Disciplina de Desarrollo

2.2.4.1 First Nations in Canada

Many members of First Nations communities in Canada are experiencing stress related to socio-economic factors, a higher incidence of chronic diseases, the state of the environment, and cultural oppression (126). There are consistent health and socio-economic disparities that exist between First Nations and the rest of the non- Aboriginal, Canadian population. A report conducted by Health Canada entitled A Statistical Profile on the Health of First Nations in Canada: Determinants of Health 1999-2003 describes the non-medical determinants of health among on-reserve First Nations communities across Canada (126). This report highlighted many statistics describing socio-economic factors that adversely impact First Nation communities including unemployment, lack of education, and poor housing. According to this report (2001), the unemployment rate for registered, on-reserve First Nations is four times higher (27.7%), than the general Canadian population (7.3%). Many previous studies utilizing other matrices for analysis of cortisol secretion (saliva, serum, plasma or urine) have found a positive relationship between increased cortisol secretion and lower income (17-21). The proportion of on-reserve First Nations who complete high school by the age of 20 is 36%, compared to 85% in the equivalent general Canadian population. On reserve- households below the Canada Mortgage and Housing Corporation (CMHC) adequacy standard are 10-fold higher than general, off-reserve housing (22.4% compared to 2.0%) (126). Higher incidences of substance abuse and drug overdoses, premature fatalities, family violence, poverty, poor birth outcomes,

depression, suicidal ideation, death from alcoholism, homicide and suicide are all also evident in First Nation communities (126-132).

In addition, many chronic diseases are found at higher incidences in First Nations when compared to the rest of the Canadian population (133). Approximately one third of Aboriginals in Canada (i.e. First Nations, Métis and Inuit) aged 15 and older have been diagnosed with a chronic health problem (132). T2D is currently 3- to 5-fold more prevalent in First Nation communities and its incidence is increasing (134, 135). According to BMI standards, 73% of on-reserve First Nations members are overweight (vs. 48% of general Canadians) (126). Historically, First Nations have had lower cancer incidences when compared to non-Aboriginal populations, however there is evidence that the future cancer burden in First Nations will be high (136).

First Nation communities have a long and deep tie to the land and are thus, more directly impacted by the state of the environment than most Canadians. The traditional philosophy of First Nations communities is based on the idea that everything and everyone is interconnected. The inextricable links between the health of people and the health of the environment is recognized and respected. It is thought that a loss of land (both by displacement of communities, and by contamination of resources) greatly contributes to culture stress (137). In many First Nations communities there is, or there is a perception of a deteriorating environment. Unfortunately, in many of these communities both are true. This has contributed to a loss of tradition, culture and change from traditional diet in some First Nations communities and has impacted negatively health risks and risks to the local economy. At least one quarter of all First Nations housing units have a water supply that is inadequate due to health requirements or supply (126). It was reported that a majority of participants in a First Nation community responded that environmental issues are of equal importance to social concerns (11). In a study by Richmond and Ross, Community Health Representatives and Academics from rural First Nations communities stated that decreased environmental resources and/or access to these resources contribute to life imbalance, a loss of life control and act as a negative influence on social life (138). This illustrates the magnitude of importance First

Nations communities place on the health of their environment and how its deterioration acts as a stressor for many in these communities.

First Nations communities in Canada have experienced massive disruption and alteration of their traditional lifestyle, including cultural oppression and forced assimilation through the implementation of residential schools. From 1892 until 1996, when the last residential school was shut down, Aboriginal children were removed from their families and communities and sent to church- or government-run schools. It has been well documented that this loss of culture, language, tradition, family bonding and ties to Elders has manifested in poor socio-economic outcomes, such as suicidal thoughts and attempts, a history of physical and mental abuse and depressive symptoms in both residential school survivors, and in subsequent generations (139, 140).

Stress is often hypothesized as a key determinant of poor health in Aboriginal populations (141), however little research has explored this concept. The few studies examining chronic stress and/or cortisol content in any Aboriginal community worldwide have all found increased cortisol levels in the Aboriginal community compared to the general population. Poa and colleagues examined the relationship between insulin resistance and antipsychotic medication in an indigenous Maori population in New Zealand and found that the indigenous group had significantly higher levels of both insulin resistance and plasma cortisol compared to healthy, age-, sex-, and BMI-matched controls (142). Similar to Canada, T2D is more prevalent in this indigenous New Zealand population compared to the general European population. The authors propose that the HPA axis and increased cortisol may play a key role in development of insulin resistance. Australian Aboriginals had significantly higher levels of urinary cortisol than a sample of residents from Oxford, United Kingdom (143). American First Nation women from a Northern Plains reservation with a lifetime diagnosis of PTSD had elevated salivary cortisol concentrations, but similar diurnal patterns to matched female controls without PTSD (144). Of note, Daniel et al. found that concentrations of glycated hemoglobin, an indicator of psychogenic stress, were significantly higher (18.2% greater) in the indigenous groups (Australian Aborigines, Torres Strait Islanders and First Nations in Canada) than for the non-indigenous groups (Greek migrants and Caucasian

Australians) (145). The authors suggest that at the population level poor conditions associated with westernization may be biologically stressful for indigenous populations. Our current study (Chapter 4) is the first known study comparing hair cortisol content of two distinct cultural First Nations communities.

2.2.4.2 Naivasha, Kenya

Individuals in Naivasha, Kenya are known to be concerned about their health, especially the health of their children and grandchildren, poverty, access to clean and safe drinking water as well as to the potential health risks resulting from exposure to environmental contaminants, particularly pesticides. There are many local and international news reports featuring Lake Naivasha with dire and exaggerated information. These have contributed greatly to the negative perception surrounding the floriculture industry in Naivasha. Media have blamed the floriculture industry, particularly its use of pesticides, both for the health problems seen in Naivasha and the ecological issues plaguing Lake Naivasha. In 2008, the United Nations classified this region as one of the world’s 204 Environmental Change Hotspots (146). There is now an international focus on Lake Naivasha with many research groups investigating its problems.

Due to a rapid influx of migrants to Naivasha to look for work in the floriculture and other industries, there has been a tremendous population boom causing the introduction of massive unplanned settlements (slums) which lack infrastructure, waste water and solid waste treatment facilities and are overcrowded (16, 17). This has resulted in increased health concerns because of waterborne diseases including typhoid and cholera. There are many real health concerns in Naivasha, Kenya. The infectious disease, malaria, is found to be the most commonly reported diagnosis for both males and females in Naivasha, accounting for 31% and 36% of the medical records surveyed, respectively. This is not surprising as malaria is a leading cause of morbidity and mortality in Kenya, accounting for 30-50% of Kenya’s outpatient visits and 20% of hospital admissions (147). The occurrence of respiratory diseases, which include diagnoses for bronchitis, respiratory tract infections and asthma, followed malaria at 30% and 27% frequency in males and females, respectively. Again, this is in line with trends seen in the rest of the country. The Centers for

Disease Control and Prevention (CDC) reports that the second highest cause of death (10%) in Kenya is attributed to lower respiratory infections (148).

Naivasha has a concentrated population of female sex workers (FSW) due to the large number of truck drivers, migrant and seasonal workers in the floriculture industry. Naivasha is a main truck stop along the East Africa Transport Corridor linking Mombasa, Kenya to Kampala, Uganda (149). The prevalence of HIV in Kenyan FSW is much greater than the Kenyan general population, with estimates between 24 and 47%, compared to 7% (150-153). A study conducted by Okal and colleagues in 2011 found that FSW also face violence from both clients and law enforcement agencies on top of risks of HIV and Sexually Transmitted Diseases (149).

Largely due to the floriculture industry, with people coming from all over the country looking for jobs, Naivasha is a mixed tribal community with a large population of white expatriates which creates a lot of strain in the communities (154, 155). Although people may be migrating to Naivasha for job opportunities and a better livelihood, these are not always available. This creates tension in the communities in Naivasha and puts increased pressure on an already weak infrastructure. Subsequent to the controversial 2007 Presidential elections in Kenya, the settlement communities in Naivasha, particularly Karagita, were some of the areas hit hardest by intertribal clashes, including murder (156).

There are patriarchal cultural norms that are pervasive in the communities in Kenya. Women are often responsible for both productive tasks such as running a household, caring for children, collecting water, gathering firewood, food production as well as their reproductive roles. Consequently, Kenyan women typically perform the largest share of labour (12, 157). In addition to assuming productive and reproductive roles, many women also undertake formal work outside the home, particularly in the floriculture industry in Naivasha. Women are often responsible for the most labour intensive roles in the flower farm such as picking, packing and ensuring cosmetic quality due to their dexterity, eye for quality and speed (12, 158). As with First Nations in Canada, the role of stress as a determinant of health in sub- Saharan African populations including Kenya, has been seldom explored.