The Public Health Advocate: Finding Our Roots (Spring 2019)

the

PUBLIC HEALTH ADVOCATE SPRING 2019 10 LABORING IN AMERICA’S TOBACCO FIELDS 18 OLD DRUGS, NEW SOLUTIONS 25 QUEER, HERE, AND MISTREATED: LGBTQIA+ DISPARITIES IN HEALTHCARE

FINDING OUR ROOTS

the

PUBLIC HEALTH ADVOCATE A UC BERKELEY UNDERGRADUATE PUBLIC HEALTH JOURNAL

TABLE OF CONTENTS 4

Chinatown’s Housing Crisis

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The Rise of Vaccine Hesitancy

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Are Probiotics All They Claim To Be?

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Laboring in America’s Tobacco Fields

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Is Brown the New Black? Brown Fat’s Potential on Combating Obesity

ONLINE MANAGING EDITOR Navya Pothamsetty

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Food as Medicine

EXTERNAL RELATIONS MANAGER Haley Chen

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Old Drugs, New Solutions

DECAL MANAGER Nirali Patel

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Air Pollution: A Lurking Problem

STAFF

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None of the Respect, Half of the Responsibility, All of the Work

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Queer, Here, and Mistreated: LGBTQIA+ Disparities in Healthcare

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Supervised Injection Sites: Feasible or Idealistic?

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A Political Period: How the “Tampon Tax” Perpetuates Homelessness

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The Truth Behind Factory Farming

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The Silent Epidemic

SPRING 2019 ISSUE

EDITORIAL BOARD EDITORS-IN-CHIEF Brandon Chu Ilhaam Burny

PRINT MANAGING EDITORS Alisha Mehdi Erika Kumar

COPY EDITORS Angela Li Jill Litman Joy Suh Kameswari Potharaju Vanessa Tran CONTRIBUTING WRITERS Ally Qi Nhat Nguyen Claire Maher Sabrina Jones Elise Rio Saher Daredia Felicia Zhornitsky Shreeya Thussu Jennifer Kwon Subeksha Sharma Manisha Sahoo Vivian Bui

WITH SPECIAL THANKS TO

UC Berkeley School of Public Health Alumni Association 2 | SPRING 2019

LETTER FROM THE EDITORS Dear readers, What is public health? Every semester, when our staff begin the long process of writing their first articles, they are guided by that one crucial question. Is it the promotion of healthy behaviors? Equitable access to resources? Good governance that addresses community concerns?

Perhaps it’s all of the above. But for our writers, the answer to this question is not as important as the journey required to find it. It serves an unceasing reminder to look deeper.

As students and advocates, we must understand the many ways individual well-being can be influenced by social and environmental factors. We must also recognize the important role poverty, stigma, and identity have in shaping how we live our lives. In essence, writing about today’s public health issues demands that we unravel their root causes.

“Finding our roots” encapsulates the work our writers have done this past semester to understand the intricate, often complex, causes of public health problems. In “Food as Medicine,” our online managing editor Navya Pothamsetty introduces us to a family doctor who helped develop a

program that looks at food insecurity with an interdisciplinary lens. Sabrina Jones in “None of the Respect, Half of the Responsibility, All of the Work” explores the history and biology behind society’s unfair treatment towards women.

Finally, “The Silent Epidemic” by Joy Suh provides a firstperson account of the ways homelessness and drug addiction often result from larger economic forces like unaffordable housing.

As you read the articles prepared by our student writers, we hope you take the time to reflect on your own circumstances and how your health has been influenced by your surroundings.

In doing so, you, too, could find your roots.

Your advocates,

Brandon Chu and Ilhaam Burny

THE PUBLIC HEALTH ADVOCATE | 3

CHINATOWN’S HOUSING CRISIS Single residency occupancies are often cramped and ill-maintained.

But for immigrants in San Francisco’s Chinatown, there are few alternatives.

BY CLAIRE MAHER PHOTO BY SPECCHIO.NERO FROM FLICKR

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n San Francisco’s Chinatown, families who have recently immigrated from China and Hong Kong frequently live in “single-residency occupancies,” more commonly known as SROs, because of economic reasons and language barriers.

Because of the lack of support for these immigrant families, they are often forced to stay for extended periods of times in these inadequate facilities and cramped quarters, leading to lasting health impacts on children brought up in these facilities. However, recent gentrification and building projects threaten the future availability of these SROs as landlords look to lease to wealthier clients.

“INSIDE THE ROOM, A FAMILY OF FIVE SHARES A SINGLE BUNK BED, WITH A SMALL TABLE CRAMMED IN THE CORNER IN ORDER TO CREATE A STUDY SPACE.” 4 | SPRING 2019

SROs were an integral feature of American cities starting around the 1880s, intended to house America’s booming population. Factory workers, laborers, migrant workers, foreigners, and other travelers frequented these establishments, as they were often the most affordable and flexible housing option. SROs were particularly prevalent in San Francisco, which became known as “Hotel City,” and its SROs quickly grew to become ethnic enclaves for poor immigrants from China, the Philippines, Japan, and Latin American countries.

By the 1950s, SROs were commonly thought of as “poor people housing,” leading many cities to start demolishing them in favor of creating more upscale neighborhoods and higher-priced apartment blocks. In San Francisco alone, between 1970 and 2000, almost 9,000 SROs were demolished or converted.

This created a strain on the availability of affordable housing, and with no plan for the construction of alternative housing units, homelessness and poverty in San

Francisco dramatically increased with its effects still visible today.

In San Francisco’s Chinatown, SROs are still one of the primary sources of housing for residents. Almost twothirds of Chinatown residents live in SROs, and this number has been steadily growing since 2001. In this area of the city where the median household income is $25,909, SROs continue to be the only affordable housing option, often priced around $700 per month. In stark comparison, San Francisco’s median apartment cost in 2015 was $3,880 per month, over five and a half times more expensive than a SRO. According to Dr. Winston Tseng, a professor of public health at UC Berkeley who has worked extensively with underserved Asian populations, most of the residents in the SROs are new immigrants from China who come to America in order to seek better opportunities and escape impoverished, unsafe environments in their home country. These immigrants are typically unable to speak English,

with some being illiterate as well, and bring with them very few resources.

Because rent in San Francisco is often astronomically high compared to the rest of the country, SROs are typically the only affordable form of housing for recent immigrants.

“These SROs are typically the size of a single bedroom, around 8 by 10 feet, for one or two families,” Tseng describes after visiting an SRO of a former student.

Each floor of the building typically contains 10 rooms, with a communal kitchen and bathroom per floor. Inside the room, a family of five shares a single bunk bed, with a small table crammed in the corner in order to create a study space. Besides a bed and table, the rest of the room is packed with dishes, clothing, and food, making it difficult to walk and move around.

Often times, the SROs are commonly ill-maintained. According to a 2015 report by the SRO Families United Collaborative, 48% of families report negative health impacts from their housing conditions. Small windows in the rooms and poor lighting create a gloomy atmosphere throughout the entire day, making it hard to study or work in the room. Noise pollution and loud neighbors cause disruptions and make it hard to work or sleep. In fact, sleep deprivation due to the noise continues to be a chronic issue for many residents, with over 15% of people suffering from lack of quality sleep.

These poor building conditions and lack of maintenance have clear impacts on tenants’ health. With no communal areas or shared spaces, residents have no other places to go to escape. The tight quarters and shared bathroom and kitchen spaces leads to an easy spread of diseases and infections, and rodents and bed bugs are common complaints.

Tseng also describes the lasting effects that these conditions have on the tenants, particularly due to long-term toxic stress.

Toxic stress is the result of prolonged exposure to an adverse environment and can result from chronic neglect and overwhelming family economic burdens, according to Harvard’s Center for the Developing Child. The effects of

long-term toxic stress can be felt for a lifetime and often manifest themselves through developmental delays, a weakened immune system, and various health problems including heart disease, substance abuse, and depression.

Tseng warns that residents living in these SROs are particularly at risk for these conditions due to the inadequate living facilities and the numerous economic hardships that they face.

Many of these residents do not speak English, so they are often exploited by their employers, with 50% of restaurant workers paid less than minimum wage due to a lack of understanding of labor laws and their contract. Tseng also describes how residents face racial discrimination and exposure to negative rhetoric towards immigrants, which serve to cultivate a constant fear of deportation. These many issues that tenants face on a daily basis leads to chronic, toxic stress that often results in many physical ailments later on in life.

With children accounting for 48% of the population living in SROs, many of the long-term effects are felt by the young. Parents are often worried that their children will not have the space and freedom to properly grow and develop and will be impacted later on in life in regards to physical and mental health. SROs are cramped with no space to move and play, and the surrounding areas are often dangerous as well. The lack of privacy and quiet spaces also makes studying and doing homework difficult. This results in students not being able to perform at their best and limiting their ability to succeed and seek a better life for themselves. Parents are also often poorly educated, unable to speak English, and have to work long hours to survive, restricting their ability to help their children with the homework and instill the discipline and work ethic required to succeed.

In addition to these dangerous living conditions, Tseng describes how the future of SROs has recently come under attack due to the rapid gentrification of San Francisco. Landlords have increasingly started to intimidate families to move out in favor of working

“THE EFFECTS OF LONG-TERM TOXIC STRESS CAN BE FELT FOR A LIFETIME AND OFTEN MANIFEST THEMSELVES THROUGH DEVELOPMENTAL DELAYS, A WEAKENED IMMUNE SYSTEM, AND VARIOUS HEALTH PROBLEMS INCLUDING HEART DISEASE, SUBSTANCE ABUSE, AND DEPRESSION.” professionals and students who are able to pay significantly higher rent, leaving families few other housing options and at risk of homelessness.

Chinatown provides a cultural safe haven for families with limited English proficiency, and the destruction of this community jeopardizes the vibrancy and diversity of Chinatown.

In order to protect this community, several organizations in San Francisco such as Chinatown Community Development Center have started to petition the city to increase protections for these residents. The SROs and Chinatown, they argue, are an integral part of the city and add value and diversity. Ensuring the safety of these SROs and improving the living conditions are vital to the livelihood and security of thousands of residents in Chinatown, as well as the continued well-being of this historic and unique part of San Francisco. 

ABOUT THE AUTHOR

Claire Maher is a second-year intended Public Health major. At Berkeley, she tutors chemistry as well as works in the Zoncu Lab conducting research on cell signaling. In her free time, she enjoys hiking, reading, and exploring SF!

THE PUBLIC HEALTH ADVOCATE | 5

THE RISE OF VACCINE HESITANCY Vaccines have been successful in reducing the risk of preventable diseases.

Then why have vaccine hesitancy rates risen so much in recent years?

BY SUBEKSHA SHARMA

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accine hesitancy, the reluctance to be vaccinated, has garnered a lot of press in recent years due to multiple measles outbreaks in the United States. Traditional news outlets portray vaccine hesitancy as a black and white issue, but it is more nuanced than it seems. According to Dr. Art Reingold, division head of epidemiology at the UC Berkeley School of Public Health, “Dividing the world into those who are pro-vaccine and anti-vaccine is overly simplistic. In reality, there are vast ranges of people in the middle who will take some vaccines but not others, or take vaccines despite skepticism. It is important to keep in mind that most parents are just looking out for the health of their children.” To fully understand this issue, the supporting reasons for vaccine hesitancy must be explored.

In middle-income countries, the

6 | SPRING 2019

perceived and often false risks of vaccines have been cited as the primary reason for vaccine hesitancy, rather than the barriers of religious beliefs or lack of awareness. There are many common misconceptions that are spread around in the vaccine-hesitant community.

One of the most common falsehoods is that vaccines — particularly the measles, mumps, and rubella (MMR) vaccine — have a plethora of side effects and can even cause other illnesses such as autism.

Reingold states, “The [1998] study that claimed an association between the MMR vaccine and autism could never prove an association; that’s not the way it was set up. The study was eventually proved to be fraudulent and has since been redacted.” More recent studies have repeatedly shown that there is no link between the MMR vaccine and autism spectrum disorder.

However, vaccines are not completely free of risks. According to Reingold, “Anyone who says that a vaccine is 100% risk-free is not being truthful. In reality, there can be negative consequences, but the risks that these side effects pose are vastly lower than the risk of the diseases themselves.” While there may be a few side effects of vaccines such as a mild fever or sore arms, these both temporary and negligible. More serious side effects happen so rarely that there is not enough data to assess the links between the side effects and the vaccines, states the World Health Organization. Multiple studies also show that simultaneous vaccination with multiple vaccines has absolutely no harmful effect on a child’s immune system.

Some simply argue that vaccines are not effective to begin with, and that those who contract diseases have

already been vaccinated. It is true that it is possible to contract a disease even if one has been vaccinated, as no vaccine can be 100% effective. However, most vaccines are effective 85% to 98% of the time. Secondly, the number of people who are vaccinated vastly outnumbers the number of people who are not vaccinated, and many statistics used by anti-vaxxers exploit this fact. Some people who are vaccinated may end up contracting the disease, but this does not prove in any way that vaccines are not effective. Vaccines still protect most people and have been proven to work in almost all cases.

Reingold argues that because most parents and doctors have not encountered first-hand the diseases vaccines prevent against, they do not fully understand the implications. “Many people see illnesses like measles as benign, and not a problem for them, as they do not live in areas of the world where the effects are visible. This is partially true, as the risk of contracting measles in most areas of the United States is relatively low, but it is not zero.” Even though the prevalence of these preventable diseases in the U.S. is low, they certainly still exist; it is possible to infect those who cannot be vaccinated due to severe allergies or other health issues. Those

“IN REALITY, THERE CAN BE NEGATIVE CONSEQUENCES, BUT THE RISKS THAT THESE SIDE EFFECTS POSE ARE VASTLY LOWER THAN THE RISK OF THE DISEASES THEMSELVES.” who are unable to be vaccinated often rely on herd immunity, which protects vulnerable individuals only when a high enough proportion of the population is immune to a disease, generally due to vaccination. The loss of herd immunity in certain areas would be devastating for many. Although vaccination has seriously reduced the prevalence of these diseases in developed nations, there are

many places in the world where these diseases are still epidemic. Travellers can pose a serious threat to these areas if they are unvaccinated.

The rise in number of vaccine-hesitant individuals impacts the world as a whole. The World Health Organization reported vaccine hesitancy to be one of the top 10 public health hazards in 2019, among the likes of Ebola and cancer. Although Reingold agrees that vaccine hesitancy is an issue, he says, “It is not exactly a crisis in the United States. There are pockets of space where vaccine-hesitancy is unusually high, but for the most part, vaccination rates are good. However, we still do not want these vaccine preventable diseases to come back.” Worldwide cases of measles have increased by about 50% in the last year. Additionally, 90% of those who come into contact with a person infected with measles will catch the disease unless they have been vaccinated. The number of unprotected people in some areas of the United States is high enough to cause the rapid spread of threats.

What can be done to curb the threat of vaccine hesitancy? Although many stress the importance of education, Reingold is skeptical. “Often the boomerang effect is observed, when we attempt to persuade those who are vaccine-hesitant of our side of the issue, they often come out of the conversation even more critical of vaccines than before,” he says.

Another approach is to tackle social media platforms that allow the spread of false information. However, censoring content online could face legal backlash and is difficult to regulate. An approach taken by California is to require vaccines in children attending public schools and to not allow religious or philosophical exemptions. This policy has had a positive effect on immunization rates.

However, policies have their issues as well.

“Policy is effective,” states Reingold.

“Unfortunately, there are ways around it. The number of children given medical exemptions to vaccines has increased twofold, however, the medical issues that would result in medical exemptions have not. There are even

doctors who advertise that they will sign off on medical exemptions, often times on unfounded reasoning.” Multiple doctors have been brought toward the California Medical Board due to charges that their work surrounding medical exemptions has been unethical.

Meanwhile, 20 other states have moved in the opposite direction, proposing bills that make it easier to obtain nonmedical exemptions for vaccines. When asked what can be done to curb this rise, Reingold states, “Vaccine-hesitancy is a global problem. Unfortunately, we just don’t have the solutions at this point in time.” 

“THE WORLD HEALTH ORGANIZATION REPORTED VACCINE HESITANCY TO BE ONE OF THE TOP 10 PUBLIC HEALTH HAZARDS IN 2019, AMONG THE LIKES OF EBOLA AND CANCER.”

ABOUT THE AUTHOR

Subeksha Sharma is a second-year intended Public Health major. In addition to writing for PHA, she volunteers as a mentor for an elementary school STEM program and advocates for improved public health legislation. After graduating from UC Berkeley, she hopes to pursue a career in reproductive healthcare. In her free time, she enjoys cooking, hiking, and watching copious amounts of Netflix.

THE PUBLIC HEALTH ADVOCATE | 7

ARE PROBIOTICS ALL THEY CLAIM TO BE? What’s the science behind your kombucha?

BY ELISE RIO

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oncerns and even obsessions with hot new diets, food fads, calorie intakes, and healthy recipes are not new. But the past decade has seen a significant increase in the obsession for the care of our guts, due in part to recent advances in technology. For most of the past century, scientists were unable to study the microbiome because they had difficulty growing bacteria in the lab. Because of its mysterious nature, bacteria was regarded with suspicion, but with the development of thirdgeneration DNA sequencing in the late 1990s came a renaissance in microbial research and an ensuing fascination for the microbiome. The view towards microbes shifted. Companies like Activia began to advertise the presence of microbes in their yogurts, grants for microbiome health research grew to the millions, and food and drug companies found a new source of revenue in the creation of probiotic and prebiotic supplements.

While interest in new fields of science, especially those that have the

8 | SPRING 2019

potential to improve human health, are not inherently a problem, scientific interests can often become interpreted too quickly and transformed into a money-making machine. Today we live in a world where almost 83,000 kiloliters of kombucha, a fermented tea beverage, are consumed each year and where the kombucha market size is projected to reach $5.45 billion by 2025. Companies such as Pepsi have even begun to make their own kombucha beverages under the brand name “Ke-Vita� to increase their market shares.

The probiotic and prebiotic industry, which also sells supplements in the form of pills, powders, and gels in supermarkets across the country with the promise of restoring the balance of gut microbes, reached a market size of $36.6 billion in 2015 and continues to grow. Notably, these dietary supplements continue to line our shelves and dominate the health industry even when the Food and Drug Administration (FDA) still does not require premarketing demonstration of safety and efficacy.

There are many advantages to accessible probiotics and prebiotics.

Prebiotics are particular forms of dietary fibers that can act as fertilizers for the bacteria in our gut. In contrast, probiotics such as those found in kombucha are live bacteria that can repopulate the gut. Many foods in our natural diets, such as bananas and yogurt, contain both probiotics and prebiotics.

However, supplementing the diet with extra bacteria can be helpful for people who have various health issues, such as those who are intolerant of natural foods filled with probiotics, those who take high antibiotic doses, or those who have trouble with bloating or diarrhea.

Proponents of probiotics claim they promote digestion, strengthen the immune system, help with weight loss, and even protect against some diseases. Supplements have served to deprofessionalize health and allowed people to take control of their bodies by doing their own research and deciding independently how they want to improve their diet. It can be empowering for a person to be able to find foods that strengthen and energize their body and reduce uncomfortable or embarrassing symptoms. Dr. Cori Hayden, a medical anthropology professor at UC Berkeley discussed how deprofessionalizing healthcare is an important mission as many cheap and simple treatments that support wellbeing do not necessarily need to be prescribed by medical professionals. In the journal article “The Anthropology of Microbes,” the authors highlight the impact food and diet can have on everyday life and how a healthy microbiome and a feeling of control over one’s health can reflect positively on a person’s social, political, and economic life.

“HOWEVER, IN THE PAST DECADE, GUT HEALTH HAS MOVED AWAY FROM BEING A CURIOUS NEW FIELD OF INTEREST TO A FULL-BLOWN CRAZE.”

However, in the past decade, gut health has moved away from being a curious new field of interest to a fullblown craze. While it is sometimes difficult to find the right balance of regulation in biopolitics, a complete lack of intervention can be dangerous.

The FDA will approve probiotics and prebiotics if they are generally recognized as safe for use and do not claim to be cures for any ailments.

However, the term “generally safe for use” does not appear to have specific requirements and is usually determined by experts hired by the companies rather than an unbiased regulatory agency. If the company restricts its medical claims, the supplement does not need to go through any more regulatory hoops.

According to the FDA website, while over-the-counter probiotics are generally safe, it can also be challenging to determine the purity of the bacteria culture. Detecting unwanted contaminants in the substances is difficult because microbes often have a high mutation rate and individuals within the same species of microbes can have vastly different genomes. The FDA also recommends that probiotics and prebiotics only be taken by people whose guts need additional support, such as those suffering from acute diarrhea, and does not recommend them for the healthy public.

According to Berkeley Wellness, probiotic products can contain anywhere from 1 billion to over 250 billion bacterial organisms. In the past few years, many clinical trials have studied the effectiveness of taking probiotic supplements to prevent antibiotic-related diarrhea, but results have been inconclusive at best. Two studies, one in the Lancet in 2013 and the other in the Annals of Internal Medicine in 2014, “found that probiotics were no better than a placebo in preventing diarrhea in older people taking antibiotics.” Another Israeli study published in Cell in 2018 found that in some cases probiotic supplements even slowed the restoration of microflora after antibiotic treatment which can lead to opportunistic infections. There

has also been significant research on the effects of probiotics on weight loss, which have yielded inconclusive results.

When positive benefits were found, the benefits were only minimal. While the side effects of probiotics may be mild, such as bloating and gas, probiotics may also have deeper adverse physiological effects and have been shown to overstimulate the immune system and modify metabolic pathways.

While extensive government regulation has drawbacks, there can be severe consequences from a lack of regulation when an industry grows too large or powerful. The FDA should consider looking more carefully at the probiotic industry, especially when new products come out with claims that may mislead people who are not well-versed in medical terminology. Probiotics are a promising field, but there is currently no substantial evidence to support their increasingly widespread use. Rigorous studies are needed to determine better conditions and doses for probiotic use and to help the FDA make informed decisions on what types of probiotics and prebiotics supplements should and should not be sold over-the-counter. 

ABOUT THE AUTHOR

Elise Rio is a junior from Southern California, currently studying the social determinants of health and healthcare from historical, economic, and political perspectives. She is passionate about community outreach, breaking down power dynamics in both community and international health disciplines, and doing research in microbiology. After she graduates she hopes to earn an MD/PhD. In her free time she loves to travel, sail, dive, try all types of food, and drink white mochas at Strada.

THE PUBLIC HEALTH ADVOCATE | 9

LABORING IN AMERICA’S TOBACCO FIELDS It’s illegal for anyone under 18 to purchase nicotine products.

But it is legal for children as young as 16 to work on the farms that make them.

BY FELICIA ZHORNITSKY

10 | SPRING 2019

A 16-YEAR OLD tobacco worker, on the left, stands in a tobacco field in North Carolina wearing her work clothes.

PHOTO BY BENEDICT EVANS / COURTESY OF HUMAN RIGHTS WATCH

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any Americans look back at their first job as a period of growth and learning. But such a quintessential experience is not the case for some children in North Carolina, Kentucky, Tennessee, and Virginia, where backbreaking labor and hazardous work conditions are a regular part of their first job. Although it is illegal for anyone under the age of 18 to buy nicotine products, minors who are 16 and older are allowed to work in tobacco fields in the United States. While the topic of dangerous child labor in the present day is usually associated with third-world countries, anywhere from 2,000 to 3,000 children are facing risks to their long-term health in tobacco fields on our home turf.

“THE AVERAGE WORKDAY OF A CHILD LABORER IN A TOBACCO FIELD DAYS STARTS BEFORE 6 A.M. AND ENDS AFTER 6 P.M.” The Fair Labor Standards Act of 1938 restricts children under the age of 16 from working in most industries in the United States, but it exempts farming.

Children as young as 12 years old can work on big farms with permission from their parents and can do hazardous work at 16. Norma Flores Lopez, who supports farmworker families as Governance and Development/Collaboration Manager at East Coast Migrant Head Start Project, says this decision was most likely rooted in racism towards African Americans, who made up the majority of the farmworker population at the time. But today, it disproportionally affects low-income members of the Latinx community.

The average workday of a child laborer in a tobacco field days starts

before 6 a.m. and ends after 6 p.m. In a Human Rights Watch interview, some children reported working until late in the night during the peak of the season.

The fields transform from cold and wet to extremely hot in the afternoon sun.

They do not get regular breaks and are not allowed to rest if they feel sick or have trouble keeping pace with the older, more experienced workers. In addition, these farmworkers are paid based on the piece rate, meaning they only get money for however much they harvest. These factors contribute to an environment that puts immense pressure on working until complete exhaustion, which increases the likelihood of getting heat stroke or fainting.

Workers also do not have reliable access to sanitation, water, or safety equipment. In the rare case that children are given any protective gear, it is old or too big and therefore has no effect.

They often wear dark plastic trash bags instead, which often lead to overheating.

There is also very little education on the dangers of working in a farm. Lopez, who began working in the fields with her family when she was in third grade and continued until she started college, says, “We were taught that pesticide was medicine for plants. We had no idea that it was poisonous. We would use a container of water that had been sitting out for days not knowing it was laced with pesticides or other chemicals.” She describes looking forward to the feeling of pesticides in the air from a nearby field because it was refreshing in the midday heat.

While the effects of pesticide exposure are difficult to study due to the impossibility of creating a controlled environment, it has been linked to birth defects and illnesses such as cancer, Alzheimer’s, and Parkinson’s disease.

Lopez has had several family members who were afflicted or passed away from these illnesses and she worries that she will develop one herself later in life.

While the above risks can arise in any field working environment, there is an added danger when working with tobacco. Nearly 75% of the child tobacco field laborers interviewed by the Human Rights Watch reported symptoms such as nausea, vomiting, dizziness,

headaches, sleeplessness, and a loss of appetite. These are all indicators of green tobacco sickness or nicotine poisoning, which develops when workers’ clothing comes in contact with wet tobacco leaves.

Reid Maki, who works toward getting resources for labor reduction as Director of Child Advocacy for the National Consumers League and Coordinator of the Child Labor Coalition, says, “Child laborers describe [the effects of green tobacco sickness] as ‘feeling like they’re going to die.’” A study that focused on nicotine exposure in tobacco harvesters found that they absorbed about 0.8 mg of nicotine daily. In comparison, the average nicotine intake per cigarette is 1.04 mg. Although these children are not allowed to buy cigarettes in stores, they are absorbing the equivalent of about one cigarette worth of nicotine just by going to work.

When asked why she continued to work in the fields despite its challenges, Lopez said, “Being exposed to pesticides and chemicals was hard, but I had to do it knowing what big of a need my family had.” This sentiment is echoed among all of the child laborers in the tobacco fields. They often come from lowincome families that depend on them to start earning money at a young age.

In addition, there is a limited supply of jobs in these rural areas and some of the children are not eligible for other ones due to their immigration status.

“WE WERE TAUGHT THAT PESTICIDE WAS MEDICINE FOR PLANTS. WE HAD NO IDEA THAT IT WAS POISONOUS. WE WOULD USE A CONTAINER OF WATER THAT HAD BEEN SITTING OUT FOR DAYS NOT KNOWING IT WAS LACED WITH PESTICIDES OR OTHER CHEMICALS.” There are almost no policies in place to protect child laborers in tobacco fields. According to Maki, “Several major tobacco companies have told the

THE PUBLIC HEALTH ADVOCATE | 11

farmers they bought from not to hire kids under 16; however, when we ask our partners who go out in the field, they say they don’t see much difference.”

In fact, it is not rare to see children under 12 working in the tobacco fields. There are few incentives for growers to follow the rules and the benefits from having as many employees as possible outweigh the very minimal risk of getting caught.

The Obama Administration proposed banning child labor in tobacco as part of the Hazardous Occupations Orders in 2011, but then decided not to under political pressure from farm lobbies.

Both Maki and Lopez agree that the government should ban children under 18 from working in the tobacco fields.

Lopez says, “As a country, we believe

that every child, regardless of their skin color, deserves to grow into a happy, healthy childhood. Right now, children in agriculture are being robbed of this opportunity. Especially in tobacco, we want to see more safety measures. We don’t think this is a job that is appropriate for any child to do.”

Child labor is an important issue that is often overlooked in the United States.

This should not be the case, especially considering the threats to their health that minors working in tobacco fields face. An increase in awareness and public refusal to accept this degradation in quality of life will force the government to create better protections for child laborers, letting these kids just be kids without worrying about the long-term

health risks that will arise from their first job. 

ABOUT THE AUTHOR

Felicia Zhornitsky is a first-year intended Public Health major who is interested in infectious diseases and international health.

In addition to writing for PHA, she mentors children at a local elementary school and competes with the Cal Ballroom team. She enjoys poetry, performances, and exploring new places.

“SOFIA,” A 17-YEAR-OLD tobacco worker, works in a tobacco field in North Carolina below. She started working at 13 and said her mother was the only one who taught her how to protect herself in the fields.

PHOTO BY BENEDICT EVANS / COURTESY OF HUMAN RIGHTS WATCH

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IS BROWN THE NEW BLACK?

BROWN FAT’S POTENTIAL IN COMBATING OBESITY Obesity and diabetes are growing public health concerns.

Could the key to combating metabolic disease be fat itself?

BY SAHER DAREDIA

THE PUBLIC HEALTH ADVOCATE | 13

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ccording to findings from the Centers for Disease Control and Prevention, nearly four in 10 adults in the United States have a body mass index that classifies them as obese.

Since the turn of the century, adult obesity rates have continued to increase steadily, rising 30.5% from 1999 to 2000 and 39.6% from 2015 to 2016. Younger Americans have not escaped this trend.

The obesity rate among the country’s youth, ages 2 to 19 years old, stands at 18.5%. Conditions that arise as a result of obesity, such as heart disease, stroke, type 2 diabetes, and certain cancers, are responsible for preventable and premature death.

While traditional methods such as exercise and dieting are encouraged to combat this epidemic, the underlying principle of any obesity treatment is the same: energy expenditure must exceed energy intake. In recent years, thermogenic tissues have become the central focus of studies on the mechanisms involved in metabolic diseases like obesity. Thermogenesis, the metabolic expenditure of energy as heat, is the primary way mammals lose energy derived from dietary consumption.

According to Felicia Castriota, a

researcher in the Environmental Health Sciences graduate program at UC Berkeley, “Thermogenic tissues have gained increased attention for the treatment of obesity and type 2 diabetes due to their role not only in heat generation but also in energy expenditure, glucose homeostasis, and lipid metabolism.” Some evidence suggests obese humans may have defective diet-induced thermogenesis.

One of the main sites for thermogenesis in mammals is brown adipose tissue, commonly known as BAT. Adipocytes are cells that compose adipose tissue and specialize in the synthesis and storage of fat. White adipose tissue (WAT), or white fat, is the predominant form of fat in mammals and is found under the skin and in deposits in the abdomen. White adipocytes soak up dietary fat and store it as large droplets for future energy needs.

The overloading of white adipocytes with dietary fat can lead to obesity and diabetes. Under a microscope, WAT can be distinguished from other types of fat by its few mitochondria — the structures in the cell responsible for energy production — and a single, large lipid droplet.

Unlike white adipose tissue, brown adipose tissue has many mitochondria and little storage capacity for fat.

Newborns have rich supplies of brown fat on the upper spine and shoulders that make up about 5% of their body mass and keep them warm. It was commonly believed that brown fat disappeared by adulthood, but it is now known that adult animals also harbor small reserves of BAT around the neck, shoulders, and organs such as the kidneys, adrenal glands, liver, and pancreas. People with lower body mass indexes were also found to have a greater content of BAT, indicating its essential role in metabolism. Brown adipocytes promote metabolism as major sites for thermogenesis, the formation of heat from the conversion of chemical energy.

BAT is specifically responsible for nonshivering thermogenesis, which is defined as an increase in metabolic heat without muscle activity.

The production of heat by BAT is only possible due to the activation of uncoupling protein 1 (UCP1). After exposure to the cold, the hormone norepinephrine is released from the sympathetic nervous system, stimulating the expression of UCP1 through an

THE ILLUSTRATIONS BELOW depict the difference between brown adipose tissue (BAT) on the left and white adipose tissue (WAT) on the right. WAT can be distinguished from BAT by the number of mitochondria and lipid droplets in the cell.

BROWN ADIPOSE TISSUE

WHITE ADIPOSE TISSUE

nucleus mitochondrion lipid droplet

ILLUSTRATIONS BY BRANDON CHU

14 | SPRING 2019

“WHILE TRADITIONAL METHODS SUCH AS EXERCISE AND DIETING ARE ENCOURAGED TO COMBAT THIS EPIDEMIC, THE UNDERLYING PRINCIPLE OF ANY OBESITY TREATMENT IS THE SAME: ENERGY EXPENDITURE MUST EXCEED ENERGY INTAKE.” elaborate signaling cascade. UCP1 then uncouples the proton gradient of the electron transport chain which normally produces ATP, the complex molecules that provide energy to drive cell processes. Instead of ATP, heat is generated. The burning of energy to generate heat not only offers protection from the cold but also prevents the storage of energy as WAT. Therefore, BAT has the potential to treat obesity and other metabolic syndromes. Aside from cold exposure, BAT can be activated by the “browning” of white adipocytes — or the conversion of WAT to “beige” adipocytes. Beige adipocytes are a type of fat that is mixed in with WAT. Beige fat burns lipids and produces heat much like BAT, but with slightly lower efficiency.

The potential effects of environmental pollutants on energy homeostasis and the development of obesity has garnered increased attention.

Endocrine disruptors such as those found in pesticides, including DDT and its primary metabolite DDE, have been shown to impair BAT mass and function and cause obesity and other metabolic disorders. According to a 2014 study, exposure to DDT around the time of birth caused decreased energy expenditure and BAT activity in mice, which led to increased body weight and insulin resistance. Increased insulin resistance is a precursor for type 2 diabetes, heart attacks, strokes, and cancer.

In addition to endocrine disruptors, exposure to airborne fine particulate

matter like PM2.5 has been shown to lead to a reduction in the weight and mitochondrial size of BAT, thereby causing insulin resistance. Several studies with mice that had been exposed to PM2.5 for a long time have experienced a negative regulation of BAT development by inducing apoptosis, or cell death, through a decrease in UCP1 content. On the other hand, anti-obesogenic pollutants like perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA) actually increase oxidation in brown fat mitochondria, upregulate UCP1, and reduce body weight. Due to their diverse chemical structures and doses, different types of environmental pollutants have different impacts on BAT thermogenesis. Studying environmental pollutants associated with obesity allows us to better understand the pathways associated with BAT function and may allow us to potentially counteract toxicant-induced obesity by directly targeting thermogenic adipocytes.

Ongoing research and therapy development has made significant progress in the use of brown adipose tissue as a tool to combat metabolic disorders.

Castriota explains, “Researchers are now focusing their efforts on trying to understand which external factors either stimulate or impair the activity of these thermogenic tissues, and how these effects impact physiology.” Studies have shown that BAT mass and activity can be activated with certain drugs, increasing metabolism and long-term weight loss. Researchers at the Joslin Diabetes Center in Boston discovered that mirabegron, a drug commonly used to treat an overactive bladder, activates β3-adrenergic receptors on the surface of brown adipocytes. PET and CT scans of men who took mirabegron and a placebo showed an increase in BAT activity in those with the drug, resulting in an increased resting metabolic rate by an average of 203 calories per day.

Some new approaches have even directly increased BAT mass by the transplantation of adipocytes. Until a year ago, there was no non-invasive method to measure the heat generation

of brown adipose tissue. Recently, a team at the Technical University Munich and the Helmholtz Zentrum München succeeded in developing a laser technology to visualize BAT activity without injecting radioactive tracers.

Despite these possibilities, cold exposure is still the most effective method of stimulating BAT activity. Since prolonged exposure to cold is not ideal for humans, further research must focus on finding new stimulants for BAT. In addition, increasing energy expenditure via BAT activity to combat obesity may actually lead to compensation in other manners, such as increased food intake.

Castriota explains, “While no known drawbacks of BAT overstimulation are yet known, overstimulation of BAT may have off-target effects, potentially related to cardiovascular dysfunction.

Therefore, more research is required.”

Although the contribution of thermogenic tissue in alleviating metabolic disorders is still a matter of debate among researchers, the potential of brown adipose tissue is undeniable.

Further exploration of the ability of BAT activation to become a new treatment for metabolic disorders and their complications is imperative in order to change the lives of thousands. 

ABOUT THE AUTHOR

Saher Daredia is a junior from San Jose, California majoring in Molecular Cell Biology and Public Health with a minor in Global Poverty and Practice. Because of her passion for toxicology research and community-based advocacy, Saher hopes to pursue a career that allows her to use diverse approaches to promote the health of marginalized communities. In her free time, Saher enjoys being outdoors with friends and family, cuddling with her dog Bolt, and consuming copious amounts of coffee and hummus (not necessarily together, of course).

THE PUBLIC HEALTH ADVOCATE | 15

FOOD AS MEDICINE A key part of good well-being begins with a healthful diet full of fresh foods.

What are physicians doing to address the issue of food insecurity?

BY NAVYA POTHAMSETTY

M

ost of us have been told from a young age that “you are what you eat.” According to academic literature, access to fresh and healthy foods lessens one’s chance of developing chronic diseases such as asthma, hypertension, and diabetes. Food is an integral part of our health, but few patients receive resources to treat food insecurity from primary care clinics.

Telling someone to “eat healthier” isn’t enough: people must have sustainable, accessible sources of healthy food, especially socioeconomically vulnerable populations. It’s not any one person’s

16 | SPRING 2019

fault. It’s a consequence of a fragmented, byzantine system of community benefits and healthcare.

An Integrative Approach Many food access problems stem from ineffective top-down regulation methods, such as policy. It’s hard to accomplish legislative changes due to bureaucracy, partisanship, and inefficiency, but there is another way to remedy the problem. Starting from the bottom-up and looking to community organizations and leaders often offers a better solution. Dr. Steven Chen, a

family physician, has a possible way of what that can look like in practice. He worked with other healthcare providers at Hayward Wellness Center to develop a program, Food is Medicine, that uses a multidisciplinary approach to treating food insecurity. In his words, Food is Medicine “gives practical, deliverable effects and allows a provider to close the gap between clinical care and upstream social determinants of health.”

A half-hour appointment once every six months isn’t enough for a doctor to treat a patient’s medical needs holistically, let alone their social and emotional needs.

An interdisciplinary approach facilitates addressing all three areas simultaneously and allows the patient to have a more centralized locus of care.

“A HALF-HOUR APPOINTMENT ONCE EVERY SIX MONTHS ISN’T ENOUGH FOR A DOCTOR TO TREAT A PATIENT’S MEDICAL NEEDS HOLISTICALLY, LET ALONE THEIR SOCIAL AND EMOTIONAL NEEDS.” Socioeconomic factors affect a person’s health, and patients in the Alameda Health System struggle with accessing food, a permanent home, a job, or a combination of these things.

Access to resources and health education is often the best prevention against sickness. Treating the disease before it develops, or primary prevention, is the main idea behind Food is Medicine.

“We know that patients who are food insecure do not do as well with diabetes,” explains Chen. “We can only move diabetes so far if we don’t address the underlying issues, food insecurity being one of them.”

The Four Pharmacies Food is Medicine incorporates more than just access to healthy foods. The program consists of four “pharmacies” that address a different component of health. The “Food Farmacy” is one arm: every patient is screened for food insecurity, a process that doesn’t happen at most doctors’ offices.

“Once you start asking patients, you’re going to start getting positives,” Chen maintains. “And that usually scares providers if you don’t have a way of addressing it.” Food is Medicine tackles the problem through different interventions. “I can write a ‘produce prescription’ that can then be redeemed at our ‘Food Farmacy,’” Chen explains, showing how the program works to close both the education and resource gap.

As a primary care provider, Chen also writes prescriptions to the three other pharmacies integrated into the Hayward Wellness Center’s system.

Their “Social Needs Pharmacy” includes the Health Advocates, a team of volunteers, community health workers, and program staff that help with issues such as housing, legal referrals, and CalFresh applications. The Health Advocates program spans across different Alameda locations and is comprised mostly of college volunteers, mainly from UC Berkeley. The third pharmacy is behavioral, which usually involves a small group medical visit with a health coach addressing physical activity, mindfulness, nourishment, and socialization. These three pharmacies, in addition to the traditional clinical pharmacy, comprise a network of resources and professionals providers that patients can rely on for a holistic approach to health.

Grown from Community Roots Food is Medicine is a unique, scalable model for integrated, communitybased healthcare programs. Health, like community welfare, is affected by so many different variables.

Solutions strengthening one area while supporting another is bound to have spillover benefits. For example, sourcing healthy food from local farms increases community job creation, which increases employment and an overall standard of living, improving health. Additionally, strengthening the physical connection people have with their food source is a plus.

“I think the area that’s missing when we’re talking about food is asking ‘Where does food come from?’” Chen says. “Well, food comes from soil.” He explains that thinking about the connection between health and the land is another facet our society has become distanced from. “The land has to be taken care of, and you do that from touching soil and going to farms,” he says.

For anyone interested in public health, medicine, or creating any sort of change in a community, integration across disciplines is key. This type of

education isn’t commonly found in most schools, even at top universities.

Although nutrition is one of the biggest predictors of health, Chen mentioned that his education at Stanford Medical School and UCSF’s internal medicine program never included training on food in a medical context. Instead of only treating the symptoms of food insecurity, healthcare providers of all kinds should make nutritional information and resources more accessible for their patients. The same goes for housing, government benefits, and access to mental health resources.

“It’s about breaking the silos and having it more integrated into the workflows,” Chen explains. Whether we are students about to enter the healthcare industry, professionals already in the field, or even patients, we can all do our part to advocate for better, more integrative approaches to care. 

“INSTEAD OF ONLY TREATING THE SYMPTOMS OF FOOD INSECURITY, HEALTHCARE PROVIDERS OF ALL KINDS SHOULD MAKE NUTRITIONAL INFORMATION AND RESOURCES MORE ACCESSIBLE FOR THEIR PATIENTS.”

ABOUT THE AUTHOR

Navya Pothamsetty is a third-year majoring in Public Health and the Online Managing Editor of The Public Health Advocate. At Berkeley, she teaches with Peer Health Exchange and the Health Service Internship.

Navya loves to run, try new foods, and watch Brooklyn 99 with her sister when they travel together.

THE PUBLIC HEALTH ADVOCATE | 17

OLD DRUGS, NEW SOLUTIONS

Milk cartons and medication bottles share one similarity: an expiration date.

But what do expiration dates for prescriptions really mean?

BY NHAT NGUYEN

“

A

couple of weeks ago, I woke up with an incredibly painful UTI [urinary tract infection],” recalled Dr. Quynh Dinh, a doctor of internal medicine at Kaiser Permanente, Woodland Hills. “So I went to the cupboard to look through my antibiotics and took some ciprofloxacin seven years past its expiration date. Worked like a charm.”

Most of us will throw away a carton of milk past its expiration date, let alone a bottle of expired pills. Similarly, hospitals, pharmacies, and nursing homes ensure that their medications are of the highest quality by routinely throwing out medications that have past their expiration dates, but it has become common practice for pharmaceutical companies to donate large amounts of expired drugs to developing countries.

So just how safe or dangerous are expired medications?

If food is any indication, there is more to labeled expiration dates than meets the eye. In the United States, drug expiration dates are mandated by the Food and Drug Administration (FDA) as the minimum amount of time that the stability and full efficacy of the drug is guaranteed by real time data or accelerated estimations. But as a minimum duration, printed expiration

18 | SPRING 2019

dates are necessarily conservative, and a drug’s true shelf life — the amount of time a drug can remain above 90% of its original potency — often surpasses the expiration date by several years.

Given that the FDA does not require pharmaceutical companies to print the date when a drug loses its maximum potency, it is against their financial interests to test drugs longer than necessary. A single drug, on average, costs almost $2 billion to develop, and every year that the drug stays off the market for testing is another year that the company loses profit. For example, a company might test a drug for three years, release the drug into the market, and print the expiration date accordingly.

But the shelf life of the drug might be an additional four years; the company just didn’t test the drug for that long.

“I see people all the time throwing away stuff like Advil and Tylenol the second they see that it’s past the expiration date, even when their kid has a rising fever,” Dinh says. “I understand that people are scared about the label, but drugs don’t lose all potency — much less become toxic — the day after the expiration date. It’s just a minimum date that the pharmaceutical company guarantees. It takes months and years for drugs to degrade any substantial

amount, especially for common overthe-counter medications.”

For obvious reasons, the FDA prohibits the sale and distribution of expired drugs by healthcare providers.

But in 1985, the FDA collaborated with the Department of Defense in an initiative known as the Shelf Life Extension Program (SLEP) aimed at assessing the safety and efficacy of military drug stockpiles worth over $1 billion. The results of initiative, which were documented in a 2006 study in the Journal of Pharmaceutical Sciences, reported that over two-thirds of 122 drugs tested in SLEP were effective for four years or more after their expiration date.

Additionally, the Department of Defense reported that the initiative saved them $2.1 billion, money that would have otherwise been spent replacing the expired medications. Although data from SLEP has not been released to the public, it is odd that the FDA advocates against the use of expired drugs despite supporting data that the department itself helped to uncover.

The World Health Organization (WHO) also shares the FDA’s cautious sentiments in drug donation policies.

Among various stringent conditions that WHO enforces is one in which “donated

“PRINTED EXPIRATION DATES ARE NECESSARILY CONSERVATIVE, AND A DRUG’S TRUE SHELF LIFE — THE AMOUNT OF TIME A DRUG CAN REMAIN ABOVE 90% OF ITS ORIGINAL POTENCY — OFTEN SURPASSES THE EXPIRATION DATE BY SEVERAL YEARS.” quantities should match the needs to be consumed before they are expired.” As a direct result of such policies, over half of the 34,800 tons of drugs and medical supplies worth $425 million that were donated to Herzegovina and Bosnia between 1992 and 1996 were deemed unusable.

The vast amounts of unused, expired medications has immense potential to aid countries burdened with disease, natural disasters, and armed conflict.

Dinh describes her experiences in Vietnam where she was born: “When I was a kid, I spent a lot of time helping out in my dad’s clinic. He was a surgeon back then, but since we were in a small village surrounded by mostly farmland, he had to deal with basically anything that came through the clinic’s doors.

One of my responsibilities was cleaning and organizing the medicine cabinet.

Unless it was some liquid or IV drug, he always told me to save the medications that were past their expiration dates. He treated hundreds of patients with these drugs and nothing bad ever happened as a result. Of course, not all drugs can be used like this, but many many drugs can.”

Dinh later recounted a more personal encounter with expired medications: “Before 1975, the U.S. provided large amounts of drugs to South Vietnam, and after the communists took over, many of those drugs were saved. In the city, there was a French hospital called Grall Hospital that treated the French and bigname communists. I remember because when my mom developed leukemia, my dad had to go to Grall Hospital to beg for the expired leukemia drugs that the U.S. had given before. He had ordered the medications from the U.S., I think, but if we had waited until it arrived, it would’ve been too late.”

As Dinh continues to explain, this is the unseen face of medicine in

developing countries. In Vietnam, there are too many hospitals filled to the brim with patients for expiration dates to be given the same weight they carry in the U.S. While Dinh reiterates that she in no way recommends that the use of expired medications become standard practice for severe and complex conditions such as leukemia and transplants, she notes that there are many conditions such as infection that are ubiquitous and easily treated with antibiotics or other drugs if expiration dates were taken with a grain of salt.

Expired drugs pose a unique solution to some of the healthcare problems in developing countries, but it isn’t perfect. First, not all drugs are resistant to expiration. Degraded tetracycline, for example, has been linked to severe adverse side-effects such as renal tubular acidosis, a rare kidney ailment. Even if drugs have longer shelf lives than their expiration dates indicate, extension is highly variable and dependent on production, storage, and the individual drug.

Furthermore, if countries receive medications they don’t need, the cost required to properly dispose of those drugs is significant. Pharmaceutical companies also send expired or unusable drugs to developing countries for tax benefits and to avoid paying for proper drug disposal in their native country.

Currently, there is no international body responsible for regulating non-requested drugs across borders, and it is further prohibited by the Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal to return donated drugs back to their native country.

Lastly, there is the question of ethics. Should we allow pharmaceutical companies to exploit the needs of developing countries to dispose of subpar medicines? Does the donation of

expired drugs establish a discrepancy in accepted medical care? Are populations in developing countries implied to be valued less through the donation of expired drugs? For many, these ethical concerns are enough to dismiss expired drugs as a viable option, but for other pragmatists like Dinh, the choice is clear. “If I was still living in Vietnam and my children were sick and there were only expired medications,” Dihn says, “I would take it instantly, no question.”

Expired drugs have the potential to solve a globally prevalent problem, and their disadvantages can and should be confronted and mitigated. WHO guidelines should be revised to reflect that expiration dates are an arbitrary measure that is not an accurate depiction of a drug’s lifetime. Data from the Shelf Life Extension program should be released to help individuals, companies, and international organizations make more informed decisions on the effective use of expired drugs. This potential solution should not be casually overlooked. Expired drugs might be the product of a double standard for medical care or pharmaceutical companies looking for a tax break, but this is a matter of pragmatism, not purity.

“Maybe not everyone should push it like me and take ciprofloxacin seven years past its expiration date,” Dinh commented, “but, hey, it works.” 

ABOUT THE AUTHOR

Nhat Nguyen is a first-year intended Molecular and Cell Biology major. In addition to writing for The Public Health Advocate, he also writes for the Berkeley Political Review and works in the Diep Lab at UCSF studying antibiotic resistance. In his free time, he enjoys hiking, playing the piano, and exploring San Francisco with friends.

THE PUBLIC HEALTH ADVOCATE | 19

AIR POLLUTION: A LURKING ISSUE It might be invisible, but air pollution can have direct effects on human health — especially for disadvantaged communities.

BY MANISHA SAHOO

P

ollution and climate change have been hot topics in public discussion for many years. They’re often used as buzzwords in popular media and literature, but they conceal pressing issues that often go unnoticed, lurking just beneath the surface. Air pollution is a major industrial byproduct, and many don’t realize the major effect it has on their communities and health.

Air pollution is more detrimental to our societies than media often portrays.

Polluted air is the result of chemical compounds, such as sulfur dioxides and nitrogen dioxides, being released into the atmosphere and mixing with water particles and oxygen. As air and water pollution increase, the risk for secondary issues such as acid rain increases. Burning fossil fuels also releases pollutants,

20 | SPRING 2019

contributing heavily to air pollution and its spillover effects. Air pollution harms a wide range of communities and environments, including the decimation of animals and plants in and around bodies of water, the destruction of trees and their leaves due to acid rain fog, the leaching of nutrients from the soil, and crop destruction. It also increases incidence rates of respiratory diseases such as bronchitis, asthma, pneumonia, and other lung problems.

The detrimental effects of air pollution extend further than just wildlife. An 1980 analysis by the National Crop Loss Assessment Network, set up in cooperation between the government and advocacy groups, discovered that 90% of crop losses are due to air pollutants like sulfur oxide and nitrogen oxides.

At that point in time, air pollutants affecting crop growth resulted in a $2 billion loss in those crop industries.

Air pollution’s toll on human health has been heavy; people of color are disproportionately affected by air pollution. A 2017 study demonstrated that, in 2000, non-white populations across the country were exposed to 40% more nitrogen dioxide than white populations. In 2010, this percentage had decreased to 37%. A health report

“THE DETRIMENTAL EFFECTS OF AIR POLLUTION EXTEND FURTHER THAN JUST WILDLIFE.”

published by the City of Berkeley Public Health Division in 2018 showed that rates of hospitalization due to asthma in children under 5 as a whole has been on a slow decrease since 2000. However, in African American children under 5, rates of hospitalization due to asthma have skyrocketed since 2011 and occur in astronomically higher numbers than for any other race.

The highest concentration of hospitalizations due to asthma occur in a path following the I-80 freeway. Berkeley city officials name air pollutants as a major contributor to increased rates of asthma occurrence and hospitalization due to asthma. In Richmond, California, a community that is 48.8% African American, residents have faced many environmental health issues, stemming from the Chevron plant in the city. In 2009, 34% of adults who lived in the city longer than 15 years had asthma. That same year, the rate of asthma among children was 17%, double the national average.

Despite this foreboding information, the severe effects of air pollution receive little media attention. The issue itself gets little screen time in the 24-hour news cycle. This begs the question: why should people care? From a public health perspective, reducing the number of cases of respiratory diseases linked to acid rain could save the U.S. $50 billion a year in healthcare visits and treatment costs. Rates of mortality, morbidity, and emergency visits would drastically drop if air pollution and its effects were addressed and minimized.

However, Dr. John Battles, professor of forest ecosystem management at UC Berkeley and researcher at the Battles Research Lab, stresses that people should care about this issue because fundamental human rights are being violated. There is a disproportionate impact of air pollution on people of color, and Battles says, “There are fellow humans out there, even living in the same neighborhoods [as us], who are disproportionately impacted.”

People should care because the most disadvantaged communities suffer the most, and companies that benefit from

operating the way they do pay no cost to society to minimize or eliminate the effects of their actions.

However, Battles does not see the issue of air pollution as hopeless. He raises the example of acid rain, once a major problem for the United States that, as a country, we were able to tackle.

Acid rain has been proven to occur with increased vehicle emissions and air pollution, but Battles says that the decrease of emissions over time, with regulations like the 1990 Clean Air Act and California’s cap-and-trade program, has greatly reduced the prevalence and effects of acid rain. Sulfate and nitrate emissions dropped 30% and 50%, respectively, with clean air regulations, and the National Atmospheric Deposition Program has collected data showing that the concentrations of acid ions in rainwater has decreased correspondingly.

The Acid Rain Program operated by the Environmental Protection Agency is a continuation of the Clean Air Act. Its goal is to establish requirements for the power sector to vastly reduce emissions of sulfur oxide and nitrogen oxides. In 2017, this program forced SO2 emissions down to almost a quarter of what they were in 1990 and decreased NOx emissions down to about a third of what they were in 1990. While acid rain is not an issue we have completely solved, strong regulation and legislation has been proven to control it and set up a cleaner future.

People can also tackle air pollution in their own lives by making the switch to alternative, renewable energy sources.

Driving cleaner, “greener” cars would make a great impact on the emission of environmental pollutants. Battles suggests holding industries accountable by reevaluating our use of products made irresponsibly. He also recommends rethinking our transportation behavior and our ecological footprints. But the task of battling air pollution cannot fall on the shoulders of the public alone. Industries have to be held accountable at a state and federal level.

It is incredibly important to push for legislation that advocates for stronger

“PEOPLE SHOULD CARE BECAUSE THE MOST DISADVANTAGED COMMUNITIES SUFFER THE MOST, AND COMPANIES THAT BENEFIT FROM OPERATING THE WAY THEY DO PAY NO COST TO SOCIETY TO MINIMIZE OR ELIMINATE THE EFFECTS OF THEIR ACTIONS.” industrial regulation codes to curb pollution emissions and holds private corporations responsible for these environmental health consequences is incredibly important in protecting our futures.

Furthermore, in the current political climate, environmental protections like the Clean Air Act are at risk of being dismantled. California’s own protections are at risk of being removed in an effort to shift the task of making emissions regulations to the federal level. People must reach out to their representatives and protect these programs if there is to be any hope of eliminating acid rain and its damaging effects. Advocacy is a powerful tool, Battles says. “We have to get the argument out.” 

ABOUT THE AUTHOR

Manisha Sahoo is a freshman from Fremont, California, intending to major in Public Health. She has a passion for community health and understanding the application of public health in various fields. When she’s not writing articles or drowning in schoolwork, she’s competing on a traveling Model United Nations team and reading books about dinosaurs.

THE PUBLIC HEALTH ADVOCATE | 21

NONE OF THE RESPECT, HALF OF THE RESPONSIBILITY, ALL OF THE WORK Men have historically been favored over women.

Even today, the bias persists.

BY SABRINA JONES

22 | SPRING 2019

S

tretching back to humanity’s earliest musings, the favoring of males over females is a stark common theme. Lamentably, this familiar trope has not fully outworn its welcome even in 2019. Throughout history and to this day, societies around the world have placed unreasonable and unfair reproductive expectations on females. However, it is ironic that males are usually responsible for the reproductive issues that females are often targeted and blamed for. What is almost laughably ironic is how frequently it has been revealed that males are actually responsible for reproductive issues targeted and solely blamed on females.

Historical Biases Around the World In the past, many mothers were unjustly blamed for not giving birth to sons. Sons were, and still often are, valued more highly than daughters.

In some cases, daughters were seen as not only less worthy but also dirtier — literally — than their male counterparts.

Penned in Leviticus 12 of the Bible, a woman is considered “unclean” for 14 days after giving birth to a daughter but only seven days after giving birth to a son. Few Christian scholars have been able to explain this discrepancy — one might conclude that it is simply a reflection of the misogynistic times at the time it was written. A notorious example of this culture can be seen with King Henry VIII. The English monarch married six times, and famously terminated many of his marriages due to his proclivity for a son. His wives were reviled for giving birth to daughters instead and subsequently beheaded.

Not until almost 400 years later in the 20th century did female scientist Nettie Stevens discover that sex determination of offspring was actually linked to the chromosome given by the male parent, rendering King Henry VIII not only horrific in his misogyny but also hypocritical in his ideals. Normally, each parent contributes one sex chromosome to their children. Females have two X chromosomes and thus constitutively provide an X chromosome, while males have one X and one Y chromosome.

Therefore, the offspring will be a biological male, if and only if the father contributes a Y chromosome during fertilization.

Current Impacts in the U.S. Yet, for centuries, females have been unfairly blamed and brutalized for giving birth to daughters instead of sons.

Even in the present day, women in India and Pakistan, while not wives of royalty, are beaten and even killed in some cases simply for the “transgression” of having a daughter. For the daughters brought into this world, too many fall victim to one of patriarchy’s worst manifestations: female infanticide. This acceptance of this barbaric practice in China and India, two of the most populous countries on Earth, has disturbingly resulted in severely skewed gender ratios.

American women of 2019 face different but still subversive forms of pressure during pregnancy like attacks on reproductive choice in many conservative states. For parents having children at an age beyond 35, females are faced with heavier scrutiny than men for the same thing.

It is true that females are born with a limited number of egg cells that can give rise to offspring, while males continuously produce sperm cells throughout much of their life after puberty. In addition, men never experience menopause, the point in time when a woman’s menstrual cycle is permanently halted, signaling the end of their fertility. However, despite these factors that prolong possible reproduction for older men, in no way does this mean it is completely safe and healthy for their offspring.

The Male-Biased Mutation Rate Recent studies have found that the age of the father has a significantly larger impact on the amount of new mutations in their offspring than the age of the mother, refuting historical beliefs.

This is a result of the male-biased mutation rate. Essentially, the father will always contribute more mutations to their offspring than the mother with concerning impacts.

The reason a male-biased mutation rate even exists is because unlike the cells that differentiate into eggs in a female’s ovaries, sperm cells divide continuously throughout a man’s lifetime. With each division, sperm cells accumulate more mutations that are passed along to their offspring. On the contrary, egg cells are arrested and do not continue dividing over a woman’s lifetime. This lack of continued divisions in female egg cells means that they are not garnering more mutations for mothers to pass to their offspring. Thus, a huge disparity in the number of mutations contributed by each parent emerges from this difference.

“FOR CENTURIES, FEMALES HAVE BEEN UNFAIRLY BLAMED AND BRUTALIZED FOR GIVING BIRTH TO DAUGHTERS INSTEAD OF SONS.” Present in almost all animals, this male-biased mutation rate was first discovered by sequencing entire genomes of Icelandic families. These researchers then assigned the origin of each new mutation in the offspring to a parent. In all of the families they sampled, researchers found that the father contributed between four and six times more mutations to their offspring than the mother.

Why Should We Care?

The reason these mutations are concerning is due to the convergence of multiple direct and strong correlations between the age of fathers at conception, number of mutations passed down, and risk of both schizophrenia and autism in offspring. Schizophrenia is a mental disorder that disrupts how an individual thinks, feels, and behaves.

Autism is a developmental disorder that adversely impacts communication and social interaction. Older fathers are significantly more likely to have offspring suffering from one or both of

THE PUBLIC HEALTH ADVOCATE | 23

these disorders.

More research is needed to conclusively establish causation, but these serious disorders can have tremendous, negative outcomes on affected individuals. It might seem reckless not to exercise caution with this information already available. Yet this is the current state of affairs.

Differences in Attitudes Towards Older Parents While it is common for pregnant women 35 years and older to freeze their eggs and be closely monitored, it is seen as “crazy” by some men’s doctors to freeze sperm or refrain from having children even after 45 for males. This imbalance is important to consider because freezing gametes is an expensive procedure that costs upwards of tens of thousands of dollars, and it is disproportionately recommended for women. Furthermore, this unequivocal foolhardy advice has concerning implications for the children borne of older parents.

For the unconvinced, one can do a simple Google search of “freezing sperm” and compare the number of results to that of “freezing eggs.” While only 8 million results appear for “freezing sperm,” 405 million results come up for “freezing eggs” at the time of this article’s publication, over a 50-fold difference.

Clearly, the pressure is much greater for women to deliver healthy offspring and practically nonexistent for fathers. Even sources like Men’s Health that mention the increased risk for numerous diseases and mental health problems for children of older fathers do not recommend any discouragement or even caution for men having children at older ages. Fathers contribute half of the DNA to their children yet are not expected to bear half of the responsibility of ensuring their children can grow up to be healthy individuals.

The Struggles of Single Motherhood This imbalance is one of the many reasons why 82.2% of single parents are mothers, not fathers. Transfer student, single parent, and UC Berkeley poet

24 | SPRING 2019

Tashie Williams-Powell never had the support of her child’s father after she found out she was pregnant with her now 5-year-old son Chancellor. Nor did her doctors notice the absence of her child’s father. Despite her pregnancy being high-risk, Williams-Powell said she didn’t “remember them asking much about my son’s father or considering his health throughout my trimesters.” They also never thought to ask about the father’s age despite the myriad of mental health risks discussed previously.

Beyond pregnancy, being a single mother has many challenges. WilliamsPowell relates how “managing school, home, and health, all while taking care of all of the very same needs for [her] child” in addition to a “job and many other responsibilities … feels like having multiple full-time jobs.” Undoubtedly, this feeling is common among many single parents.

Yet student parents lack support from the university and society in general.

Williams-Powell reports that even childcare provided by the university does not align with class schedules. She is often left footing the bill for expensive childcare and “limited in her ability to attend classes or campus social events.”

Williams-Powell recalled an incident where her professor barred her request to begin an exam half an hour later to simply be able to take her son to school, which reflected the lack of empathy student parents face. Additionally, the fact that many campus libraries do not allow Williams-Powell to enter with her child makes it more difficult for her to fulfill her responsibilities as a student and access the resources to which she is rightfully entitled.

These are problems created by the university that contribute to the burden faced by single parents. Being able to serve on committees meant to address the needs of student parents would seem like a given. However, they are not scheduled around the lives of student parents, leaving them out of the loop.

Williams-Powell says that resources like the Student Parent Center and The Village Residents’ Association make a genuine effort to seek, accept, and

incorporate the input of the student parents they serve.

Restriction of Pregnancy in Modern America Just as resources for student parents fail to involve the student parents themselves, the reproductive legislation of this country fails to account for the other half of responsible individuals in its application. During the Kavanaugh hearings in September of 2018, Senator Kamala Harris of California famously asked, “Can you think of any laws that give government the power to make decisions about the male body?”

Hundreds of laws exist to restrict women’s choices after conception. Yet there is not a single law that restricts men’s choices before or after conception.

Despite the fact that males contribute an equal share of DNA to their offspring, this country’s legislation does not suggest men are equally responsible for their creation and subsequent care and development. Change starts with doctors holding fathers to the same health standards mothers are expected to uphold. It continues with our university ensuring student parents, both mothers and fathers, have the same opportunities as traditional students to fully contribute to our academic community and lead lives outside of parenthood. It culminates with our nation holding men to the same legal requirements women meet in safeguarding our children’s health. 

ABOUT THE AUTHOR

Sabrina Jones’s writing for the PHA draws motivation from her deep-rooted passion for social justice. As a Molecular Environmental Biology senior at Cal, she also enjoys leading teams in mental health work and homeless community outreach, researching in two labs, dancing on AFX Fame, and living life to the fullest. Someday, Sabrina aspires to be a prosecutor in the great state of California.

QUEER, HERE, AND MISTREATED LGBTQIA+ DISPARITIES IN HEALTHCARE

The fight for LGBTQIA+ acceptance has made major strides in recent years.

The goal of health equity, however, has yet to be achieved.

BY JENNIFER KWON

I

n the last few decades, major strides have been taken towards improving the rights of LGBTQIA+ communities. Over 25 countries have legalized same-sex marriage in the past twenty years. University students study the rich, history of the LGBTQIA+ community in LGBT classes. Within the past few years, European countries such as Denmark have explicitly guaranteed transgender and intersex rights through

successful legislation. These changes allow transgender people to legally declare their gender identity without receiving irreversible sterilization surgeries or mental disorder diagnoses.

However, recent news shows there is still a long way to go. An story from 2017 detailed the imprisonment of LGBTQA+ members living in Chechnya in what some news outlets called a “gay” or “queer purge.” Legislation circulating

within Central Eurasian countries such as Kazakhstan and Kyrgyzstan prohibits “propaganda” of media promoting non-traditional sexual relations.

These explicitly illegalize non-cis and non-heterosexual individuals and institutionally normalize homophobia.

Rather than promote tolerance, these governments spread anti-LGBT attitudes.

What about the U.S. government?

THE PUBLIC HEALTH ADVOCATE | 25

The erasure of the very definition of “transgender,” one of several reversals of Obama-era initiatives instituted by the current Trump Administration, suggests that we are not advancing LGBTQIA+ rights. In fact, the U.S. Department of Health and Human Services is trying to establish a “legal definition of sex under Title IX” to prohibit gender-based discrimination. As stated in the memo obtained by The New York Times, “the sex listed on a person’s birth certificate” defines a person’s sex unless proven otherwise by “reliable genetic evidence.”

This new definition directly contrasts previous policies that allowed people to identify other than their assigned sex at birth. Controversially, the current administration stated that individuals who have or need to transition genders are banned from serving in the military.

Fortunately, here at UC Berkeley, there are plenty of resources, including health-related care, for LGBTQIA+identifying students. There are LGBTQIA+-identifying counselors and healthcare experts at the Tang Center who specialize in helping students with LGBTQIA+-specific issues. There are also many organizations that advocate

for the general LGBTQIA+ community, such as the Queer Student Union, but also address the intersections of multiple identities, such as Cal Q&A, an organization dedicated to supporting queer-identifying Asian students. Over the past few decades, students have protested and earned physical spaces like QARC, the Queer Alliance Resource Center, and GenEq, the Gender Equity Resource Center.

However, this is not the case for many LGBTQIA+-identifying individuals living outside of UC Berkeley, other universities, and even the United States. Violence and abuse against LGBTQIA+-identifying individuals should be treated as a domestic and international public health concern.

This is why incidents such as the passage of Russia’s anti-gay propaganda law, which bans the distribution of information that normalizes or promotes “non-traditional sexual relations” are incredibly concerning to activists in Russia and around the world. Bans on homosexuality or even anything remotely sexual, such as sex education, has had devastating healthrelated consequences, such as the rise of

HIV among gay men in Russia.

Domestic research suggests that “social conditions” that impact the health of American LGBTQIA+ communities “are characterized by rejection and discrimination” from families, workplaces, and even local governments and religious institutions such as the Westboro Baptist Church. This can create an unwelcome environment for LGBTQIA+ individuals. Due to family rejection, LGBT youth are often forced to leave their homes. LGBT adolescents, especially those who are homeless, do worse physically and mentally compared to their heterosexual counterparts.

The Pacific Center for Human Growth is an organization dedicated to serving the surrounding LGBTQIA+ communities located on Telegraph Avenue in Berkeley, California. Jared Fields, its deputy director, details one remarkable narrative of a young trans runaway who escaped to the Bay Area due to “life-threatening physical abuse” at her birth home in another state.

The young girl was sexually abused while seeking an emergency guardian.

Furthermore, she couldn’t register for any state-run system, such as school ILLUSTRATION BY JENNIFER KWON

26 | SPRING 2019

“ADDRESSING LGBTQIA+ ISSUES REQUIRES RESEARCH PRIORITIZATION OF RESEARCH, UNIQUE ‘PUBLIC HEALTH PREVENTION AND INTERVENTION PROGRAMS’ DESIGN, AND ‘CULTURALLY SENSITIVE CARE.’” or healthcare, because the runaway status would notify the police, who would bring her back home. When she was receiving preventive treatment for STDs, the health center broke its confidentiality promise and called the police, who described her as “the other state’s problem.” Fortunately, she found the Pacific Center shortly after arriving in the Bay Area. It is important to note that her female-presenting gender identity contributed heavily to her negative experiences with official institutions in the Bay Area, in addition to her runaway status Many individuals also experience hardship while integrating themselves into the LGBT community once they recognize their identity. LGBTQIA+identifying individuals experiencing rejection due to their identity are more likely to suffer from “depression, suicidal ideation,” substance abuse, and risky sex. “Early [peer] victimization and emotional distress” are major contributors towards healthcare disparities between heterosexual, cis youth and LGBTQIA+ youth. The latter group receives “poor quality of care due to stigma, lack of healthcare providers’ awareness, and insensitivity” to the needs of these communities. Fields, who currently runs a youth group comprised of mostly middle and high school-aged queer students, notices that trans youth in particular “are often not accepted by family, are misgendered at school, lack support from [their] school system … and suffer gender dysphoria.” As a result, trans youth are more susceptible to self-harm.

Addressing LGBTQIA+ issues requires research prioritization

of research, unique “public health prevention and intervention programs” design, and “culturally sensitive care.”

Moreover, we shouldn’t only focus on the contrast between LGBT and non-LGBT healthcare and treatment disparities. Those whose identities lie within the intersection of ethnic or cultural minorities and the LGBTQIA+ community face particularly unique healthcare struggles. In one study, participants “who identified as a racial or ethnic minority and as LGBTQ” more often used public health services rather than private ones and lacked regular healthcare access as opposed to “those who identified as non-Hispanic White and LGBTQ.” In addition, Black and Latino gay men experience the highest rates of HIV. When asked about his views on healthcare disparities within the queer, multiethnic, and multiracial communities that the Pacific Center tries to serve, Fields commented that “trans POC” folx constitute a growing majority of patients “who need immediate help in extreme situations and crises,” such as homelessness. He also mentions that a majority of those who come to “dropin” seek food and shelter. Trans folx are especially susceptible to “disbelief” from medical professionals and the general healthcare system; “even with scientific studies done by white people,” people still “don’t believe them” and call them “untruthful” because of internalized homophobia and “systemic racism against femme black people.”

Once we become aware of these injustices, how can we as students and citizens help reduce these disparities within healthcare and quality of life for LGBTQIA+ individuals? For Fields, one solution is to urge students and those involved in local government to advocate for increased awareness of and support of programs such as the youth group that he runs within the Pacific Center. This group provides a safe haven for youth who “don’t like being at school” due to bullying and lack of support from the school administration.

Additionally, faculty are “underpaid and overworked,” so while they may want to run a Gay Straight Alliance, they often

don’t have the “bandwidth” to do so.

In addition to advocacy, students can explore volunteering opportunities from national organizations and initiatives such as the American Civil Liberties Union and The Trevor Project to local ones such as the San Francisco LGBT Center. For students looking to make an impact within the intersections of queer, cultural or ethnic, and gender identities, involvement with organizations such as OutRight Action International; the Asian Pacific Islander Equality in Northern California; the Black Youth Project 100, an advocacy organization operating with a “black queer and feminist lens”; Queer Health Access, a group focused on female-queer intersectionality; United We Dream’s LGBTQ Justice initiative, a program exploring undocumented-queer intersectionality; and Rainbow Street, an organization providing “critical assistance to LGBT individuals living in crisis in the Middle East and North Africa” are many viable options. Truly championing LGBTQIA+ diversity and intersectionality often begins with stepping off campus and out of our comfort zones to dedicate the necessary time and energy towards furthering the work of these organizations. 

ABOUT THE AUTHOR

Jennifer Kwon is a first-year intended Public Health major and Global Poverty and Practice minor hoping to pursue an MPH in Epidemiology/Biostatistics. When she’s not writing her next article for PHA, Jenny loves exploring the intersections of accessibility, human rights, culturally competent healthcare, technology, and design through her involvement with organizations like Cal Queer & Asian and the Berkeley Disability Lab. In her free time, Jenny loves drawing and binging Buzzfeed Unsolved and Korean variety shows.

THE PUBLIC HEALTH ADVOCATE | 27

SUPERVISED INJECTION SITES: FEASIBLE OR IDEALISTIC?

Supervised injection sites allow drug users to seek medical care if needed.

The process of establishing them, however, is much more complicated.

BY VIVIAN BUI

I

n response to the troubling increases in intravenous drug user-related overdose deaths and infectious disease transmissions of HIV and hepatitis C, public health experts have proposed supervised injection sites as an innovative intervention for drug injectors. This solution goes by many names such as safe injection facilities and drug consumption facilities. Despite the different names, they are all legally sanctioned and controlled health care settings where drug users can inject their own illicit drugs.

Here, drug users are under direct health care supervision and can be referred to treatment services. These sites aim to reduce rates of drug injection and related risks in public areas. Injectors are provided direct and timely contact with medical care, drug treatment, counseling, and other social services. As a result, public spaces are safer because there are fewer used needles.

This solution first emerged in the

28 | SPRING 2019

mid-1980s in select European countries, such as Germany, the Netherlands, and Switzerland. Since then, safe injection site initiatives have been implemented in North America, specifically in Downtown Eastside of Vancouver, an area that has historically had many chronic drug injectors. This Vancouver pilot program served to gather population-based data to evaluate the solution’s effectiveness. A 2011 study comparing drug-related overdose mortality rates before and after the establishment of North America’s first safe injection facility found a reduction in overdose mortality, with a 35% reduction in mortality noted within 500 meters of the facility after its opening.

There have been recent pushes by policymakers for supervised injection facilities in the United States, two of whom were recognized as some of the 50 people transforming health care in 2018’s Time Magazine. In 2018, Mayor London Breed and California

Assemblywoman Susan Talamantes Eggman rallied for a bill to reduce overdoses by making San Francisco the first American city with a supervised injection facility. They modeled the initiative after that implemented in Eastside Vancouver.

According to the California Legislature, the proposed Assembly Bill 186 aimed to “operate overdose prevention programs [in the City and County of San Francisco] a hygienic space supervised by health care professionals, where people who use drugs can consume pre-obtained drugs, sterile consumption supplies, and access to referrals to substance use disorder treatment.”

Kim Phan, a public health microbiologist at the Orange County Health Care Agency, understands this stance. “Recently, the rate of HIV infection is on the rise. Preventive measures should be taken to prevent the infection by taking pre/post-exposure

medications or stop sharing needles among drug users. If one continues to inject drugs, carefully use or dispose of needles may help to slow down the rate.”

Despite this, former Governor Jerry Brown vetoed the bill in September 2018, countering that enabling illegal drug use will never work. He believes that our paramount goal must be to reduce the use of illegal drugs and opioids that wreak havoc in our communities, as is written in his veto message. Brown’s solution was to expand California’s drug treatment programs and residential, outpatient, and case management.

Governor Brown presented a common argument against safe injection sites.

Contrary to popular belief, there will be no supply of drugs at these injection sites, only medical care, supplies, education, and resources. Despite this setback, Democrats are still pushing their legislation forward. There is a fullscale model of a safe injection site at the Glide Foundation in San Francisco’s Tenderloin neighborhood. “The model, called Safer Inside, is equipped with supervised injection booths, medical equipment, trained staff, and a clinical area that provides users with access to health care and harm reduction services,” reports NBC Bay Area.

With Gavin Newsom as the new governor of California, there is hope for the future of safe injection sites in the state. As noted by the SF Chronicle, Governor Newsom remains “very, very open” to this solution for intravenous drug user-related overdose deaths.

“ALTHOUGH SAFE INJECTION SITES SHOULD BE CONSIDERED TO FILL AN IMMENSE GAP IN OUR CURRENT SYSTEM OF CARE FOR MARGINALIZED POPULATIONS THAT OFTEN LACK RESOURCES AND AWARENESS, THEY ARE NOT THE SOLE ANSWER TO THE DRUG CRISIS.”

In November 2018, the Denver City Council passed an ordinance to create a supervised drug use site pilot program, which is still awaiting further legislative approval. More than half a dozen other states, including Maryland and New York, have considered creating statewide initiatives and reintroducing similar bills to support these sites.

Many proposed Senate bills and civil lawsuits have convergently emerged to block these sites. The Trump Administration has threatened cities considering these safe-injection policies with filed lawsuits implying that these sites are illegal under the Controlled Substances Act. Although there are 120 overdose prevention centers globally, these efforts likely will not take root in the United States anytime soon.

Dr. Daniel Ciccarone at the University of California, San Francisco, whose research centers on the treatment and prevention of HIV/AIDS and related diseases within socially marginalized populations, is not entirely on the bandwagon for supervised injection sites. “There exists many levels of feasibility questions, with one being the political one,” Ciccarone says. “In the current week, as of this exact moment, it’s not going to happen. But in a year and a half, if we bring in more Democrats and more congressional power, it can become plausible on a political level.

But the next question if it will work in America is unknown. Americans are more rebellious, and supervised injection facilities require submission in the power sense. Americans have to go in, and ‘the Man’ is going to watch you inject.”

Overall, although safe injection sites should be considered to fill an immense gap in our current system of care for marginalized populations that often lack resources and awareness, they are not the sole answer to the drug crisis.

Ciccarone believes that “just because we open a site up doesn’t mean it’ll work. A lot of planning has to be done to make this viably successful. In an ethnographic sense, I can think of some places where it will work and lots of situations where they won’t work. So you need to pay

A NALAXONE KIT, pictured above, is often used to reverse the effects of opioid overdoses.

PHOTO BY JAMES HEILMAN FROM WIKIMEDIA COMMONS

attention to the details: design them well and advertise them in a way that makes the benefits outweigh negatives to clients and their cultural beliefs.”

With years of planning needed to create successful injection sites, Ciccarone suggests alternatives to these sites. “If I had a billion dollars right now, it would be towards the expansion of buprenorphine because that is a very useful tool underutilized in this country.

We have so many treatments, 60-70% of treatments is behavioral stuff, which is fine as an adjunct, not as a principal treatment. A ton of money is wasted on ineffective treatment.”

If federal money becomes allocated to multiple solutions that work in conjunction with each other and take into account social and biological plausibility, the future of drug overdoses does not look too dim. 

ABOUT THE AUTHOR

Vivian Bui is a freshman, intending to double major in Public Health and Molecular and Cell Biology. In her free time, she loves learning about the human body, trolling her friends, and watching inspirational TED videos. Vivian hopes to attend medical school and influence public policy in the future.

THE PUBLIC HEALTH ADVOCATE | 29

A POLITICAL PERIOD:

HOW THE “TAMPON TAX” PERPETUATES HOMELESSNESS Homeless individuals already face significant barriers in achieving good health.

For women, another challenge lies in menstruation stigma.

BY SHREEYA THUSSU

30 | SPRING 2019

H

ave you ever gotten your period in a place where you could not access a pad or tampon?

If you have, you are one of the 86% of women who have experienced this situation, and probably had to resort to toilet paper or some other equally unhygienic alternative in a dingy or questionably unsanitary public restroom. Now imagine you were one of the 216,000 women in the U.S. who experience homelessness. Getting that surprise period is not a simply minor inconvenience. Relying on limited access to public restrooms and using dirty rags are often the only available options you can use to survive your period.

Menstruation has always been a taboo and complex social and legal issue.

The four to six day monthly struggle is exacerbated for homeless individuals because sanitary products are taxed as luxury items as a result of the infamous “tampon tax” which is still in place in all but five states, including California.

The tax was debated on in December 2018 by the California Legislature after it was last brought to the floor in 2016

by Governor Jerry Brown who sought to make sanitary products tax-exempt.

For a female, homeless individual, spending $8 on a box of tampons may be the equivalent of purchasing two hot meals. This has resulted in the practice of washing and reusing dirty rags in public restrooms. The existing support from homeless shelters often operating above max capacity is minimal. Some shelters reportedly only provide two pads per cycle, when an average woman uses close to 20 tampons or pads per cycle. The public health repercussions of poor menstrual hygiene are immense: yeast infections, urinary tract infections, hepatitis B, and, in extreme cases, infertility are some of the many health risks that homeless women face.

So why is it so hard to pass a bill removing a tax on sanitary products when they seem indispensable to all women? The core of the issue seems to lie in the social stigma surrounding periods, rather than the legislative proposal itself.

Historically, there has been a disconnect in male-dominated politics between

understanding the needs and concerns of women when it comes to drafting and passing legislation regarding female-specific issues. For instance, the Food and Drug Administration (FDA) classified sanitary products as “cosmetic” until 1976, which made them ineligible to be tax-exempt. Even today, there is debate on which category sanitary products should be classified under, and it is unclear to lawmakers in the FDA whether they can be tax-exempt on the grounds of being “for treatment or prevention of illness and disease in human beings.” This is in spite of the very apparent health risks that result from lack of menstrual hygiene.

Zena Amran, an officer in the Berkeley chapter of #HappyPeriod, a national organization which distributes menstrual hygiene kits to the homeless, strongly believes that the biggest contributor to the issue is the social stigma surrounding periods. “We need to have a conversation surrounding menstruation and the fact that it is natural. Even now, when I get my period, I feel like I am hiding something, whispering around asking for a tampon.

It took me a long time to be okay with saying that I am on my period.” Amran makes a valid point — if we cannot even acknowledge periods as natural, biological processes, we cannot expect to convince lawmakers of why sanitary products are necessities.

Natalia Garban of the Suitcase Clinic echoes this sentiment. “If I were to get my period unannounced, I could simply ask a friend or a classmate for a tampon,” she says. “However, a person living on the street does not have access to the same network as we do. If a woman on the street asks for a pad or tampon, people passing by would probably ignore her. The stigma surrounding homelessness is still very prevalent, and I think it contributes a lot to the issue. Many women rely on our clinic spaces and other homeless shelters, but the supply is obviously not regular. We cannot provide help 24/7.”

While recognizing contributing factors, we must also acknowledge the grassroots-level organizations that are

“FOR A FEMALE, HOMELESS INDIVIDUAL, SPENDING $8 ON A BOX OF TAMPONS MAY BE THE EQUIVALENT OF PURCHASING TWO HOT MEALS.” making efforts to increase accessibility of sanitary products. In Berkeley, organizations like the Suitcase Clinic, the Berkeley Free Clinic, and #HappyPeriod all distribute free sanitary products to homeless clients. #HappyPeriod conducts regular drives into shelters and encampments, distributing over 200 kits to the homeless population in and around Berkeley. Suitcase Clinic and the Berkeley Free Clinic provide free sanitary products to their clients during their hours of operation. These efforts are just a few examples of the advocacy and efforts being poured into working to both encourage healthy conversations about periods, and increase accessibility of sanitary products for the homeless population. 

ABOUT THE AUTHOR

Shreeya Thussu is a second-year majoring in Molecular and Cell Biology, with a minor in Data Science. When she is not on the fifth floor of Moffitt, she spends her time volunteering at Berkeley Free Clinic and exploring Berkeley’s food scene.

THE PUBLIC HEALTH ADVOCATE | 31

IDYLLIC DEPICTIONS OF FARMING often betray the bad living conditions that many farm animals face in factory farms.

THE TRUTH BEHIND FACTORY FARMING Unsanitary factory farming practices affect more than just farm animals.

It can have direct effects on human health, too.

BY ALLY QI

32 | SPRING 2019

I

n today’s factory farming industry, animals are crammed into wired cages, metal crates, and other torturous devices. The sheds they are stuffed into are windowless, and these animals will never get the chance to engage in natural processes such as building nests, playing with the soil, and raising families. The ultimate goal of these factory farms is to maximize output while minimizing costs, but this is often done at the expense of the animals involved, the people living near the farms, and the surrounding environment.

Millions of animals are harmed by “forcing them to live with dangerous levels of air pollution” on cramped factory farms says Jonathan Lovvorn, Chief Counsel for Animal Protection Litigation at the Humane Society of the United States. Moreover, according to Farm Forward, “The factory farm record on the environment is no better: World Watch, the Sierra Club, the Pew Commission, Greenpeace, and other major environmental watchdogs have singled out factory farms as among the biggest polluters on the planet.”

“SOME OF THE GASES RELEASED BY THESE CESSPOOLS HAVE IRREVERSIBLE HEALTH EFFECTS SUCH AS SEIZURES, COMAS, AND EVEN DEATHS.” At first glance, factory farms may seem like a serious issue only for animals and the environment. However, they are also a serious public health and environmental justice issue for nearby communities. People residing near these factory farms have complained about the spraying of feces and urine into the air as a way of disposing animal waste.

According to the Natural Resources Defense Council, people who work on or reside close to factory farms breathe in hundreds of gases. Some of the gases released by these cesspools have irreversible health effects such

as seizures, comas, and even deaths.

Based on a series of maps released by the Environmental Working Group, the majority of these factory farms and their lagoons are built in low-income communities and communities of color. According to research conducted by the Food Empowerment Project, corporations often locate their factory farms to these areas as they believe that “the residents do not have the political will and won’t present obstacles, or that these low-income residents need the jobs and will not complain.”

In response, organizations such as the Factory Farming Awareness Coalition (FFAC), are making efforts to help spread awareness of both the negative health effects and racial injustices of this issue to different communities.

“We’re giving these animals antibiotics, but there’s been a fast rise in antibiotic resistance” says Monica Chen, the national programs director of the FFAC. There’s evidence that MRSA, an antibiotic-resistant infection, is being spread from factory farms, and what’s worse is that “it can kill not just workers and people living on the farm, but any single one of us.” Aside from the negative health effects created by these factory farms, there is also a “huge problem of environmental racism that needs to be addressed,” says Eli Townsend, an intern currently working with the FFAC. “Facilities are being set up in these low-income areas, and people who have mortgages to pay off are unable to immediately leave as their house values drop, making things even more difficult for these already lowincome area neighborhoods.”

One way scientists are trying to combat the factory farming issue is by decreasing the demand of meat and creating alternative meat sources. “The idea is that if the demand for meat decreases, then factory farms will have less incentive to produce more meat due to decline in demand,” says Chen, who comments on Berkeley’s recent decision to pass Green Mondays, a movement encouraging people to not consume meat for one day of the week. Another example is Beyond Eggs, “which aims to

replace factory farm produced chicken eggs as ingredients for big name brands of processed foods. For less than the cost of eggs, as well as being much safer and having better functionality in recipes.”

These sources of protein are plantbased, and artificial animals aren’t being made.

With the help of organizations such as the FFAC, it’s possible more people will become aware of the severity of the issue.

Through efforts such as continuous scientific research in creating meat and protein substitutes, the demand for factory farmed products will slowly decrease, and the world can move one step closer to a cleaner environment. 

“ONE WAY SCIENTISTS ARE TRYING TO COMBAT THE FACTORY FARMING ISSUE IS BY DECREASING THE DEMAND OF MEAT AND CREATING ALTERNATIVE MEAT SOURCES.”

ABOUT THE AUTHOR

Ally Qi is a second-year intended Public Health major with an intended minor in Science and Math Education. She has diverse interests in microbiology and epidemiology as well as teaching in low-income communities. In her free time, she enjoys reading and playing basketball with friends.

THE PUBLIC HEALTH ADVOCATE | 33

A HOMELESS ENCAMPMENT in Mosswood Park, Oakland is one example of Imago Dei Street Clinic’s efforts to reduce the number of opioid overdoses.

PHOTO BY JOY SUH

THE SILENT EPIDEMIC Homelessness and drug addiction are often the results of many social and environmental factors. How is one organization working to address both?

BY JOY SUH

I

t’s a Saturday morning at Mosswood Park, Oakland. We make our way towards the entrance of the reclusive encampment tucked away adjacent to the freeway. This encampment, as we’ve been told by other homeless individuals, is known to use hard drugs and could use the clean needles and Narcan we’d brought with us. We approach the fenced entrance with our bags of health supplies, side stepping the innumerable bags of trash and scattered litter on the ground. On a nearby tree, someone has stapled papers with emergency numbers and hotlines, the ink faded and the pages tattered. We pass by the tents quietly, stopping at each one to ask if we could offer them some socks, shaving razors, dental floss, and water amongst other things. There is the faint but certain smell of feces in the air. A dog pokes his head out and stares. The constant roar of the adjacent highway is deafening, but finally, a voice responds. A hand, a head,

34 | SPRING 2019

and then a torso emerge from the tent.

From the several occasions I’ve volunteered for outreach with Imago Dei Street Clinic, I’ve become familiar with scenes like these and similar landscapes of drug addiction and informal settlements scattered across Oakland and Berkeley.

In the past few years, the spike in opioid related deaths has garnered national attention. The National Institute on Drug Abuse reported over 47,000 opioid overdose deaths in 2017, compared to approximately 8,000 in 1999. According to the California Opioid Overdose Surveillance Dashboard, the majority of victims in Alameda County in 2017 were young adults aged 25 to 29 and middle-aged adults between 45 and 49.

While California’s age-adjusted drug overdose death rate is comparatively low to other states at 11.7 per 100,000, the state experienced a 44% increase in its synthetic opioid overdose death rate from 2016 to 2017 alone. The suspected

culprit is a highly potent synthetic opioid known as fentanyl that has been linked to drug overdose deaths across the nation.

Usually prescribed to treat severe pain, fentanyl is 50 to 100 times more potent than morphine and is used by drug dealers looking to increase their profits by mixing the cheap synthetic into cocaine, heroin, and meth amongst other drugs. In 2017 alone, fentanyl was involved in almost 60% of all opioid related deaths. Unsuspecting drug

“USUALLY PRESCRIBED TO TREAT SEVERE PAIN, FENTANYL IS 50 TO 100 TIMES MORE POTENT THAN MORPHINE AND IS USED BY DRUG DEALERS LOOKING TO INCREASE THEIR PROFITS.”

users administering a regular dosage of the dangerous drug cocktail end up accidentally overdosing and dying.

Local organizations such as Imago Dei are working to tackle these issues on the ground, providing aid to the homeless and training individuals to use Narcan.

Founded by two UC Berkeley students, Imago Dei Street Clinic is a 501(c) (3) non-profit, Christian-affiliated organization that provides naloxone, fentanyl test strips, and health supplies to homeless communities.

Naloxone, branded as Narcan, is a synthetic opioid antagonist used to stop a drug overdose. It acts by binding to opioid receptors, effectively blocking the opioid and working to reverse respiratory failure. Other signs of an opioid overdose include unresponsiveness, unconsciousness, and constricted pupils. Narcan can be administered three different ways: an injection, autoinjection, or nasal spray.

It is a relatively safe drug with minor and rare side effects, allowing for the administration of multiple doses, which may be necessary in the case of a fentanyl-related overdose.

Imago Dei receives free Narcan for distribution through the Naloxone Distribution Project initiated October 2018 and funded by the California Department of Healthcare Services and the U.S. Substance Abuse and Mental Health Services Administration.

Having received training from the HIV Education and Prevention Project of Alameda County (HEPPAC) and the written support of a collaborating doctor, the co-founders, along with the outreach teams they lead, are permitted to distribute and train individuals to use Narcan. From their other partnerships, Imago Dei receives clean needles from Berkeley Needle Exchange Emergency Distribution, and private donors provide the funding for hygienic supplies. To prevent drug users dying of an accidental overdose from using drugs laced with fentanyl, fentanyl test-strips can be used to test their drugs for the deadly synthetic opioid before they use.

Currently, there are over 600 ongoing lawsuits against eight Sackler

family members who own Purdue Pharma LP, the manufacturer of the painkiller OxyContin. While holding drug companies legally accountable for their role in feeding this epidemic seems straightforward, understanding substance abuse itself is complex and addressing the problems we face moving forward even more so.

I spoke with Imago Dei’s co-founders directors Danny Kcomt and Julie Ambo about these issues. Kcomt described drug addiction as the byproduct of hopelessness, mental illness, the lack of economic opportunities, and many other reasons. He explained how homelessness can be a risk factor for substance abuse when displaced people find themselves in unsheltered environments where drug usage is common and used as a coping mechanism. “The assumption [is] that this targeted demographic will have the greatest impact on overdose death rates if trained and equipped with naloxone,” he said.

In the Bay Area, homelessness and the housing crisis are intimately related as Ambo explained to me. “With housing and apartment prices skyrocketing and unfair evictions and unfair landlords, they get turned out onto the streets.

FLYERS STAPLED on a tree, below, in Mosswood Park contain emergency numbers for individuals to call for help.

PHOTO BY JOY SUH

“UNTIL WE SEE AN EMERGENCE IN CIVIC RESPONSIBILITY AS A VALUE, WE ARE GOING TO CONTINUE TO SEE BODIES PILE UP IN THIS INVISIBLE PLAGUE.” But then, since they have ties with the area, they’ll stay in the area and remain homeless even if they might be able to find cheaper housing elsewhere,” she said. The efforts of Imago Dei and many other organizations involved in addressing problems of homelessness and drug abuse have not been in vain.

I myself had a homeless couple who had previously been trained recount to me how they administered Narcan to a man who had overdosed, buying enough time for paramedics to arrive and ultimately saved his life. But in the grand scheme of things, is it enough?

For Kcomt, who also works for HEPPAC, these issues are a byproduct of the abandonment of civil responsibility for the wellbeing of all and illustrate a need for stronger social values. “We need to build a society willing to not [only] be activists or allies, but citizens responsible for the wellbeing of all. This does not need to be political or religious, but until we see an emergence in civic responsibility as a value, we are going to continue to see bodies pile up in this invisible plague.” 

ABOUT THE AUTHOR

Joy Suh is a third year Public Health major interested in infectious diseases, molecular epidemiology, and slum health. She has previously served as PHA’s co-editor-in-chief and works as a research assistant in Dr. Lee Riley’s lab. In the future, she hopes to pursue an MD/MPH and continue to advocate for public health issues for everyone.

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