CPHS Fellows 2004-5

Jeffrey Aguinaldo | Kirstin Borgerson | Jennifer Coelho |
Andrea Daley| Lydia Kapiriri | Jennifer Keelan | Shannon Madden |
Wendy McGuire | Carolyn McLeod | Mary Powell

Jeffrey Aguinaldo
Lupina/OGS Doctoral Fellow

“Gay men’s health: Talking about sexuality, drugs, and risk”

Biography: Jeffrey P. Aguinaldo is a qualitative researcher working towards a Ph.D. in the Department of Public Health Sciences at the University of Toronto, and has a M.A. and B.A. in Psychology from Wilfrid Laurier University and York University respectively. He continues to develop his skills in discourse analysis and discursive psychology in ways that intersect with his political commitments to queer, feminist, anti-racist, and more recently, dis/ability practice. He has presented widely on past research and theoretical projects including discourse analytic approaches to the study of gay men's domestic violence and rereading the removal of homosexuality from a disability studies perspective. More recently, his interests have focussed on the interpretive practices of gay and bisexual men in talking about their health as well as talk and texts of social scientists influential in the domain of gay men's health. He is presently employed as a researcher at the HIV Social, Behavioural, and Epidemiological Studies Unit, Faculty of Medicine, University of Toronto and offers research consultation to the Polaris HIV Seroconversion Study.

Project Abstract: The purpose of my research is to explore the social construction of gay men’s health, focussing specifically on talk and text about (gay) sexuality, drug use, and HIV risk. The social science literature has identified HIV/AIDS and drug use as major public health concerns among gay, bisexual, and heterosexual men who have sex with men, so much so that HIV transmission and substance ab/use are now understood as "intertwining" epidemics among these marginalised populations in North America. I utilise a fine-grain discursive analytic approach to a broad range of data including social science literature, newspaper and magazine articles from the gay media, and informal interviews with gay, bisexual, and heterosexual men who have sex with men talking about gay sexuality, drug use, and HIV risk. This study contributes to the substantive field of gay men’s health by exploring how theories in health research themselves construct "the problem" in gay men’s health and how, from a micro-analytic perspective, a fine-grain discursive approach to talk and text can envision alternative ways of thinking about and addressing gay men’s health concerns. Furthermore, this research contributes to the field of discourse analysis by demonstrating how the social world is accomplished in and through talk.

Kirstin Borgerson
Lupina/OGS Doctoral Fellow

“Understanding the Role of Scientific Evidence in Medicine”

Biography: Kirstin Borgerson is a doctoral candidate in the Department of Philosophy at the University of Toronto. She completed her MA at the U of T, and received her BA from the University of Saskatchewan. Kirstin’s research interests include philosophy of science, bioethics, feminist philosophy, and epistemology. She has done some teaching in the philosophy department, and has recently been invited to act as a guest editor for a special issue of the journal “Perspectives in Biology and Medicine” on evidence-based medicine. She is also a member of the U of T varsity women’s rowing team.

Project Abstract: The question of what counts as good evidence in medicine is of critical importance to both physicians and philosophers, and is vital to the future of health care. Given the current move toward ‘global bioethics’ and the need for standards of health-care treatments that can apply in a cross-cultural health care setting, determining what counts as good evidence is medicine is becoming more challenging. As a result of recent attention to ‘Evidence-based Medicine’, physicians have called for the development of a theory of evidence that encompasses the existence, nature and kinds of evidence, with particular attention to the medical field. Much work has been done in philosophy of science on the project of defining ‘good evidence’. At the same time, the question of what counts as good evidence in medicine, especially given the current medical context, has yet to be fully addressed by contemporary philosophers, who have tended to focus their contributions to the field of medicine on issues arising within the scope of bioethics. In my research, I hope to clarify the requirements of 'good evidence' in medicine through 1) an in-depth investigation of the philosophical origins of 'evidence' and 2) a critical analysis of the more recent writing done on the subject of evidence from within the medical community.

In the first two years of my PhD program at the University of Toronto, I applied myself to the task of understanding the philosophical issues at play in the contemporary debate over what counts as good evidence in medicine. My current task, in the final two years of my program, is to research the specific challenges presented to scientists by practitioners of alternative medicine who claim to have different standards of evidence. Thesis chapters will address the philosophical foundations of evidence, the use and abuse of evidence in science and medicine, and the insights gained from the debate over the status of ‘alternative’ forms of evidence.

Jennifer Coelho
Lupina/OGS Doctoral Fellow

“The Effects of Food Context on Eating Behaviours in Restrained and Unrestrained Eaters”

Biography:Jennifer Coelho is a doctoral candidate in the Department of Psychology at the University of Toronto. She is specializing in Social/Personality/Abnormal Psychology, and is completing a clinical extension in Eating & its Disorders. As part of this clinical extension, Jennifer recently completed a clinical research practicum in Australia, working as a psychology intern at an eating disorders clinic affiliated with the University of Sydney. Her doctoral research is currently focusing on food cravings in chronic dieters and non-dieters, and the effects of exposure to food cues on mood and eating behaviour.

Project Abstract: Obesity is a rising concern in North America, with recent reports indicating that more than 50% of Canada’s population is either overweight or obese. Given that being overweight can lead to a variety of negative physical and mental health consequences, researchers need to address issues related to obesity. Researchers have identified that one of the most common eating patterns reported by overweight individuals is eating because of carbohydrate cravings. Investigations focusing on food cravings may provide insight into the prevention of obesity and its negative consequences. However, experimental research on food cravings is relatively sparse, with many studies in the area relying on retrospective self-report measures in order to assess the consequences of food cravings. In order to address this issue, Jennifer’s dissertation research will investigate potential techniques for inducing and measuring food cravings, and examine the role of chronic dieting in moderating eating behaviour in response to food cravings.

Andrea Daley
Lupina/OGS Doctoral Fellow

“Lesbian Women and Serious Mental Illness: Negotiating Identities”

Biography: Andrea Daley is a doctoral candidate in the Faculty of Social Work and is enrolled in the Collaborative Program in Health Services and Policy Research at the University of Toronto. Andrea received her B.S.W. and M.S.W. at York University (Toronto). She brings to the Comparative Program on Health and Society extensive experience as a mental health clinician within the areas of community care, homelessness, and serious mental illness. Additionally, Andrea brings to the program the experience of her advocacy work within LGBTQ communities, particularly within the area of LGBTQ health. Currently, as a private practitioner she works with clients experiencing loss due to chronic mental illness, and clients experiencing issues related to gender and sexuality. Andrea’s research interests include the invisibility of marginalized groups within health care policy and program delivery, women and serious mental illness, and sexuality and identity. For example, her Master’s thesis Lesbian Health and The Assumption of Heterosexuality: An Organizational Perspective explored ways in which the assumption of heterosexuality and language shape knowledge production as well as the construction of lesbian subjectivities within the context of organizational health policies and practices. Andrea has published several articles related to the assumption of heterosexuality within health care organizations, and it’s impact on the health care experiences of lesbian women.

Project Abstract: In this doctoral research project Andrea will explore how lesbian women with schizophrenia negotiate their identities as they contend with the ‘double stigma’ of mental illness and lesbian sexuality within psychiatric communities as well as within the society at large. Lesbian women with serious mental illness (schizophrenia, bipolar disorder, depression) often struggle with the challenge of integrating two aspects of identity that are devalued by the dominant culture. The ‘double stigma’ of being chronically mentally ill and lesbian means having to endure ostracism by the society at large due to mental disability and sexual orientation. The effects of ostracism and alienation as a result of mental illness and sexual orientation are pervasive and often mean a loss of dignity and personal identity as lesbians with serious mental illness interact with their environments. Within psychiatric institutions the needs of lesbian clients are often ignored because they are viewed as going through a phase like that of the ambivalent sexuality of an adolescent which they will eventually outgrow. As importantly, many lesbians with serious mental illness feel awkward participating in gay and lesbian organizations because of their mental health history. Consequently, lesbians with serious mental illness experience barriers to alternative avenues for development that subcultures normally provide.

Currently, there is a gap in the psychiatric literature on sexuality and the research literature on lesbian health. In this way, the assumption of heterosexuality in the psychiatric literature and selection bias in research on lesbian health promote and maintain the marginalization of lesbian women with serious mental illness. This research project will be an important contribution to the field of mental health, in that, the findings of this research will provide a base for further investigations into the psychosocial needs of lesbian women with schizophrenia. Additionally, the findings of the research will suggest how psychiatric programs and lesbian and gay services could combine their expertise in an effort to provide effective support and interventions for lesbian women with schizophrenia. Finally, this doctoral research will empower lesbian women with schizophrenia by giving them a forum in which their voices can be heard.

Lydia Kapiriri
CPHS & Joint Centre for Bioethics Post-Doctoral Fellow

“Accountability for reasonableness in priority setting: A comparison of priority setting processes in health at three levels in Canada, Norway and Uganda”

Biography: Lydia Kapiriri is a post-doctoral research fellow at the University of Toronto, department of medicine, Joint Centre for Bioethics under the mentorship of D.K. Marti, PhD. I am a medical doctor with a Masters degree in Public health from the Royal Tropical Institute, Amsterdam and a Ph D from the University of Bergen, Norway. My research has focused on various aspects of health systems and of late specifically on priority setting. My PhD thesis titled: Opportunities for Public accountability in priority setting in health: the case of Uganda , addresses various dilemmas faced by decision makers in developing countries and also looks at the values, the actors and processes of priority setting in Uganda. This work has been published in form of papers in various peer reviewed journals. My Post-doctoral focuses on a comparative study of priority setting processes at three levels in Uganda, Canada and Norway.

Project Abstract: Because no health system can afford to pay for every service it wishes to provide, priority setting is one of today’s most important health policy issues. Studies have shown that priority setting is a complex and value laden process that lacks universally acceptable procedures, criteria or guidelines. Thus there is increasing focus on fair procedures in priority setting. To date, there are few studies that compare and evaluate the degree of fairness of different priority setting processes across countries and levels. Such comparative studies would provide evidence of ‘good practices’ in the different contexts, which can be shared and contribute to improving priority setting in health care.

This study compares priority setting processes in Canada, Norway and Uganda. The objectives are to describe priority setting processes in the three countries; to evaluate the processes against the leading ethical framework for fairness; “Accountability for Reasonableness” and to compare and share identified lessons of good practices and facilitate improvement. While Norway was among the first countries to attempt to systematize priority setting, Canada, with its complexity of priority setting processes has been described as a laboratory from which several lessons can be drawn. While Uganda, a low-income country, with a decentralized administrative system similar to the other two countries, has not yet gained much experience in systematic and explicit priority setting. There have been few empirical studies that have attempted to compare priority setting procedures in different countries using a common framework, and more so comparing developed and developing countries. Such studies would facilitate shared learning. The framework, we use, provides a common language for discussing priority setting and so facilitates “improving the public’s grasp of the need for limits and the appropriate grounds and conditions for making decisions about them.

Jennifer Keelan
CPHS & SSHRC Post-Doctoral Fellow

Biography: Jennifer Keelan is a CPHS and SSHRC Postdoctoral Fellow. She completed her PhD in History of Science and Medicine at the University of Toronto’s Institute for the History and Philosophy of Science and Technology, under Professor Pauline Mazumdar. Her Ph.D. thesis focused on late nineteenth anti-vaccinationism and the social and medical factors involved in early epidemiological reasoning for compulsory vaccination including the calculations of risk, and public testimony about medical science. Her work examined the assessment of the various smallpox vaccination technologies in Canada and the United States in the context of late nineteenth century bacteriological sciences. Her postdoctoral research compares the attempts to repeal compulsory vaccination in the United States, Canada and the UK at the turn of the century. She is particularly interested in how diverse social groups experienced and understand risk and how this intersected with popular notions of medical authority and expertise in the public sphere. She recently co-organised an international conference in the history of immunology at the University of Toronto, and was a co-founder of the annual Joint Atlantic Seminar for the History of Medicine which will take place at Harvard October, 2004.

Project Abstract: <coming soon>

Shannon Madden
Lupina/OGS Doctoral Fellow

“Evaluating Interventions to Improve Priority Setting”

Biography: Shannon Madden is a PhD Candidate in the Department of Health Policy Management and Evaluation and the Joint Centre for Bioethics (JCB). She completed her MSc at UofT and her BHSc at the University of Western Ontario. Shannon is involved in bioethics as it relates to health policy. More specifically, her interests include priority setting in health care within Canada and around the world. Shannon has spent the past three years very involved in priority setting research at the JCB with her supervisor Douglas Martin. Shannon is a member of the Canadian Priority Setting Research Network, and her contributions to this field to date include one published paper (4th author), a number of presentations at national conferences, and two published reports. Shannon is also the student representative for the Canadian Bioethics Society where she has served for two years. She also sits on her student’s council and on the Society of Graduates in her department. This year, Shannon was award the Ontario Graduate Scholarship. She is both pleased and honored to have been awarded the Lupina/OGS Doctoral Fellowship.

Project Abstract:Priority setting (also known as rationing or resource allocation) is one of the most important and thorny problems facing the Canadian health care system -- indeed any health system. There are several interventions that have been proposed for improving priority setting, including: Accountability for Reasonableness, Program-Budgeting and Marginal Analysis, Health Technology Assessment, and ethical theories of justice. Although such interventions for improving priority setting have been described, their effectiveness has not been evaluated because there exists no evaluation framework or tool. Developing a conceptual framework would help to draw out the definition of an ‘effective’ priority setting intervention. Further, developing an evaluation tool would help to assess the effectiveness of those interventions meant to improve priority setting.

Priority setting is necessary for health system sustainability, but priority setting is difficult and there is no agreement about how to do it ‘right’ or even how to do it ‘well’. There is no consensus about the goals of priority setting, and consequently, there is no agreement on how to evaluate priority setting.

The overall aim of this project is to address the research question: How can we measure the effectiveness, or value added, of interventions to improve priority setting. The specific objectives are: 1. Develop a conceptual framework for evaluating effectiveness of interventions to improve priority setting; and 2. Develop a tool to evaluate the effectiveness of interventions to improve priority setting.

Wendy McGuire
Lupina/OGS Doctoral Fellowship

“Beyond Clinical EBM: Developing an Evidence Base for Public and Population Health”

Biography: Wendy McGuire is a doctoral candidate in the Department of Public Health Sciences (Social Science and Health Program) at the University of Toronto. She completed her MSW at the University of Toronto and her BA (Sociology) at the University of Guelph. Wendy has coordinated provincial and national studies on the use of evidence and the measurement of performance in the delivery of Canadian health care. She currently works as the Knowledge Transfer Coordinator in the Department of Health Policy, Management and Evaluation. Her research interests include the social determinants of health and illness, health inequalities, the role of theory in health research, and the relationship between knowledge, policy and practice in the area of public and population health. Wendy is actively engaged in the scholarly and social activities of her department, as the President of the Public Health Sciences Student Association (PHSSA), and one of the coordinators of the Social Science and Health monthly doctoral student seminar series.

Project Abstract: The clinical Evidence-Based Medicine (EBM) movement emerged in the early 1990’s and has rapidly taken off as a tool to improve the efficiency and effectiveness of clinical care, to ration health services, and to manage and classify the enormous volume of medical research being produced. Numerous problems have surfaced when the clinical model of EBM has been applied at the level of policy and to the health of the population as a whole. These include disagreements over the nature of evidence, the type of society policy-makers ought to pursue to achieve the health outcomes citizens want, and differences in the process of utilization in a policy rather than clinical context. Yet, the dominant approach to Evidence-Based Population Health (EBPH), which has been rapidly adopted in Canadian health policy, is modeled after EBM. Due to its origins in the discipline of epidemiology, EBPH fails to adequately theorize or explain social structures, which are at the centre of a population health approach. The type of knowledge that is legitimated in this model is therefore limited in its ability to address and impact the underlying social relations that cause illness and health inequalities. In my dissertation, I will explore differences between the nature of the biological and the social and develop a model of EBPH that can account for the interactions between these different layers of reality.

Carolyn McLeod
CPHS New Faculty Fellow

“The Ethics and Politics of Medical Conscience Clauses”

Biography:Carolyn McLeod has been an Assistant Professor of Philosophy at the University of Western Ontario since 2002. She came to Western from the University of Tennessee, Knoxville, where she was an Assistant Professor for one year. From 1999-2001, a Social Science and Humanities Research Council of Canada Postdoctoral Fellowship took her to the Center for Bioethics, University of Minnesota as well as the University of Western Ontario. In 1999-2000, she held a second postdoctoral fellowship from the Center for Bioethics itself.

Prior to being in Minnesota, she was completing her PhD in Philosophy at Dalhousie University. Her supervisor was Susan Sherwin, who was named Distinguished Woman Philosopher of the Year for 2004 by the Society for Women in Philosophy (U.S.). Carolyn received both her Master’s and Bachelor’s degrees in philosophy from Queen’s University.

Throughout her career, she has focused on philosophical issues in health care ethics. Both her PhD and Master’s dissertations were in reproductive ethics. With her recently published book, Self-Trust and Reproductive Autonomy (MIT Press 2002), she was able to bring together interests she has in reproductive ethics, philosophical moral psychology, and feminist theory. Other publications of Carolyn’s include papers on the nature of trust, integrity, autonomy, and objectification. These appear in such as places as the Canadian Journal of Philosophy, the Journal of Social Philosophy, and Health Care Ethics in Canada (Harcourt Brace 2004, 2nd edition). Carolyn also has a piece forthcoming in the Oxford Handbook of Bioethics on feminist objections to commodifying women’s bodies through various reproductive practices.

Project Abstract: Many ethical issues in health policy concern legitimate conflicts between the rights, needs or wishes of some and social justice for all. The issue I will address is a case in point: the conscience of health care providers, or of institutions, versus social justice in health care (i.e., justice for social groups, such as women and people of colour).

My general topic is conscience clauses in health policy, which exist to protect health care providers or institutions that make conscientious objections to performing certain medical services. Under this topic, I pose the following: Q1) What is a genuine conscience clause? Q2) When are genuine conscience clauses morally justified? Answering Q1 involves thinking about what conscience is, while answering Q2 requires careful reflection upon “the rights of some versus social justice for all” problem, as applied to conscience clauses.

Sorting out when protecting conscience is morally justified in any health care situation would be too large a project for this fellowship. So I have narrowed my topic down significantly to the impact of conscience clauses on social justice for women in reproductive health care. Reasons for making this move include my own expertise in reproductive ethics, along with the fact that conscience clauses appear to be significant determinants of women’s reproductive health, in Canada and the U.S., because of the controversial nature of many reproductive health care practices.
My goals for the project are to try to influence policy on conscience in reproductive health care, and to complete a book manuscript on the ethics and politics of conscience clauses.

Mary Powell
CPHS Visting Scholar

“The Ethics and Politics of Medical Conscience Clauses”

Biography:Mary Powell is an associate professor of political science at Laurentian University in Sudbury, Ontario. She teaches in the fields of public administration, gender and politics, and health policy. Mary had also worked in government and non-government organizations as a specialist on social policy and decentralization. With Laurentian colleagues, Mary has conducted research on the experience of women in blue-collar jobs in mining, focusing on Inco, one of the world’s largest nickel producers, and a major Sudbury employer. Chief among her research interests is public health in Ontario. In her current project she is analyzing recent crises in public health (withdrawal of provincial funding, the Walkerton crisis, and SARS) and their historical antecedents.

Project Abstract: I am working on a manuscript examining the development of public health in Ontario from 1882 to 1984.The manuscript has been accepted for publication by McGill-Queen’s University Press. Completing revisions suggested by reviewers from Aid to Scholarly Publications is a main aim of my sabbatical, the period for which I am applying for a financial support.

My second objective is to undertake research to extend the manuscript from 1984 to 2004. Three major events have had a profound effect on the public’s view of public health and on the government’s handling of the public health dossier: first, the decision by the Harris government to download public health onto the municipalities; second, the Walkerton water contamination crisis; and third, the SARS outbreak, which highlighted weaknesses in public health structure.

Both downloading and program shifts/ cutbacks should be viewed as part of a pattern of historical institutionalism in which institutions (particularly cabinet, the senior bureaucracy, and the network of provincial and local public-health physicians—or its absence) structured political situations and affected policy outcomes. The contrast between periods is compelling. Institutions reinforced each other to strengthen policy based on expert advice during the period 1945-65. With downloading, the clash of institutions was evident: the breach between the public service and cabinet as ideology replaced expertise, the end of provincial stewardship of municipalities, and the abandonment of universality in public health. The isolation of public health from other elements of the health system was built into the structure of the Department of Health. Analyzing these developments will make an important contribution to understanding of the interplay of institutions, politics, and policies.