Why language matters: insights and challenges in applying a social determination of health approach in a North-South collaborative research program.

BACKGROUND: Focus on "social determinants of health" provides a welcome alternative to the bio-medical illness paradigm. However, the tendency to concentrate on the influence of "risk factors" related to living and working conditions of individuals, rather than to more broadly examine dynamics of the social processes that affect population health, has triggered critical reaction not only from the Global North but especially from voices the Global South where there is a long history of addressing questions of health equity. In this article, we elaborate on how focusing instead on the language of "social determination of health" has prompted us to attempt to apply a more equity-sensitive approaches to research and related policy and praxis. DISCUSSION: In this debate, we briefly explore the epistemological and historical roots of epidemiological approaches to health and health equity that have emerged in Latin America to consider its relevance to global discourse. In this region marked by pronounced inequity, context-sensitive concepts such as "collective health" and "critical epidemiology" have been prominent, albeit with limited acknowledgement by the Global North. We illustrate our attempts to apply a social determination approach (and the "4 S" elements of bio-Security, Sovereignty, Solidarity and Sustainability) in five projects within our research collaboration linking researchers and knowledge users in Ecuador and Canada, in diverse settings (health of healthcare workers; food systems; antibiotic resistance; vector borne disease [dengue]; and social circus with street youth). CONCLUSIONS: We argue that the language of social determinants lends itself to research that is more reductionist and beckons the development of different skills than would be applied when adopting the language of social determination. We conclude that this language leads to more direct analysis of the systemic factors that drive, promote and reinforce disparities, while at the same time directly considering the emancipatory forces capable of countering negative health impacts. It follows that "reverse innovation" must not only recognize practical solutions being developed in low and middle income countries, but must also build on the strengths of the theoretical-methodological reasoning that has emerged in the South.

The social determination of health and the transformation of rights and ethics1.

The hyper-neoliberal era has seen the collapse of the ethos of life and the formation of a civilisation of extreme greed. In this global context, the pre-eminence of a technologically endowed but epistemologically and ethically misguided form of science has contributed to forms of 'scientific illiteracy' and strategies of planned ignorance that nourish a neo-conservative form of governance. The challenge of transforming the paradigm of bioethics and the right to health beyond the biomedical horizon is an urgent priority. Building on the strengths of a social determination approach and a meta-critical methodology and rooted in critical epidemiology, this essay proposes powerful tools for a radical shift in thought and action linked to rights and ethics. Together, medicine, public health, and collective health provide a path forward to reform ethics and advance the rights of humans and nature.

Chronic pesticide poisoning from persistent low-dose exposures in Ecuadorean floriculture workers: toward validating a low-cost test battery.

Chronic pesticide poisoning is difficult to detect. We sought to develop a low-cost test battery for settings such as Ecuador's floriculture industry. First we had to develop a case definition; as with all occupational diseases a case had to have both sufficient effective dose and associated health effects. For the former, using canonical discriminant analysis, we found that adding measures of protection and overall environmental stressors to occupational category and duration of exposure was useful. For the latter, factor analysis suggested three distinct manifestations of pesticide poisoning. We then determined sensitivity and specificity of various combinations of symptoms and simple neurotoxicity tests from the Pentox questionnaire, and found that doing so increased sensitivity and specificity compared to use of acethylcholinesterase alone--the current screening standard. While sensitivity and specificity varied with different case definitions, our results support the development of a low-cost test battery for screening in such settings.

Collaboration between infection control and occupational health in three continents: a success story with international impact.

Globalization has been accompanied by the rapid spread of infectious diseases, and further strain on working conditions for health workers globally. Post-SARS, Canadian occupational health and infection control researchers got together to study how to better protect health workers, and found that training was indeed perceived as key to a positive safety culture. This led to developing information and communication technology (ICT) tools. The research conducted also showed the need for better workplace inspections, so a workplace audit tool was also developed to supplement worker questionnaires and the ICT. When invited to join Ecuadorean colleagues to promote occupational health and infection control, these tools were collectively adapted and improved, including face-to-face as well as on-line problem-based learning scenarios. The South African government then invited the team to work with local colleagues to improve occupational health and infection control, resulting in an improved web-based health information system to track incidents, exposures, and occupational injury and diseases. As the H1N1 pandemic struck, the online infection control course was adapted and translated into Spanish, as was a novel skill-building learning tool that permits health workers to practice selecting personal protective equipment. This tool was originally developed in collaboration with the countries from the Caribbean region and the Pan American Health Organization (PAHO). Research from these experiences led to strengthened focus on building capacity of health and safety committees, and new modules are thus being created, informed by that work.The products developed have been widely heralded as innovative and interactive, leading to their inclusion into "toolkits" used internationally. The tools used in Canada were substantially improved from the collaborative adaptation process for South and Central America and South Africa. This international collaboration between occupational health and infection control researchers led to the improvement of the research framework and development of tools, guidelines and information systems. Furthermore, the research and knowledge-transfer experience highlighted the value of partnership amongst Northern and Southern researchers in terms of sharing resources, experiences and knowledge.

Establishing a community of practice of researchers, practitioners, policy-makers and communities to sustainably manage environmental health risks in Ecuador.

BACKGROUND: The Sustainably Managing Environmental Health Risk in Ecuador project was launched in 2004 as a partnership linking a large Canadian university with leading Cuban and Mexican institutes to strengthen the capacities of four Ecuadorian universities for leading community-based learning and research in areas as diverse as pesticide poisoning, dengue control, water and sanitation, and disaster preparedness. METHODS: In implementing curriculum and complementary innovations through application of an ecosystem approach to health, our interdisciplinary international team focused on the question: "Can strengthening of institutional capacities to support a community of practice of researchers, practitioners, policy-makers and communities produce positive health outcomes and improved capacities to sustainably translate knowledge?" To assess progress in achieving desired outcomes, we review results associated with the logic framework analysis used to guide the project, focusing on how a community of practice network has strengthened implementation, including follow-up tracking of program trainees and presentation of two specific case studies. RESULTS: By 2009, train-the-trainer project initiation involved 27 participatory action research Master's theses in 15 communities where 1200 community learners participated in the implementation of associated interventions. This led to establishment of innovative Ecuadorian-led master's and doctoral programs, and a Population Health Observatory on Collective Health, Environment and Society for the Andean region based at the Universidad Andina Simon Bolivar. Building on this network, numerous initiatives were begun, such as an internationally funded research project to strengthen dengue control in the coastal community of Machala, and establishment of a local community eco-health centre focusing on determinants of health near Cuenca. DISCUSSION: Strengthening capabilities for producing and applying knowledge through direct engagement with affected populations and decision-makers provides a fertile basis for consolidating capacities to act on a larger scale. This can facilitate the capturing of benefits from the "top down" (in consolidating institutional commitments) and the "bottom up" (to achieve local results). CONCLUSIONS: Alliances of academic and non-academic partners from the South and North provide a promising orientation for learning together about ways of addressing negative trends of development. Assessing the impacts and sustainability of such processes, however, requires longer term monitoring of results and related challenges.

Promoting the health of marginalized populations in Ecuador through international collaboration and educational innovations.

This paper examines two innovative educational initiatives for the Ecuadorian public health workforce: a Canadian-funded Masters programme in ecosystem approaches to health that focuses on building capacity to manage environmental health risks sustainably; and the training of Ecuadorians at the Latin American School of Medicine in Cuba (known as Escuela Latinoamericana de Medicina in Spanish). We apply a typology for analysing how training programmes address the needs of marginalized populations and build capacity for addressing health determinants. We highlight some ways we can learn from such training programmes with particular regard to lessons, barriers and opportunities for their sustainability at the local, national and international levels and for pursuing similar initiatives in other countries and contexts. We conclude that educational efforts focused on the challenges of marginalization and the determinants of health require explicit attention not only to the knowledge, attitudes and skills of graduates but also on effectively engaging the health settings and systems that will reinforce the establishment and retention of capacity in low- and middle-income settings where this is most needed.

Occupational exposure to pesticides during pregnancy and neurobehavioral development of infants and toddlers.

BACKGROUND: Few studies have examined the effects of in utero exposure to organophosphate and carbamate pesticides on neurobehavioral development in infants and young children. This study considers the potential effects of maternal occupation in the cut-flower industry during pregnancy on neurobehavioral development in Ecuadorian children. METHODS: Data were collected during 2003-2004 for 121 children aged 3-23 months and living in the rural highland region of Cayambe, Ecuador. Children were administered the Ages and Stages Questionnaire and were given specific developmental tests including prehension (reach-and-grasp) and visual skills. Information was gathered on maternal health and work characteristics, the home environment, and child health status. Growth measurements and a hemoglobin finger-prick blood test were obtained. We conducted multiple linear and logistic regression analyses. RESULTS: Children whose mothers worked in the flower industry during pregnancy scored lower on communication (8% decrease in score, 95% confidence interval [CI]: -16% to 0.5%) and fine motor skills (13% decrease, 95% CI: -22% to -5), and had a higher odds of having poor visual acuity (odds ratio = 4.7 [CI =1.1-20]), compared with children whose mothers did not work in the flower industry during pregnancy, after adjusting for potential confounders. CONCLUSIONS: Maternal occupation in the cut-flower industry during pregnancy may be associated with delayed neurobehavioral development of children aged 3-23 months. Possible hazards associated with working in the flower industry during pregnancy include pesticide exposure, exhaustion, and job stress.

Effect of community of residence on neurobehavioral development in infants and young children in a flower-growing region of Ecuador.

OBJECTIVE: In this study we compared neurobehavioral development in Ecuadoran children living in two communities with high potential for exposure to organophosphate (OP) and carbamate pesticides to that of children living in a community with low potential for exposure. METHODS: Women residing in the study communities who had a child 3-61 months of age completed a questionnaire about maternal and child health and sociodemographic characteristics. The Ages and Stages Questionnaire (ASQ) was administered to each child (n = 283). Growth measurements and a hemoglobin finger-prick blood test were obtained. We used multiple linear regressions to evaluate associations between community of residence and delayed development, adjusting for child health status and other characteristics of the home environment. RESULTS: Children 3-23 months of age who resided in high-exposure communities scored lower on gross motor (p = 0.002), fine motor (p = 0.06), and socioindividual (p-value = 0.02) skills, compared with children in the low-exposure community. The effect of residence in a high-exposure community on gross motor skill development was greater for stunted children compared with non-stunted children (p = < 0.001) in the same age group of 3-23 months. Children 24-61 months of age residing in the high-exposure communities scored significantly lower on gross motor skills compared with children of similar ages residing in the low-exposure community (p = 0.06). CONCLUSIONS: Residence in communities with high potential for exposure to OP and carbamate pesticides was associated with poorer neurobehavioral development of the child even after controlling for major determinants of delayed development. Malnourished populations may be particularly vulnerable to neurobehavioral effects of pesticide exposure.

Advancing health equity in healthy cities: Framing matters.

To improve the governance needed to create Healthy Cities, it is essential that policy processes directly engage marginalized populations and address the forces that affect health equity. Framings such as that provided by the Latin American collective health/social medicine/critical epidemiology orientation to critical processes of social determination of health enables a move beyond a reductionist focus to challenge the drivers that undermine health, and are consistent with policy directives such as the Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development.

Epidemiology of the 21 st century and cyberspace: rethinking power and the social determination of health.

The study of epidemiologic processes as a form of socially determined movement requires a renewed understanding of the social order, and thus, an updated understanding of the social relations that move society. Recently, the dominance of big corporations on cyberspace has become visible as a new historical process that conditions the social order and extends the technological subordination of daily life, therefore expanding community massive submission to standard conducts. The new digital technological revolution, about which some frightening prognoses are made for the next decades, could easily imply the advent of an era of radical subsumption of life processes. This will negatively affect not only our general way of living, thinking and planning, but also our deepest daily intimacy. This movement implies radical effects on health which we call cybernetic determination and subsumption. This novel process raises new questions on public health and prevention; but also requires a new reading of reality, a rethinking of human life and health, of its social determination, which implies the need for new new categories and analysis and renewed challenges for critical epidemiology.

La determinación social del autismo en población infantil ecuatoriana / The Social Determination of Autism in an Ecuadorian Child Population / A determinação social do autismo na população infantil equatoriana

Resumen Introducción: la determinación social del autismo es un análisis desde la perspectiva de la epidemiología crítica, cuyo objetivo es entender el autismo de forma integral, es decir, desde su realidad individual y colectiva. El propósito del estudio fue identificar las condiciones y las características diferenciales de las familias de niños con y sin autismo. Analizar cómo estas condiciones están presentes con mayor o menor fuerza, tanto en los casos como en los controles, para profundizar en el conocimiento de la situación de la población infantil autista en el país. Evaluar los procesos protectores y destructivos que los rodean, y levantar hipótesis para confrontarlas en futuros estudios. Desarrollo: se trata de comprender cómo estas lógicas de poder se expresan en procesos destructores o protectores del metabolismo sociedad-naturaleza en sus modos de vida, y analizar cómo estos pueden intervenir en el genotipo y en el fenotipo. Un estudio transversal fue realizado en 2016 con 69 niños diagnosticados con autismo y 91 niños neurotípicos, en una edad comprendida de 2 a 12 años, provenientes de Quito y Guayaquil. La investigación reveló que un 56.5 % de la población autista se ubicó en la capa media (Quito) y pobre (Guayaquil), condición que limitó el acceso al diagnóstico temprano: el 73.4 % de padres detectó los signos de alarma antes de los 3 años, y acudió al pediatra sin poder obtener un diagnóstico acertado. La población de la capa pobre presentó un mayor porcentaje de comorbilidades que las registradas en la capa media. El gasto requerido fluctuó entre 100 y 25 mil dólares, según la inserción social. Conclusión: estos resultados muestran una clara diferenciación entre los modos de vida, de acuerdo con la condición socioterritorial de la muestra.

Abstract Introduction: The social determination of autism is an analysis from the perspective of the critical epidemiology and the neurodiversity paradigm, which objective is to understand autism holistically, therefore insertion from a personal reality to a group. The purpose of the study was to identify differential conditions and characteristics of families with children diagnosed with autism and families with children not diagnosed with autism and to analyze how these conditions are present with more or less strength in cases or in controls, to get to know the situation of autism disorder diagnosed children in the country. The investigation also evaluated the protective and destructive processes that surround them, with the purpose of raising hypothesis to confront in future studies. Development: The research focused on understanding how these logics are expressed in destructive or protective processes of the society-nature metabolism in their ways of life and analyzing how these intervene in the genotype and phenotype. A cross-sectional study conducted in 2016 in the cities of Quito and Guayaquil, with 69 autism disorder diagnosed children and 91 neurotypical children, aged 2 to 12, revealed that 56.5 % of the population with autism appears to be in the middle social and economic class in Quito and the poor social and economic one in Guayaquil. Their social and economic conditions limit the access to early diagnosis: 73.4 % of parents detected the signs of alarm before the children were three years old and took them to be evaluated by the pediatrician, without being able to obtain an accurate diagnosis. The population of a poor social and economic class presented a higher percentage of comorbidities than the one located in the middle class. The required expenditure fluctuated between 100 to 25 thousand dollars, according to the social insertion. Conclusion: These results show a clear differentiation between lifestyles, according to the socio-territorial condition of the sample.

Resumo Introdução: a determinação social do autismo (DSA), é uma análise desde a perspectiva da epidemiologia crítica, cujo objetivo é entender o autismo em forma integral, portanto, desde sua realidade individual e coletiva. O propósito do estudo foi identificar as condições e características diferenciais da família de crianças com e sem autismo. Analisar como estas condições estão presentes com maior ou menor força tanto nos casos quanto nos controles, para aprofundar no conhecimento da situação das crianças com autismo no país. Avaliar os processos protetores e destrutivos que os rodeiam, e levantar hipóteses a ser confrontadas em futuros estudos. Desenvolvimento: tenta-se compreender como estas lógicas de poder, se expressam em processos destrutores ou protetores do metabolismo sociedade-natureza em seus modos de vida, e analisar como estes podem intervir no genótipo e fenótipo. Um estudo transversal realizado no 2016, com 69 crianças diagnosticadas com autismo e 91 crianças neurotypical, em uma idade compreendida de 2 a 12 anos e provenientes de Quito e Guayaquil. O estudo revelou que um 56.5 % da população com autismo localizou-se na capa meia (Quito) e pobre (Guayaquil), condição que limitou o acesso ao diagnóstico temporão: o 73.4 % dos pais, detectara os signos de alarma antes dos 3 anos, e foi ao pediatra sem conseguir obter um diagnóstico acertado. A população da capa pobre apresentou uma maior percentagem de co-morbidades que as registradas na capa meia. O gasto requerido flutuou entre 100 até 25 mil dólares, segundo a inserção social. Conclusão: estes resultados mostram uma clara diferenciação entre os modos de vida, de acordo à condição sócio territorial da amostra.

Integrating participatory community mobilization processes to improve dengue prevention: an eco-bio-social scaling up of local success in Machala, Ecuador.

BACKGROUND: This project investigates the effectiveness and feasibility of scaling-up an eco-bio-social approach for implementing an integrated community-based approach for dengue prevention in comparison with existing insecticide-based and emerging biolarvicide-based programs in an endemic setting in Machala, Ecuador. METHODS: An integrated intervention strategy (IIS) for dengue prevention (an elementary school-based dengue education program, and clean patio and safe container program) was implemented in 10 intervention clusters from November 2012 to November 2013 using a randomized controlled cluster trial design (20 clusters: 10 intervention, 10 control; 100 households per cluster with 1986 total households). Current existing dengue prevention programs served as the control treatment in comparison clusters. Pupa per person index (PPI) is used as the main outcome measure. Particular attention was paid to social mobilization and empowerment with IIS. RESULTS: Overall, IIS was successful in reducing PPI levels in intervention communities versus control clusters, with intervention clusters in the six paired clusters that followed the study design experiencing a greater reduction of PPI compared to controls (2.2 OR, 95% CI: 1.2 to 4.7). Analysis of individual cases demonstrates that consideration for contexualizing programs and strategies to local neighborhoods can be very effective in reducing PPI for dengue transmission risk reduction. CONCLUSIONS: In the rapidly evolving political climate for dengue control in Ecuador, integration of successful social mobilization and empowerment strategies with existing and emerging biolarvicide-based government dengue prevention and control programs is promising in reducing PPI and dengue transmission risk in southern coastal communities like Machala. However, more profound analysis of social determination of health is called for to assess sustainability prospects.

La interacción entre la exposición a agrotóxicos y componentes relevantes del sistema inmune en comunidades de La Paz Bolivia: una mirada desde la epidemiología crítica / The interaction between exposure to agrotoxins and relevant components of the immune system in La Paz Bolivia communities: a view from the critical epidemiology

La salud desde la epidemiología crítica es un proceso complejo/dinámico/dialéctico, socialmente determinado, con dominios general, particular y singular donde se desarrollan procesos malsanos (destructivos) y procesos saludables (protectores). Algunos autores señalan un aumento de la prevalencia de enfermedades asociadas con las alteraciones en la respuesta inmune, por exposición agrotóxicos, pero esta información en humanos es escasa y controvertida.Pretendemos conocer la interacción entre la exposición a agrotóxicos y componentes del sistema inmune: enzimas fagocíticas MPO y FAG por citoquímica e Interleucinas 6 y 8 por quimioluminiscencia en 5 comunidades de La Paz Bolivia, aplicando también un cuestionario correspondiente a la epidemiología crítica (matriz de procesos) y estrés laboral.Se analizaron perfiles epidemiológicos de 113 voluntarios (agricultores):60 mujeres y 53 varones, encontrándose diferencias significativas (Chi-cuadrado): tipología del modo de vida (reproducción económica, uso agrotóxicos, trabajo secundario), procesos destructivos, equipamiento de protección, capacitación, edad. Observándose actividad enzimáticadisminuida MPO y aumentada FAG, para ambos géneros en edad laboral activa. Sin significancia: interleucinas y estrés laboral.Existe afectación en la funcionalidad enzimática en células de primera línea de defensa del sistema inmune y en la relación de concentración de interleucinas, en agricultores más o menos expuestos a agrotóxicos considerando sus estilos y modos de vida.

Health from critical epidemiology is a complex, dynamic and dialecticprocess, socially determined, with general, particular, and singular domainswhere unhealthy (destructive) processes and healthy (protective) processesare developed.Some authors point to an increase in the prevalence of diseases associatedwith alterations in the immune response, due to pesticides exposure, but this information in humans is limited and controver-sial.We intend to know the interaction between exposureto pesticides and components of the immune system:MPO and FAG phagocytic enzymes by cytochemistryand Interleukins 6 and 8 by chemiluminescence) in 5 communities of La Paz Bolivia, applying a questionnairecorresponding to critical epidemiology (matrix of pro-cesses) and work stress.Epidemiological profiles of 113 volunteers (farmers)were analyzed: 60 women and 53 men, finding sig-nificant differences (Chi-square): lifestyle typology(economic reproduction, pesticides use and secondarywork), destructive processes, protective equipment,training, age. Observing decreased enzymatic activityMPO and increased FAG, for both genders of activeworking age. Without significance: interleukins andwork stress.There is an affectation in the enzymatic functionalityin cells of the first line of defense of the immunesystem and in the concentration ratio of interleukins,in farmers more or less exposed to pesticides considering their styles and ways of life.

Latin American critical ('Social') epidemiology: new settings for an old dream.

BACKGROUND: Epidemiology's role as the 'diagnostic' arm of public health has submitted epidemiological reasoning and practice to the crossfire of oppositional social values and demands. In Latin America, the visible signs of extreme social and political authoritarianism and inequity, as well as the growing unfairness of the World economy, inspired a culture of social critique and a corresponding academic reform movement, which nurtured a profound social awareness among health scientists. Aims The authors' aim is to call attention to the need to overcome this scientific North/South divide. An imperative, at a moment when the demolition of health standards under the pressures of global economic acceleration and 'unhealthy health policies,' confront us all with the common challenge of cross-fertilizing the strengths of academic traditions from both South and North. METHODS: The present paper offers a fresh perspective from the South about the relevance of progressive Latin American public health (termed 'collective health') by highlighting a number of its hard scientific contributions which, unfortunately, remain almost unknown to mainstream medical and public health researchers outside Latin America. RESULTS: An armed form of structural greed has now placed the world on the brink of destruction. At the same time, however, fresh winds blow in the continent. CONCLUSION: This paper is an invitation to confront the menacing forces producing our unhealthy societies and an opportunity to form fraternal partnerships on the intercultural road to a better world, where only an epidemiology of dignity and happiness will make sense.

[New model of accumulation and agro-business: the ecological and epidemiological implications of the Ecuadorian cut flower production]. / Nuevo modelo de acumulación y agroindustria: las implicaciones ecológicas y epidemiológicas de la floricultura en Ecuador.

The article refers to the results of an integrative research project that aim to analyze ecosystem and human health's impacts of cut flower production in Cuencas del Rio Grande region (Cayambe and Tabacundo zones). In order to assess the complex object of study and its multiple dimensions, an interdisciplinary approach has been constructed, based on the following components: a) pesticides dynamics analysis; b) pesticides distribution and commercialization processes in the region; c) economic and anthropological transformation determinate by the flower production; d) epidemiological process of human health impacts; e) and the design of participatory, multicultural and integrative information. The research consolidated an important geo-codified data base on the impacts of cut flower production to workers, communities, aquatic systems and soils, offering evidences of the actual flower production system severe impacts and leading to a reflection about the sustainability of the productive systems and the future of the ecosystems.