Jerry Spiegel

Background: Pollution is a major planetary health concern that claims ~9 million lives a year and threatens the integrity of ecosystems that support life on Earth. Chemical contamination has effects at local, regional, and global scales. However, research at some scales may be privileged due to data availability and research practices, leading to persistent gaps. Based on empirical research, this dissertation explored two overarching questions: (1) how can systems thinking expand our understanding of the scale challenges of data to assess pesticides contamination distribution and effects in countries with potentially high levels of exposure?; and (2) how can systems thinking provide a framework to bridge local exposure studies with the critical appraisal of planetary health contamination research at broader scales? Methods: I applied geospatial science to identify areas with the potential to affect human health and the integrity of ecosystems in Ecuador, a country with alarming pesticide use practices. In addition, I used spatial clustering detection and Bayesian multi-level spatial regression to assess the distribution of perinatal health outcomes and their association with application rates. Finally, I conducted a systematic scoping literature review of contamination research in Indigenous food systems. I reflected on the results based on our marine toxicology research conducted in solidarity with the Tsleil-Waututh Nation in Canada. Conclusions: The challenges of pollution to planetary health require the integration of knowledge across scales. Conceptual frameworks that foster multi-scalar discussions can fill knowledge gaps, link multi-level evidence and shift the accountability of contamination issues to scales with the agency over pollution drivers. We found widespread use of pesticides in Ecuador threatening human health and strategic ecosystems. Regional assessments and interventions should follow in the areas of concern highlighted in this study. Moreover, a nationwide coordinated strategy to monitor and control the effects of prenatal pesticide exposures is warranted. Although seldom studied, large-scale drivers of pesticide contamination should be integrated into existing knowledge at local scales. This should promote multi-level controls beyond solely relying on local-level behavioural exposure controls. Conversely, meaningful collaborations with Indigenous populations are vital to strengthening the analytic frameworks of multi-scalar integrative approaches to human health.

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This dissertation critically examines the ways in which public health professionals in Canada carry out their role in a settler colonial setting. I specifically focus on investigating how such practitioners are engaging with disparate narratives about health impacts of mining on Indigenous communities in Canada. I apply two methodological approaches (a scoping review and in-depth interviews) to produce insights that inform a pedagogical tool-creating approach (social cartography).Through a scoping review of 89 government related documents that guide regulatory and approval processes of mining developments and policy, I identify key framings, definitions and narratives used discursively through these state processes. These documents convey strong messages naturalizing the state’s authority over Indigenous people and normalizing the dominance of Settler Canadian standards. Settler Canada is depicted as exceptional and exemplary, in contrast to Indigenous people who the documents repeatedly characterize as essentially infantile. Analysis also reveals calculated sidestepping of consent, and problematic use of ‘balance’ as a metaphor in ways that discount Indigenous resistance to Canadian authority over land, cast market-driven resource extraction as inevitable, and dismiss Indigenous refusals of consent to access land. Exploring the degree to which public health professionals align with or contest state narratives, I carried out 41 in-depth key informant interviews. The qualitative analysis, using thematic review assisted by NVivo, shows a repeated national narrative of caring for Indigenous Peoples - characterized as ‘in need’ yet as healthy if adapting to Settler Canadian paradigms. This suggests that educational-behavioural interventions addressing problematic practices may be of limited effectiveness without first grappling with structural dimensions of complicities, personal and professional investments, cherished narratives, and entitlements. Consideration of structural influences on roles of public health professionals illustrates that available orientations to professional practice may be circumscribed by imperatives of a settler colonial national narrative. In assessing study findings from an anti-colonial lens, I reflect on the study’s contributions to the literature, and implications for practice, training, research and action. I conclude that, through grappling with difficult knowledges to inform accountable and anti-colonial engagement, public health professionals could broaden imaginations toward a professional orientation centred on responsible relationship.

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Empirical evidence is lacking on the degree to which structural or upstream forces contribute to tuberculosis (TB) incidence in the general population, and in healthcare workers, a group known to be at high-risk for this disease, let alone on how these forces are addressed in policy. This dissertation used a multi-method design to examine the link between upstream forces and TB. First, it utilized a linear mixed-effects regression to investigate the association between globalizing processes and TB incidence in the 22 high burden countries. Secondly, semi-structured in-depth interviews were conducted in South Africa to explore how macro-level determinants of TB incidence in the general population and among healthcare workers are perceived by key stakeholders, identifying barriers and facilitators to the implementation of effective prevention and control measures. South Africa’s current National Strategic Plan was then examined to ascertain how these factors were being addressed. The World Health Organization (WHO) Health Systems Building Blocks framework was also applied to assess interventions for protecting healthcare workers.Globalization was found to be associated with higher TB incidence in high burden countries. In the South African context, a history of colonization, the migrant labour system, economic inequality, poor shelter, health system challenges, the HIV epidemic, and pertinent socio-cultural factors were all perceived to be the major drivers of the epidemic. Although South Africa’s current National Strategic Plan makes a firm discursive commitment to addressing the structural drivers of TB, analysis from this dissertation revealed that this commitment was not clearly reflected in projected budgetary allocations.As many low and middle-income countries continue to integrate their economies into the global market, there is a need to consider ways to address unintended inequities that accompany this integration. In South Africa, while funding allocation to improve diagnostic procedures and investment in more efficacious drugs are laudable, attention to structural drivers of TB is deficient. Although a national TB policy for healthcare workers will soon be launched, it is perceived that implementation and adherence to such policies may well remain problematic unless the policy explicitly addresses the drivers of this scourge.

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This dissertation aims to inform more equitable and effective practice in the emerging field of global health. To address this overriding question of how principles of equity and effectiveness can best be implemented, I critically analyze discursive and practical challenges facing Northern researchers as they approach health problems in the global South, and explore solutions to these challenges. This exploration employs a case study on the articulation of a specific problem in a specific, nominally ‘Southern’, setting: pesticide-related health effects in Ecuador's banana-producing El Oro province. I employ three methodological approaches, in three substantive chapters. Chapter 2 uses discourse analysis to understand how Latin American research sites are framed in peer-reviewed pesticide epidemiology articles. These articles often employ geographic representations of Latin America as inexplicably underdeveloped to demonstrate the need for pesticide research and health sector interventions, typically exhibiting ‘mainstream’ (Northern) public health institutional dynamics. I also show how some epidemiologists are pursuing more politically engaged approaches, in an uneasy negotiation with epidemiology's disciplinary norms. Chapter 3 reports on ethnographic pesticide risk perception work in El Oro, drawing on theories from anthropology and human geography. I document how pesticide risk perception narratives reflect El Oro's position in unstable global commodity chains. Scalar elements of these narratives combine individual and structural explanations for health problems in complex ways. In Chapter 4, I describe a political ecology of health explanation of pesticide exposure in El Oro. I employ a modified meta-narrative methodology, complemented by ethnographic fieldwork, to synthesize literature relevant to the pathways – biological, political economic, environmental and cultural – leading to pesticide-related impacts in El Oro. This analysis complements Chapters 2 and 3 in making the case for empowerment-based participatory approaches to pesticide exposure problems (and, by extension, to global health more generally), with special attention to international linkages, environmental complexity and political economy. The introduction, conclusion and 'linking' material between chapters serve to enhance the coherence of the dissertation by providing additional material not appropriate for inclusion in the three chapters, including elements of reflexivity.

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This dissertation considers the implications of applying of global health perspective to guide the development of culturally appropriate mental health services in Canada. Recognizing that forces of globalization can both affect determinants of health that vulnerable populations face and the kind of mental health services that are available, I focus on the situation of immigrants in the Greater Toronto Area, a population that has been prioritized for increased access to equity-driven health services, drawing on my personal and professional positionality with the issues examined. This study specifically examines Latin American immigrants, a group that has been identified as a high-growth population at-risk for mental health difficulties. An extensive and comprehensive review of social determinants of health as it relates to the mental health of Latin American immigrants in Canada is conducted, and the availability and effectiveness of patient-centred care for Latin American populations is also reviewed, with particular attention to the standard delivery versus the cultural adaptation of cognitive behavioural therapy – currently regarded as the ‘gold standard’ in psychotherapeutic treatment. Clinical, service delivery, and social policy issues that may arise in providing culturally appropriate, patient-centred care are exemplified in the findings of a secondary qualitative analysis of focus groups that were conducted for a feasibility study for a culturally adapted cognitive behavioural therapy (CA-CBT) for Latin American immigrants in Canada. A key contribution of this work is the synthesis of the foregoing evidence to conclude that the provision of culturally adapted mental health services is necessary but not sufficient to promote the health equity of Latin American immigrant population in Canada. Recommendations for policy, future research, and changes to the philosophy of psychiatric practice are discussed, and the findings are related to debates on the concept of “global mental health” that are currently underway.

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This dissertation explores how knowledge management approaches and socio-political systems affect the accessibility to and application of evidence to improve the health of socially and politically disempowered groups of people. As, dengue provides a particularly vivid example of a human health issue intricately linked to biological, environmental, social and political systems, this study is embedded in a participatory dengue prevention and control program in Machala, Ecuador, that is committed to capacity-building and scaling-up. Guided by a transformative emancipatory approach with a focus on equitable participation, a multi-method approach was pursued including ethnographically-framed stakeholder analyses, social network mapping and analysis, illustrative vignettes and participatory indicator development. Six major stakeholder groups were identified in Machala: community, local government, government functionary, government administrator, researcher and private sector. Varying degrees of collaboration and interaction with one another as well as with the problematic of dengue are shaped by the dynamics of differing health priorities, paternalism/equitable participation, quemeimportismo/social resentment, nepotism/centrism/social justice, marginalization/self-determination and Buen Vivir. Power dynamics and knowledge valuation schemes dictate definitions of success and shape evaluation tools and processes tend to marginalize experiential and tacit knowledge, perpetuating narrow conceptions of health, benefit and dengue transmission risk. Overall, opinions regarding evaluation criteria did not significantly differ by stakeholder group, which suggests that social and cultural dynamics, as well as history and narrative of place, may be far more important factors in determining both stakeholder priorities and the character of intersectoral spaces than previously thought. A participatory evaluation tool is developed to assess both impact and process-related performance of proposed dengue prevention and control strategies. A knowledge translation model is developed with a strong emphasis on equitable participation and health equity. This study observes that there is deep need for change in underlying institutional power structures and research-to-policy processes, without which new evaluation tools will likely not “make sense” or result in improved policy, programs and community well-being. These findings and their implications challenge current macro, mid and local-level knowledge management strategies. This study indicates that opportunity for change exists through participatory evaluation processes situated at the interface of equitable knowledge translation and social determination.

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Statement of the Problem This study has taken advantage of a “natural experiment,” the holding of International Cancer Control Congresses (ICCC) to conduct research that assesses the value of such undertakings, and examines ways for effectively pursuing positive change in improving policy and practice related to cancer control. Given the importance of this global challenge, this study investigates the question: Do International Cancer Control Congresses influence reported changes in participant behaviors and activities that enhance the development or implementation of population-based cancer control programs and increased collaborations? Methods of Investigation The population of interest included all the congress registered participants for two International Cancer Control Congresses—362 individuals at the 3rd ICCC for the first pod of surveys; and 310 participants at ICCC4 for the second pod of surveys. The primary data collection instrument was self-report surveys, surveyed in two pods. Each pod included an on-site survey followed by a follow-up survey a few months later on the same census sample of participants. Research instruments for data collection included surveys, interviews, conference documentation, observations as well as secondary data from WHO publications and appropriate web based publications like country plans and others. The study was organized as a mixed methods research using a triangulation design that allowed a mix of both quantitative and qualitative data in a single study.Conclusions The study indicates that most respondents gained professionally in improved understanding of global population based cancer control programs and new insights into cancer control. Through sharing best practices and insights gained at the congress in their jurisdictions, many indicated that the Congress has helped them in their cancer control work, including increased awareness for establishing collaborations and for setting up surveillance systems; also highlighting for them the importance of expediting national cancer/integrated non-communicable disease plans. Increasing their networks, participants continue experiencing a rise in interest and involvement in cancer control. The Latin American Region research reveals that it takes time before initiatives emerge and can be attributed to ICCC. In revealing which finds are inconclusive, this study offers opportunities for cohort longitudinal investigations.

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Patent system harmonization obligations found within international trade agreements have been subject to intense scrutiny over the past two decades due to the potential negative implications for public health in developing countries. In 1994, NAFTA became the first trade agreement to include patent system harmonization obligations. Mexico as a signatory to NAFTA was the first developing country to adopt the patent system of developed countries via patent system harmonization. This makes Mexico a particularly relevant case study on the subject. The central research question addressed in this dissertation is: Does NAFTA patent system harmonization promote access to medicines in Mexico, while incentivizing pharmaceutical R&D? This dissertation undertakes a comparative legal analysis, a scoping study, and qualitative stakeholder analysis to address the central research question. Evidence is provided that compulsory licensing as a safeguard is inadequate as a downstream measure in the promotion of access. A key finding is that international trade agreements should be drafted with optimal pharmaceutical patent protection standards in mind. Further, patent system harmonization results in a net health benefit that can be maximized through the provision of feedback evidence to decision-makers in order to develop responsive laws and policy. This dissertation proposes that: if we reform the granting of patent terms from a fixed twenty year life period to a flexible and adjustable term determined through an assessment of health and economic conditions that exist during any given time period, we will improve both global equity in access to medicines and reduce economic inefficiencies in our current model for pharmaceutical R&D, while maintaining adequate incentives to conduct pharmaceutical R&D. The proposed reform is akin to the use of interest rates as an economic growth and stabilization tool in monetary policy. It would require government patent offices to analyze global conditions in pharmaceutical access and R&D, and accordingly adjust the number of years of patent protection awarded. This novel contribution to the academic literature informs Canadian, Mexican, and developing country decision makers on how to design appropriate policy for the benefit of public health.

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This work aims to better understand the capacity of small farmers, their organizations and other social players in the Ecuadorian indigenous communities of Quilloac and San Rafael to reduce pesticide-related environmental health risks. I used a multi-method approach that included Pierre Bourdieu’s field theory along with a 187-household survey, ethnographic methods, and participative approaches in 2007-2008. This study analyzed community capacity-building as social relationships co-determined by human agency and social structure in local and global contexts. By mapping community stakeholders’ differential access to cultural, social and economic capital, this study reveals connections between the degree of access to resources and health vulnerabilities.Four key findings emerged. First, in a context in which workers were forced to diversify their income through strategies such as emigration and urban employment, families had reduced time for their crops and increased reliance on pesticides. Members of households with fewer people applied pesticides more times. Elders from poor households were left to care for crops and experienced more problems with pesticide handling and symptoms. Children experienced increases in accidental pesticide poisoning cases that coincided with a period of high farmer migration to find work. Second, despite numerous well-intended efforts by community leaders, farmers with the highest participation in agriculture had less contact with community organizations. Third, structural factors such as inequitable land distribution, unfavorable market policies, and limited state support for small farmers represent critical barriers for harnessing the capacity of small farmer organizations. Fourth, community leaders tended to adopt peasantry-focused strategies that were likely to further marginalize some vulnerable families who combined non-agricultural activities with their farming, which was characterized by consumption crops with low workforce and high pesticide use. My findings provide theoretical and practical contributions for understanding the causes of environmental health inequities. Results from this research informed the development of several community-based initiatives (workshops, a radio show). My approach described important contextual barriers that need to be addressed by national and international stakeholders in order to harness the capacity of local organizations. It also identified specific social mechanisms that could increase health inequities despite great efforts by community organizations.

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