCready, Producer, were available at the end of the projection to discuss with the audience. This is how I understood that several of the men who choose to marry these young women come from regions in India where there is now an important gender imbalance. Of course, I couldn’t help but make connections with medical technologies such as ultrasound and other prenatal tests that facilitate the elimination of female foetuses in countries where women are seen as less valuable.

According to a study that examined the sex ratio at birth using hospital records, there would be currently around 44 million “missing women” in India (Sahni and colleagues, 2008). The authors suggest that neglect of girls (for instance, not seeking proper medical care on time), infanticides and feticides would all be responsible. This study examined the evolution of the sex ratio over a period of 110 years and found that an important fall “coincided with the availability of ultra sound for antenatal sex determination” in the early 1980s (892 girls per 1000 boys). The ratio also fell significantly in 1995 (855). In 1996, a Pre-natal Diagnostic Techniques Regulation and Prevention of Misuse Act was implemented, which made antenatal sex determination and sex selective abortion illegal in India. Sahni and colleagues observe however that the Act “has had little impact on the problem” since the sex ratio in 2005 (865) did not differ much from that in the decade before.

While their study is based on hospital records only (which is an important limitation given the fact that two-thirds of births take place at home or outside medical institutions), these authors have found “that gender bias exists regardless of religion, caste and socio-economic class, although it seems that it is more prevalent among the middle classes compared to the poor.” This last observation is compatible with the national census data examined by George (2006) who stresses that “the prosperous and/or educated misuse prenatal technologies to efficiently eliminate girls” and that the decline in sex ratio “in urban areas is greater than in rural areas because of the increased access and utilization of medical services.”

Now, getting back to the documentary, a movie like Bas! does certainly raise awareness and may help prevent other young women from falling prey to trafficking. One is forced however to recognize that such disturbing cultural practices have multiple ramifications, including so-called technological “advances.”

This is one of the reasons why I believe that another story must be told about women who survive child trafficking and forced prostitution. They should be valued for what they are: living proofs of how human resilience may be nurtured. What they went through makes them different, more knowledgeable about some of their country’s shortcomings and about how social prejudices must be challenged, not reinforced by medical technology. Perhaps only men with a heightened respect for who these women are should pretend for marriage? Or perhaps these women should be supported to pursue their life as singles? The story nevertheless should tell to the rest of the world that cultural shifts —sometimes way beyond technological breakthroughs— are part of the greatest inventions of all.

The video trailer is available here :
Bas! Beyond the Red Light – documentary trailer

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Marc-André Gagnon and Joel Lexchin, Professor at York University, developed a more robust estimate of the promotion expenditures of the U.S pharmaceutical industry. They found that it spends almost twice as much on promotion as it does on R&D. In 2004, up to US$57.5 billion had been spent on drug promotion (24,4% of the annual sales), which represented close to US$61,000 by physician. This first observation ran counter to the argument that pharmaceutical companies deserve more business-friendly regulatory measures because they represent innovative research-driven enterprises.

According to Gagnon, while the number of physicians in the U.S. increased by 38% between 1996 and 2004, the number of sales reps increased by 150%. Within the same period, the number of promotional meetings increased by 254%. Indeed, the Top 10 prescribing physicians received from 2 to 4 times more rep visits, private funding of continuing medical education increased by 465% (surpassing public funding) and direct to patient promotion increased by 509%. Although ethical guidelines and disclaimers do accompany most of these activities, the problem is that most people, including doctors themselves, believe they can’t be fooled by marketing strategies. Plenty of evidence nevertheless shows that marketing does in fact influence prescribing practices (see www.pharmaceuticalpolicy.ca).

In a recent conference, Gagnon presented his analysis of the dominant business model of the Big Pharma companies: the top 17 companies representing 64% of the world market share. He showed how they massively engaged into producing medical knowledge. Up to 70% of the industry’s R&D budget goes to Contract Research Organizations (whose independence is close to nil) to conduct various clinical studies. The other 30% is contracted out to university-based researchers under strict rules (nondisclosure of findings).

According to Gagnon, 75% of the industry sponsored Phase IV clinical trials (post-marketing) are established mainly for promotional purposes, focusing on the efficacy of one drug compared to a placebo for instance. When conducted rigorously and independently, post-marketing studies are, however, important for measuring safety, or setting up the comparative cost-effectiveness of one drug against another. The industry is thus introducing system-wide biases by flooding the pool of available publications.

Parallel to this industry-driven production of clinical trials, another practice has emerged over time: ghostwriting. Physicians and researchers who take part in clinical studies are offered to sign as authors scientific papers that are in fact written by staff hired by pharmaceutical companies. While these papers are submitted to standard peer-review processes, they nonetheless enable the portraying of even less than convincing research findings in a positive light (that is through carefully formulated abstracts and conclusions). Gagnon argues that even though clinicians who take part in Big Pharma sponsored clinical trials may have good intentions, produce what could be labeled “good science,” and do not necessarily infringe ethical codes of conduct, they become part of a system that changes the overall value of clinical research.

Today’s clinical research landscape is changing because one of the key imperatives behind the Big Pharma’s dominant business model is to respond to shareholders’ concern for economic growth. Few individuals or organizations can escape the new rules of the game: this is the key property of institutional dynamics. Therefore, perhaps what we need is research that can lead to developing alternative business models that are more clearly geared at producing healthy societies.

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Research is being conducted notably on essential oils from clove, lemongrass, thyme or even oregano.

In Manchester, in the United Kingdom, a team reviewed the effect of essential oil vapours extracted from lemongrass and geranium in reducing bacteria present in the air and on surfaces. They discovered that spreading essential oil vapours could reduce 89% of the bacteria present in the air in an office environment.

At the Sligo Institute of Technology in Ireland, researchers are trying to understand which components of essential oils are the most efficient against these bacteria. They are studying how the essential oils could be used to treat patients directly.

The bacteria that are concerned, such as the staphylococcus, are responsible for infections acquired in hospital environments. Even if, in most cases, the infection is easily treated, some vulnerable patients can die from it. Also, these bacteria have developed a resistance to some antibiotics such as the methicillin or the vancomycin.

It is true that, for the moment, the studies have been conducted in laboratories. However, researchers hope to be able to apply the results directly in hospital environments.

	If essential oils can kill antibiotic-resistant bacteria, could they be an alternative for the use of antibiotics in general? Could they reduce the use of chemical products in the cleaning various areas?

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Bilge Mutlu, from the University of Wisconsin, wanted to learn more and studied the impact of introducing robots in a hospital and how these affected the life of the workers. Results show that the arrival of robots is felt differently from one service to the other.

In oncology for example, workers are facing critical situations and are constantly working in an emergency environment. They have to be adaptable and they often have to stop their task to take a patient to the operating room. The robot, on the other side, is programmed to complete its task on fixed hours. Furthermore, it needs another person to achieve its work (such as loading linen in its tray) and if nobody is there, the work cannot be done. In this unit, the staff sees the robot as an inefficient worker who is not able to react to urgent situations.

On the contrary, in the post-natal unit, critical situations do not occur as often and the workers do not need to multitask that much. A maintenance staff member does not have to transport patients and is always there to load the linen on the robot. In a context where it is easier to program tasks, the relations with the robot are better and the the team sees it as a useful and necessary colleague.

Therefore, to be used in the best way and to be accepted by more workers, the robot should not be designed according to the organization. It should rather be thought according to the working culture and the unit where it will be introduced.

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Perhaps the first question that comes to mind when thinking about public participation is: who exactly should participate? There are many answers to this question. Some advocate recruiting “ordinary” people who have no direct stake in the concerned field and who can therefore, it is argued, provide an outside perspective and represent the “public interest.” Others favour participants who have direct experience with the problem or issue – people with concrete knowledge, such as patients or users of the technology. Still others argue for the participation of, for example, representatives of community organizations or patient associations.

The reasons underlying efforts to mobilize the public are no less varied: to understand the point of view of citizens, to make political decision-making processes more transparent or more legitimate, to inform the population, to make society more democratic,… to manipulate public opinion? The goals of consultation processes are not always well defined; yet clear objectives are crucial to identifying the “proper” participants, the questions to ask and the consultation process to adopt. It is rarely citizens who initiate discussions on issues around techno-scientific developments because the public is generally not knowledgeable about this sphere. Rather, it is policy makers and researchers who lead mobilization efforts. Moreover, increasingly, some are stressing the need to support participants so they are able to fully grasp the issues being debated. The degree of “training” required varies depending on the objectives. Such diversity is also evident in the methods used to obtain the public’s participation; creativity abounds, with a range of approaches from more to less formalized and no fixed hierarchy of methods. The situation is in constant flux, not only for researchers, but also for governmental and non-governmental organizations. So not just “who” but also “why” and “how” continue to be key questions.

But what if citizens talk to experts and policy makers but are not heard? Or do not receive any response to their input? Clearly, two other dimensions need to be considered. The first is the development of the capacity of experts and policy makers to hear and discuss with the public. The second is the asymmetry in position between the public and experts / policy makers, and how this plays upon the public’s ability to influence the process. Thus, public participation also raises the issue of power relations.

Finally, on what subjects is the public’s input needed? Should the scope of their intervention be circumscribed to a particular area? The examination of the risks associated with an innovation is often seen to be the special domain of the public. But why confine the public to the discussion of risks? Is it only because a technology presents no risks that it becomes desirable? Is safety the only value that needs to be debated? Risks, values, potential uses and users, directions in the development of applications; why limit a priori the subjects on which the public’s views are solicited? Increasingly researchers are asking that the public be brought into the process to reflect and voice their opinions – both downstream and upstream in the process of techno-scientific development and policy making. Public input is now being sought on directions, not just consequences. And once the possibilities for discussion have been expanded, how will the subjects for discussion be selected? And who will select them?

Hinnovic invites you to hear what our collaborators have to say on these issues. Julia Abelson discusses public participation in policy making with our journalist. Through texts and interviews, a number of collaborators – Olivier Demers-Payette, Devidas Menon, Ghislaine de Langavant, Antoine Boivin, Janet Wale, Michel Venne and Yanick Farmer – share their experiences and thoughts on public participation in a variety of health science and technology fields. Finally, Marian Barnes raises questions about the place given to emotions in the contributions of the public at consultations.

Happy reading!

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