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Giant Mine Remed Giant Mine Remediation Project Team ation Project Team Outline of scope for asses Outline of scope for assessment of indirect ment of indirect stress ef stress effects of pote fects of potential arsenic exposure ntial arsenic exposure Ketan Shankardass, MHSc, PhD July 7, 2015

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Beyond the requirement of a human health risk assessment to be completed, Appendix F of Measure #10 from the “Report of Environmental Assessment and Reasons for Decision, Giant Mine Remediation Project” (Mackenzie Valley Review Board, June 2013) specifies that there must be evaluation of “the indirect effects of potential exposures to arsenic on wellness, including stress effects.” This document shares a working outline for the scope of work. It draws mainly from my

• wn framework of environmental determinants of stress and disease (Shankardass, 2012) and

preliminary considerations based some review of the extant literature and facts on the ground. The approach to measurement is also guided by concerns outlined for assessment of direct effects on human health in Measure #10. Future revisions will incorporate the input of the Giant Mine Working Group, Dr. Sue Moodie and the Independent Peer Review Panel. Future revisions are also contingent on a pending contract between myself and the Government of Canada. In that sense, this document is meant to focus and facilitate the on-going discussion that will inform the scope of work. This outline includes: (1) a conceptual framework for understanding how arsenic exposure (as reflected in the built, natural and social environment) can increase harmful manifestations of chronic stress; (2) a literature review of historical and baseline information related to indirect effects of environmental determinants of stress in Yellowknife; and (3) an approach to for the design, measurement and analysis of data to complete the evaluation. Concept Conceptual Framework: al Framework: Environmental determinants of arseni Environmental determinants of arsenic exposure and place-based stress c exposure and place-based stress Stress has been conceptualized and empirically studied in unique ways by psychologists, sociologists, psychoneuroimmunologists and others since Hans Selye first described the ‘General Adapatation Syndrome’ in 1936 (Selye, 1936). I have argued that a unified approach is required in order to more fully understand how social inequalities in health are generated and maintained (in addition to other individual and structural determinants of health) (Shankardass 2012; Shankardass and Dunn 2012). The ‘stress process’ described by Leonard Pearlin and colleagues (Pearlin et al 1981) offers a way to integrate diverse knowledge about stress. In brief, it describes how sources of stress (‘stressors’) can be translated into broad manifestations on human health depending on a series of mediating factors (Table 1).

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Giant Mine Remed Giant Mine Remediation Project Team ation Project Team Outline of scope for asses Outline of scope for assessment of indirect ment of indirect stress ef stress effects of pote fects of potential arsenic exposure ntial arsenic exposure Ketan Shankardass, MHSc, PhD July 7, 2015

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Table 1. Stress process Stress process stage stage So Sources urces Med Mediators ators Ma Mani nifesta festations ns Potential stressors, e.g., meaningful life events and daily strains ‐ Perception of stressors ‐ Assessment of resources for coping ‐ Genetic features Emotional, behavioural and physiological dysfunction I have recently described the stress process in terms of an individual construct embedded in the environment (Figure 1; Shankardass 2012). This approach highlights the deterministic role

• f both stressors and resources contained in the built, natural and social environment as individual

perceive and coping with stress over time. Importantly, environmental factors are potentially static

• r dynamic (and sometime both where there is some aspect of permanence), and can have a

variable effect on the same individual over time. Figure 1.

• NB. Solid arrows indicate the pathways that relate environmental determinants of stress to chronic

diseases via primarily physiologic changes in response to stress hormone dysregulation (1) and in relation to healthy and unhealthy habits related to coping (2); pathways of endogeneity (e); and pathways of confounding (c); while dashed arrows that cross solid arrows indicate effect modification. The notion that individual’s construct a ‘sense of place’ (Jorgensen and Stedman, 2001) is important for understanding how exposure to hazards of the environment (including arsenic trioxide) affect our experience of stress and the manifestation of chronic disease, in particular. Such hazards can interrupt one’s sense of place through cognitive, affective and conative pathways

Giant Mine Remed Giant Mine Remediation Project Team ation Project Team Outline of scope for asses Outline of scope for assessment of indirect ment of indirect stress ef stress effects of pote fects of potential arsenic exposure ntial arsenic exposure Ketan Shankardass, MHSc, PhD July 7, 2015

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because of ‘place identity’, ‘place attachment’ and ‘place dependence’. Place identity refers to beliefs about the relationship between self and place (i.e., to what extent does one internalize their places as a part of their identity?); place attachment refers to feelings about the place (e.g., how are we positive and negative about our places); and place dependence refers to the behavioral exclusivity of places in relation to alternatives (i.e., to what extent do we rely on these places? would we be just as supported and happy in other places?). The devastating impact of the arsenic hazard in Yellowknife is that “contamination is … invisible… sort of like a ghost… it’s in places that are supposed to be safe. It’s like the monster under your med. And that’s the really devastating impact of things like this is you start to be afraid to live in the place that you are.”

• Dr. Erin Freeland Ballantyne in Shadow of A Giant (Johnson and Ferguson 2015)

A place-based approach is also enriched by acknowledging the bi-directional relationship between individual and the places that they spend time in living, working and doing other things (so-called ‘third places’). So, arsenic trioxide could be more or less relevant, threatening, culturally damaging, for different individuals. Likewise, specific environmental resources offered to help ameliorate indirect effect on stress may be more or less relevant, appealing, culturally appropriate (or otherwise meaningful), or practically accessible for individuals. Individuals may also be more or less prone to utilize resources in their neighbourhoods according to how they perceive their surroundings over time. Folkman et al (1986) describe stress as individuals “in a dynamic mutually reciprocal, bidirectional relationship” with their context, while Luginaah et al (2002) described how residents living in the shadow of industrial hazards engage in “cognitive reappraisal” of places over time. Literature review: histori Literature review: historical al and base and baseline information line information An initial (read: very brief) review of scholarly and grey literature found some impacts on stress for families of workers involved in the 1992 strike in the Journal of the Canadian Medical Association (Williams, 1992), as well as anecdotal evidence about relevant stressors in the interactive documentary, ‘Shadow of a Giant’ (Johnson and Ferguson, 2015). A more systematic review will be completed in preparing the scope of work. This includes reviewing a paper by Paci and Villebrun (2005) in Pimatisiwin on community health impacts of mining for the Dene nation. I have also been in contact with the Dechinta Centre for Research and Learning, and anticipate contacting other relevant experts and organizations to find more literature. Beyond looking strictly for historical and baseline data about stress effects of arsenic exposure in Yellowknife, this search could be expanded to include stress impacts of arsenic and other environmental toxins on communities (indigenous/non-indigenous) elsewhere. Approach Approach

Giant Mine Remed Giant Mine Remediation Project Team ation Project Team Outline of scope for asses Outline of scope for assessment of indirect ment of indirect stress ef stress effects of pote fects of potential arsenic exposure ntial arsenic exposure Ketan Shankardass, MHSc, PhD July 7, 2015

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Design Given the role of very personal psychological processes of perception and coping that mediate the impact of arsenic trioxide and related stressors on human health, a community survey would allow for diverse perspectives to emerge on this complicated hazard. This could comprise of a (repeated) cross-sectional survey completed by a representative sample of the population, including closed and open ended questions that assess the level and distribution of chronic emotional and psychological stress and coping related to arsenic trioxide exposure at the Giant Mine. Additional measures could assess other mental and physical health sequelae and social impacts. To facilitate a life-course perspective on stress effects, sampling should include participants from distinct age groups of interest: pre-born (i.e., expecting mothers, toddler, child, teen and adult. Sampling should also be representative of gender, socio-economic dimensions and indigeneity. Assessment of emotional and perceived psychological stress Current emotional and (chronic) perceived psychological stress can be assessed in the community survey using two short validated tools. The single-item Distress Thermometer (DT) measures state

• distress. The DT a simple Likert scale shaped like a vertical thermometer that asks the subject to

select a number corresponding to their level of distress (Zwahlen, Hagenbuch, Carley, Recklitis & Buchi, 2008; NCCN, 2013). Perceived psychological stress can be measured using the 4-item Perceived Stress Scale (Cohen et al., 1983), which is an overall measure of perceived distress, as well as global distress (Cohen, Kamarck & Mermelstein, 1983). There are several plausible moderators of the relationship between the above-described stress measures. Thus, additional data should be collected to help explore the role of psychological traits, including trait anxiety and trait pessimism. A place-based approach suggests a need to stratify assessment by age, gender, socio-economic dimensions, indigeneity (for example) to explore whether the experience of emotional stress leads to more chronic types of (psychological) stress and certain coping outcomes. Assessment of specific sources of perceived stress In order to identify the ways that arsenic trioxide at the Giant Mine affects the community (including the role of related factors), participants could be asked to rate the salience of potential stressors (e.g., using a three- or five-point Likert rating from Not stressful at all through Very stressful). Participants should also be able to suggest and rate stressors not included in the survey. If a repeated cross-sectional approach is adopted to the survey, then the list of potential surveys could be informed by the findings of prior surveys. A proposed grid for evaluating the relevance of possible stressors historically/over time is included Table 2. A process should be identified for developing a more comprehensive list of possible stressors.

Giant Mine Remed Giant Mine Remediation Project Team ation Project Team Outline of scope for asses Outline of scope for assessment of indirect ment of indirect stress ef stress effects of pote fects of potential arsenic exposure ntial arsenic exposure Ketan Shankardass, MHSc, PhD July 7, 2015

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Table 2. Ti Time peri me period

• d

Possible stre Possible stressors relevant to arsenic ssors relevant to arsenic triox trioxide at Giant Min de at Giant Mine Wh While ile the mine the mine was in operation was in operation Sin Since the m e the mine ne closed but not closed but not currently currently Currently Currently Food contamination (ingestion) Air contamination (ihalation) Water contamination (ingestion) Contamination of the general environment (absorption) Food insecurity due to disruptive impacts on hunting/fishing/foraging Personal or family history of employment at mine Current personal or family employment in mine site remediation Impacts of mine closure on employment In addition to the survey, a process of ‘concept mapping’ could be utilized to further investigate the specific sources of stress being experienced across the community. Concept mapping is a computer-assisted, graphical and quantitative approach where groups of participants create, organize and represent knowledge of a subject in response to a main idea or concept (see Burke et al 2006 for an example). In this case, participants could use the list of all salient stressors (including those suggested by participants) as a starting point with the goal to represent how these stressors are inter-related and why they affect them. Concept mapping is broadly similar to the use

• f focus groups but reflects a more participatory and usually more structured and systematic
• approach. While concept mapping is more intensive for participants and in terms of time and

money, it can also facilitate more useful and actionable interpretation of survey findings. A more geospatial approach could also be useful for identifying specific places for

• intervention. For example, some process of community mapping could be used to identify and

validate the effect of specific locations. Assessment of coping behaviours and related resources, and other manifestations on human health For stressors identified as currently important, participants could be asked to describe the type (indicative of healthier and less healthy habits) and effectiveness of their coping behaviours. Assessment of presence and accessibility of appropriate and adequate resources for coping with stress related to arsenic trioxide at Giant Mine could be evaluated, including using community mapping approaches.

Giant Mine Remed Giant Mine Remediation Project Team ation Project Team Outline of scope for asses Outline of scope for assessment of indirect ment of indirect stress ef stress effects of pote fects of potential arsenic exposure ntial arsenic exposure Ketan Shankardass, MHSc, PhD July 7, 2015

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Mental and physical health problems could also be assessed to examine the potential for

• ther impacts on human health. For example, anxiety disorders could be assessed using the 20-

item State-Trait Anxiety Inventory (Spielberger, 1968, 1977) and chronic disease outcomes could be self-reported. Assessment of resources Analysis To be completed ‐ Quantitative: Stratified descriptive and correlation analysis, as well as multiple regression models to examine whether certain types of stress are associated with other manifestations

• n human health.

‐ Qualitative: Concept mapping and geo-spatial mapping Reporting Reporting In line with Meausure #10 of the Report (Mackenzie Valley Review Board, June 2013), reporting

• ught to addressing the following:

‐ “Provide a plain language explanation of the results in terms that are understandable to the general public, and communicate this to potentially affected communities in a culturally appropriate manner; ‐ Provide interpretation of results and related guidance; and ‐ Based on the results of this human health risk assessment, and on the results of the health effects monitoring program (described in Measure 9 above), the Developer will, if necessary in response to this information, identify, design and implement appropriate design improvements and identify appropriate management responses to avoid or reduce the severity of any predicted unacceptable health risks. All of the above, “may also require engagement and involvement of agencies those who specifically deal with psychological, medical, and clinical and societal manifestation of stress related issues in the area of study.” (Personal communication, A. Mohapatra) Literature Cited Literature Cited List to be compiled