Invited Master’s Students Blogs from Waterloo

The following pieces were written by my students.

Criminalization of Sex Work: a threat to public health and social wellness everywhere

The following was written by Jill Barclay.

When Craigslist rolled out the erotic services section of their website, at varying times, throughout cities in the United States, the overall female homicide rate was reduced by as much as 17%. Now, the erotic services section no longer exists and advertising for consensual sex is illegal for both the individual posting the ad and the website that hosts it. This is all thanks to the Stop Enabling Sex Traffickers Act (SESTA) and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). Though the bill, passed in April of last year, was touted as a way to fight online trafficking, the criminalization of online sex advertising has instead put the lives of some of the most marginalized people, sex workers, at risk.

Criminalization of sex work— which is fundamentally the exchange of consensual sex acts between adults for money or goods—strips people of their right to autonomy and privacy. It is widely accepted by groups including The World Health Organization, UNAIDS, and Amnesty International, that the decriminalization of sex work would reduce sex workers’ risk of violence, promote better access to medical care, destigmatize sex work, and protect other women from predatory men. Whether you like it or not, sex work affects everyone.

If the SESTA/FOSTA is not repealed, I believe it is likely that the rate of homicides against women will increase, STI rates will go up, and violence against sex workers will escalate. This law will result in the deaths of sex workers. The effects have already been felt in the short time the law has been in place. Sex workers have been forced back onto the street where they can no longer screen their clients before a meet up, or avoid violent and exploitative pimps to manage their work. The law also makes it harder for sex workers to share client lists through online for a, hosted by sex advertising websites to avoid bad or violent persons. One sex worker explained, “You just don’t get that opportunity as a street worker; you have to make a snap judgment call based on physical appearance and demeanor, which doesn’t really tell you anything.”

Laws should be put in place to better protect people, not further marginalize them. This bill perfectly exemplifies bad lawmaking: it criminalizes the work of primarily marginalized groups without addressing the root causes of why these groups are criticized in the first place. The majority of sex workers are women of colour, migrants, homeless youth, and LGBTQ+ people. When putting forth the FOSTA/SESTA law, these key groups were not consulted even though they will be most affected by the bill. What results is a bad law with even worse outcomes.

It is not as if we didn’t know what the outcome of this law was going to be. In 2016, The French Prostitution Act was passed as an attempt to hinder prostitution in France by increasing criminal consequences for clients of sex work, rather than sex workers themselves. However, a 2018 report published by Médecins du Monde found that the law had detrimental effects on the health and safety of sex workers. Those most impacted by this law were undocumented migrant women, who reported that their precarious living conditions were pushed further into impoverishment. The French Prostitution Act had significant harmful affects on the health, safety, and livelihoods of sex workers operating in France. The same is expected in the United States as well as any other country that chooses to criminalize sex work.

The United States is a powerful country that has a presence on the world stage, so much so, that it can set standards and norms. If other countries adopt similar laws, the livelihoods of many will be at risk. Marginalized populations disproportionately rely on sex work as a means of surviving.

The law should distinguish between sex work and sex trafficking—they are two different things. If we really wanted to help stop sex trafficking, we should decriminalize sex work. The decriminalization of sex work would create a better system to deal with sex trafficking—sex workers could seek justice for crimes against them; improve the health of themselves and their clients; and redirect law enforcement efforts to fighting sex traffickers instead of prostitution. In fact, when sex work is decriminalized, the increase in sex workers results in less reliance on sex trafficking in the first place.

Many societies believe prostitution is fundamentally degrading and harmful. The desire to protect women is often the narrative behind criminalization of sex work. When we dig deeper, however, we see how criminalization of sex work actually traps vulnerable populations into a cycle of exploitation. Typically sex work is a job done as a last resort. Many struggle with discrimination and poverty, giving them few options to earn a livelihood. Criminalization makes it difficult for sex workers to report violence because of their vulnerability to incarceration. Once you put someone through the justice system for simply trying to survive, you are hindering their ability to get out of sex work in the first place. You are further marginalizing them.

When Rhode Island largely decriminalized sex work, the female gonorrhoea rate went down more than 40% and reported rapes went down more than 30% overall. Men substitute sex with non-consenting women for consensual sex with sex workers instead. The first step to the decriminalization of sex work is the repeal of SESTA/FOSTA. Decriminalization of sex work improves the health and safety of marginalized peoples, and promotes human rights for sex workers, their families and their communities. Providing a safe, regulated framework for sex workers through decriminalization promotes better public health. Laws that criminalize sex work only increase the opportunities for sex trafficking to take place. The first step to fighting sex trafficking has to be decriminalization of legitimate sex work.

Sex work is the oldest profession there is and it exists everywhere. Going beyond just decriminalization, the legalization and regulation of sex work would benefit everyone. It could even be seen as an untapped economic market where a lucrative amount of wealth could be generated through taxation. In 2007 alone, Atlanta’s sex trade brought in $290 million.

The current criminalization of the profession fuels violence against women, discrimination of marginalized populations, and weakens public health. All the evidence supports the notion that decriminalization is consistent with reduced sex trafficking all while improving public health. The USA’s position on the global stage is an important one and how they react to the criticism and failure of SESTA/FOSTA will set a precedent for future laws involving sex workers.

The Usefulness of Retail Clinics in the United States of America

The following was written by Brittany Ennis.

Going to the doctor in the United States is an inconvenience. People have to make an appointment, take time off from school or work and get to the doctor’s office. Then, they may have to make additional appointments to see specialists or to have tests done. Frankly, many people do not have the time or the patience to go to the doctor, ultimately putting their jobs ahead of their health.

In the United States, the hassle of going to the doctor comes at a high price. According to the U.S. Census Bureau, in 2017, 8.8% of American citizens did not have any kind of health insurance. This is approximately 28.1 million people. For those that have health insurance, coverage comes at varying levels.

Due to the cost of healthcare in the United States of America, retail companies like CVS, Walgreens and Walmart have seen an opportunity and opened health clinics in their stores. The clinics offer basic services at a reduced cost.

However, on September 13, 2019, Walmart took retail healthcare to a new level by offering dental and optometry services in their new Walmart Health Centre in Dallas, Georgia. In addition, the company offers expansive services like X-rays, electrocardiogram tests, ultrasounds, health screening, labs and mental health counselling in their first stand-alone clinic.

The clinics are run by nurse practitioners, not doctors. Although they are able to do the majority of the tasks that a doctor completes (diagnosing a patient, prescribing medications and specializing in a field), they do not have medical degrees. Many workers are also fresh out of college. This could indicate that they do not have a lot of experience beyond internships. Further, the clinics or centres offer both walk-in and scheduled appointments, but this can be problematic. If a person has to schedule the appointment, then it takes away the convenience factor. Alternatively, if a person opts to walk-in, the wait could be very long.

More importantly, if someone goes to the clinic, and is diagnosed with a major issue that requires further testing or treatment, they will have to see a specialist or surgeon. For instance, if a person finds out they have a malignant tumour that requires surgery; it cannot be done at Walmart. If the patient needs their wisdom teeth extracted, but the teeth are impacted, they will need to book an appointment with a dental surgeon. These clinics cannot eliminate the financial burden that comes with advanced medical treatments and procedures.

With that being said, service prices are very low and similar for children and adults. For example, an annual checkup for a youth is $20 and $30 for an adult. Mono, flu and strep tests are $20 and a pregnancy test is $10. The intake session for individual counselling of a new patient, costs $60 and for further appointments a forty-five-minute session is $45. Teeth cleaning for children starts at $15 and $25 for adults. Teeth whitening is $225, and fillings range from $75-125. Last, a routine vision exam is $45.

By comparison, HRB Solutions, a benefits company, offers a list of approximate national rates for uninsured Americans. An adult routine checkup is $200-300, for a child it is $150-200. For dental hygiene the average cost of a checkup, which includes X-rays and cleaning is $288. By comparison, Walmart’s starting price of $50 offers a more affordable rate, especially for multi-member families.

Retail healthcare programs are developing to expand the services that they offer. Walmart’s new Health Centres are a huge step in helping people with medical issues that require further examination or counselling. With mental health issues being a growing concern in the United States, having counsellors provide primary care to people struggling with their mental health is beneficial. CVS is offering nutritionists and dieticians to help people eat healthier and achieve weight goals.

It is important to realize that the retail clinics are about preventative care. According to a survey with West Health Institute and the University of Chicago, 47% of people do not go to the dentist or for a regular checkup due to the price. In addition, the survey revealed that costs mean 40% of people skipped annual routine physicals, 40% skipped a recommended test and 44% did not go to the doctor when they were sick or injured.

There are way too many stories of Americans who die because they went to the doctor too late, or because their illness was too advanced, and their insurance company refused to cover costs of treatment. This leaves people either waiting to die or going into debt trying to prolong their life. If retail clinics can diagnose illnesses earlier, then people can get treatment before their situation becomes critical. These clinics could literally save lives.

Finally, the retail clinics shed light on a growing business: private healthcare. Although the clinics favour preventative care, it is important to remember that they are still in the early stages of developing the services they offer. If the government in the United States cannot provide healthcare options that satisfy the needs of the citizens, then perhaps Walmart, CVS and other retailers can.

For an American without health insurance, or even an American with health insurance, this is a convenient option that allows them to get a jump start on preventative care at a low cost.

Fentanyl: A Global Problem Requiring Multilateral Cooperation

The following was written by Emily Standfield.

On the first day of my fourth year of university, in two of my five courses my class was offered a fentanyl test kit. My professors advised me to always, always, always test my recreational drugs for fentanyl. Most importantly, the message was: if you’re not getting your weed (or heroin, or anything) from your own backyard, there’s a high likelihood that there’s fentanyl in it.

Fentanyl has quickly become the most dangerous opioid on the market—it’s cheap, it’s incredibly potent, and easy to transport. It’s fifty times stronger than heroin and one hundred times stronger than morphine; for those without a tolerance to fentanyl, the lethal dose is two milligrams, or equivalent to about two grains of salt.

Although the total number of drug overdose deaths in the United States declined by about 5% in 2018, deaths relating to fentanyl and methamphetamine continue to rise. In fact, life expectancy in the United States fell in 2016 and 2017, for the first time in decades, partly due to the fentanyl crisis. In Canada, this drug is rampant on the West coast. In British Columbia and Alberta, the number of deaths leaped from 42 in 2012, to 418 in 2015.

Why is this drug so dangerous? How is it so prevalent in North America, yet so untraceable by law enforcement? For starters, fentanyl is a human produced drug—unlike heroin, it doesn’t have to be harvested, cultivated, processed, etcetera. It can be made in any lab setting with the right chemical ingredients, which, unfortunately, are fairly common. Fentanyl analogs allow manufacturers to remove or add an atom to the synthetic opioid, creating molecules that act like fentanyl, but are not identifiable as such. These new molecules evade testing by law enforcement and health professionals. The Drug Enforcement Administration (DEA) reported in 2017 that 55% of synthetic opioids were identified for the first time that year.

While this is a rampant problem in Canada, I’m most interested in the effect it’s had in the United States. Fentanyl mostly enters the USA from Mexico, often mixed with heroin, and from China, through the mail. You can even order fentanyl online, through websites that only require a credit card number and an address. Since such a small dose is so effective, manufacturers can send the powder in a single envelope, making it almost impossible to monitor.

In order to stop the international transport of this opioid, multilateral cooperation is vital. President Trump has, instead, fought brutally to build a wall between the USA and Mexico and engaged in a trade war with China for over a year. Domestically, President Trump has taken actions against the crisis, most importantly in October 2018, by signing into law the Support for Patients and Communities Act. It’s a package of bills that call for improved detection of fentanyl, by increasing border security and requiring UPS to collect information on all mail received from China. Internationally, though, the USA has taken miniscule steps forward.

What started me on this fentanyl deep-dive was a tweet from President Trump that I saw in the summer. On August 1, Trump tweeted: “Additionally, my friend President Xi said that he would stop the sale of Fentanyl to the United States—this never happened, and many Americans continue to die!” Contrary to what this tweet implies and despite increased security and trade disputes, President Xi’s interests have remained aligned with America’s efforts to stop the movement of fentanyl. Fentanyl is not purely a North American problem; China worries about fentanyl in its own population as well. And, if we prefer to consider more selfish Chinese motives, China also worries about the reputation of its global pharmaceutical companies, which are not benefiting from China’s fentanyl-supplying reputation.

In 2018, as a representation of this support, President Xi agreed to label fentanyl as a class of controlled substances, and has continued to treat the opioid as a security threat. Trump’s tweet was met with indignation from President Xi, who accused Trump of politicizing the issue. On August 21, Liu Yuejin, deputy head of China’s National Narcotics Control Commission, announced that China would still like to work with the USA on the fentanyl problem, but that Trump’s actions would “hurt the good relationship between the two countries”. Although the trade war between the United States and China continues to worsen, hopefully when it comes to the fentanyl crisis, both leaders can be reasonable. In order to stop the movement of this drug—which has quickly become a global health threat—multilateral cooperation is essential.

While it’s interesting to discuss the international impact of fentanyl, it’s also something that directly affects me. As a university student in my early twenties, I know how prevalent recreational drugs are among my peers. The fact that a dose as small as two grains of salt can be fatal is terrifying. For the safety of everyone—recreational drug users, law enforcement, and bystanders alike—the end of the fentanyl crisis is imperative.

Ongoing and Neglectful Canadian Indigenous Health Care Policy

The following was written by Micah Winter.

Two weeks ago, I was reading an article from the CBC that detailed how the Quebec Cree, or the Eeyou as they refer to themselves, have to travel and live, isolated from their communities, solely to seek specialist medical aid. This article caught my eye as I had been hearing about the faults of the Non-Insured Health Benefits (NIHB) plan for some time. This case was just the most recent to get media attention.

The NIHB plan is a Canadian example of how global Indigenous peoples continue to be trapped within a settler narrative where their rights, as defined by the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), are denied. This program is an inequitable health policy buried beneath Canada’s “free and accessible health care for all” image.

Based on the 1979 Indian Health Policy, NIHB is administered by the Department of Indigenous Services Canada. The idea is that the program will cover a range of health services that include dental, vision, prescription drugs, medical supplies and equipment, medical counselling, and transportation to registered and recognised First Nations and Inuit. After many calls to action by Indigenous groups and medical professionals, a joint review process (JRP) was created in 2014 with then Health Minister Rona Ambrose and the Assembly of First Nations. This was a comprehensive review process aimed at identifying the areas of NIHB that were lacking, and increasing patient care and program efficiencies. Between 2015-2018 the JRP analysed client surveys and held community site visits to gain information on the existing system. After this process there were a few ‘quick-wins’, i.e. issues that were easily addressed, but the fundamental problems remained.

A principle issue with the NIHB program is travel. Most First Nations communities are ‘fly-in’ only, accessible by vehicle only when the ice roads open up in the winter months. As an aside, it is critical to note as climate change advances, and the winters get warmer, this will put further pressure on the travel costs as ice roads will no longer be available. Without travel coverage there is no access to services. Certain travel costs are often not covered under the NIHB plan. This has been explained by the following example, “to qualify for a wheelchair funded through the Ontario Assistive Devices Program (OADP), a child in Ontario must first be seen and assessed by an OADP-approved therapist. Yet most of these therapists are salaried hospital employees [therefor they do not bill OHIP directly], and thus, travel for First Nations children is not covered under the NIHB” (CBC). To put it in the simplest way possible; no travel means no service.

Interestingly, if a child required service from a physician, the travel cost would be covered. Although, one would think that a wheelchair for mobility or speech therapy for a young child who is not speaking, would be good investment for these children’s future (and there are many studies that prove this investment is fiscally responsible). However, the NIHB policy suggests non-physician care is not basic medical care, and travel for the services is not covered.

The most difficult part of this NIHB plan, and frustrating aspect of the activism to change it, is that the federal government does not seem to care. Nearly two years ago, over $110,000 was spent by the government to fight an eleven-year-old First Nation’s girl in court in an attempt to block a $6,000 orthodontic treatment. The same amount of money could have paid for over 18 of those exact orthodontic surgeries. This is only one example of how the federal government would prefer to maintain the status quo, following the established structures, and thus, the existing settler mentalities are reinforced.

It is argued by some that, because Indigenous people live far away from these health services, it is therefore their responsibility to pay for these treatments and travel. Yes, they do live far away, and yes, Indigenous populations have a high burden of illness. However, we have to think about why this is the case. The Indigenous people of Canada have lived here since time immemorial. However, at present day they live on land that has been allocated by the federal government (and not necessarily the land promised). This allotted land is often negatively affected by other government decisions (federal or provincial), like hydroelectric dams or deforestation which reduces the access and availability of traditional food sources, or contamination of land as in the long-standing Grassy Narrows dispute over mercury poisoning in North Western Ontario. This, amongst other social detriments, i.e. Residential School Syndrome and loss of language, diminish the overall health of Indigenous individuals and communities.

The NIHB is a health policy that is unique to Canada, but there are similar, Indigenous specific, policies that have been established throughout the settled world. Canada is consistently ranked at the top of the Human Development Index (HDI) along with New Zealand and Australia. These are three countries that have prominent Indigenous populations and a shameful history of persecution. The HDI examines three crucial components of human development: a long and healthy life, access to knowledge and a decent standard of living. These are important statistics with one major shortfall; Canada, like New Zealand and Australia, is addressed as a singular entity, a homogenous society, and there is no separate examination of the Indigenous component. Without this specific critique Canada maintains its image as a generous health care state. It is only when one delves deeper, that it is apparent this may not be the case. Awareness needs to be drawn to this existing neglectful policy, and this blog post aims to do just that.

The Words: Medical Assistance in Dying and How We Have Failed

The following was written by Isabella Sellar Voll.

The scene plays out innumerable times daily in doctors’ offices across the country. Nearly banal in its regularity, but nevertheless profound in its implications. The news. The results. The words.

Words like aggressive, degenerative, untreatable, progressive, inoperable or terminal. Sometimes there are tears as worst fears are realized. Sometimes there is stoic silence. Inevitably there are questions about quality of life, time left and treatment options.

Eventually, there comes resolve. For some, resolve brings a desire to fight to the last breath, while others vow to cherish each moment in peaceful acceptance of fate. Resolve might drive some to pursue experimental or unconventional options to prolong life. While others resolve to seize control over death when the time is right – to die when and where they choose, with the dignity that they deserve.

Since Canada legalized Medical Assistance in Dying (MAiD) in 2016, over 6,700 Canadians have chosen to pursue this option. Historically, accessing MAiD was severely restricted by prohibitively narrow criteria for qualification. According to existing law, a patient’s death must be “reasonably foreseeable” to qualify. However, on September 11, 2019, a Quebec Superior Court judge ruled that this ‘imminent death’ requirement was unconstitutionally restrictive.

What does this mean for Canadians?

Well, nothing quite yet. Application of the judgement was suspended for six months, offering legislators time to amend the laws. In the interim, those who qualify for MAiD under the existing criteria will continue to have access to the services upon request.

Advocates of MAiD suggest, and it is undoubtedly true, that chronic, debilitating disease often strips a patient of their agency. MAiD offers patients an element of returned control. MAiD is pursued because patients want to choose when and how their life will end – before suffering becomes too great, limitations of disease too prohibitive, or the loss of self too unbearable.

Studies have shown, however, that people also pursue MAiD for systemic reasons: for fear of the dehumanizing experience of residential care (well-founded, as cases of patient abuse in nursing homes continue to rise), or because they are loathe to become a burden on family-cum-caregivers.

Suffering related to the social isolation of disease and the lack of appropriate alternative care available to patients is also often commonly cited. This indicates that, at times, MAiD is pursued directly as a result of an overburdened and underperforming health care system. People choose to die prematurely because the system currently in place to walk them through illness and death is inadequate to the task of supporting them. People choose to die because we, as a community, are failing them.

Regardless of what side of the right-to-die debate you fall on, this failure is unconscionable. To put it bluntly, for some, dying in Canada sucks. A determined focus on curative care in the medical establishment de-centres the patient, and creates a vacuum in the space between diagnosis and end-of-life care for many patients – especially when their death is not imminent. The Canadian Institute for Health Information indicates that most doctors have neither the capacity nor the training to navigate the ongoing needs of the chronically or terminally ill.

In its truest form, palliative care re-centres the patient – not in pursuit of a cure, but rather, of the improvement of quality of life and management of disease in all its stages. Ideally, it addresses both the physical and non-physical symptoms of disease. It is equally appropriate at the onset of illness through to end-of-life.

In Canada, the concept of palliative care is erroneously perceived (and practiced) almost exclusively as an end-of-life strategy. Not only does this result in a general lack of access for patients throughout their illness, but also in a stigma such that palliative care comes to publicly signal giving up hope in a kind of existential surrender. Combined, these conditions not only limit a patient’s power over their end-of-life circumstances, but likewise reduce their capacity to engage with their disease management while still living. This is significant to the right-to-die debate as fear of the future and loss of control are circumstances frequently cited as central to patient pursuit of MAiD. Many of these concerns could be mitigated with comprehensive and accessible palliative care options.

Studies show that only 15 percent of Canadians actually receive palliative care in their last year of life. Even those with access receive far too little, too late. This is not good enough.

MAiD and access to palliative care in illness are, of course, not oppositional binaries. By presenting them in tandem I have not intended to ascribe such a controversy. This post is intended, rather, as a clarion call for a more compassionate and holistic response to living through illness. It is the recognition that many Canadians lack access to the crucial elements of care which, if properly and adequately provided, would mitigate some of the pressure, pain, fear and burden (emotional, physical and financial) that illness places on individuals and families. It would offer back a measure of control in a time of chaos.

Coretta Scott King proposed that “the greatness of a community is most accurately measured by the compassionate action of its members.” Canada is taking a step toward respecting, with care and compassion, the wishes of those who seek to end to their suffering through medically assisted means. Unfortunately, Canada’s record for compassionate care of the living – particularly of those living with illness- remains a woeful tale of inadequacy and insufficiency.