Yale Global Health Review Vol. 6 No. 1 by Yale Global Health Review

FALL 2018 & SPRING 2019

VOLUME 6, NO. 1

THE YALE

GLOBAL HEALTH REVIEW

WELLNESS MAKES THE WORLD GO â&#x20AC;&#x2DC;ROUND

An Examination of Refugee Access to Care within the 21st Century By Tomeka Frieson | p. 31

LETTER FROM THE EDITORS 2018-2019

VOL. 6, NO. 1

Dear Readers, We are very excited to release our first issue as the new executive board! We hope that our publication can serve as a platform for discussions about global health in the Yale community and incite change. The articles in this issue cover a wide range of topics in a diverse array of countries around the world. We begin by examining pressing issues in global health, such as the health consequences of war and natural disasters, and then move to issues of health policy and new technology, including prescription drug pricing, artifical intelligence, and e-cigarettes. Key themes examined in this issue include the limitations of healthcare in developing nations and the drawbacks of controversial new health techologies. We’d like to sincerely thank our staff members for their hard work. Releasing this issue would not have been possible without the dedication and passion of our writers, editors, and publication and design team. We’d also like to thank you, our readers, for taking the time to read our work and think critically about how to drive the frontier of global health efforts forward in the future. For more information on global health, please visit our website at yaleglobalhealthreview.com. Better yet, to get involved, send us an email at yaleglobalhealthreview@gmail.com. All the best, Elizabeth Qian-Wang and Katarina Wang

Editors-in-Chief Elizabeth Qian-Wang Katarina Wang Associate Editors-in-Chief Krista Chen Debbie Dada Tomeka Frieson

OUR TEAM Production & Design Team Lynn Sohn - Art Director Antalique Tran - P&D Director Yousra Omer - P&D Director Debbie Dada Tomeka Frieson Katarina Wang Elizabeth Qian-Wang

Senior Editors Tomeka Frieson Erica Lin Krista Chen Rohan Garg Marisa Peryer Jenesis Duran Kelly Farley

Staff Writers Ben Grobman Stephen Wang Nishanth Krishnan Irene Pak Indira Flores Lena Goldstein Tomeka Frieson Kelly Farley Sam Brakarsh Janine Kara Parmida Zarei Vanessa Blas Matthew Pettus Debbie Dada

Associate Editors Yousra Omer Max Ackerman Heather McClure Debbie Dada Nancy Lu Hannah Ro Front Cover

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PICTURES Back Cover

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ABOUT US The Yale Global Health Review is the premiere undergraduate-run publication at Yale University covering topics in health. We feature original research, thoughtful commentary, and balanced reporting with a global health focus. Our goal is to bridge scholarship and practice, connect students and faculty, and bring together voices from across a spectrum of disciplines and sectors. The YGHR is a hub for discussion and engagement on all issues relevant to global health—in print and online, at Yale and beyond. SPONSORS We would like to thank the Yale Global Health Leadership Institute, Yale Global Mental Health Program, Yale China, the Yale School of Public Health Admissions Department & the Yale Undergraduate Organizations Committee for their support.

Peter Brown - Pexels VOLUME 6, NO. 1

CONTENTS 3

A BUMP IN THE ROAD

PROTACs

BAGS, BOXES, AND BRUSSEL SPROUTS

How Vaccine Hesitancy is Making Measles Mainstream Ben Grobman An Opportunity for Prescription Drug Pricing Reform? Stephen Wang

The Changing Face of Urban Farming Nishanth Krishnan

ARTIFICIAL INTELLIGENCE IN HEALTHCARE Irene Pak

THE ELUSIVE ANTIDOTE TO RISING PRESCRIPTION DRUG PRICES Nishanth Krishnan

THE FIRST CRISPR BABIES

A Reflection on the Promise and Perils of Gene Editing Kelly Farley

THE HEALTH CONSEQUENCES OF THE WAR IN YEMEN

LESSONS FROM CHICAGO

FACING THE HEAT

THE CHALLENGES OF TRUMP’S PLAN TO ERADICATE HIV/AIDS

JUUL LABS

A CASE STUDY

D UN

Lena Goldstein

PROTECTING THE NATION FROM FOREIGN TERRORIST ENTRY INTO THE U.S.

G O ‘R

CERVICAL CANCER SCREENING

The Medicalization of Spirituality in Sub-Saharan Africa Sam Brakarsh

How the Rapid Expansion of Dollar Stores is Affecting Community Health Indira Flores

HE WOR ES T LD K A

WEL LN ES

A DIME IN THE DOZEN

PSYCHOSIS AND POSSESSION

Effects of the Trump Travel Ban on the American Healthcare System Janine Kara

Ben Grobman

An Examination of Refugee Access to Care within the 21st Century Tomeka Frieson

Police Violence and the Health of Disenfranchised Communities Parmida Zarei Health Consequences of the Global Trend Toward More Powerful Hurricanes Indira Flores

Vanessa Blas

Public Health Initiative or Tech Startup? Matthew Pettus

Tobacco Use in Indonesia Debbie Dada Photos from Flickr

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VOLUME 6, NO. 1

A Bump in the Road: How Vaccine Hesitancy is Making Measles Mainstream

By Ben Grobman

Flickr

n early 2019, UNICEF released a shocking report: in 2018, 98 countries saw an increase in the incidence of measles as compared to 2017, with a near 50% increase in measles incidence worldwide. 10 countries accounted for three-quarters of the total increase, chief among these being Ukraine (30,338 reported cases), followed by the Philippines (13,192 reported cases) and Brazil (10,262 reported cases).1 But the most significant aspect is that measles has returned in multiple countries where it had been previously thought to be completely eradicated. Prior to becoming the third global leader in measles cases in 2018, Brazil had reported zero cases of measles in 2017.2 And in the United States, which had declared measles as eliminated nearly two decades ago, incidence of measles increased from 120 cases in 2017 to 791 cases in 2018, a massive six-fold increase.3,4,5 This worldwide increase in measles incidence is due to a variety of factors, including political and social instability in countries such as Yemen and Venezuela, lack of health infrastructure in developing or war-torn countries, and hesitancy regarding the efficacy and safety of vaccines.6 This last factor is the likely culprit behind the recent and sudden measles outbreaks in developed countries, which have led the World

Health Organization to deem vaccine hesitancy as one of the 10 biggest current threats to global health.7 Measles, which has affected humans for centuries, was first conclusively described in Persia during the 10th century CE.â ¸ Measles is one of the most contagious infectious diseases in existence, and is spread through airborne droplets that can be dispersed via coughing and sneezing. Additionally, the measles virus can remain contagious in the air up to two hours after an infected person has left the vicinity.4 As a result of its extreme contagiousness, an estimated 9 in 10 unvaccinated people exposed to the measles virus will develop an infection.4 Infected individuals generally begin to show symptoms 10-14 days after initial exposure: mild fever, cough, runny nose, and sore throat.9 Soon after, they break out in a rash of small red spots that spreads from the face to the rest of the body. At the same time, fever symptoms become exacerbated, often reaching 104-105Â° Fahrenheit.9 In rare cases, individuals may develop even more severe complications, including possibly fatal forms of encephalitis and pneumonia, as well as possibly permanent brain damage and blindness.4,10

Before the widespread introduction of the measles vaccine in 1963, contracting measles was an unavoidable rite of passage for children, as 90% of people had been infected with measles at some point by age 15.11,12 An estimated 30 million cases of measles killed 2 million people worldwide every year.11,12 In the United States alone, there were an estimated 4 million cases and 450 deaths each year.11 But, within three years of the introduction of the measles vaccine, measles cases in the United States decreased by 60%.11 Incidence in the United States was further reduced with the 1989 CDC recommendation that all children receive a booster vaccination to further reduce susceptibility.11,4 As a result of these efforts, measles was declared successfully eliminated in the United States by the year 2000.11 Despite the demonstrated efficacy of the measles vaccine, flawed and biased studies have created unfounded fears of the vaccine, increasing difficulty of vaccination efforts. Most notably, British doctor Andrew Wakefield published a 1998 paper in highly esteemed medical journal The Lancet correlating the measles, mumps, and rubella (MMR) vaccine with development of autism.13 The ar-

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ticle was soon retracted by the majority of its authors, and a number of studies quickly disproved the article’s results. In 2010, The Lancet published a complete retraction of the Wakefield study, and it was found that Andrew Wakefield had numerous conflicts of interest, blatantly distorted data, and severely flawed methodology, all of which amounted to deliberate scientific fraud for which Wakefield’s medical license was stripped.13,14,15 Even so, Wakefield had done irreversible damage to vaccination efforts and generated a new wave of vaccine hesitancy with ramifications that still resonate in the general public to this day. Unfortunately, vaccine hesitancy and conspiracies have not been limited to fringe websites and internet trolls. In 2012, eventual United States President Donald Trump Tweeted, “Massive combined inoculations to small children is the cause for big increase in autism….” Later on, in 2014, Trump Tweeted, “Healthy young child goes to doctor, gets pumped with massive shot of many vaccines, doesn’t feel good and changes-AUTISM. Many such cases!”16 Although Trump’s many conspiratorial ramblings, such as birtherism and climate change hoaxes, tend to be forgotten as just one of his many constant bombastic disruptions of the news cycle, his affinity for vaccine hesitancy has not decelerated with his ascendance to the Oval Office. While campaigning for president in 2016, Trump held a private meeting with former doctor Wakefield, who even appeared at one of Trump’s inauguration balls after the 2016 election.17 Additionally, Trump had briefly

Increased vaccine hesitancy and outbreaks of vaccine-preventable diseases have also been linked to the rise of populist movements in Europe. According to a recent study published in the European Journal of Public Health, there is a very strong positive correlation between the percentage of voters voting for populist parties and the percentage of people who have doubts about the efficacy of vaccines.19 In August 2018, the Italian populist government suspended a law that had made routine vaccinations mandatory for children to attend school.20 According to the previously mentioned study, Italy has the highest rate of vaccine distrust in Europe, with rates nearing 20%. Ironically, the cause of a large portion of this Italian anti-vaccination sentiment can be traced back to a 2012 Italian court ruling that connected an autism case to the MMR vaccine—a finding justified using the very same scientifically unsound 1998 article by Andrew Wakefield.21,22 Although the ruling was overturned in 2015, the damage was already done.23 Since then, the rise of populist anti-vaccination sentiments has led to increases in measles incidence across Europe, with 60,000 cases and 70 deaths from measles in 2018.19 Mainstream vaccine hesitancy is problematic on multiple fronts. Aside from the obvious negative consequences for those who choose to remain unvaccinated, vaccine efficacy relies on what ‘herd immunity,’ the concept that when there are enough people vaccinated, there are not enough unvaccinated hosts through whom diseases can

Wikimedia

Measles is one of the most contagious diseases in extistence

considered appointing well-known vaccine skeptic Robert F. Kennedy Jr. to chair a commission investigating the link between vaccines and autism, although plans for the commission were eventually abandoned.18

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infect and propagate For measles, a 95% population vaccination rate is required to prevent the spread of measles in a community.24 When this threshold is not met, there is an elevated risk of measles outbreaks

among the unvaccinated population. Additionally, given that the measles vaccine is only 93-97% effective, a failure to meet the threshold may still put vaccinated individuals at risk of contracting measles. Even more devastating are the consequences for those who cannot be vaccinated due to medical reasons or for whom vaccines lose potency due to compromised immune systems. This includes young infants, people with AIDS, and people with cancer who are undergoing chemotherapy.24 For these populations, when disease exposure is possible, they are placed at particularly high risk regardless of their personal perspective on vaccines. The effects of anti-vaccine sentiment has been recently observed in the Pacific Northwest, where widespread vaccine hesitancy has led to low vaccination rates and measles outbreaks.25 The majority of states in the U.S. mandate vaccination of children in order for them to attend school, unless they have a religious exemption. 17 states do not carry this mandate, however, creating further risk of easily preventable measles outbreaks. The results of this more flexible vaccine policy have recently been displayed in Clark County, Washington. A recent outbreak of measles led Washington governor Jay Inslee to declare a state of emergency, amidst fears that the Pacific Northwest, with high rates of unvaccinated children, could be catapulted towards a far more serious outbreak than has been seen in modern day.26, 25 It is true that outbreaks of measles and other vaccine-preventable diseases are significantly fewer than near their pre-vaccination peaks, and vaccination rates remain high across the world. Still, measles remains a deadly and widespread disease in the developing world, having caused 110,000 deaths worldwide in 2017.10 This may represent an 80% decrease since the year 2000, but it is still an unacceptably high number of deaths for a disease that is entirely preventable through a simple and safe vaccine with 97% efficacy.27 Continued vigilance regarding maintenance of necessary vaccinations and the dissemination of accurate and scientifically-backed information regarding vaccines is essential, so that millions more lives can be saved and easily preventable diseases that used to be a thing of the past will not become part of our world’s future. www Ben Grobman is a junior in Saybrook College majoring in history. He wrote this article his sophomore year. He can be contacted at ben.grobman@yale.edu

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PROTACs:

An Opportunity for Prescription Drug Pricing Reform? BY STEPHEN WANG

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The Biology of PROTACs

he most common class of pharmaceutical agents available on the market are small-molecule compounds, which bind to specific grooves/ binding pockets on proteins inside our cells. By binding to those proteins, these small-molecule drugs can inhibit the function of their targets and in turn inhibit the molecular drivers of many diseases.1 Proteolysis Targeting Chimeras, or PROTACs, are small-molecule compounds capable of degrading—as opposed to inhibiting—disease-associated proteins. Initially conceived in Professor Craig Crews’ lab at Yale University as a tool to study protein degradation,2 the field of PROTACs has grown quickly, in both basic science research oriented towards studying the biochemistry of protein degradation and translational research oriented towards optimizing these compounds for their use in the clinic. PROTACs’ unique ability to degrade their target proteins completely eliminates the activity and function of the protein. On a molecular level, PROTACs’ two-pronged chemical structure allows them to hijack the cell’s endogenous proteasome, machinery for naturally degrading defunct proteins. This mechanism of action is advantageous over traditional pharmaceuticals in a number of ways. In preclinical testing, PROTACs have demonstrated an ability for catalytic turnover, as one compound can eliminate multiple proteins. Pharmacologists, in determining the correct dosage for optimal therapeutic efficacy, often need to administer higher amounts of an inhibitor, and this comes at a cost to patient safety as most inhibitors exhibit some off-target effect. However, the necessary dosage of PROTAC is theoretically much lower and could thereby cause less severe side effects. Furthermore, PROTACs, as a general class of small-molecule compounds, can be synthesized to target any number of proteins implicated in a wide range of diseases. Their mechanism of action has also been shown to be able to target proteins that are currently deemed “undruggable” by traditional small-molecule inhibitors, including some proteins like p38 that are implicated in cardiovascular disease, chronic obstructive pulmonary disorder, and diabetes.3 Due to their unique biochemical properties and mechanism of action, PROTACs should be considered a new subclass of pharmaceutical agents. They have the potential to occupy a large part of the

pharmaceutical drug market and have the marketability of an alternative therapeutic that could prove more efficacious and safe than traditional inhibitors. As the first clinical trials for PROTACs towards prostate cancer therapy start up soon, now is the time for policymakers and politicians to take advantage of the introduction of this disruptive technology and push through prescription drug reform. The Exorbitant Cost of Prescription Drugs It is well-known that prescription drugs prices are not proportional to their R&D expenditures, but rather seem to be determined by market forces. Left unregulated, this pricing method leads to exorbitant prices and a variety of negative financial and clinical health effects for a large percentage of the American populace. In order to understand the scope of prescription drug costs, it is important to note that in 2016, $328.6 billion was spent on prescription drugs, which accounts for 10% of overall US healthcare expenditures.4 Those other expenditure categories include hospital services, residential personal care services, medical equipment expenses, and physician services.

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As the first clinical trials for PROTACs towards prostate cancer therapy start up soon, now is the time for policymakers and politicians to take advantage of the introduction of this disruptive technology and push through prescription drug reform.

”

To shed some light on what factors go into deciding the price of prescription drugs, we can look at a study of Pfizer’s pricing of Ibrance, a breast cancer drug. In this article, Rockoff points out that the final price set ($9850 a month) was largely based on “a complex analysis of the need for a new drug with this one’s particular set of benefits of risks, potential competing

drugs, the sentiments of cancer doctors, and a shrewd assessment of how health plans were likely to treat the product.”5 In short, the price of Ibrance was not set based on R&D costs—it was instead primarily based on ensuring a competitive rate to allow Pfizer to generate profit. Simply put, larger pharmaceutical companies like Pfizer often have the capital to ignore R&D costs in determining price. Furthermore, the cost of R&D taken on by larger pharmaceutical companies is not reflective of the true costs of drug development. Companies like Merck and GlaxoSmithKline will often acquire smaller biotechs after much of the preclinical development and its associated costs have been taken care of.6 Thereby, the risk these bigger companies take on is reduced, as much of the ground work in identifying and validating the efficacy and safety of these drug candidates has already been done, either by small private companies or academic labs. To some degree, as much of academic research is funded through public grants awarded by the National Institutes of Health, much of the financial burden

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Flickr

If we are to prevent the unfair accumulation of profit by pharmaceutical companies on life-saving treatments, we must be careful to introduce regulation to make that purported miracle available to more patients.

and risk associated with drug development actually lies on the shoulders of the federal government—and by extension—on taxpayers and consumers of healthcare that will have to pay again for the drugs they funded in the first place. In the case of PROTACs, the fundamental understanding that informs PROTAC design has been conducted in a Yale University lab. The translational studies towards optimizing the drug for clinical use have been run by a New Haven based biotech called Arvinas, LLC. To acquire more funding for clinical trials of castration-resistant prostate cancer and estrogen receptor positive breast cancer, in September 2018, Arvinas released their initial public offering (IPO) for 7,500,000 shares at $16 a share. Only recently has Pfizer stepped in to partner with Arvinas in a $830 million deal to push through the first clinical trials for PROTACs targeting prostate-cancer-associated proteins.7

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The high prices of prescription drugs is one issue within healthcare that carries weight on both sides of the political spectrum. Despite intense disagreement split along party lines around the Affordable Care Act and healthcare reform in general, the issue of prescription drug price reform is not much of a partisan issue— both the Trump administration and much of the Democratic party support prescription drug pricing reform and have expressed a willingness to work with their political rivals and counterparts, which is a notably unprecedented act of bipartisanship in the modern-day healthcare debate and political sphere in general.8 This political situation is likely caused by the nature of the prescription drug issue: it’s a problem that establishes a dichotomy between the American public as a whole and the pharmaceutical industry. It is an issue that also pits federal and state governments who generally support more regulation to bring down costs against

big players within the industry who would prefer the status quo, semi-laissez faire marketplace for prescription drugs. The high cost of prescription drugs has been historically protected by two legal mechanisms. The exorbitant and ever-rising costs we see as healthcare consumers today is in part due to patent protections and in part due to the lack of price caps for prescription drugs, established by Medicare Part D. In the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Congress voted in favor of measures that prevented the federal government from being able to negotiate drug prices directly.9 The Act instead gave bargaining power to private insurance plans, which as a conglomerate don’t have as much lobbying power as big pharmaceutical companies. This in turn led to a de facto lack of price controls on any prescription drug covered under Medicare. While Medicare primarily only covers individuals over 65,

a majority of prescription drug costs are incurred by older Americans.10 Subsequently Medicare was obligated to cover those drug costs, which increased the overall expenditure on prescription drugs. Another major factor that protects high drug costs is the federal patent system. When a pharmaceutical company first introduces a drug candidate to clinical trials, they will patent-protect the drug candidate by registering it as a new biologically active compound with a novel chemical structure. Under current federal patent laws, the company has a period of 20 years of immunity from competition, whereby no other manufacturers can produce the same compound, which are known as “generics.” The patents serve as incentives for innovation. As healthcare economist Richard Epstein claims, “the social gain to consumers as a class comes from the fact that the higher rate of profits will induce more research and development, allowing life-saving drugs to hit the market sooner.”11 But this statement linking higher profits and increased access to medicine is undergirded by a false assumption. By claiming that patent-protecting profits for the drug manufacturer incentivizes these companies to produce more life-saving medicines, Epstein assumes those drugs that do make it to market are affordable for the general populace. Unfortunately, affordability is a bigger issue than Epstein reports, especially for individuals in America that now find themselves uninsured or underinsured since the Republican repeal of multiple components of the Affordable Care Act. What’s the point in having more drugs on the market, if only the wealthy can afford them? Increased drug production fueled by patent-protection does not necessarily guarantee increase access to medicine. If we care about ensuring most people can actually receive medications that will save their lives, we should focus our efforts on limiting the profits of the pharmaceutical industry. According to a foundational legal case (Corp v. Mossinghoff) in the establishment of patent law, the economic rewards during this government-granted period of market exclusivity can be thought of as a “carrot,” and “upon grant of the patent, the only limitation on the size of the carrot should be the dictates of the marketplace.”12 In other words, this case decided that the patent owner expends resources only when expecting to receive a carrot, and that carrot’s growth should not be stunted. As we’ve seen countless times, pharmaceutical companies will often hike up prices to reach

the limit of market value—to fertilize carrot growth as much as possible. One can’t help but wonder why we still allow for the market to decide prices, when cases like Mylan Pharmaceuticals’ Epipen and Turing Pharmaceuticals’ Daraprim clearly demonstrate how profit-driven desire often drives cost to an unreasonable level at the expense of the consumer. By allowing the market to decide on prices, we allow pharmaceutical companies to get away with charging exorbitant prices. These prices exist, because most people are willing to spend anything to get the life-saving treatment they need. As prescription drugs constitute life-saving treatment, their prices should not and cannot continue to be unregulated. The carrot’s size must be controlled. The Regulation of PROTAC-based Pharmaceutical Agents Instead of allowing the market to decide the prices of PROTACs, I advocate for explicit price caps set on prescription drug candidates that gain FDA approval. Under current patent law, a pharmaceutical company can reap profits over and above the amount spent for research. To reduce the per-pill cost of paying for PROTAC-base therapies, I propose implementing price caps based on the relative doses of active ingredient needed to achieve therapeutic effect. Say if a traditional drug requires X mg of Active Pharmaceutical Ingredient (API) to reduce tumor size by half, and a PROTAC requires only 3/4 X mg of API to reduce the tumor also by half, then the PROTAC therapy should be priced accordingly at 3/4 the cost of the inhibitor. By tying the pricing methodology back to the biochemical differences between PROTACs and traditional inhibitors, we can use empirical evidence to inform prescription drug prices. This proposed price cap reform would no doubt be strongly opposed by the pharmaceutical industry, whose major players are often represented by the trade group, Pharmaceutical Research and Manufacturers of America. In order to successfully implement such price caps, bipartisan political backing would be needed. From recent news, bipartisan efforts and openness to trying new methods of reform on prescription drug prices seem to be in vogue, which is promising for the feasibility of introducing price cap reforms.13 Additionally, these measures would have to be implemented on the federal level, to prevent pharmaceutical companies

from threatening to leave one state or refusing to sell products to any given region of the country.14 Furthermore, one needs to consider an important prerequisite to the proper implementation of price caps: accurate reporting by industry players of the revenue they generate from drug sales. As of now, a huge barrier for establishing accountability for pharmaceutical firms in their decisions to set drug prices is a lack of information on their itemized expenditures. The dose-based price cap that I propose here would require accurate reporting from pharmaceutical companies on their revenue and R&D associated costs. The enforcement of this increased measure for clarity could be enforced in the patent award process. Some kind of legal contract could be made wherein any patent assigned for a PROTAC drug therapy mandates a company’s reporting to the FDA on revenue and associated R&D costs 10 years and 20 years since the beginning of the patent. Failure to report financial data would lead to termination of the patent. In an ideal world, we would also combine price caps with some form of legislation that limits a company’s spending allowed on detailing physicians. By reducing the amount companies are allowed to spend on advertising and informing physicians of their brand name medicines, we create a more even playing field in the kinds of prescriptions written by physicians. We can better create a balance between prescriptions of cheaper, equally effective generic medicines and prescriptions of more expensive, leading-edge, brand-name medicines. Both pieces of legislation pushing for percentage-of-revenue price caps and for reduced detailing expenditures would no doubt be a hard-fought political and legal battle, as the pharmaceutical lobby is undoubtedly powerful and far outspends any other industry on lobbying American politicians. These kinds of reforms could bring us closer to a value-based pricing system, which serves as market-friendly alternative to the current version of a volume-based pricing method. The value-based pricing system is in my opinion, the most realistic option among currently proposed methods for reducing healthcare costs. Under a value-based system, prescription drugs would be priced according to the benefits in health outcomes they help facilitate. By capping profit amounts to a percentage of R&D expenditures, we will establish a culture of expectation of lowered prices while maintaining similar levels of beneficial health outcomes. Furthermore, as value-based pricing

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would likely increase the stringency of efficacy and safety measurements required for a drug to get FDA approval (as companies would be more reticent to modulating an already-existing drug that does not add much additional value), overall revenues from prescription drug sales would decrease. This would no doubt lead to backlash from the pharmaceutical industry.

While by no means are my proposed set of reforms for regulating the prices of PROTACs a comprehensive plan developed for immediate implementation, it is my hope that it can be a useful first step towards regulation of the prescription drug market as a whole.

An additional counterargument against value-based pricing is the claim that measurements of value are hard to define and can vary not only due to the intrinsic efficacy of a drug, but also the administration of medicines and adherence to treatment regimens. Much of the criticism of these methods largely center around the infeasibility of implementing such a system due to imprecise metrics of “value.” How can one measure the value of a drug when so many factors that affect treatment efficacy lie beyond the control of the drug manufacturer and even the healthcare provider? The good news is that the goal of reducing prescription drug prices seems to be a bipartisan issue. Both political parties support experimenting with value-based prescription drug pricing.15 Republicans would like value-based pricing models, as it shifts the focus of health reforms to market-based solutions. Democrats would also support value-based pricing, as it protects patients and consumer interests in guaranteeing value from their healthcare investments.

With new drug candidates appearing regularly every year, it is difficult to claim that PROTACs can truly become a disruptive force in the arena of pharmaceutical drug pricing just based on its unique biochemical properties. At the end of the day, despite the differences in molecular mechanism of action, PROTACs will still be taken as an orally-ingestible pill. Therefore, most patients and payers—who find themselves degrees removed from the biology behind PROTACs—won’t consider the difference. Policymakers and drug pricing advocates should do the same, and preempt aggressive marketing strategies of pharmaceutical companies by implementing regulation on prescription drug prices, just as if PROTACs were your run-of-the-mill inhibitor. The regulation of the entry of PROTACs into the clinic is a prime opportunity for regulating prescription drug costs at large.

The Time Is Now

If there is a proper time for policy wonks and advocacy groups to lobby for prescription drug price capping, it is now. The public

distrusts the pharmaceutical industry more than ever before, especially with the opioid crisis’ saliency as a public health emergency and the nefarious role of the Sackler-owned Purdue Pharmaceuticals in seeding it.16 Furthermore, high-profile news cases have helped shift public opinion of the industry. Take for example, Martin Shkreli’s company Turing Pharmaceuticals hiking up the price of the life-saving drug Daraprim used to treat toxoplasmosis,17 or of Mylan Pharmaceuticals tripling the price of EpiPen,18 the emergency epinephrine auto-injector used by people with severe allergies. These cases have eroded the trust of the public, casting the pharmaceutical industry as less of a manufacturer of life-saving drugs and more of a profit-driven industry that often takes up price-gouging methods to maximize profits. In fact, a recent Gallup poll showed that only 28 percent of Americans have a positive view of drug makers, which is the lowest rating in the 16 years Gallup has recorded public opinion.19 In short, people are angry with the pharmaceutical industry. If PROTACs pass through clinical trials, they will soon flood drug markets for treatment towards some of the most high-profile and expensive diseases, such as prostate and breast cancer. If left to the devices of what is currently a relatively unregulated prescription drug pricing market, PROTACs could play a big role in driving up America’s overall healthcare expenditures. As a drug that fundamentally acts differently than traditional pharmaceutical agents, bigger biopharmaceutical companies and PhRMA can market PROTACs as a disruptive “miracle drug.” If we are to prevent the unfair and exorbitant accumulation of profit by pharmaceutical companies on life-saving treatments, we must be careful to introduce regulation to make that purported miracle available to more patients. Price caps, which will indubitably be unpopular with major stakeholders in the pharmaceutical industry, ultimately will decrease prohibitive costs for therapy and increase access to PROTAC-based therapies, and lead to better patient health. It is a hard battle to fight but is one that must be undertaken, if only to chase after the dream of more equitable outcomes in American healthcare. www Stephen Wang '19 is a Molecular Biophysics & Biochemistry major from Houston, Texas. He is interested in drug discovery research and pharmaceutical reform.

PROTAC mechanism.

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U.S. Department of Defense

You can reach him at stephen.wang@yale.edu

Bags, Boxes, and Brussel Sprouts The Changing Face of Urban Farming By Nishanth Krishnan

Lufa Farms Montreal green house. (2013).

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n Fair Haven, a solitary wind turbine breaks above the familiar pattern of low-lying red brick buildings and thick brush. Beside it lies a small clearing of grass housing neat planters filled with leafy greens and vegetables. This humble garden belongs to New Haven Farms, a local organization that runs a number of urban farms in the city. Since 2012, New Haven Farms has run the Phoenix Press Farm, named after its neighboring wind-powered press, with a mission to change the city’s relationship with food. The discussion of sex-selective abortion in this country will be theoretically developed through a diachronic perspective, which focuses specifically on the way cultural practices have developed over time. This theoretical perspective is appropriate because of its relevance to the discussion of changes through history in the justification for and feasibility of partaking in sex-selection. It is a relationship that has been tenuous in recent decades. New Haven households are food insecure at a much higher rate than the national average, with 22% reporting food insecurity against 15% nationwide in 2017.1 Food insecurity is a position where families are unable to afford food or simply do not have access to it. Low access to healthy, nutritious food options has also exacerbated chronic health issues,

Wikipedia

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with nearly 1 in 5 food-insecure households reporting diabetes and over 3 in 4 reporting obesity.1 New Haven Farms is trying to change the script. Since its inception, the nonprofit has partnered with regional medical centers to create a 20-week program for city residents dealing with chronic health issues like diabetes and obesity to learn about nutrition and gardening healthy produce.

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in physical development, access to education, and future earning potential. Kenya’s Sack Farms A creative solution to this problem can be found dotting Nairobi’s densely populated Kibera district. In small pockets of empty land, empty plastic sacks that once carried rice and coffee beans have been repurposed into micro urban farms. Tradi-

In places where chronic health conditions go hand-in-hand with low access to fresh, health, nutritious food options, high-yield urban farming can become a vital source of fruit and vegetables for families most in need.

“We’re really using our farms to grow food as medicine and connect it with families in need,” says Jacqueline Maisonpierre, the former Farm Director and current Executive Director of New Haven Farms. The farms are also open to the broader community, and Maisonpierre adds that their “farm centers [are] for people to come together and promote healthy lifestyles.” Through these initiatives, New Haven Farms is helping local residents shape their relationship with food and become personally invested in the foods they eat. One by one, small urban farms are changing the way people in cities across the world understand their health through food. These farms can take amorphous shapes and forms, and as a result urban farming has grown into an umbrella for all kinds of urban agricultural operations. From a small windowsill planter to a sprawling rooftop greenhouse, urban farms are incredibly diverse. Metropolitan areas in every country face several of the same food insecurity problems as New Haven does. Globally, 33 percent of the world’s urban population earns an income below the global poverty line of 2.00 USD per day, so fluctuations in food prices keep many families on the edge of food insecurity.2 In Kenya, political instability, geographic constraints, and consequences of climate change mean that families in the capital city Nairobi can spend up to 70 percent of their income on food.2 Food insecurity has a ripple effect, particularly on children in affected households. Without consistent meals, children face barriers

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tional sacks are filled with manure-fertilized soil, tucked with seeds, and gently cut open for aeration.3 With time, vegetables like spinach and kale sprout up from sacks scattered across the slum, which sack farmers can sell at the marketplace.4

Sack farming has become a successful, if unlikely, strategy to overcome some of the barriers causing food insecurity. The method provides a consistent source of food and income, shielding farmers from the impact of fluctuating food prices. An added benefit is that most produce grown in sack farms are nutritious vegetables, which helps boost the dietary value of meals made from the harvest. But what ultimately drives the adoption of sack farms is that they occupy a fraction of the space of traditional farms. Whether in Kibera’s slums or midtown Manhattan, space is a precious commodity in dense urban areas. Complicating the issue is the fact that cities have strict land-use restrictions that may not allocate space for urban farming projects. This makes obtaining the appropriate land for an urban farm operation expensive and time-consuming or, in the worst case, nearly impossible. In Houston, urban farms must share resources and receive permission from existing land owners in order to operate, creating an uneasy symbiosis between property owners and farmers.5 It is hardly a tenable existence, given that in Houston’s rising real-estate market developers are increasingly opting for profit-generating commercial development instead. Without specific allocations for urban ag-

riculture, more and more farms will get squeezed out by the rising costs. The formation of urban land trusts is yielded as an antidote to this issue. New Haven has benefited from the New Haven Land Trust, which began operations in 1982. The cooperative emerged out of a partnership between the city government and local foundations, and for over thirty years the trust has supplied and maintained over 50 urban farms in the city.6 Community farm projects in Houston are pushing for a similar land trust to manage designated downtown agriculture districts in the hopes that a trust could avert efforts to commercially develop the land for generations to come. In many urban areas, the necessity of land trusts is becoming increasingly apparent as citizens and city governments look for ways to continue growing urban farms in their city. As the world population becomes increasingly centered in metropolitan areas, finding long-term solutions for urban farming land-rights will only grow more pressing. On some metrics, it is easy to characterize the importance and value of urban farming. Though traditional farming is still every nation’s primary source of food, urban farms now account for 10 to 15 percent of global food production.5 As seen in Kibera and New Haven, urban farms sometimes constitute one of the few sources of fresh foods in inner city areas. Transporting foods from distant locations is also a large contributor of greenhouse gas emissions, with 4 percent of total emissions coming from food transportation.7

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One by one, small urban farms are changing the way people in cities across the world understand their health through food.

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But sometimes, the value of an urban farm to a community cannot be captured in numbers. Urban farms bring a value to neighborhoods that is not always captured in terms of revenues and profit margins. Farms can be a public space and a gathering place for people from different communities. Like at New Haven Farms’ vegetable patch under the windmill, people of all ages enjoy coming together on weekends

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to laugh, play, and talk while they go about farm tasks. A green space can be a welcoming reprieve from the bustling city around it—to some, this space is priceless. France’s Sky Farms Across the Atlantic, urban farmers in Paris are faced with an even more complicated space problem. The city center of France’s capital is almost entirely developed, leaving few opportunities to start new projects on the ground. Yet, urban farming is growing rapidly in the city. The question: where is the space to grow? The answer: up. In recent years, farms have been sprouting up on Parisian rooftops, at the encouragement of the city government. Unoccupied rooftops offer an accessible and sunlight-rich location for greenhouses. Indeed, in recent years, the government has recognized these undervalued spaces and their potential for urban farms. Paris has a set a goal developing of 330 thousand square meters of urban farm land by 2020 and has been incentivizing both nonprofit and commercial groups to spearhead the effort.8 One company sees an opportunity for innovation to meet this goal. A startup called Aéromate is using rooftop hydroponics to grow Brussel sprouts, watercress, and other vegetables. Hydroponics does not require soil, but rather uses nutrient-enriched water dripped directly onto plants’ roots. The water is then collected and re-enriched, which conserves resources and encourages recycling. Aéromate’s hydroponic system places a premium on sustainability, rather than high-yield food production. Instead of working towards high-yield agriculture, both the government and the startup envision urban agriculture as an environmentally-friendly alternative to traditional farming in the countryside. Unlike Kibera or New Haven, Paris has a relatively low food insecurity rate. Less than 10% of families experience a severe degree of food insecurity.9 As a result, the

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expansion of urban agriculture in the city is not driven by demand for food but rather a desire for environmentally conscious agriculture. In this light, hydroponic technology is an attractive solution, since it forgoes chemical fertilizers and utilizes water conserving irrigation techniques. Farming in a Box

Between Kenya’s simple but effective sack farms and France’s sustainability-driven hydroponic systems, urban agriculture can successfully serve a diverse variety of needs. In the US, some urban farms are blending these two approaches to create innovative technologies for everyday farmers. A company called Freight Farms is rethinking farming by pioneering one of the first mobile urban farms. Much like Kenyan sack farmers, Freight Farms is repurposing shipping containers into mobile urban farms. Like Aéromate, the company is using water conserving techniques to limit water usage down to 5 gallons a day.10 But the technology does not end there: the containers are internet-integrated and have a dynamic magenta LED lighting system, allowing farmers to check and control the conditions of the farm through their mobile device. On one hand, Freight Farms synthesizes many of the best motivations for urban farming into one, forty-foot-long container. The company emphasizes their machines as sustainable, high-yield, and educational. Each one of their “Leafy Green Machines,” as the company calls it, is mobile and can be placed in tight spaces that grounded urban farms cannot. On the other hand, Freight Farms loses many of the intangibles of community urban farms. Each machine is prohibitively expensive, with a 13,000 dollar a year annual operating cost after the initial purchase.11 High overheads place pressure on urban farmers to maximizing output, at the expense of other possible uses like converting it into a classroom. A profile of a Freight Farms customer by NPR describes how one operator has grown crops year-round and still struggles to bring a profit.12

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In this regard, a Leafy Green Machine from Freight Farms differs from other urban farms discussed earlier because of its audience. These machines are meant to become the foundations for local businesses, or for existing farms looking to scale up. The primary motivation for buying one therefore is not necessarily for increasing food access in urban areas, so much as it is charging a premium to customers for locally produced food. This aspect of Freight Farms is, by itself, not good or bad, merely different from other urban farms. The high cost in particular serves as a wedge between community members people who might benefit from a local garden versus the upper-market customers who pay more for Freight Farms produce. What is in a Farm? The meaning of “urban farm” continues to expand as new innovations, companies, and communities continue pioneering new techniques. In 2018, the diversity of farming is immense, from sophisticated American machinery growing high-end products in Freight Farms’ shipping containers, to Kibera’s simple coffee containers packed with soil and seeds. These new urban farms are not static. Based on the needs of the community

and the resources available, these urban farms can fulfill a wide range of demands. In places where chronic health conditions go hand-in-hand with low access to fresh, healthy, nutritious food options, high-yield urban farming can become a vital source of fruit and vegetables for families most in need. On the other end of the spectrum, advanced urban farms that integrate technology and sustainable thinking can produce the same foods at a fraction of the environmental impact as traditional farms.

Lettuce, seen here, can grow without soil in a hydroponic system. Hydroponic Vegetable. (2016). Flickr

As the effects of climate change and the increasingly urbanized world population begin to manifest, the pressure for urban farming to provide a larger role in global food systems is almost inevitable. Urban farming, molded by forces of public demand, will have larger role in our day-today food consumption. Whether on rooftops or in sacks, new urban farms will help feed a new urban world. www

Nishanth Krishnan is a junior in Timothy Dwight College Majoring in Molecular, Cellular, and Developmental Biology. He wrote this article his sophomore year. He can be contacted for questions at nishanth.krishnan@yale.edu

Wikipedia

Agriculturalist showing youth how they sack garden. (2017).

VOLUME 6, NO. 1

Artificial Intelligence in Healthcare

By Irene Pak

Flickr

YALE GLOBAL HEALTH REVIEW

he term “artificial intelligence” (AI) rouses a mixture of feelings for many. Some envision a world controlled by robots–a vision inspired by films like “The Terminator.” Others are concerned about the consequential loss of jobs and the inevitable impacts this would have on both the US and global economy. Yet still, others find hope in this era of rapid technological development stemming from AI, whose applications in many fields, especially healthcare, can potentially benefit countless lives around the globe. To understand this, it is first important to understand what artificial intelligence is. AI is a field of computer science rapidly developing to simulate humans’ visual perception, speech recognition, decision-making, and language-processing, all of which fundamentally tie back to mimicking human intelligence.8 Ultimately, this is meant to lead to the creation of machines that think, learn, adjust, and perform tasks as competently as humans do. A few of the most prominent applications of AI in healthcare have been improving efficiency of radiologists’ image analysis and implementing robot-assisted surgery. Uncertainty is an intrinsic and inevitable feature of medical practice and patient care–in particular, in radiology. Due to insufficient proof caused by a constant lack of convincing radiological images or dependable clinical information, the ubiquity of uncertainty in radiological practice makes it nearly impossible for radiologists to be certain about their diagnoses. In fact, the best radiologists are not the ones who are the most certain about their diagnoses, but rather the ones who can best convey their uncertainty about each case, most effectively reduce such uncertainties, and make the wisest diagnoses despite the given conditions and time constraints.7 But now, AI can play an integral role in improving the efficiency of image analysis. By noting certain anomalies in radiological images for radiologists to review, but with greater speed and accuracy, these technological developments can give radiologists more time to focus on the uncertain aspects of their review that require more analysis and interpretation.5 What used to take radiologists weeks or months to reach a diagnosis may eventually take a mere few days, allowing this

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medical service to be accessible to a greater number of patients as well. According to an experiment conducted by researchers from NYU Langone Health in 2011, such automated analysis could determine specific lung nodules from chest CT images nearly 62% to 97% faster than a panel of radiologists could.5 An MIT-led research team developed an AI algorithm that could analyze 3D brain scans up to 1,000 times faster than before.4 In 2017, a group at Stanford University tested an artificial intelligence algorithm’s ability to detect and identify skin cancers against 21 dermatologists. The results of the clinical study demonstrated that AI was capable of classifying skin cancers as competently as the dermatologists could.5 As a matter of fact, Baidu Research recently announced that a study of the deep learning algorithm they created indicates that AI- based technology can outperform human pathologists in detecting breast cancer metastasis.10 Even British prime minister Theresa May announced that an AI revolution would greatly help the UK’s National Health Service prevent thousands of cancer-related deaths by predicting those with an early stage of cancer–a system they hope to implement by 2033.11 The Harvard Business Review’s findings suggest that the resulting increase in efficiency from artificial intelligence can potentially lead to almost $3 billion in annual savings.5 In addition to the radiology department, AI can be applied in surgical departments. After analyzing data from medical records before operations, AI-assisted robotics can physically guide surgeons during surgical procedures, as well as use data from previous experiences to inform surgeons about new surgical techniques. A study was conducted over 9 surgical sites of 379 orthopedic patients on an AI-assisted robotic technique created by Mazor Robotics, a manufacturing company of robotic guidance systems for spine surgery. It revealed that the implementation of this technique had resulted in 5 times fewer complications that occurred during surgeries compared to the number that occurred when surgeons operated alone.5 Recently, for the first time in human history, surgeons at Oxford’s John Radcliffe Hospital used robotic devices designed by PRECEYES, a Dutch medical robotics company, to conduct eye surgery, successfully removing a membrane from

the back of an eye. The trial demonstrated that a surgeon using the robot performed the surgical procedure with equal or better efficacy than when operating alone.2 In addition, by far the most advanced surgical system called the da Vinci allows doctors to perform complex surgical procedures with greater control than the conventional approaches.5 By 2015, over 3,400 sets had been used!8 HeartLander, a miniature robot, assists heart surgeons by entering a small incision on the chest to deliver cardiac therapy to the surface of the beating heart. Like HeartLander, many robot-assisted surgical technologies are considered “minimally invasive,” meaning they involve small incisions and, therefore, reduce the need for patients to heal from large surgical incisions.11 In fact, the Harvard Business Review’s findings suggest that this surgical development can create nearly $40 billion in annual savings and even reduce the length of patients’ stay in hospitals following their surgeries by 21% due to fewer surgical complications and errors.5 Several other potential applications of artificial intelligence in health care include AI- powered virtual assistants and assistance in hospital administration and office management. There is an increasing potential in the ability of AI-powered virtual nurse assistants to help patients. For instance, Sensely, an app that directs its users to the healthcare resources they need, has incorporated a virtual assistant named Molly.3 The University of California, San Francisco and the United Kingdom’s National Health Service have been using this AI-powered nurse avatar to interact with their patients, assess their symptoms and medical conditions through questions regarding their health, and direct them to the most effective medical care they need.5 Care Angel’s virtual nurse assistant even converses with patients, providing wellness checks through both voice and AI.1 According to the Harvard Business Review, these AI-powered nurse assistance can potentially save 20% of the amount of time nurses spend maintaining their patients and nearly $20 billion annually.5 Artificial intelligence helps nurses and physicians with not only patient maintenance tasks, but also back-office administrative work. Though it may be hard to believe, activities that are unrelated with direct pa-

What used to take radiologists weeks or months to reach a diagnosis may eventually take a mere few days, allowing this medical service to be accessible to a greater number of patients.

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tient care consist of over half of a nurse’s workload and nearly a fifth of a physician’s activities. Technologies based on artificial intelligence, such as voice-to-text transcription, can improve the administrative workflows and diminish the amount of time-consuming clerical duties like writing chart notes, filling prescriptions, and ordering tests.5 This will allow medical

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Medical AI technology has been impacting healthcare in rural areas of countries like China as well. An internet healthcare company supported by the national rural healthcare program developed a portable all-in-one diagnostic station that is being used by the village. It can run 11 tests, including blood pressure measurement, electrocardiographs, and

Using machine learning methods developed for artificial intelligence, we were able to bring together data to identify bat species with a high probability of harboring Ebola

professionals to focus more on the patients themselves and have more direct contact, gradually developing closer connections that will lead to more effective patient care. Artificial intelligence can impact healthcare not only at a domestic level within the United States, but at a global scale as well. In fact, believe it or not, AI is likely to have a more significant impact in developing countries than in America. Many of these developing countries have been striving to provide universal health care. However, most are struggling to do so due to a lack of sufficient resources. Due to their poor working environments, many of these countries are unable to attract and retain high-quality medical professionals and are, therefore, plagued with a severe shortage of skilled healthcare providers in rural areas.8 For instance, while one hospital in Boston has 126 radiologists, Liberia only has two.13 As a result of this lack of specialized resources, the quality of healthcare in rural areas of developing countries is low, and many patients need to be treated by nurses or paramedical health workers.8 This is where AI- based technology can help. In 1998, a computer-assisted diagnostic system called the Early Detection and Prevention System (EDPS) was developed and implemented in India’s rural clinics lacking physicians. It provided guidance and recommendations for nurses and paramedical personnel with a 94% rate of consistency with physicians, according to a study conducted by Kempegowda Institute of Medical Science in Bangalore, India. In fact, another study revealed that patient responses to the utilization of this system were generally positive, because most believed the computer system was more accurate than the medical personnel there—and even the village health nurses liked it.8

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routine urine and blood analyses, as well as upload results and medical records to an online data analysis system that can generate a diagnosis for the village health personnel to review and reference without a physician.8

Several companies are also trying to implement artificial intelligence in their efforts to improve access of health care in some of the most remote parts of the world. For example, in Rwanda, a system named Zipline uses drones to deliver urgent medical supplies and blood over impassable terrains, such as mountains and washed-out roads directly to hospitals and clinics. What used to take hospitals multiple hours to pick up blood from regional centers now takes less than 30 minutes to be delivered. This drone system has dramatically impacted and saved countless lives, including women and children who might not have survived otherwise, even helping reduce the waste of blood by 95%, according to Zipline.16 A field of artificial intelligence known as machine learning, which utilizes statistical techniques to allow computer systems to “learn” from data without prior programming, has also made a huge impact in developing countries.12 As many around the world are aware of, the Ebola virus recently devastated countless African communities, similar to many of the outbreaks that have occurred over the years. Barbara Han, a disease ecologist at the Cary Institute of Ecosystem Studies, once stated, “Using machine learning methods developed for artificial intelligence, we were able to bring together data from ecology, biogeography, and public health to identify bat species with a high probability of harboring Ebola and other filoviruses. Understanding which

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species carry these viruses, and where they are located, is essential to preventing future spillovers.”15 This prevented any further deaths from this devastating outbreak. As can be seen, the biggest advantage to machine learning is its ability to deal with complexities. A large number of variables interacting at once may make the interpretation of data values and findings difficult– but machine learning can handle it. Machine learning is most effective at not only understanding the spread of a disease, but also providing relief. An ideal world would have machine learning technology identify a disease, develop a cure for it, locate the most likely location for the outbreak to strike next, and transport the cure there in autonomous vehicles or drones–all with minimal human interaction or control. Of course, there are many bridges to cross and setbacks to overcome before such a world of artificial intelligence can become a reality. One of the most significant setbacks stems from the worries people have towards the underlying harm AI could inflict–especially its threat to jobs in the medical field. There are many concerns about robots taking over a majority of medical professions. The limit of human abilities, such as inconsistent accuracy and susceptibility to fatigue and clumsiness, may make the seeming infallibility of robots seem more desirable and reliable. This arouses a widespread fear of robots replacing radiologists, surpassing the skill of surgeons, and taking over the field of pharmacy, among other things. In fact, Vinod Khosla, a Silicon Valley-investor, stated that machines will substitute 80 percent of doctors in the future.14 In late 2016, Professor Geoffrey Hinton, known for his artificial neural networks, claimed that it was “quite obvious that we should stop training radiologists,” for AI-based algorithms analyzing radiological images are soon going to be better than humans.14

An example of a semi-humanoid robot manufactured by SoftBank Robotics that is intended to make people happy, enhance people’s lives, facilitate relationships by connecting people with the outside world, and provide insight into human-robot interactions.

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Despite the many signs indicating the revolutionary impact AI will have in the medical field, fearing that the majority of medical professionals will be replaced by artificial intelligence is irrational and unfounded. Although robots may be less erroneous than medical professionals, these machines lack the ability to carry out one of the most important aspects of a physician’s job–to feel empathy. Beneath the prescribing of medications, diagnosing of medical conditions, operating on bodies, is the human bond between a doctor and his or her patient. Developed over

18 Wikimedia

the course of many appointments, this connection is what drives doctors to fight for their patients’ lives and further motivates patients to convalesce. Doctors comforting nervous patients before surgery, listening to their patients’ needs with a smile, holding their patients’ hands while revealing a diagnosis to them–nothing in AI can ever replace these. A trial conducted by NHS revealed that patients would rather get a shorter appointment with a doctor than take the recommendations of a chatbot.14 This shows that patients do not trust a robot or algorithm with a life-changing decision, nor will they ever. Robots may be more efficient, but they will never replace the integral role empathy plays in patients’ recovery. So a healthcare run by technology without human empathy will never become a reality. In addition, sometimes, formulating a diagnosis is not a straight-forward task that can be completed merely through tests and imaging. In fact, a medical con-

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responsibilities and duties that robots cannot perform. For example, IBM Watson may be able to sift through millions documents in mere seconds and provide physicians with evidence-based treatment options, but it will never be able to carry out the Heimlich maneuver—or any first-aid maneuver for that matter— as quickly and reliably as humans do.9 But these are skills that are undeniably just as crucial when it comes to saving patients’ lives. Overall, physicians and surgeons really only have 0.42 percent chance of their professions being automated.14 This is not to say that AI will not have an immense impact in healthcare in the next 10 to 15 years. In fact, it already is. Under the lead of Professor Brian Scassellati, who is a Professor of Yale University’s Computer Science, Cognitive Science, and Mechanical Engineering and the Director of the NSF Expedition on Socially Assistive Robotics, a team of students in the Yale So-

One of the most underrated, yet serious concerns for the implementation of artificial intelligence is not so much the consequential loss of jobs as it is the potential accumulation of dependency on technology.

dition may have some of the most unexpected origins that only humans would understand. An episode of American television series House M.D. tells the story of a young boy who was mysteriously poisoned. Despite different hypotheses and treatment options, the physicians eventually realize that the boy had picked up an insecticide in the jeans he bought from a street vendor, who had kept the trousers in his truck. Having not washed the pair of pants before wearing it, the boy’s skin had absorbed the poison.6 This is a case that would have been nearly impossible for a machine or algorithm to decipher. Although data values, test results, and imagine analysis compose a large portion of a doctor’s work, sometimes a diagnosis requires creativity and deeper problem-solving skills that AI robots will never have. Last but not least, there will always be medical tasks that algorithms and machines will not be able to perform. It is true that much of the office and administrative tasks can be automated for nurses’ and doctors’ convenience, but there are

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cial Robotics Lab have been developing in-home robots for children with autism, a disorder that 1 in every 48 children is diagnosed with. Such robots have been being sent into several clinics and homes to provide social therapy for these children, as well as a daily practice of skills that a human therapist would do. Unlike the repetitious and, oftentimes, boring therapeutic procedures for autism, these robots create a more exciting atmosphere for the children and their families, providing more motivation for them to complete the therapy. And the team has already seen immense success in their robots improving these children’s social skills! Yet, Scassellati states that one of the most underrated, yet serious concerns for the implementation of artificial intelligence is not so much the consequential loss of jobs as it is the potential accumulation of dependency on technology. Technology is developing so rapidly that scientists need to make sure they are not leading people to build dependencies they should not be along the way, even dependencies on robots. Scassellati

and his team have focused on making sure the children they work with do not learn merely how to interact with their therapeutic robots which could lead to an unhealthy dependency, but rather how to build up relationships with people, by supporting the children’s interaction with the robots alongside their parents. This is not to say that job loss is not a serious concern as well. It is, but it is not quite what the media makes it out to be. Ever since the first technology was produced, there has been an inherent fear of technology taking over humans’ jobs and changing our culture. According to Scassellati, “the word ‘robot’ was basically invented by that idea.” Take, for example, the Industrial Revolution. Back then, people worried that the introduction of automation into factories would eliminate the entire population of workers in factories at the time. And yes, it did eliminate some jobs. But in their place, these technological developments brought about an immense change in the landscape of employment that led our society and economy to what it is today. Such introduction of technology changes what kinds of jobs there are and how productive individual workers are. But that doesn’t mean jobs as a whole will disappear. Yes, AI will change what several occupations look like, and some may disappear, but they will also create jobs that we have never seen before. “My job exists because of this technology!” exclaims Scassalleti, “Technology changes employment, but it does not necessarily destroy it.” Regarding their robots, Scassalleti states, “We don’t think that what the technology there is doing is replacing any specific job, but what it is potentially doing is actually making the individual therapist able to much more productively serve their patients and clients.” Through the data the robots constantly accumulate about the client, therapists are able to monitor their patients in between clinic visits. This informs them on things their patients really do need help on and things they should focus on during the children’s clinic visits, thus making these interactions between the children and therapists more productive and effective. Scassalleti believes that scientists and researchers play an important role in dissipating people’s unfounded fears towards AI development. It is their responsibility to ensure that what they build is explainable to people and not to sensationalize what they do. “To explain to people not just what, but why we build

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Wikipedia

certain things and make certain choices, because those are the kinds of things that people really do understand.” But, the burden is equally on the media. Many well-intentioned scientists have provided very careful, accurate explanations. But the stories that result from them have had sensational headlines that try to grab readers’ attention. And the way the media does that is by capitalizing on people’s fears. “I’ve seen the most well-intentioned descriptions get re-shaped by a copy editor and become another story of ‘robots are stealing all our jobs’ and ‘robots are taking over the world,’” mentions Scassalleti. It is jointly up to the scientific community and the media to make sure these stories are coming across accurately. It is something one cannot do without the other. And I hope that, through this article, people will see past their deep-seated, yet irrational fears towards technology and realize why investing in the development of artificial intelligence is truly worthwhile.

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According to Hugh Harvey, a radiologist and clinical academic, it is estimated that, in 10 years, AI will be routinely used in National Health Service’s practice. Anna Fernandez, the lead of Health Informatics/Precision Medicine at Booz Allen Hamilton, told The Medical Futurist in 2017 that, within just three years, machine-learning algorithms will be approved and used all around the United States.14 But keep in mind that, no matter how advanced artificial intelligence gets, these technological innovations serve to help medical professionals focus on aspects of healthcare they were unable to before, rather than replace them. At the end of the day, a trained physician is still required to understand and act on the recommendations made by AI software. By pointing doctors in the right direction, artificial intelligence can help reduce error rates in complicated situations, decrease the time spent over menial tasks, and most importantly, improve medical efficiency dramatically. Though it may

seem like a daunting, uncertain task right now, collaboration between humans and AI technology is crucial because artificial intelligence and humans are strongest when they cooperate. As Scassellati states, “technology is so young. We are so far away from making the Terminator-type fears a reality.” Therefore, we need to cast away these unfounded fears and support the development of artificial intelligence to push our healthcare system further. Remember, AI and humans are two players on the same team with a single goal in mind: providing the best healthcare for people all across the globe. www

Irene Pak is a sophomore in Benjamin Franklin College who plans on studying Molecular, Cellular, and Developmental Biology. She wrote this article her first year. She can be contacted for questions at irene.pak@yale.edu.

A DIME IN A DOZEN

By Indira Flores

Flickr

Inside of a Dollar Tree

n Chapel Street in New Haven, Connecticut, lies a store familiar to many Yale students and local residents alike: The Dollar Tree. For some shoppers, this store—where every item is priced at one dollar or less—is a convenient spot to buy cheap goods ranging from tissues to notebooks to party hats. For others, Dollar Trees and other dollar retail chains are the only stores where they can afford to buy necessities like groceries. Though inexpensive, most of the food choices available at these stores are not conducive to maintaining a healthy diet. A new study published by the Institute for Local Self Reliance (ILSR) shows that a recent rapid growth in the number of dollar stores in the United States is leaving food deserts in its wake in low-income areas that in turn leads to higher rates of cardiovascular disease and obesity in these communities.¹ As these types of stores gain popularity in Asian and European countries as well, similar patterns of health problems could also begin to appear abroad. The reach of dollar stores in the United States is expanding. Since 2011, the two dominant dollar store chains, one of which is the Dollar Tree, have grown from a total of 20,000 to 30,000 locations in the US. The chains have already identified another 20,000 locations as potential future dollar store outlets. They are popping up every-

where from small towns to urban areas, with the greatest number of dollar store locations per 10,000 residents situated in southern states like Louisiana, Mississippi, and Alabama. New dollar stores tend to establish themselves in low-income communities and are most concentrated in areas with few or no grocery stores.¹

ever, are brought up by the disproportionately high ratings given by people from rural and low-income neighborhoods. This is likely more a result of them relying on these stores as the only local source of affordable shopping than the dollar stores actually leaving lasting positive impacts on their communities.²

Thanks to a business model of offering deeply discounted products, the appeal of dollar stores is obvious to the frugal consumer. They attract a wide range of middleand higher-income populations who may want to save money and buy certain dollar store items every so often, but do not necessarily rely on them as their main source of shopping. Instead, these stores primarily open in low-income communities, providing affordable products to those who need them most. According to surveys released by the Morning Consult approximately a year prior to the release of the ILSR study, dollar stores in America have favorability ratings of over sixty percent. More than fifty percent of shoppers also view dollar stores as having a positive impact on their communities. These favorability and positive impact rankings, how-

While dollar stores may offer unrivaled prices of goods, including food, the fact that they are outcompeting local grocery stores in the neighborhoods where they pop up is not a total win for shoppers. Sometimes, a dollar store will open in a community with no pre-existing grocery stores nearby, eliminating any incentive for such a food source t o

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How the rapid expansion of dollar stores is affecting community health be established, since it would be unable to compete in the market. Other times, a dollar store opens where community grocery stores do exist and proceeds to run them all out of business. Like an invasive species, dollar stores in low-income areas often drive any potentially growth-checking competitors to extinction. They make it difficult for other types of local businesses to keep up, take root, and grow too, thus harming a community’s commercial stability and employment opportunities. The displacement of grocery stores by dollar stores also creates food deserts, which the Centers for Disease Control and Prevention (CDC) defines as “areas that lack access to affordable fruits, vegetables, whole grains, low-fat milk, and other foods that make up a full and healthy diet.”³ Dollar stores are not sufficient substitutes for grocery stores. Most of them only stock a limited selection of non-perishables and processed foods like canned peaches, potato chips, and frozen waffles, with no fresh food options to be found.⁴ It follows, then, that although the food at dollar stores might be affordable, it cannot sustain full, healthy diets for the customers who rely on this fare alone. Lacking access to healthy foods is a primary risk factor for cardiovascular disease. As the current leading cause of death in Americans, heart disease results in over 635,000 deaths in the US every year.⁵ Already, these diseases disproportionately affect African Americans and those of low socioeconomic status due to a deep history dealing with societal risk factors, including lack of access to safe neighborhoods for exercise and healthy food options. T h e

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CDC states that diets high in saturated fats, trans fat, sodium, and cholesterol are linked to higher rates of heart disease and obesity.⁶ And yet, these are often the only diets feasible in neighborhoods characterized by a combination of low incomes, high percentages of African Americans and Hispanics, and high population density. Studies have proven that such communities across the country lack access to local supermarkets.⁷ Additionally, these same neighborhoods with limited access to grocery stores tend to have increased access to unhealthy fast food and convenience stores- a problem that the rapid proliferation of dollar stores in these areas is only exacerbating. Low-income zip codes in America have 30 percent more convenience stores, which tend to sell mostly high-sodium and high-sugar packaged food items, than middle-income zip codes.⁷ These convenience stores, and unhealthy packaged foods more generally, also tend to be priced lower than healthy food items and fresh produce. Under these circumstances, people with low incomes are more likely to shop where prices are lower.⁸ The recent dollar store trend clearly demonstrates this pattern and will likely intensify the prevalence of cardiovascular disease and obesity in low-income communities. It marks another case in a long history of institutional health consequences for the population that already demonstrates the greatest need for better healthcare. The United States is not the only country where dollar stores exist. In Singapore, ValuDollar and Japan-based Daiso Sangyo are two popular discount retail chains. Plenty of shoppers frequent these stores regardless of the state of the economy. In Singapore especially, as one of the wealthiest cities in Asia, the average consumers at its dollar stores are price-conscious shoppers looking for a wide array of bargains and nifty gadgets like “grape grippers”, rather than low-income shoppers dependent on the stores for necessities.⁹ In Europe, many stores and companies are also following America’s lead and specializing in products sold at a one-euro price point. Although consumers from a range of economic backgrounds shop Flickr

at these stores, the fact that their growth has especially launched in the past decade, as countries like Spain and Italy fell into periods of recession, indicates that they profit most from low-income consumers.10 Since dollar stores serve different target audiences in Singapore versus America, their expansion in the city-state would likely not result in the same health consequences as it does here. The similarity in target audience and growth of European dollar stores compared to American ones, however, could be a predictor of similarly increased rates of cardiovascular problems and obesity to come in those low-income communities abroad. Although dollar stores can provide some immediate, affordable food options for communities in need, they are likely causing more harm than good in the longrun as the health and economic stability of these areas continues to deteriorate. The ILSR recommends that communities take action to halt the expansion of dollar stores by setting limits on chain retailers in the area and strengthening other planning review policies. However, if the root of the problem is that these communities lack affordable healthy food options locally, the most effective suggested solution may be expanding financing for locally owned grocery stores and food banks via loans and tax incentives. These programs are often the most successful and rewarding for communities. The Pennsylvania Fresh Food Financing Initiative, for example, supported more than eighty grocery store projects in the state.¹ In New Haven, non-profit organizations like the Downtown Evening Soup Kitchen and the Restaurant Rescue Project work towards providing nutritious food directly to those in need. Encouraging non-profits and government bodies to help finance local grocery stores and food banks could be the best way to improve the health of residents in low-income communities and eliminate their need to rely on stores like the Dollar Tree for food altogether. www

Indira Flores is a junior in Grace Hopper College who plans on studying Molecular, Cellular, and Developmental Biology. She can be contacted for questions at indira.flores@yale.edu.

Cervical Cancer Screening

3D illustration of human papillomaviruses (HPV)

YALE GLOBAL HEALTH REVIEW

By Lena Goldstein

nce the leading cause of cancer death among women, the CDC estimates that this year, in the United States, less than 5,000 women will die from cervical cancer. This dramatic reduction in mortality (>60% in the last several decades) is accompanied by a similar decrease in the annual incidence of cervical cancer.1 These dramatic statistics rest solely on one technique: cervical cancer screening. While cervical cancer was thought to be associated with a sexually transmitted disease, its exact etiology was not known definitively until the 1980s. Harald zur Hausen, a German scientist, won the Nobel Prize after he successfully isolated strains of human papillomavirus (HPV). He then used these strains to probe biopsies of cervical cancer. 2 Still, it was not agreed until 1999 that virtually all cases of cervical cancer (99.7%) contain HPV DNA within them.3 Today, the process of HPV-mediated carcinogenesis is well understood: the viral DNA is inserted into the DNA of the rapidly dividing cervical cells thereby disrupting genes that normally suppress cancer. While more than one hundred strains of HPV have been identified, only 14 are classified as “highrisk” strains capable of inducing cancer.4 This timeline of biological discovery for cervical cancer, like with so many other diseases, diverges drastically from the history of treatment and screening. Several decades prior, in 1925, Dr. George Papanicolaou began methodically collecting vaginal smears volunteered by women working in the New York Women’s Hospital. These were evaluated for the first diagnostic marker in determining cervical cancer in its early stages of growth.⁵ Coined the “Pap Smear,” this screening method was first published in 1941 in The American Journal of Obstetrics and Gynecology.6 Soon thereafter, the Pap smear was implemented for use in mass screening programs and campaigns led by the American Cancer Society and National Cancer Institute.⁷ Today, the Pap smear is still the cervical cancer screening method of choice amongst most American women, though more recently testing for high risk strains of the HPV virus itself has become more widely available. Human Papillomavirus

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HPV is common; in fact, most sexually active men and women will become infected at some time during their adult lives, making HPV the most prevalent sexually transmitted disease in the United States.⁸

There are several known risk factors for high-risk HPV infection, including early age of sexual activity, immunosuppression, multiple sexual partners, tobacco use, low socioeconomic status, and long-term use of oral contraceptives.⁹ While most cervical HPV infections are transient and self-limiting, approximately 10-15% of cervical HPV infections remain persistent. These are the infections lasting more than two years. It is not known which of the above risk factors determines persistence of cervical HPV infection (though longitudinal studies are underway), but oncogenic HPV strains are more likely to resolve in younger women.¹⁰ While there is no treatment for asymptomatic HPV infections, there are several HPV associated conditions, such as genital warts, that require treatment.11 Among persistent strains, the progression to invasive cervical carcinoma occurs throughout a 10 to 20 year period in immunocompetent hosts.12 Most importantly, slow oncogenesis allows cervical abnormalities to be detected early and treated in a minimally invasive manner.10 Undeniably, the most effective method for preventing cervical cancer is detection in a precancerous stage. Unidentified or untreated precancer can transform into invasive cervical carcinoma. Cervical Cancer Screening Methods Despite the resounding success of the Pap Smear in countries such as the United States in the last several decades, much of the developing world still lacks access to screening. As a result, more than 80% of cervical cancer deaths occur in the developing world, and cervical cancer remains the second most common cause of cancer death among women in resource-poor countries.⁷ This unequal burden can be reduced by utilizing new biotechnology discussed below. The general success of a cervical cancer screening program is reflected in the optimization of false negative and false positive results.10 In medical testing, sensitivity is defined as correct identification of patients with disease (true positives) and specificity as the ability to recognize those patients who are disease-free (true negatives). Goals of an effective screening program also include minimizing cost and risk to patients as well as maximizing patients screened per physician per day. Additional factors that should be considered when designing the best screening programs include sustainability, percent-

age of patients lost to follow-up, quality control, and documentation. As discussed above, the Pap smear remains an important cervical cancer screening technique. Yet, its limitations prove difficult to overcome in resource-poor settings. First, Pap smears involve an examination, during which a sample of cervical cells is collected. The sample is sent for evaluation by a cytopathologist, and the turn-around time for results can take between several days to several weeks. The time lag between performing test and obtaining results can lead to a high rate of women lost to follow up care. An additional shortcoming of the Pap smear is that while it has a high specificity, it has a relatively low sensitivity. In addition, it is rather costly and there is a shortage of well-trained cytopathologists in resource-poor countries. In fact, in a recent study completed in Peru among 4,535 women, Almonte and colleagues found that cytopathologists only correctly identified (within a sample of Pap smears) 33.6% of high-grade precancers and 42.5% of carcinomas in situ.13 Geographically, undeniable disparities in access and appropriate diagnosis of the Pap smear persist. If the Pap smear shows evidence of dysplasia (precancer), additional testing is re-

quired before treatment can occur to determine the severity of the precancer/cancer. This testing, which needs to be performed by a highly trained physician is typically colposcopy (visualizing the cervix with magnification) and biopsy. Again, there a shortage of welltrained colposcopists in resource-poor countries and there is shortage of pathologists to read the biopsy specimens. These limitations led to the development of several new cervical cancer screening techniques to be used predominantly in resource-poor countries. Most notably, the Visualization with Acetic Acid (VIA) exam provides a low-cost alternative to the Pap Smear in which a diagnosis is made immediately. In a VIA examination, acetic acid is applied to the cells on the cervix, causing any abnormal cells to turn white. Remarkably, the VIA exam seems to address many of the shortcomings of the Pap smear; a recent comparison of the techniques demonstrated higher sensitivity of the VIA exam than Pap smear.14 Most importantly, however, is that the VIA exam can be performed and diagnosed as positive or negative within minutes, which is more appropriate in low-resource settings where women are frequently lost to follow-up care. Of course, VIA is only a diagnostic marker, and like the Pap smear, gives diagnostic information that requires further medical observation or intervention. Reducing the turn-around time from at minimum one week for a Pap smear diagnosis to a few minutes for the VIA diagnosis has revolutionized screening programs in developing countries. Unfortunately, VIA is not without its limitations. Specifically, the diagnosis is

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Pap smear of normal cells (left) and HPV-infected cells (right)

dependent on the provider’s skill level. While mid-level providers such as nurses and midwives can perform VIA, the skill at which they interpret the results varies considerably. Without documentation of the pathology and with no images of the cervix, there is very limited quality control or objective documentation for future reference. Digital Cervicography (DC), in which a photograph of the cervix is obtained, bridges this important gap by facilitating permanent patient records. When used as an adjunct to VIA, digital cervicography allows for magnified surface morphology and quality control without adding any significant cost or time to the screening process. The advantages of this technology are only just being realized, and the future looks towards telemedical support and the use of artificial intelligence to interpret the DC images. As mentioned above, advances in the world of of molecular biology have allowed for the direct detection of the DNA of the high risk HPV virus. While this test is quite expensive in comparison to the Pap smear and VIA, it is both more sensitive and specific than either of those two tests. In 2001, the American Society for Colposcopy and Cervical Pathology convened with other organizations and decided that the, “management of abnormal cervical pathology by triaging with molecular HPV testing became a “preferred” management strategy.”15 The FDA has approved two approaches: co-testing (HPV-test combined with the Pap smear) or just screening with the HPV-test.16 Cost and laboratory supplies required for HPV-DNA Assay tests were barriers in low-resource settings however, recently the CareHPV system, a rapid, low-cost, high-volume HPV detection system, was developed with a grant from the PATH foundation to be used in low-resource settings. This system can test 90 specimens in three hours at a cost of $6 per specimen which is less than 5% of the cost to run an HPV test in the U.S. In a global health settings, where mass-screening programs are underway, testing patients for high-risk HPV (hrHPV) strains can serve as a precursor to traditional cytologic or colposcopic screen-

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ing. This triaging eliminates any patient negative for high-risk HPV from further examination based on data that demonstrates that the progression of cervical lesions is always associated with persistent hrHPV infections. Finally, HPV-DNA testing samples can be obtained by the patient herself (by performing a vaginal self-swab), thereby greatly reducing the number of on-site providers necessary.17 Treatment Methods and Considerations Cancer of the cervix progresses sequentially; persistent HPV infections manifest in precancerous abnormalities in cervical cytology called cervical dysplasia. Cervical intraepithelial neoplasias (CIN) progress from low grade (CIN 1) to moderate grade (CIN 2) to high grade (CIN 3) on histology. Standard recommendations following diagnosis of CIN 1 include monitoring for progression,18 while treatments for CIN 2 -3 include cryotherapy, loop electrosurgical excision procedure (LEEP) and cold knife conization (CKC).19 Unidentified or untreated dysplasia can transform into invasive cervical carcinoma, where they become very difficult to treat. Many of the challenges involved in primary cervical cancer screening in low-resource areas apply to treatment programs as well. Patients lost to follow-up (due to a lag time between primary test and results) can be reduced if screening programs adopt a “screen-and-treat” approach. The World Health Organization guidelines for treatment CIN 2-3 focus primarily on a “screen and treat” approach in which treatment decisions depend on the results of a screening test rather than on histological (biopsy) confirmation.20 The screen-and-treat approach links the screening process to immediate treatment, streamlining the healthcare process for patients and providers. Screening Intervals and Guidelines The American Society for Colposcopy and Cervical Pathology publishes regularly updated guidelines for cervical cancer screening. The demographic for screening consists of women ages 30-65, though the frequence is

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3D illustration of HPV infecting the reproductive tract

dependent upon the screening test performed. The co-testing method (cytology and HPV testing) should be repeated every five years, while cytology testing alone should be repeated at a three year interval. These intervals are due in part to the increased sensitivity of cotesting. Unfortunately, evidence suggests that co-testing is being used (mostly in developed countries) at intervals shorter than every three years, amplifying the potential harms associated with screening and increasing the number of colposcopic referrals.21 For women ages 21-29, the recommended protocol involves cytology (Pap smear) screening every three years. Interestingly, HPV testing is not recommended, because of the high prevalence of HPV in younger women (most of this HPV will prove transient).22 High-Risk HPV Prevention Preventing persistent high-risk HPV is fundamental to eliminating cervical dysplasia and carcinoma. Because barrier contraceptive methods such condoms are only 70% effective at preventing HPV infection transmission, vaccinations serve as a better alternative. 23 Ideally, the vaccination doses should commence prior to HPV infection. The Center for Disease Control and Pro-

tection outlines the three FDA approved HPV vaccinations for use in the United States, including Gardasil, Gardasil-9, and Cervarix. 24 While no evidence suggests that HPV vaccinations lose their effectiveness over time, long-term data is still being collected and patients should continue to undergo cervical cancer screening as described above. Conclusions There are more than 1.7 billion women worldwide who have never been screened for cervical cancer. Screening a women over the age of 35 just one time in her life can decrease her risk of dying from cervical cancer by 70%. While preventing all incidence of cervical cancer is unrealistic (no screening method has perfect sensitivity), screening/treatment protocols and biotechnology can be utilized to change the global burden of cervical cancer disease. Most importantly, many of these strategies can be adapted as part of high volume, low-cost, and rapid screening programs for low-resource settings. www Lena Goldstein is a sophomore in Silliman College who wrote this article her first year. She can be contacted at lena.goldstein@yale.edu.

The Elusive Antidote to Rising Prescription Drug Prices By Nishanth Krishnan

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n 2003, then president George W. Bush beamed as he signed Medicare Part D into law in front of a bipartisan roster of congressmen and women. In bright, block letters, a sign on Bush’s desk read “Keeping our promise to seniors.”¹ Medicare Part D was a landmark addendum to the original Medicare program, intended to provide supplemental coverage for items like prescription drugs for the nation’s 40 million seniors. “Our government is finally bringing prescription drug coverage to the seniors of America,” Bush told reporters.2 Among those standing behind Bush during the signing ceremony was Senator Chuck Grassley (R-IA), chief architect of the law and chair of the Senate Finance Committee. “[This] legislation brings Medicare into the 21st Century by making the program more competitive, which keeps costs down,” Grassley would say during a committee meeting.3 Sixteen years later on a cold February morning, Grassley took his seat in a Capitol Hill hearing room and faced seven executives from multinational drug manufacturers, seated solemnly behind a long wooden desk. Grassley arched forward, briefly greeted the men and women seated before him, and began to speak. “America has a problem with the high cost of prescription medicines.” www

ing symptoms of malaria.5,6 Under the pretext that the drug was previously sold at a loss, Turing issued price increase well over 5000 percent. In courts of justice and public opinion, consumers displayed outrage laced with unsettling confusion on how such price spikes were legal. Reports from investigative journalists and Congress brought drug pricing to the fore of the public conscious. A year later, similar outrage erupted immediately when Mylan, producer of EpiPen epinephrine injectors, engaged in price gouging by dramatically raising prices.7 Mylan and Turing are glaring examples of a broader systemic issue posed by exclusive manufacturing rights to drugs. With no available generic version of the drug, Daraprim was leveraged by its manufacturer to demand extraordinary prices. As Americans and their representatives on Capitol Hill have come to learn, price gouging is a practice levied by many pharmaceutical companies doing business in America. The Curious Case of Evergreen Patents At its most basic level, patents afford inventors protected rights to an idea in exchange for making the discovery public. To reward innovation, patents issued in the United States often include terms that protect these rights generally for twenty years. After the patent term expires, the patent enters the public domain.

Drug patents are no exception. However, current laws permit companies to make modifications to a patented drug, which can then be patented again. As long as the change demonstrates an improvement to the drug’s efficacy, however slight, the new patent will effectively extend the company’s rights to the drug well past any initially allotted time.⁸ Evergreening, as the described practice is appropriately called, has been at the crux of burgeoning prices for essential drugs, like artificial insulin. Used by 30 million Americans to treat the disease, insulin is used to supplant the body’s lack of insulin in Type I Diabetes and quickly lower blood sugar in Type 2 Diabetes.⁹ Ironically, insulin was never patented by its inventors, who were keen on seeing the drug become widely available for the benefit of humanity. The royalty-free license for producing artificial insulin was provided by the University of Toronto to manufacturers shortly after its creation in 1923.⁹ But, since then, improved variations of insulin that are faster acting and injectable have been patented by pharmaceutical companies. In the North American market, three companies retain near-exclusive control of insulin sales: Sanofi, Eli Lilly, and Novo Nordisk. Their grip on insulin sales, supported through tactics such as paying competitors to exit the market, has been widely noted for years. But more recently, their utilization of evergreening patents

For nearly as long as prescription medicines have been sold, the issue how such medicines are priced has existed alongside it. By the turn of the 21st century, the complexity of private and public insurance programs, like Medicare, had turned pricing into a complicated calculus. The emergence of price negotiators and other middlemen introduced new dimensions to the pricing problem. But, as Congress reasoned in 2003, pricing mechanisms were inconsequential as long as the out-of-pocket costs for end consumers were reasonable.4 Complaints of rising drug prices from the average American continued to swell until 2015, when Turing Pharmaceuticals fired a figurative flare gun and signaled to America how deeply broken the system was. Turing had recently acquired the rights to sell pyrimethamine, marketed as Daraprim, in the United States.5 Since its FDA approval in 1953, pyrimethamine has been listed an essential drug by the World Health Organization to treat life-threaten-

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Social Security Administration

Former President Bush signing Medicare Part B into law in 2003. Medicare Part B would receive increasing scrutiny for its role, or lack thereof, in controlling prescription drug costs.

has been cited by the Congressional Diabetes Caucus as one of the primary reasons that drug prices remain high long after the drug’s development.⁹ Insulin has changed minimally in the past few decades. The same cannot be said for its price. In 1996, Eli Lilly launched a fast-acting insulin product called Humalog. The $21 vial of Humalog in 1996 now costs $274—well over 12 times the original price.10 Similar drugs from Lilly’s two competitors have increased prices in tandem, and with no comparable generic alternatives, consumers and their insurers are forced to shoulder the exorbitant cost. In the early 2019 hearings on drug pricing, Senator Grassley, expressed concern that his office had received thousands of letters from constituents complaining of insulin prices, among others. “I’ve heard about people skipping doses of their prescription drugs just to make them last until the next paycheck,” Grassley remarked to the pharmaceutical executives he called before the committee in February. In a letter to the CEO of David Rick, the chief executive of Eli Lilly, Grassley and Ranking Member Senator Ron Wyden (D-OR) requested specifics relating to any changes to the insulin formulation and delivery that merited the price increase. While the responses provided by Rick were not disclosed, Eli Lilly soon made the announcement that a half-priced alternative, Insulin Lispro, would be made available to customers.10,11

Though experts chalk the move up to a temporary solution, it seems clear that a crackdown on disproportionate price increases for modest improvements could be strategy for success. Along with it, the Senate Finance Committee has made clear that increased scrutiny on evergreening practices will follow soon. Last year, the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act was revived and is seeing renewed bipartisan interest in recent months. The bill will provide an enforceable pathway to create generic drugs in the hopes of broadening drug markets for products like insulin.12 A supported system for creating generics could catalyze market competition that Eli Lilly, Sanofi, and Novo Nordisk have actively avoided.

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America has a problem with the high cost of prescription medicines.

The Rebate Game

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In 2017, 56 percent of Americans with health coverage received their insurance through their employer.13 This is a unique and historically-rooted aspect of the nation’s healthcare system. A special type of company called Pharmacy Benefit Managers (PBM) administers facets of private insurance programs. PBMs can process phar-

macy prescription orders and coordinate with a network of pharmacies that insurers can use to get medications. Most critically, a PBM can create drug formularies. Formularies are essentially master lists that control which medications are covered, or not covered, under the employer insurance plan. When a PBM adds a company’s drug to their formulary, like Eli Lilly’s insulin product, the drug will be covered by insurance and the PBM will negotiate the drug’s selling price with pharmacies. In exchange, the PBM will take a cut of the profits earned by the drug’s manufacturer. Given how many Americans receive insurance through their employer, it is in a company’s best interest to have their drug listed on PBM formularies. But a problem emerges when multiple companies offer competing but similar products, like how Eli Lilly, Sanofi, and Novo Nordisk offer similar insulin medication. In order to get their insulin product on formularies around the country, all three companies offer generous rebates to PBMs. Over the years, competing rebate offers have sharply increased, as each company offers increasingly lucrative rebates to sway PBMs. The cyclical nature of these increases has pushed rebate payments to astronomical levels. In his testimony to the Senate Finance Committee, Dr. Oliver Brandicourt noted that his company, Sanofi, paid 7.3 billion dollars in discretionary rebates for all their drug sales in 2018.14 This adds to the 4.3 billion dollars in mandatory rebates payments made to public insurers like Medicare. With 21 billion dollars in gross sales, Sanofi disburses out over half of its revenue for rebate programs.14 As a consequence, Sanofi and other drug manufacturers have had to routinely increase list prices in order to recoup costs. While the list price is ultimately higher than the cost paid by PBMs, they are the starting point for new price negotiations each year.

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Senator Chuck Grassley (R-IA), architect of Medicare Part B, speaks during a Senate hearing.

Still, the price increases reflect the enormity of ballooning rebate offers. In fact, while Sanofi has increased the list price of its drugs across the board, the net price after rebates has been decreasing year over year. “Patients are in fact being asked to pay more when PBMs and health plans are paying less for the medicine,” stated Brandicourt. “This situation defies logic and should not happen.”14

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To their end, associations representing PBMs are eager to place blame back on pharmaceuticals. In a statement regarding a government decision to consider changes to the rebate model, the Pharmaceutical Care Management Association notes that “eliminating the long-standing safe harbor protection for drug manufacturer rebates to PBMs would increase drug costs.” From their perspectives, PBMs play a valuable role in negotiating lower prices for consumers and encouraging the adoption of generic alternatives. But Congress appears unwilling to follow either industry’s suggestion on who is at fault for rising prices. “We’ve all seen the finger pointing. Every link in the supply chain has gotten skilled at that,” noted Senator Grassley during the hearing.14 Regardless of where any blame ultimately lies, the Trump administration and Congress are equally keen on changing the current system to tamp down on inflating rebates.

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The issue of soaring drug prices has prompted creative and widereaching proposals for roping in costs.

Untying Medicare’s Hands

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As Senator Grassley grilled executives from the nation’s largest pharmaceutical companies, the largest health insurer in the country was absent. With over 59 million Americans covered, Medicare has historically been America’s largest insurer and purchaser of prescription drugs.15 So why was it absent from Senate hearings on drug pricing negotiations? It is because Medicare does not negotiate drug prices. In fact, it is legally barred from negotiating at all. When Bush signed Medicare Part D in to law, one of the sharpest criticisms of the expansions was that it continued to restrict the Centers for Medicare and Medicaid Services (CMS) from engaging in drug pricing negotiations with pharmaceutical companies. Even while Medicare Part D was being drafted in 2003, the rationale for this seemingly self-defeating policy was clouded; the so-called “non-interference” clause was designed to prevent the Department of Health

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A pharmacist helps an elderly gentleman choose his medicine.

and Human Services from interfering with the drug marketplace, out of a fear that the department could use throw their weight to demand prices below market value.16 However, it is increasingly evident that this longstanding policy is interfering with Medicare’s ability to advocate for lower prices as American taxpayers foot ever-increasing health care costs.

grams, like those run by the VA, in working with drug companies to lower costs for consumers. Though the overall impact on Medicare’s bottom line is unknown, new legislation like the Medicare Negotiation and Competitive Licensing Act will pave the way for increased options for the government to address rising drug costs in its own health care system.

“Medicare is one of the largest drug purchasers in the country. It should not be restricted from negotiating the best deal with drug manufacturers,” noted Senator Amy Klobuchar (D-MN) during an announcement for the Medicare Negotiation and Competitive Licensing Act.17 Klobuchar and other representatives introduced the bill earlier this year in hopes of providing a concrete path to improving Medicare’s negotiating position. As proposed, the Medicare Negotiation and Competitive Licensing Act would enable Medicare administrators to negotiate with manufacturers directly. To strengthen Medicare’s bargaining power, the act would also allow Medicare to give competing companies a license to produce an alternative generic, should negotiations fail.

An Appetite for Reforms

While the bill is still being debated and changed, there is a high likelihood that Medicare will receive some level of authority to negotiate this year. Both Republican and Democratic voters strongly support this change, with an average of 92 percent in favor across both parties according to a poll from Henry J. Kaiser Family Foundation.16 With this change, Medicare could join other government insurance pro-

Whether it is stamping out loopholes like evergreen patents, or expanding the negotiating rights of Medicare, the issue of soaring drug prices has prompted creative and wide-reaching proposals for roping in costs. Already, government hearings and testimonials have prompted drug manufacturers to reevaluate their business models and offer plans to produce generics and cheaper alternatives. In both chambers of the legislature, new bills are riding the political momentum to install new protections that prevent abuses in the system, like ballooning rebate rates. More than ever, ideas addressing issues in every layer of the system have created a positive outlook for manageable drug prices in the coming decade. www Nishanth Krishnan is currently a junior in Timothy Dwight College majoring in Molecular, Cellular, and Developmental Biology. He wrote this article his sophomore year. He can be contacted for questions at nishanth.krishnan@yale.edu.

Wellness Makes the World Go â&#x20AC;&#x2DC;Round An Examination of Refugee Access to Care within the 21st Century By Tomeka Frieson

YALE GLOBAL HEALTH REVIEW

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f one out of every three of us were a refugee, what would we do to ensure that we or the person next to us had proper access to healthcare—healthcare that could keep our families well and provide our future offspring a secure life? Having 33% of a country’s entire population categorized as refugees is not as hypothetical as one would think. In fact, quite presently, countries such as Jordan and Lebanon are dealing with the real-life ramifications of such an issue of delivering healthcare to those who seek asylum in their country.¹ In order to best start a discussion where various aspects of migrants’ and refugees’ access to healthcare are addressed, important terms, such as those describing the subjects and institutions in question, must first be clearly defined. A refugee, for instance, is not the same as a migrant nor an asylum seeker nor an internally-displaced person. Internally-displaced people, for one, do not have to cross country borders in order to escape socio-political persecution; their displacement, while indeed forced, takes place within the country.² Migrants, on the other hand, are more generally characterized as those who relocate in order to improve their lives (e.g., by finding work or reuniting with family), rather than due to blatant threat or persecution. What’s more, asylum seekers are those who have applied to the host country’s government for refugee status in order to permanently flee from persecution, but have not yet been granted federally-endorsed refugee status in the host country (i.e., they are still seeking their asylum). Refugees, then, are asylum seekers who have fled their home country due to armed conflict or persecution on the grounds of religion, race, nationality or political beliefs, yet have also officially been recognized by the host country’s government for having done so. These are the individuals who are forced from their homes with little hope of ever returning, and these are the individuals who are the focus of this investigative piece.³ Choosing refugees as the focus of this investigation stems from two socio-political interests. Firstly, because refugees are forced from their homes with very little chance of ever returning, it is important to more deeply understand how this permanent change in residence and introduction to a totally new healthcare system can be met by various social, cultural, and political barriers. Secondly, though, because refugees are officially recognized by their host countries, it is

easier to investigate access to and receipt of healthcare services from a political point of view, investigating more precisely what roles asylum countries’ legislative policies play in access to care. It is important to note that sanctuary cities and countries are more than just places around the world where refugees tend to gather in both safety and solidarity; these jurisdictions actually have policies in place to limit cooperation with or involvement in federal immigration enforcement actions. As such, refugees are typically guaranteed an extra layer of political protection against forces that might want to send these individuals back to areas of danger.⁴ While there are various sanctuary cities, states, and countries around the world that in and of themselves are in various stages of economic development, two countries with particularly disparate economic backgrounds—Lebanon and Germany— will be the focus of this investigative article. The goal of this investigation is to examine refugee access to care within the 21st century by examining various social, political, and cultural factors, as these all come together to create a comprehensive picture of global health. In addressing the refugee crisis through the lens of global health, then, it is important that the geographic, political, social, and cultural factors that all contribute to and stem from this topic be addressed as well. Thus, the two countries chosen were done so based on variations of the aforementioned factors: Lebanon for being the country hosting the largest number of refugees per national population, as well as a country that, while still economically developing, is more developed than many other countries around the world; and Germany for being the economically well-developed country that took in the largest number of refugees in 2017.¹ These countries, while similar in their ability to accept refugees within their walls, differ in terms of the amount of refugees accepted and how they each address the healthcare aspect of the refugee crisis. More than just a “them” issue, though, this is an “us” issue; just within the US, there are more than 150 sanctuary cities and counties.⁵ Taking this into account with the fact that refugees contribute positively to America’s economic success, occupying work sectors from manufacturing to healthcare to general services, a decrease in the health and wellbeing of refugees would impact the country in more ways than one.⁶

A Syrian refugee and her newborn baby at a health clinic

Starting with Lebanon, then, where 1 out of every 3 people encountered is a refugee, what draws refugees to this particular country? The answer might lie in where, precisely, refugees are fleeing from. According to the United Nations High Commissioner for Refugees (UNHCR), refugees seeking asylum within Lebanon typically originate from Lebanon’s bordering country of Syria.⁷ Thus, while the frequency of Syrian refugee immigration to Lebanon could be due to pre-existing familial ties (i.e., other family members may have already had to immigrate to Lebanon), it is also most likely due to proximity, being close enough to home to not have to spend all monetary resources on relocating but far enough to escape the eminent danger that prompted their emigration. This being said, in 2017, Lebanon ranked 4th globally in countries of asylum for refugees. Nevertheless, the country ranks 1st globally in its number of refugees per national population.¹ This statistic presents an immediate challenge for refugees, especially in cities like Arsal, where its refugee population is four times that of its constituents.’ In these types of areas, where rented rooms and tent cities are typically filled to capacity, refugees constantly face unspoken social and political pressures to consolidate or become invisible.⁸ For Syrian refugees continuous-

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A Congolese refugee family

ly seeking asylum in Lebanon, then, the question arises as to whether any Lebanese immigration policies are in place to address the refugee crisis. If so, is refugee health addressed or alluded to at all within the country’s healthcare policies? Research shows that Lebanon barely has any immigration policies, aside from allowing refugees to apply for government-backed political asylum and assurance that refugees can stay in the country should their mother country be too dangerous to return.⁹ On the other hand, there is, in fact, a healthcare system in place that serves refugees, allowing them to access primary care and emergency/ hospital care at a low cost. The discrepancy between the lack of immigration laws and more defined healthcare policies may stem from the fact that, for Lebanon, refugee health is public health. In 2015, Syrian refugees composed 30% of the total Lebanese population. If a group of refugees were to, say, contract a contagious disease, there is nothing stopping that disease from rapidly spreading, especially in areas of congested settlement. More than this, the disparate provision of healthcare among refugees and non-refugees would undoubtedly cause social tensions that could possibly launch the country into civil war if uncontrolled.10 Thus arises the question

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Iraqi refugee children

of whether or not refugees are aware of their ability to access and receive these healthcare services. According to Gertrude Dadzie, a scholar in public policy and administration at the University of Albany, while many refugees are aware of their ability to access these resources, the issue arises in actually doing so. For instance, many refugees struggle to or simply cannot afford healthcare expenses, even when highly subsidized by healthcare partners. They must then rely on overworked public hospitals to deliver their necessary healthcare. Invisible social barriers to refugees’ access to care also exist; even those who can afford healthcare costs can be turned away by hospitals or charged very high sums due to institutionalized discrimination. 11 Given the historical interactions of Lebanese and Syrian people, though, this social conflict makes sense; Syrian troops occupied Lebanon from 1976 to 2005, clearly not improving the countries’ relationships in any way.⁸ Consequently, much can be examined in the realm of interactions between refugees, the greater populace, and access to—as well as the receipt of—healthcare. To be able to access proper healthcare is one thing; to actually access it is another. According to Blanchet et al., the

Lebanese government puts a heavier focus on primary healthcare and emergency care services than more expensive treatments and hospital visits.10 Yet, given that 25% of Syrian refugee households contain at least one individual with a specific healthcare need that requires constant primary care, realistically affording and, thus, accessing healthcare services becomes a burden for many refugee families.11 Along with the disparity in access to preventive versus curative care services, the former of which might provide longer-term solutions to refugees’ healthcare needs, there appears to be another disparity between accessing and realistically receiving healthcare services.12 According to the Carnegie Middle East Center, approximately 76 percent of Syrian refugees in Lebanon live below the poverty line, set at about US$3.84 per day. More specifically, the UNHCR points out that more than half of the entire Syrian refugee population in Lebanon is currently living in conditions of extreme poverty, less than US$2.87 per day.13 This does not even include the gender pay gap, by which male Syrian refugees in Lebanon profit approximately US$206 per month to a woman’s only US$159 per month. Thus, truly being able to receive the healthcare services available to all refugees—that is, finding transportation to appointments,

paying expected regular visit fees, and affording unexpected medical costs— can be quite difficult and even impossible for some refugee families.14 The reason Lebanon was chosen above other countries as the subject of this investigation is due to the unique (yet increasingly more common) phenomenon of there being more refugees in the country than citizens. Not only does this pose an interesting plight for the Lebanese government, which is practically forced to create a healthcare system that addresses the numerous needs of refugees, but it creates a social power dynamic between the givers and receivers of healthcare. Consequently, it is not too difficult to understand how this institutionalized discrimination finds itself embedded within the healthcare system, where doctors can easily turn refugees away. Yet, to make this point more nuanced, it is important to note that Lebanon does not see itself as a permanent solution to, nor asylum for, the refugee crisis and is only considered a sanctuary country in the extent to which it houses more than 2 million refugees. 15 This all being taken into account, then, what’s going well within Lebanon to address the refugees’ access to healthcare, and what can be improved? Allowing access to healthcare services for refugees is a great first step, and Lebanon’s got that covered. It is truly the future steps—ensuring that all who require healthcare can feasibly afford it, or decreasing stigmatization within the healthcare force so that refugees can more openly and comfortably seek healthcare—where governmental struggles arise. To address these issues directly would be quite difficult due to the institutional and historical roots of discrimination, as well as the difficulty of reducing costs for inhabitants in a country that is already low on resources in many of its cities. As a country still in the transition from developing to developed, economic issues of self-sustenance will naturally arise, and although the provision of universal healthcare to refugees and other inhabitants is of importance to the Lebanese government, the country must also economically sustain itself and its increasingly privatized healthcare system. 10 Nevertheless, there are also indirect solutions, such as ensuring the access to and increasing the affordability of preventative, rather than curative, healthcare services. Some services, such as the free provision of vaccinations through WHO and UNICEF, or the waiv-

ing of vaccine-related consultation fees, are indeed in place. 16 Yet, many more preventative healthcare solutions stand to be created so that all of Lebanon’s inhabitants could spend their monetary resources on cost-effective, longer-term solutions to healthcare needs, decreasing the amount of medical expenses over time, and increasing the overall public health of Lebanon’s residents. Switching viewpoints to Germany, an economically developed country that was also the 6th largest recipient country of refugees in 2017, what draws refugees to this particular country?¹ Similarly to Lebanon, refugees, especially those from Syria, typically have family members in the country. In fact, well-established Syrian communities in Germany have been in existence for a long time, and even in 2011, 30,000 Syrian individuals already lived in Germany. 17 Yet, it is this pre-established connection with the country that draws more refugees towards it. More than this, though, Germany serves as a beacon of hope for many refugees who attempt to travel to the European Union, where economically wealthier countries may be able to offer them more financial security. With this in mind, one can only wonder how Germany chooses to address immigration through policy. According to the Migration Policy Institute, Germany has undergone a huge transition in its immigration policy over the last 20 years that has drastically increased refugees’ ability to live within the country. New legislation, for instance, not only makes it easier for refugees to become permanent residents or citizens, but integration classes are also offered, where foreigners can learn how to most effectively integrate legally and culturally into a new country. 18 This openness to immigration even extends to healthcare policies, where refugee access to medical care is legally regulated and mandated.19 Yet, despite refugees’ familiarity with the German healthcare system, barriers to accessing and receiving healthcare still exist. In addition to language barriers, real-life implementation of Germany’s refugee healthcare policies are met with legal regulations and cultural barriers. Refugees, for instance, do not typically seek primary care. Rather, the plethora of outpatient care clinics opened around the country provide refugees with medical assistance whenever they may need it. 19 Nevertheless, this method of refu-

gee access to care does not encourage long-term relationships with healthcare providers, whereby refugees’ health would be consistently and continuously followed by a particular healthcare professional. This hitch in the healthcare system may be due to the typical living situations of refugees, whereby a number of refugees live in concentrated, camp-like areas and, thus, struggle to access care while in isolation. And while refugees do have many opportunities to access care, it is important to note that the German healthcare system for refugees is still imperfect. Upon entering the country, for instance, refugees are sent to centralized camps that are isolated from major cities or nodes of activity, allowing for limited public transportation and, thus, limited abilities to receive medical care from the healthcare centers located in more populated areas. 20 Language and cultural differences can easily play into the difficulty of receiving healthcare services as well. Looking at Syrian refugees in particular, when they migrated to Lebanon, they could at least speak the same language as the country to which they were fleeing. Syrian refugees in Germany, however, are a slightly different case. The disparity in languages, with Syrian refugees communicating in Arabic and German health professionals communicating in German, can lead to mistakes in understanding, as well as frustration. Furthermore, cultural differences in how German citizens and refugees from various other countries seek out and practice healthcare, as well as stigma and discrimination arising from xenophobia, can lead to the unequal receipt of healthcare among these refugees and their non-refugee cohabitants. Thus, in the case of Germany’s provision of healthcare to refugees, what’s going well and what can be done to do better in the future? Firstly, what is going well is that refugees are very clairvoyantly offered access to healthcare, especially since Germany’s government officials acknowledge just how important refugees are to the country’s continued economic prosperity. Where Germany starts to falter, though, is the precise ways in which this healthcare is accessible by refugees. According to Christian Pross, a scholar at the Harvard School of Public Health, there are various layers of the care that can be received under the German healthcare system, with refugees with official asylum-seeking documentation and a job affording many more rights than those without either.20

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Yet, for refugees, this hierarchy of access to healthcare services has long-lasting effects. For instance, if a refugee mother living below the poverty line takes care of her six children full-time and, consequently, cannot afford to take up a manufacturing job, she might also struggle to obtain health insurance. This would lead to her family’s continuous use of emergency room treatments instead of seeking primary care and would, consequently, increase the amount of money Germany spends on state-sponsored wellness. Ameliorating this disparity in healthcare access among refugees of different socioeconomic statuses will be quite challenging. Refugees of different legal categories fall under different welfare laws, which are difficult to amend and lead to top-down bureaucracy where neither the doctor nor the refugee gets a majority of the say in the type of healthcare to be administered.20 Thus, the future of refugee access to healthcare in Germany may begin with leveling the economic playing field among refugees and other German citizens, allowing refugees increased access to part- and full-time jobs in which they could support their families, as well as earn more money with which to afford healthcare expenses. What’s more, the number of asylum-seekers registered in the country has steadily decreased from about 890,000 in 2015 to 186,644 in 2017. This was most likely due to the general perception among German government officials that the brunt of the refugee crisis had passed and that Germany no longer needed to accept such a large number of refugees. With refugee acceptance rates dropping within Germany, though, the country can now use the smaller influx to more effectively control and ensure equal access to and receipt of healthcare services for all refugees.21 In other words, with the smaller influx of refugees and the redistribution of funds and equal distribution of healthcare clinics around the country, the future of refugee healthcare access in Germany could be very bright. Choosing the two countries to discuss within this investigation was a difficult choice, as the goal was to examine two countries that differ in important geographic and socioeconomic criteria and, thus, may have unique solutions to refugees’ access to care within the 21st century and especially after the refugee crisis. This goal was indeed accomplished throughout the piece by addressing differences in refugee demographics—Lebanon has the largest ref-

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ugee-to-national-population ratio, with refugees making up 33% of the country’s total population, while Germany accepts Europe’s largest influx of refugees that only make up 0.22% of the German total population—differences in the countries’ socioeconomic status—Lebanon is considered a developing country inching closer toward development while Germany is fully economically developed—and differences in the countries’ geographic locations.22 Nevertheless, there are other factors that might affect refugees’ ability to access care that were previously only briefly mentioned. Refugees, for instance, have different living situations depending on where they flee, and the comparison of Lebanon and Germany is a great example of such a phenomenon. In Lebanon, in particular, refugees tend to live in the poorer cities around the country. Yet, cities with already-strained resources may face increasing difficulties in reallocating funds towards the creation of a new clinic when they themselves are worried about finding potable water to drink. On the other hand, refugees throughout Germany tend to live in centralized camps that are hard to access by public transportation. Depending on whether or not an outpatient clinic is located near the centralized campsites, then, the access to healthcare for these refugees can either be very good or very bad. Applying these concepts to various sanctuary cities around the world—and even those non-sanctuary cities that refugees tend to inhabit—it is evident that the geographic location of refugees matters. Thus, instead of concentrating refugees in certain low-resource areas where access to healthcare may be limited, integrating the refugees with the greater populace where consistent healthcare access is typically already established may be a way to encourage increased access to and receipt of healthcare services worldwide. When applying the lessons learned throughout this investigative piece to the vast majority of cities that host refugees around the world, it is important to acknowledge that the countries addressed within this piece might allocate more resources than average towards refugee health. This being said, not every country or city that refugees inhabit will be able to reallocate resources to address healthcare access in the same way. Because of this, what else can be done to increase refugee access to healthcare without majorly upsetting countries’ or cities’ socioeconomic situations? Take, for exam-

ple, Syrian refugees that, although not intended to be the particular subject of this investigation (as this investigation attempts to examine the typical trends in access to healthcare for all refugees around the world), have been referred to multiple times due to the very impactful Syrian refugee crisis that occurred within the 21st century. The visibility of these refugees must be increased and the discrimination faced by them decreased. There is a certain vulnerability attached to being displaced and possibly feeling both politically and socially powerless within a foreign land, and the healthcare needs of refugees are diverse. In starting to address this issue, then, Germany’s government has increasingly publicly acknowledged just how critical refugees are to Germany’s economy, a method that encourages both refugees and citizens to actively participate in advancing the nation. Thus, simply recognizing and welcoming refugees and allowing them to integrate into the rest of the population can encourage these individuals to take the necessary steps to seek out healthcare without the fear of being turned away for being a foreigner. In the case of refugees’ access to and receipt of healthcare services, refugee health is public health is global health. In fact, even in New Haven, Connecticut, from where this article has been written, thousands of resettled refugees are taking asylum. If we fail to allocate proper healthcare resources towards these refugees, we fail to take care of an integral portion of our population that contributes to both the economic and sociocultural growth of this city. And suppose an epidemic breaks out among various members of a community, city, state, or country. In collectively defending against and preventing the further spread of the epidemic, is it not better to protect all of us than some of us?

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Tomeka Frieson is currently a junior in Berkeley College majoring in the History of Science, Medicine, & Public Health and Ecology & Evolutionary Biology. She wrote this article her sophomore year. She can be contacted for questions at tomeka.frieson@yale.edu.

The First CRISPR Babies

A Reflection on the Promise and Perils of Gene Editing By Kelly Farley Wikimedia

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hat if you had the power to prevent your baby’s hereditary diseases before birth? With the continued development of gene editing, that possibility may be more feasible than once thought. In fact, with the recent work of Chinese scientist He Jiankui, it seems as if that day is coming closer and closer. In November 2018, He shocked the world when he announced that he had genetically altered two embryos in an attempt to prevent HIV infection.¹ These embryos have now been born as healthy twin girls and are the world’s first CRISPR-edited babies.¹ Since his announcement, He has been heavily criticized by the international community and has been put on house arrest by the Chinese government.² As human genetic alterations become more and more of a reality—and creating regulations regarding the matter becomes more and more of a priority—we must reflect on the promise and perils of the matter. What is CRISPR? CRISPR, short for Clustered Regularly-Interspaced Short Palindromic Repeats, is a form of gene editing first introduced in 2013.³ The CRISPR system was originally evolved in bacteria as a defense mechanism against viruses and is composed of an enzyme called Cas9 that cuts at a targeted DNA sequence and a short strand of RNA that guides the enzyme to this sequence.³ After Cas9 cuts the DNA, the cell’s natural DNA repair sequence works to put the DNA back together using a new DNA sequence provided by the CRISPR complex.³ Unlike previous gene editing technologies, CRISPR edits DNA at the nucleotide base level, allowing for precision editing of small strings of DNA.⁴ In some cases, a faulty gene is edited such that it is “knocked out” and will no longer be expressed; in others, the faulty gene is edited such that it produces the correct protein.⁴ Changing even a single DNA building block can significantly alter the proteins produced, potentially impacting the likelihood of inheriting certain diseases or physical conditions.

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The Promise CRISPR is fast, cheap, and quite accurate. Besides editing human embryos to eliminate diseases before birth, CRISPR could be used to edit diseased cells that could be reinfused into an adult patient to repopulate their body with healthy cells. This treatment could be used to treat— and even cure—the over 7,000 diseases caused by a single mutated gene and for certain types of cancer.⁴ In vivo experimentation has demonstrated the curative potential of CRISPR. In 2014, CRISPR was used to cure a fatal genetic disease in mice.⁵ Also in 2014, CRISPR was used to edit the genes of human embryos to repair a mutation associated with a heart defect.⁵ Though these embryos were not implanted, they were found to be mutation-free, without any unwanted extra mutations, implying that the technology could be successful if used clinically in the future.⁵ The Perils Germ-line gene editing (i.e. editing the genes of an embryo) can protect babies, as well as all of their descendants, from disease. While it may seem beneficial to have such long-lasting effects, it may also be worrisome. CRISPR is not yet entirely accurate. When trying to edit one specific gene, another

similar gene may also be edited. Even if we think that we are measuring the changes we are making, it is possible that our technology is not sophisticated enough to detect every change we make among the 3 billion base pairs in the human genome.⁶ If an incorrect edit were made and left undetected, the mutated gene would be passed down from generation to generation, leading to potential detrimental changes in an individual’s family and the human population as a whole.⁶ CRISPR-altered cells have already been shown to be problematic. In June 2018, two studies showed that anti-cancer mechanisms are absent in CRISPR-altered cells, thus making it more likely that these cells will initiate potentially malignant tumors.⁷ In particular, the anti-cancer gene p53 is found to be inactive in CRISPR-edited cells. This gene promotes death of cells with damaged DNA, not only preventing cancer but also CRISPR edits.⁷ Therefore, cells that survive CRISPR editing are normally deficient in p53 and especially vulnerable to cancer.⁷ In July 2018, a study showed that the DNA repair process involved in CRISPR is error-prone and results in mutations both at the CRISPR-edited site and much farther away.⁸ Even though CRISPR relies on a guide RNA that corresponds to a specific stretch of DNA to be edited, it is possible that other genes share the same DNA sequence and may be unintentionally edited. Because mutations far away from the site of CRISPR editing had previously been overlooked

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The CRISPR complex is composed of the Cas9 enzyme that cleaves the DNA and the guiding RNA that ensures that Cas9 cuts at the precise DNA site.

clinical trials involving germline ending, and the National Institutes of Health does not fund gene-editing research in human embryos.10 Germline gene editing that could affect generations to come has essentially been curbed until the safety of CRISPR is better understood.

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CRISPR makes breaks in double-stranded DNA to remove a DNA sequence, which can then be repaired by the cell's natural repair mechanisms.

when confirming the accuracy of CRISPR, there are concerns that we may not be able to fully understand the extent of the changes we make. In addition to introducing detrimental mutations, completely eliminating disease-causing mutations may be harmful. Take the elimination of all sickle-cell anemia genes, for example. While carrying two copies of sickle-cell anemia genes can be fatal, carrying only one copy protects against malaria, which is just as fatal as sickle-cell anemia.⁹ Thus, removing both copies of sickle-cell anemia from a person would merely exchange sickle-cell anemia for malaria and would likely not leave humankind any better off.⁹ With our limited understanding of how various genes are connected, gene editing could result in us unintentionally replacing one disease with another.

a biotech entrepreneur and a lecturer at the Yale School of Management, “These downsides are mostly theoretical. Designer babies are more of a science fiction story than a reality.”⁶ Currently, CRISPR technology is not advanced enough to create designer babies—and it likely never will be. Traits such as height and intelligence are controlled by thousands of genes. Furthermore, traits are not solely determined by the genetic code but are also influenced by the environment. A gene does not encode a trait. It controls a protein that interacts with other proteins to produce complicated effects. The Present In the United States, the Food and Drug Administration (FDA) does not approve

However, in other countries, the regulations regarding germline editing do not exist and/or are not enforced. In November 2018, Chinese scientist He Jiankui revealed that he had used CRISPR to genetically edit two embryos who have now been born as twin girls Lulu and Nana.¹ To prevent HIV infection spreading from the father, He removed the gene that controls the production of the CCR5 protein to which the HIV virus binds when infecting T cells.11 One embryo had both copies of the CCR5 gene removed, while, inadvertently, the other embryo had only one copy of CCR5 removed.11 Working alone, Hei was on leave from Southern University of Science and Technology when he conducted his experiment in secret. In the process, he broke Chinese law and the general international scientific consensus that CRISPR was not yet developed enough to be used in implanted embryos.12 Chinese authorities and the international community immediately condemned his work. His lab has been shut down, and he has been put under house arrest.² “Although He’s work is concerning, the reaction from both Western governments as well as the Chinese government is reassuring,” said Dr. Licholai.⁶ “The backlash has been so loud that it will probably stop anybody

But perhaps most publicized are the social concerns of CRISPR. Gene editing brings to mind thoughts of eugenics. After deciding to edit genes that result in disease, why not also edit genes that alter height or intelligence? Who gets to decide which traits are worth passing on to the next generation? Is it the parents’ right, or should the government intervene? And what happens if this technology is not available to all? If only the upper-class can afford to genetically alter their children, will the gap between rich and poor increase as the upper-class obtains even more of a life advantage? Nevertheless, scientists warn against overestimating the social implications of CRISPR. To Dr. Greg Licholai (MED 1995),

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The Chinese scientist He Jianku was criticized for using CRISPR to genetically alter the genes of two embryos who were recently born as twin girls.

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else from considering doing anything like it again.”⁶ Critics question He's motives in editing this CCR5 gene. There are many treatments that can prevent or treat HIV/AIDS, so the risk of HIV infection was much lower than the risk of CRISPR editing. Even if no off-target mutations did occur as a result of CRISPR (as He claims), some point out that a deficiency in CCR5 receptors puts the twins at risk for other diseases such as West Nile virus and influenza.¹ Questions remain regarding whether the mother was informed about other options for HIV prevention and treatment and about the risks of CRISPR therapy. If she had been adequately informed, it is uncertain whether she would have consented to the risky procedure. 13 “He was completely out of line in imposing such a terrible ethical decision on these two human beings before they were born. It was self-serving and grand-standing and a move to increase the researcher’s personal fame instead of treating a disease,” said Dr. Licholai.6 However, He argued that HIV is so stigmatized in China that preventing the disease in the first place was worth the drastic effort. The subjectivity of the ethical code surrounding CRISPR is apparent. What seems unnecessary in the Western world may have seemed urgent to him. He thought his efforts could benefit the greater good, explaining, “Do you see your friends or relatives who may have a

“

advantages and disadvantages of CRISPR. The fact remains that, while CRISPR still has its technological and ethical kinks, it also has the potential to cure a range of devastating diseases, and an

overarching ban on research in the a r e a may result in more harm than

good.

Dr. Licholai is optimistic about the development of CRISPR as it is still a very new technology.⁶ In his opinion, “The positives outweigh the downsides. The research should continue but in a responsible way.”⁶ Once the technological issues with off-target mutations are addressed, CRISPR could be safely used to drastically reduce the burden of disease without endangering the population as a whole.⁶

All in all, the shift to using gene editing as a therapeutic treatment may not be as dramatic as one would think.

disease? They need help. For millions of families with inherited disease or infectious disease, if we have this technology we can help them.”14 The Future He’s work has shocked the international community. Scientists and laypeople alike worry about scientists who betray international ethical codes, the safety of the twins, and the potential future use of CRISPR to create designer babies. Such worry lends itself to a paranoid response instead of a reflective discussion of the

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”

Moving forward, Dr. Licholai predicts that the future of CRISPR will not be dominated by ethical concerns but rather safety concerns.⁶ If CRISPR eventually meets FDA standards of safety and efficacy, Dr. Licholai finds it highly probable that the CRISPR drugs will be approved.⁶ The price of CRISPR will likely be very high because, unlike most drugs, it is a curative option: a one-time payment instead of a monthly one.6 Given the lofty price and the somewhat unreliable outcomes, the reimbursement model for CRISPR may be outcome-based, in which payment is not requested until it is proven that the ther-

apy works.⁶ All in all, the shift to using gene editing as a therapeutic treatment may not be as dramatic as one would think. “People should be educated about new medical technologies like CRISPR, both so they do not naively think it will answer all the world’s problems but also so they will not be terrified by it and shut it down immediately,” said Licholai.⁶ CRISPR will not save the world, nor will it destroy it. We should respect the perils of CRISPR while still moving forward to discover its potential.and may be unintentionally edited. Because mutations far away from the site of CRISPR editing had previously been overlooked when confirming the accuracy of CRISPR, there are concerns that we may not be able to fully understand the extent of the changes we make. www

Kelly Farley is a sophomore in Morse College interested in science communication. She wrote this article her first year. She can be contacted for questions at kelly.farley@yale.edu Pictured Above: The HIV virus can only attach to T cells displaying the CCR5 protein. He genetically engineered the embryos to not express CCR5 so the HIV virus could not bind and infect the cells. Source: Wikimedia

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Psychosis and Possession The Medicalization of Spirituality in Sub-Saharan Africa By Sam Brakarsh

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was in the Chikukwa community in Zimbabwe with a member of the traditional leadership when he removed a book from his backpack. He was young but respected because he took it upon himself to sit down and talk with all of the elders and record their traditional knowledge. I recall the moment when we were seated together and he proudly told me of the book he was reading: Where There Is No Psychiatrist by Vikram Patel.¹ When prompted, he said he read it to understand the labels the West used for such states. They provided insight but were often incomplete or misconstrued in his community. The village had possessions—where people are inhabited by a spirit, usually ancestral—but dealt with them through their traditional structures of healing and leadership. However, in a world increasingly dominated by Western conceptions of mental illness, in a region standing in the postcolonial shadow, the overlay of culture is far from simple. This image—of a copy of Where There Is No Psychiatrist sitting in Zimbabwean— has stayed with me. Over the last several decades in Sub-Saharan Africa, there has been an imposition of “Western” models of psychosis. Although there is significant benefit that comes with psychosocial drugs and technologies, the application has largely ignored the pre-existing cultural framework leading to a disruption of traditional systems of power and healing. In order to understand this conflux, it is important first to engage with both the cultural and historical context in which it is taking place. This paper places the Western concept of psychosis and the traditional view of possession in conversation with one another in order to unpack both the colonial heritage and the present-day implications of the state of modern psychiatry and the hybridization process that it is undergoing.

discussion, this influences how individuals express their illness.²

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Although there is significant benefit that comes with psychosocial drugs and technologies, the application has largely ignored the pre-existing cultural framework leading to a disruption of traditional systems of power and healing

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The role of possession is of particular interest in the history of Sub-Saharan Africa. It was often used as a form of political authority and was a central element in the traditional hierarchy with chiefs consulting spirit mediums for guidance and power.³ This system of the spiritual acted as a counterbalance to regular channels of authority. As such, the treatment of what we would now call mental illness was very different and grounded in a different cultural basis. One of the first key introductions of the Western model of psychiatry into the

region came with the advent of colonialism. Psychiatry was used as an extended arm of the colonial regime, making claims in the name of science that the ‘native’ populations in Africa were psychologically primitive.² Colonial psychiatry linked madness with ‘othering’. What was not understood, or differed from a Eurocentric normal, was seen as inferior.² At the hands of physicians, deviance was defined as anything considered exceptional to normal functioning, and was used as a new form of racial oppression.⁴ Deviance is not inherently negative nor abusive. This abuse only arises out of our perception of normalcy which, in this setting, comes from the Western notion of the psyche that dictates a Western ‘normal’ as equitable to ‘correct.’ As such, the model of colonial psychiatry was bent on ‘fixing’ the primitive, deviant ways of the natives. The legacy of this ‘othering’ process extends deep into the post-colonial period. In some areas, it is just as direct as it was under the colonial regime, with the same racial elements clinging on. However, this is both less interesting and less relevant to the more broadly accepted notion of psychiatry that exists in the present day. The second legacy still present is that psychiatrists resist this ‘othering’ process by attempting to enforce a practice where there should be no difference in treatment between Africans and Europeans. Here the focus was not on differ-

Historical and Cultural Context The present-day approach to psychosis in Sub-Saharan Africa relies on a hybridized system between the traditional and the Western cultural frameworks. Culture is central to any understanding of what was, both literally and metaphorically, lost in translation. In order to examine this context further, we need to arrive at a definition for culture. This paper presents such a definition as a set of shared beliefs, values, and knowledge frameworks that inform how people experience the world around them. Furthermore, in the context of this

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Chikukwa, Zimbabwe

ence but on emphasizing similarity.² This is an understandable response but is still partly misplaced since sociocultural contexts are not homogenous, and therefore, nor is an inclusive response. In the psychiatrists’ response to the abuse of the colonial regime, they became the new elite and took on the mantle of physician authority left behind by the colonial era. In this context, physician authority occurs when the physician inherits power over the structuring of healthcare knowledge and provision.⁴ Implicit in this dominance is the assumption that the medical profession knew exactly what they were doing and were acting in the best interest of all members of society.⁵ By imposing a model of universalism onto the African population, it is still those at the bottom of the hierarchy that suffer under the weight of an imposed normal.² To treat all people as identical is to ignore, and often wipe out, the cultures of the less powerful. The colonial regime was wrong in its assertion of racial superiority in the psyche but the subsequent generation of psychiatrists were also incorrect to assume all people have the same cultural basis for, and interaction with, psychosis. Schizophrenia—characterized by delusions, hallucinations, disorganized speech and behavior, and other symptoms that cause social or occupational dysfunction—presents a clear case of the relevance of the multiple manifestations of illness in different cultural contexts.⁶ Recently, a group of psychological researchers led by Thomas Luhrmann, examined the experience of hearing voices in different cultures, specifically in the US, India, and Ghana.⁷ The results were revealing, highlighting that “Participants in the USA were more likely to use diagnostic labels and to report violent commands than those in India and Ghana, who were more likely than the Americans to report rich relationships with their voices and less likely to describe the voices as the sign of a violated mind.”⁷ This is fairly powerful evidence pointing to the idea that the experience and manifestation of illness for people with psychotic disorders are shaped by local culture. It is necessary to echo Luhrmann’s sentiment that this has significant clinical implications that are, as of yet, overlooked. By playing into the idea of universalism, psychiatrists in the region are using their authority as physicians in unison with its colonial past to the detriment of many

Africans with different cultural standpoints and experiences of mental illness. Heaton pointedly concludes his book entitled White Coats, Black Skins with the statement that “the universalist discourse of modernization… proved itself to be nothing but a neo-colonialist agenda to keep the third world dependent upon the West through the rigging of a perpetually uneven playing field.”² This is not a restrained sentiment, but it outlines the necessity to re-examine the relationship between possession and psychosis in present-day approaches to mental health in the region.

Continued: Possession and Psychosis in Conflict

ditional and Western medical systems through language. Thinking back to the Where There Is No Psychiatrist handbook that is in use in Zimbabwe provides an example. Part 5 is entitled “localising this manual for your area” and goes on to offer a special glossary of “technical terms” followed by a “space in which you can note the word for particular items in the local language.”¹ The attempt in this case is clear and it is a noble one. Patel is trying to provide a framework that acknowledges the cultural context in order to avoid imposition. However, it is still pulling words that are not intrinsically medical into the medical domain. The basis of normalcy is imposed. The language spoken in Zimbabwe is Shona. In Shona, there is no word for ‘crazy’ or ‘mental illness’ or ‘psychosis’ or any variation of the sort for that matter. The word that is most frequently used now is kufungisisa which translates to “thinking too much”. This is not necessarily medical but, by placing it alongside a list of Western medical terms as a translation, it becomes such. This fundamentally changes where people look for issues of ‘mental health’ and shifts the complex traditional system.

This paper cannot proceed without an examination of its own language. It uses—and will continue to use—terms such as ‘psychosis’ or ‘mental illness’ when, in fact, they are not appropriate. There are no neutral, unloaded words to describe the situation sufficiently outside of our own cultural context. “Possession” is another attempt, signifying something quite different, but is an equally unfulfilling lexical solution. This, in and of itself, is a fundamental element of this discussion: the power of labeling.

In his ethnographic study of the Mueda plateau in Mozambique, Harry G. West examines this very notion of spiritualism incorporated into the ‘normal’ world.11 When a healer in the Muedan community was asked who the sorcerers are, he replied “most people are vavi [sorcerers]— almost everyone. In fact, the person who is not a mwavi [sorcerer] is a rare person indeed.”11 This is a powerful statement as to the manner in which spiritualism—or sorcery—is a part of everyday life. It is normal and always present.

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To treat all people as identical is to ignore, and often wipe out, the cultures of the less powerful.

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The power to label is one of the most potent forms of cultural imposition.⁸ this is true not only because of the ability to shape discourse, but also because people will act in accordance to the labels assigned to them.⁹ Although this is most often used with reference to crime, the analysis is equally potent in our examination of mental illness. The common phrasing is intrinsically negative and, perhaps more relevant in this instance, more medicalized.10 By taking notions of possession that would traditionally be spiritual, social, or even political, and inherently medicalizing them, psychiatry is undermining and potentially harming complex systems of culture. There are, however, attempts to navigate a hybridization between the tra-

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To turn around and say that their sorcery is not true is to say that their way of life is wrong.

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As we see in the example of schizophrenia, there is evidence that “many non-Western societies do not make such a rigid distinction between reality and fantasy.” 12 As such, the Western model of illness strips away this blurriness, delineating between medical ‘truth’ and delusions of spirituality. By doing so, Western psychiatry is simultaneously in conflict with and attempting to engulf

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traditional cultural systems. To turn around and say that their sorcery is not true is to say that their way of life is wrong. This, I believe, is a considerable oversight on behalf of anyone working to address psychosis in Sub-Saharan Africa. Key Steps Takeaways

and

Context. There is intrinsic value in sharing new insights backed by rigorous scientific methods. However, with the world in the state that it is, while navigating chasms of global power inequality, it is easy—inevitable almost—that governments, policymakers, and people slip between the gaps in implementation and into imposition. There is a long-standing history that comes with an ignorance of cultural context. For any encompassing benefit to occur, there must be an engagement with the traditional, cultural, spiritual, and political context.

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For any encompassing benefit to occur, there must be an engagement with the traditional, cultural, spiritual, and political context.

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There are many different approaches that have arisen in an attempt to incorporate this question of context in mental health treatment. One such shift is the research by Kirmayer et al. that contends that “cultural contexts influence developmental processes” and can lead to different manifestations of psychopathy.13 As such, he shows that the one-size-fits-all model

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of psychology is no longer justified. He is a proponent of tools such as the Cultural Formation Interview (CFI), used to gauge an individual’s cultural context in order to tailor treatment. This is a step but by no means a destination. This simultaneously views all symptoms through an entirely medicalized lens while also engaging with the healing of many people in need, beginning on their footing. Another important approach is a project called “Friendship Bench,” pioneered in Zimbabwe. 14 The project is comprised of strategically placed benches outside of clinics with community health workers—and often elders—present for anyone who wishes to speak about their problems. The project encompasses both the medical and the local by training lay health workers to recognize mental illness using “a locally validated assessment tool and offer evidence-based problem-solving therapy.” 14 The innovation behind the project is that the people offering the treatment are local, often referred to as “grandmother health providers.” This, to a large part, undermines conventional physician authority, giving agency and power to those embedded in the cultural context. It is also appropriate that it is the “grandmothers” who are taking on this role since, in the tradition-

al structure, it is they who often carry the task of healing. This discussion inevitably leads to a paradox: in the same breath that the Western model of psychiatry has undermined many traditional systems by painting any conception of spiritualism in falsehood, it is equally relevant to acknowledge that many African countries are dealing with high rates of untreated mental illness— to use the medical label—with a massive deficit in skilled response.15 My starting point is to decide that there is one foundational element: suffering is negative. From here we can engage with the plurality of what it means to address it. It is clear that the medical field has much to offer, but it must be implemented conscientiously: understanding cultural context, from the community level up, and recognizing the multiplicity of truth.

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Sam Brakarsh is currently a junior in Pauli Murray College. He wrote this article in his sophomore year. He can be contacted for questions at sam.brakarsh@yale.edu.

Protecting the Nation from Foreign Terrorist Entry into the United States

Effects of the Trump Travel Ban on the American Healthcare System By Janine Kara 45 Gage Skidmore

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hen Arabs, predominantly Lebanese and Syrian immigrants, first immigrated to the United States in the 1880’s to mostly Boston, Detroit, and New York, they established restaurants, businesses, and newspapers. During this period, White Americans believed that immigrants of Asian heritage were stealing their jobs. This fear was manifested in the Chinese Exclusion Act, which barred Asian immigrants from obtaining US citizenship. Up until 1952, mainly European individuals were granted citizenship, and whiteness continues to be a similar golden ticket for immigrant populations. Arabs went to court fighting several cases, claiming that they should be considered White, and they won. In 1909, the US Superior Court and Department of Justice ruled on a case that racially categorized Arab immigrants.1 George Shishim, a Lebanese police officer who lived and worked in Venice, California fought for the right to claim US citizenship. Shishim was born in Lebanon, but under the law at the time, the US government deemed him to be of “Chinese-Mongolian” ancestry and therefore ineligible to become a citizen. The growing Syrian-Lebanese community rallied behind Shishim and hired him a lawyer. One of the main arguments that largely appealed to conservative Christian justices was the connection to Jesus Christ. Shishim argued in court, “If I am Mongolian, then so was Jesus, because we came from the same land.”² Superior Court Judge Hutton swore Shishim in as a citizen. Today in the United States, “White” is recognized by the federal government as “a person having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes people who indicate their race as ‘White’ or report entries such as Irish, German, Italian, Lebanese, Near Easterner, Arab, or Polish.”³ However, although historically designated as white by the law, Arabs are not extended the privileges associated with White America.3 Religion has historically shaped immigrant experiences and newly categorized identities in the US, even amongst European settlers. In the early twentieth century, there were movements to bar entry to the US from predominantly Catholic countries, such as individuals from Ireland and Eastern Europe. In turn, immigrants from these nations who were already in the United States felt unwelcome and unwanted.4 In the Shishim case of the early 1900’s, the police officer’s main argument for Arabs being “White” was that he came from

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the same land as Jesus Christ; this aligned with the first wave of Christian Arab immigrants seeking refuge in America. In today’s America, however, the majority of Arabs who are immigrating are Muslim.⁵ The post 9/11 stigmatization of Arabs and Islam in particular has remained a prominent aspect of American society, and has increasingly become overtly negative over time with the emergence of more terrorist organizations threatening the Western world. The events surrounding 9/11 sparked the War on Terror, the emergence of Homeland Security, the Patriot Act, as well as everyday racism such as heightened security at airports, which have unequivocally altered the lives of Muslims and Arab Americans.⁶ A present-day manifestation of stigmatization of Muslim Arabs is the Trump Administration’s Executive Order 13769, the alleged “Muslim Ban” that began to take effect on January 27, 2017. To even further stigmatize Arab immigrants, the order was called “Protecting the Nation from Foreign Terrorist Entry into the United States.” Shortly after President Trump took office, he mandated a preliminary executive order (EO-1) that was a 90-day suspension of foreign nationals entering the United States from seven Muslim-majority countries, which were originally: Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen. Individuals from these countries were banned from entering due to “heightened terrorism risks,” according to Congress.⁷ This order was then replaced with EO-2, which temporarily restricted the entry (with consideration of case-by-case immigration waivers) of foreign nationals from the same countries but not including Iraq. Like EO-1, EO-2 explicitly stated that those

countries had been selected because “each is a state sponsor of terrorism, has been significantly compromised by terrorist organizations, or contains active conflict zones.”⁸ The second entry restriction was to stay in effect for 90 days. Polls showed that nearly two-thirds of Americans who voted for Trump supported the ban.

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‘India, China, the Philippines, Korea, and Pakistan are the top 5 origin groups for physicians and surgeons.’ Syria is the sixth largest contributor of physicians and surgeons; Iran is the tenth.

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I was in Lebanon in the summer of 2018 doing work surrounding the Syrian health crisis in my country. The primary investigator on my research project with the American University of Beirut was Syrian, a general surgeon by training, and no longer permitted to practice surgery (as there are strict labor laws for non-Lebanese individuals residing in Lebanon, unless they pay outrageous fees to the Lebanese government). He was, however, able to lead a life as a public health academician at a premier Lebanese university. He was planning on presenting one of his research projects at a university in America this year after

The Washington Post

These nations were included in the muslim ban because “each is a state sponsor of terrorism, has been significantly compromised by terrorist organizations, or contains active conflict zones."

both current and future physicians as well as medical students and residents who are providing much needed care to some of our most vulnerable patients.

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United States of America Passport

attaining a visa to enter the country. Devastating news had spread in Lebanon that the United States Supreme Court had voted 5-4 on Trump’s ban (Trump v. Hawaii) on any individuals (immigrants and visa holders, etc) from seven countries, many of which were Muslim-majority: Iran, Libya, North Korea, Somalia, Syria, Venezuela, and Yemen.⁸ Unlike earlier efforts, this ban was designed to remain permanent. The new law does not apply to asylum seekers or refugees, but even then, very few refugees have been admitted since this proclamation has taken effect. There were over 15,000 Syrian refugees who arrived in the US in 2016. Since the beginning of 2018, there have only been 13 Syrian refugees.⁸ Very few refugees from other Muslim countries have also been admitted since January, including 3 Iranians, 1 Libyan, none from Yemen, and 122 from Somalia. This racially-charged, xenophobic ban has not only affected Arab individuals seeking refuge from uninhabitable homelands, but also has hugely negative implications on the US healthcare system.⁸ On February 1, 2017, James L. Madera, M.D., the Executive Vice President of the American Medical Association wrote a personal letter to John F. Kelly, the Secretary of the US Department of Homeland Security.

“On behalf of the physician and medical student members of the American Medical Association (AMA), I am writing to urge that the Administration clarify the executive order titled, ‘Protecting the Nation from Foreign Terrorist Entry into the United States,’ which was issued on January 27, 2017. While we understand the importance of a reliable system for vetting people from other nations entering the United States, it is vitally important that this process not impact patient access to timely medical treatment or restrict physicians and international medical graduates (IMGs) who have been granted visas to train, practice, or attend medical conferences in the United States. The AMA is concerned that this executive order is negatively impacting patient access to care and creating unintended consequences for our nation’s health care system. Specifically, there are reports indicating that this executive order is affecting

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Many communities, including rural and low-income areas, often have problems attracting physicians to meet their health care needs. To address these gaps in care, IMGs often fill these openings. To date, one out of every four physicians practicing in the United States is an IMG. These physicians are licensed by the same stringent requirements applied to U.S. medical school graduates. They are more likely to practice in underserved and poor communities, and to fill training positions in primary care and other specialties that face significant workforce shortages. The executive order places into question those IMGs who have applied for or who have been granted visas to come to the United States to train and provide care in underserved communities. Guidance is urgently needed from the Administration to ensure the upcoming residency matching program in March 2017 does not leave training slots vacant and that all qualified IMG applicants can participate. We urge the Administration to provide details and mitigate any negative impact on our nation’s health care system.”⁹ According to the Migration Policy Institute (2015), nearly 30% of doctors and surgeons in the US; 23.8% of nurses and home health aids; and 22.3% of all healthcare workers in general are immigrants.10 Banning immigrants from these seven countries also bans doctors, nurses, surgeons, and other skilled healthcare providers, like the Syrian surgeon I worked with, from ever entering the United States, even if they qualify for the highly competitive waiver program. Waivers are now rarely given out, as they allow select citizens from banned countries to apply for entry to the United States. A rigorous selection process for this golden ticket, immigration officials are tasked with deciding if it’s “in America’s best interest” to allow “certain individuals” into

Trump’s ban (Trump v. Hawaii) on any individuals (immigrants and visa holders, etc) from seven countries, many of which were Muslim-majority: Iran, Libya, North Korea, Somalia, Syria, Venezuela, and Yemen. Unlike earlier efforts, this ban was designed to remain permanent.

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this country.11 Mohammed Al-Awadhi, a Yemeni physician actively practicing in rural Arkansas, had petitioned for his Yemini wife—who is currently battling a serious heart condition—to come to the US through the waiver program. She was approved for a visa in December 2017, and then ultimately rejected following Trump’s third travel ban, leaving her thousands of miles away from her husband with no access to treatment in a country plagued with war and famine. Due to the Trump ban, 70,000 other individuals like Al-Awadhi’s wife will now be denied from ever entering the United States. Although that seems like a small number, it is possible to imagine how many skilled health professionals the United States will be losing.12 According to Jeanne Batalova, a senior policy analyst at the Migration Policy Institute, “India, China, the Philippines, Korea, and Pakistan are the top 5 origin groups for physicians and surgeons.”13 Syria is the sixth largest contributor of physicians and surgeons; Iran is the tenth.

area for three years after residency. The CDC has found that these doctors are also more likely to serve low income patients on Medicaid.17 Nicole Smith, a Georgetown economist, shared in 2018, “Doctors—especially in rural areas that were the key constituency that supports Trump—tend to be foreign-born. The old adage that foreigners are doing the work no Americans want to do even applies to medical doctors.”18 A 2017 study showed that patients treated by foreign-trained doctors had better mortality outcomes than those treated by doctors who went through American medical schools.19 The study authors suggested for foreign doctors, over-performance might be explained by the fact that they “represent some of the best physicians in their country of origin” and had to overcome intense competition and years of training to finally practice in the US.20

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To further break this issue down into medical specialties, foreign-trained doctors do a disproportionate amount of the work in certain fields.

Since the beginning of 2018, there have only been 13 Syrian refugees. Very few refugees from other Muslim countries have also been admitted since January, including 3 Iranians, 1 Libyan, none from Yemen, and 122 from Somalia.

Immigrants make up more than 50 percent of geriatric medicine doctors, almost half of nephrologists (or kidney doctors), nearly 40 percent of internal medicine doctors, and about a quarter of family medicine physicians, according to data from the Association of American Medical Colleges.16 Additionally, as mentioned earlier, compared to US-trained physicians, foreign doctors are also more likely to practice in areas where there are doctor shortages—in particular, in rural areas. Many foreign physicians and surgeons entered the US on visas that allowed them to stay if they work in an underserved

Besides the staggering amount of immigrant physicians, surgeons, and nurses, the research immigrants do in labs across the country is also under threat. A Syrian medical researcher was interviewed in June 2018 directly after the ban was proclaimed. Having worked in America for over three years at the Mayo Clinic, he feared that his application for permanent residency would be rejected, and that he would have to leave the country and his position. 21 Other researchers who are visa and green card holders from Iran said they feared leaving the US to visit family or to attend conferences.

Batalova argued that these two countries are substantially represented in the healthcare workforce, and the ban will likely have tangible consequences at hospitals and clinics across the nation, especially in rural areas. Additionally, a data analysis performed by the Robert Graham Center showed that residents from the seven countries made up 5.7 percent of all international medical graduates in 2015.14 The report also stated that if the Trump Administration added other possible countries (ie. Pakistan, Saudi Arabia, my country of Lebanon, and Egypt), this number would increase to 16.7%.15

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They reported concerns about being barred from coming back home, describing the situation as extremely volatile, forcing them to consider moving to different countries. 21 Maryam Saeedi, an Iranian-born assistant professor at Carnegie Mellon, has been trapped in the United States, and she and her husband have recognized that this has disrupted scientific collaboration with researchers abroad. In another case, a 30-year-old Iranian woman was stopped in Switzerland before her flight to Boston for a postdoctoral genomics fellowship at the Harvard-affiliated Brigham and Women’s Hospital. After hearing similar testimonies, Saeedi drafted an online petition that launched in January 2017, signed by American peers in academia, including 62 Nobel laureates, over 31,000 US faculty members, and 43,000 academic supporters, standing against the travel ban on the basis that it was impeding international research and collaboration in science and medicine.22 As previously outlined, the Trump Administration’s Executive Order 13769 will have unprecedented negative impacts on the American healthcare system and research, and, in turn, on the health of American citizens. Highly skilled and needed foreign physicians, surgeons, and their families are being barred from entering and practicing in this country, further disenfranchising rural care centers that heavily rely on their labor. Researchers with origins from these banned countries are additionally now unable to share their work and/or learn new skills from American institutions, thus stunting global health relations and needed collaborative, innovative research. Although there is no clear way to measure the immediate impact of the xenophobically-rooted Trump ban on the healthcare system, analyzing the vital role and history of immigrant health professionals in America has indicated that the ban will have a tangible influence on the future of medicine in this country.

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Janine is currently a graduate. She wrote this article as a second-year Yale School of Public Health Student studying Social and Behavioral Sciences. She can be contacted for questions at janine.kara@yale.edu.

The Health Consequences of the War in Yemen BY BEN GROBMAN

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ince 2014, Yemen, the poorest country in the Arabian peninsula, has been wracked by a brutal civil war which has left tens of thousands dead, millions displaced, and the Yemeni infrastructure in shambles. The Yemeni crisis has often been overshadowed by the war in Syria, which has captured the attention of the world due to the sheer number of casualties and the ensuing refugee crisis. The war in Yemen, however, has left civilians in similarly dire straits, with the UN calling the situation the world’s worst humanitarian crisis.¹ The main sides in the Yemeni conflict are an international coalition backing the Yemeni government led by Saudi Arabia, and the Houthis, a group of rebels who originated in northern Yemen as a religious revival movement.2,3 The Houthi movement stems from the Zaydi sect of Shi’a Islam, which comprises the majority of people in northern Yemen, but the minority of the country as a whole.4 After the United States invasion of Iraq in 2003, the Houthis became increasingly militant, viewing the corrupt Yemeni president Ali Abdullah Saleh as too supportive of the United States.⁵ In 2004, President Saleh ordered the arrest of Houthi leader Hussein Bader Addian al-Houthi due to Houthi protesting in the capital city of Sanaa.⁶ This resulted in clashes between government forces and Houthi rebels—clashes that led to the death of al-Houthi and to six years of sporadic war between Houthi rebels and government forces.⁶

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During the course of the war, 10,000 people have been killed from violence alone, but the casualties from disease and famine have been far more devastating.

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In the wake of the Arab Spring and the resignation of Egyptian President Hosni Mubarak, Yemeni citizens, frustrated with a collapsing economy and a corrupt government, took to the streets in opposition to President Saleh and his regime.⁷ In response, on March 18, 2011, government soldiers killed 52 unarmed protesters, which led to increasingly fervent protests.⁷ Finally, in November 2011, after months of continuous

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protests and increasing international pressure, Saleh agreed to a transition of power designed by the Saudi Arabia-led and U.S.backed Gulf Cooperation Program, in which he was required to turn power over to Vice President Abd Rabbu Mansur al-Hadi within 30 days in exchange for immunity.⁷ In February of 2012, al Hadi was officially installed for a two year term as the president of Yemen in a single candidate election.⁷ Despite their previous insurgency and opposition to Saleh’s government, the Houthis used the installation of al-Hadi as an opportunity to ally themselves with remaining Saleh loyalists while further consolidating their power in the north.³ In August 2014, in response to the federal government’s removal of fuel subsidies, tens of thousands of Yemenis took to the streets of the capital in a massive Houthi-organized protest.⁸ A month later, with the help of the prevalent anti-government atmosphere and the Saleh loyalists who remained in the Yemeni government, Houthi rebels took over Sanaa. This placed the already ineffective government into complete dysfunction and threw Yemen into a further state of chaos.3 During the capture of Sanaa, the Houthis placed President al-Hadi under house arrest, but he soon escaped to the southern port city of Aden.⁹ As the Houthis continued their conquest, they pushed south into Aden, causing President Hadi to flee to Saudi Arabia.³ On March 21, 2015, in response to the Houthi takeover, a Saudi-led coalition backing President al-Hadi, with the support of the United States and Britain, launched a war against the Houthi insurgents.³ The Saudi coalition has launched countless air-

strikes, often using bombs built in the United States, that have killed huge numbers of civilians.10,11 The fighting has led to chaos, bloodshed, and the complete destruction of an already fragile national infrastructure — all of which has led to the worst humanitarian crisis in the world.¹ During the course of the war, 10,000 people have been killed from violence alone, but the casualties from disease and famine have been far more devastating.¹ Even prior to the war, access to food was a serious issue in Yemen, as two-thirds of Yemeni citizens suffered from food insecurity.³ With the destruction of war, however, food insecurity has turned into mass starvation. The war has almost completely destroyed any economic opportunity, leaving the vast majority of Yemeni families without any source of stable income with which to buy basic sustenance. This has created a situation around the nation in which there is theoretically enough food to feed most people, as shown by images of fully stocked markets in Sanaa, but very few people who have enough money to buy it in practice.12,13 Additionally, researchers have shown that in Houthi-controlled areas, the Saudi coalition has purposely targeted markets during missile strikes, further interrupting Yemeni civilians’ access to food.12 In a country of 29 million people, 8.4 million are on the verge of starvation, and a total of 22 million rely on humanitarian assistance for survival.14 In a particularly devastating situation, villagers in the rural northern district of Aslam have been forced to eat a sour paste made from the boiled leaves of local vines to survive.15 Despite the efforts of UNICEF and other humanitarian

VOA News

More than a hundred buildings still remain in rubble and survivors continue to search for any valuables

organizations, a combination of the coalition blockades meant to prevent the flow of weapons into Yemen and a Houthi distrust of aid organizations has made it exceedingly hard for these international relief groups to provide much needed food and supplies to civilians. This exacerbates the fact that, even in peacetime, Yemen is already forced to import over 80% of its food due to its desert climate. During the war, these port cities have thus become a particularly contested area, further stymying the flow of necessary food and supplies into the country.12

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In a country of 29 million people, 8.4 million are on the verge of starvation, and a total of 22 million rely on humanitarian assistance for survival.

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As a result of indiscriminate bombing and economic collapse, Yemen’s healthcare system has collapsed. 68% of the population lacks basic healthcare access.16 Due to assaults on medical facilities, many healthcare centers have closed. There are numerous accounts of coalition airstrikes destroying hospitals, many of which are run by international aid organizations such as Doctors Without Borders.17 In a devastating but alltoo-routine incident in October 2018, over 40 airstrikes hit the Houthi-controlled city of

Dreihimi, completely obliterating the local general hospital and maternity ward, and killing dozens of civilians.18 The presence of Houthi militants has also further impeded civilian access to healthcare in rebel-controlled areas. With each day, there emerge further reports of militants sending sick civilians home and turning even more away from medical facilities to create space for their own injured rebel fighters.19

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Economic collapse has caused the vast majority of publicly employed healthcare workers in Yemen to go completely without salary

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Due to destruction and lack of resources, many healthcare facilities have shut down. This has forced the remaining facilities to take on more patients than they are designed to treat. People with long-term illnesses such as cancer, kidney failure, and diabetes who need continuous care and expensive medications are now especially vulnerable.20 According to a 2017 Doctors Without Borders report, economic collapse has caused the vast majority of publicly employed healthcare workers in Yemen to go completely without salary, an issue continuing from August 2016 into late 2018.21,22 Medical professionals in rebel-controlled areas have been further impeded by Houthi rebels, who harass and threaten these doctors while demanding money from already unpaid and under-resourced

hospitals.22 As a result, numerous publicly employed health care workers have left their jobs, and those who remain are overworked, underpaid, and in constant danger.21 The crisis of starvation has been particularly devastating for young Yemeni children who lack the bodily strength to withstand the strain of hunger. Currently, 1.8 million children in Yemen are malnourished, and “400,000 of them are severely acute malnourished and... fighting for their lives every day.”23 These severely malnourished children are not only at risk of starvation, but also, according to Save the Children’s Yemen Country Director Tamer Kirolos, “... 12 times more likely to die from preventable diseases like pneumonia, measles, cholera or diphtheria. Children who are stunted suffer physical and often irreversible long-term cognitive damage.”24 As of September 2018, 5.2 million Yemeni children were at risk for famine, living in a fragile ecosystem where the slightest disruption to their food supply would place them in mortal danger.24 In 2017 alone, an estimated 50,000 malnourished children died from famine or disease, five times the estimate for civilian casualties as a direct result of violence throughout the entire war.25

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In 2017 alone, an estimated 50,000 malnourished children died from famine or disease

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During 2017, Yemen also suffered the most severe cholera outbreak in modern

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history.26 Cholera is characterized by the rapid onset of fever and dehydration, followed by shock. If not properly treated, cholera can lead to death within hours, even in healthy individuals.27 Cholera spreads through food and water contaminated with the waste of an afflicted person, rendering places that lack infrastructure particularly susceptible to its effects.28 Despite its impoverished status, there had been few cases of cholera in Yemen prior to the ongoing civil war.28 But as the government has fallen into complete disarray and bombs have decimated the country’s infrastructure, Yemeni safeguards against cholera have disintegrated.28 The bombs of the Saudi coalition have destroyed huge portions of the Yemeni water sanitation system, making clean water increasingly difficult to access.28 Due to the lack of centralized government, public servants have consistently gone unpaid, and in 2017, sanitation workers went on strike in the capital, which only furthered risk of contamination.29 As a result, cholera spread with unprecedented speed, with

over 1 million new cases in just eighteen months, a high incidence rate that overwhelmed a population already weakened by war and famine.28 Despite its severe effects, cholera is easily treatable and preventable with proper medical care.28 But as the healthcare system has crumbled, many Yemenis have been left with no access to such necessary treatment, resulting in over 2,000 cholera related deaths.28 Although the prevalence of cholera in Yemen has largely decreased since its 2017 peak, reports in early October 2018 indicated that the prevalence of cholera was again increasing, with 10,000 new cases reported each week in the previous month.30, 31

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any signs of stopping. Despite the devastation, the international community continues to show apathy, likely due to a combination of outrage fatigue after the previous decade of turmoil in the Middle East, as well as the complicity of the United States and its allies in the aerial destruction wreaked by the Saudi coalition. The most important factors in stopping what could become “the worst famine in 100 years”32 is an end to the destruction of civilian centers, coupled with a more effective influx of international aid. This can only happen if coalition forces begin to prioritize human rights over victory in this war tearing apart this small and impoverished country already in disrepair.32

10,000 new cases reported each week in the previous month.

Ben is a junior in Saybrook College majoring in history. He wrote this article his sophomore year.

The war in Yemen and the accompanying health catastrophes continue to rage without

He can be contacted for questions at ben.grobman@yale.edu.

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Lessons from Chicago Police Violence and the Health of Disenfranchised Communities

By Parmida Zarei

“Chicago activists reacting to the guilty verdict of Jason Van Dyke in the killing of Laquan McDonald”, October 05, 2018, Chicago, Illinois

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sually under the roar of protestors, Chicago fell silent on October 5th, 2018 as the nation waited with bated breath for the fate of Chicago police officer Jason Van Dyke. Nearly four years earlier, Van Dyke fired 16 fatal shots into 17-year-old Laquan McDonald, firing off yet another round of the nation’s continued unrest with police violence against communities of color. While police violence has a long history, the discourse surrounding police accountability for the use of force against unarmed civilians has been reinvigorated following a series of widely publicized cases that have spurred mass protests and demonstrations across the United States. The growing list of such cases most notably includes Sanford’s

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2018, the roar of protesters resumed as the verdict was read: second-degree murder and 16 counts of aggravated battery, one for each shot fired. Van Dyke’s monumental guilty verdict signals a potential shift in how we view and respond to police violence in the greater context of our nation’s long history of acquittals for officers accused of committing acts of violence against civilian populations. The verdict comes as a small victory in the fight for acknowledging the countless lives lost at the hands of police violence, but serves as a harsh reminder that while justice is both important and symbolic, we cannot ignore the lasting health effects of police violence that will persist far after justice is served.

Between 1988 and 2018, there were 57,574 allegations of use of force against Chicago police officers, with a 3% discipline rate.

Trayvon Martin, Cleveland’s Tamir Rice, Ferguson’s Michael Brown, and Falcon Height’s Philando Castile, all of which resulted in fatalities with no formal charges or acquittals for the officers involved.1-4 The national trend follows a similar pattern, as trials and convictions for police accused of misconduct are rare in the United States.⁵ On October 5th,

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The stark divide between police and communities of color is jarring, and the influence of race in police-civilian relations cannot be overlooked. Black Americans are more likely to report having negative encounters with law enforcement. Data indicate that Blacks are stopped more frequently than Whites, even after controlling for race-specific estimates of crime participation.⁶ Similarly, police violence disproportionately affects Blacks. While absolute numbers indicate higher rates of fatal police shootings for Whites–an argument used by many to dispel the threat of police violence for populations of color and delegitimize causes such as the Black Lives Matter movement–after adjusting for the population differences between Whites and Blacks, Blacks are at increased risk of death by lethal force by police, with Blacks being 2.5 times more likely than Whites to be shot and killed by police.7, 8

Given these racial disparities in use of police force, it is pertinent to hold police accountable. Chicago has made progress on this front by requiring civilian complaints against police to be classified as public information. In 2014, the Illinois Court of Appeals ruled in the landmark case, Kalven v. City of Chicago that civilian complaints about police misconduct, previously sealed, must be publicly available throughout the state. 9,10 Following the release of this information, the Invisible Institute, a Chicago-based journalism production company aimed

at holding public institutions accountable, developed the Citizens’ Police Data Project (CPDP). CPDP is an extensive public database that houses data on complaints against police and serves to bolster police accountability. The database contains variables such as excessive use of force, unnecessary physical contact, and firearm discharge for on- and off-duty officers, as well as neighborhood-, officer-, and race-specific information. Between 1988 and 2018, there were 57,574 allegations of use of force against Chicago police officers, with a 3% discipline rate. During this same time period, there were 64,267 civilian allegations made by Blacks with approximately 1.7% of these complaints sustained, compared to 12,304 civilian allegations made by Whites with approximately 6.5% sustained. These data indicate that Blacks filed complaints at over 5 times the rate of Whites, but were nearly four times less likely to have their complaints followed up with disciplinary action. CPDP brings these disparities to light and will hopefully inspire further research in this area, especially given our current understanding of the health consequences of police violence against marginalized communities. These data also present the opportunity for quantitative analyses that will provide an evidence-based look at the prevalence of use of force by police, especially against minorities, and the low rate at which subsequent complaints/cases are resolved. Fatal police shootings of unarmed Black Americans have implications reaching far beyond the primary victims themselves. The larger Black community is at risk for negative mental health effects, especially given national media coverage of police shootings in recent years.11 There are also associations between reported police contact and negative mental health outcomes including anxiety and trauma, providing support for adverse health outcomes beyond just physical harm.12 Marginalized, low-income neighborhoods are often targets of hyper-policing, which in turn contributes to neighborhood fragmentation. Aggressive policing creates a collective community stress that contributes to the development of negative health outcomes over time and thereby perpetuates the cycle of violence. 13 Moreover, police violence disproportionately affects youth of color and is a significant contributor to premature mortality among

these populations. 14 Police misconduct and repeated negative encounters with law enforcement have also given rise to negative perceptions of the police, especially among youth of color. Minority populations are more likely to have negative attitudes towards the police. 15 Black youth anticipate negative encounters with the police, such as being unjustly stopped, and express general mistrust for law enforcement, which is further exacerbated by police power and the lack of accountability. 16 Nonetheless, there is a dearth of research investigating the population-level effects of police violence on health.17 Similarly, the literature has not established the link between negative perceptions of the police and health outcomes. As such, there is a need to establish police violence as a public health issue in order to facilitate a dialogue about how to address the health implications of police misconduct. Negative perceptions of the police have created an environment in which police and community members are at odds with one another. In 2015, Chicago passed a bill that mandated all Chicago Public Schools to include curriculum on the history of police torture following a high-profile police brutality scandal that rocked the city. A primary aim of the new curriculum is to rebuild community trust in the police and to pave the way forward by acknowledging and addressing mistakes of the past. Perhaps more unexpectedly, however, the curriculum has ignited conversations by youth about their encounters with the police.18 This dialogue enables youth to share, discuss, and process their negative experiences with law enforcement. Other cities may benefit from incorporating similar educational initiatives in order to tackle the issue of police violence by engaging those most at risk for negative encounters with the police. Providing youth an opportunity to learn about past wrongdoings by the police creates a climate of transparency, much like Chicago’s open data initiative. Chicago has also instituted a ‘community policing’ model to address issues with police misconduct and tense relations between police and community members. Community policing is intended to drive out the ‘warrior mindset’ that police training has traditionally emphasized. The warrior mindset in policing refers to military-style police training that has conditioned police to see their role as a warrior prepared for battle in

the community. This warrior mindset reinforces an “us versus them” mentality and further widens the gap between the police and the community. By contrast, the community policing model adopts a “guardian” role that emphasizes the role of the police officer as a member of the community dedicated to serving and protecting by working alongside community members.19 The community policing model is a step forward in the struggle to bridge the gap between police and the community. Improving police-community relations has the potential to reduce the prevalence of police violence and improve the community’s perceptions of the police. We can derive three key lessons from Chicago:

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1. Police must be held accountable for their crimes.

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One way to promote police accountability is by making civilian complaints against police public information that is accessible to all civilians.

2. Teaching police misconduct in schools further promotes transparency and allows youth the opportunity to vocalize their experiences with police. 3. Adopting a community policing framework emphasizes that the police work alongside the community. The community policing model sees police as members of the community, rather than outsiders, which can improve relations between police and the community. With these lessons serving as starting points, it is possible to achieve a police culture that is not associated with violence and hyper-policing over time. With gradual changes in how we hold police accountable for serving as community leaders, we can prevent the adverse health outcomes that are a result of current police practices. www

Parmida Zarei is a second-year MPH student in the School of Public Health, focusing her studies in Chronic Disease Epidemiology. She is originally from Chicago, Illinois and can be contacted at parmida.zarei@yale.edu.

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Protest March for Laquan McDonald, November 28, 2015, Chicago, Illinois

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Facing the Heat

Health Consequences of the Global Trend toward More Powerful Hurricanes By Indira Flores

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isasters plagued the Gulf Coast and the Caribbean during 2017, all striking within a short period of time but resulting in devastation that endured. Within the span of less than two months, three major hurricanes affected the area: Hurricanes Harvey, Irma, and Maria. Each hurricane was labeled as a Category 4 storm with winds reaching speeds of 120 miles per hour and higher.¹ Unfortunately, this trend of intense water-based natural disasters has continued into 2018 with several major catastrophes occurring around the globe over the summer—a trend likely continuing due to the perpetuation of global warming.13 These disasters have significant implications on the public health of affected populations ranging from increased risk of waterborne illnesses to lack of healthy options for food and shelter. One of the first major natural disasters of the summer of 2018 occurred in Southwest Japan in the beginning of July. Starting with a typhoon and continuing with several days of torrential rain, the region experienced unprecedented amounts of flooding and landslides; one town experienced nearly two feet of rainfall within a 24-hour period.² This excessive downpour caused rivers to overflow and flood out of their banks, carrying mud and debris along with them. Once the rain ceased falling, landslides remained a serious threat due to the soggy hills, which had a higher risk of col-

lapsing. At least 155 individuals died during the four-day span of the severe downpour- the highest death toll caused by rainfall in Japan in over thirty years.³ Two million people were forced to evacuate the region, with thousands losing their homes and leaving over 250,000 remaining homes without power and running water.⁴ Two months later, Hurricane Florence struck the United States’s East Coast, causing the most damage in the Carolinas. This hurricane made landfall close to the border between North and South Carolina on September 14, and although the winds were not catastrophic, the rainfall and resultant flooding caused significant damage in the region, resulting in over 50 immediate deaths.⁵ Tens of thousands of people were forced to evacuate their homes and relocate into shelters, and between one and three million homes and business were estimated to have lost power.⁶ The population most heavily impacted was the rural poor, who makeup one of the largest socioeconomic groups in the region.⁷ While Hurricane Florence was pummelling the United States, an equally destructive typhoon struck the opposite side of the globe: Super Typhoon Mangkhut. Despite the lack of media coverage in the United States in comparison to Florence, Mangkhut was equally as ferocious with Category 5 strength. Originat-

ing in the Pacific Ocean, the typhoon began by hitting Guam as a Category 2, intensifying to a Category 5 as it hit the Philippines, and continuing into Hong Kong and China before dying off.8 While flooding affected all areas, it was the northern coast of the Philippines that was most heavily affected. Similar to Southwest Japan, the mountainous regions experienced severe mudslides during and after the storm. Over 200,000 people were forced to evacuate from the Cagayan province of the Philippines alone, and more than 400,000 homes were left without electricity in the region.⁹ Roads were also severely damaged, extending the relief process in the region by making it difficult for rescuers to enter the area. Approximately 100 people died during this typhoon, and a total of almost 900,000 people were directly affected.10 The public health implications of water-based natural disasters are numerous, extending from administering aid to rampant illnesses that emerge. When the consequences of natural disasters are discussed, the focus is mostly on the immediate effects, such as how many deaths occurred during the storm and who was forced to evacuate, and far less attention is given to the affected area after a few weeks of the disaster striking. In reality, it is during the months, and even years, following a major natural disaster that all of the public health consequences and struggles truly prove themselves.

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A report from the Milken Institute of Public Health at George Washington University illustrates this trend through a study of Hurricane Maria and its longer-term effects on Puerto Rico.11 The Puerto Rican government initially declared that there were approximately 60 official deaths to report as a result of Hurricane Maria. However, George Washington University researchers statistically determined that during the period from September 2017 to February 2018, there were a total of 3,000 more deaths in the Puerto Rican population than there were to be expected based on data from previous years with normal mortality rates. This indicates that although fewer than 100 individuals died during the course of the hurricane, the actual mortality rate multiplies at least tenfold when the aftermath is considered. Issues in public health and safety, such as waterborne illnesses and lack of healthy food and shelter, begin to explain the high mortality rates that arise in the wake of a water-based natural disaster. One of the most significant causes of death linked to public health issues after water-based natural disaster is waterborne illness. Floodwaters are notorious for containing harmful pathogens and disseminating them throughout a population. Waterborne illnesses have a wide variety of routes of transmission, including ingestion, inhalation, and simple dermal contact.12 Two of the most common waterborne pathogens that can spread during a hurricane are E. coli and salmonella. These pathogens do not spontaneously arise due to the presence of floodwaters; they remain present, but contained, in sewage systems. However, when excessive rains cause flooding, sewage areas rise alongside rivers and proceed to reintroduce dormant diseases into populations.13 A key indicator of the re-emergence of bacteria such as these is diarrheal illnesses, including hemorrhagic colitis and typhoid fever. Flooding can also cause the spread of unsafe pollutants and chemicals if the hurricane strikes a structure like a petrochemical center.⁸ However, a major concern with Hurricane Florence, which severely impacted rural areas and farmlands, was the spread of disease from drowned livestock and the flooding of hog farms containing enormous amounts of openair manure lagoons.⁷ The coastal lowlands of North Carolina, which were subject to the majority of Florence’s destruction, have some of the highest concentrations of hog farms in the state. Similarly to what occurs when sewage overflows, bacteria from livestock waste gravitate toward standing water and potential sources of drinking water. The standing water and warm, humid conditions resulting from a hurricane also serve as an ideal breed-

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ing ground for mosquitoes, one of the world’s most notorious carriers of disease. Risks of overcrowding and unhealthy conditions are also exacerbated in the time following a water-based natural disaster. Hundreds of thousands of people are forced to evacuate their homes as a result of these disasters, and many of those move into shelters. Evacuation centers are often unavoidably overcrowded, and large amounts of people concentrated into a small space leads to more rapid transmission of infectious illnesses, especially with increased prevalence of waterborne pathogens.13 The rainfall, winds, flooding, and mudslides also often lead to severely damaged infrastructure and inaccessible roadways, making it more difficult for impacted groups of people to access potable water, safe food, and medical supplies. Improperly stored consumables can also become contaminated from floodwaters. The responses of government agencies to these natural disasters may vary widely from country to country. Guangdong, China, for example, has extensive experience with typhoons and prepared extensively for Mangkhut with mandatory evacuations of low-lying areas.⁸ Fishing vessels were also ordered into well-protected anchorages, and the province had previously pursued a campaign of destroying or upgrading substandard housing to make buildings less susceptible to collapse. In the United States, many government agencies collaborate in their response to events such as Hurricane Florence, including the Energy Department, the Environmental Protection Agency, and the Federal Communications Commission.14 This delegation of responsibility allows for more focused and thorough relief efforts by each agency, but it could potentially lead to inefficiency due to the decentralization of power. To avoid this, the Federal Emergency Management Agency (FEMA) serves as the central force that leads the various response efforts for natural disasters in the United States.

FEMA exists to support American citizens and first responders in the event of major hazardous situations across the nation. When news of Hurricane Florence arose, FEMA was prepared with “millions of liters of water, millions of pounds of food, and hundreds of thousands of blankets” to distribute, as well as 27 incident support centers throughout the region and dozens of search-and-rescue teams.15 FEMA is also in charge of leading emergency response efforts in US territories, which includes Puerto Rico following Hurricane Maria. According to investigations, however, FEMA’s efforts in Puerto Rico were not as strong as their efforts in the contiguous United States.15 The reasons for this are unclear; it could be a function of the physical distance between the States and the island of Puerto Rico creating difficulty in the movement of resources, or it could be the result of some deeper-rooted factors and bias such as political motivation. Regardless, reports are clear in showing that immediate supplies and federal personnel were severely lacking in Puerto Rico, especially in comparison to the responses to hurricanes in the United States earlier in the summer. Hurricanes, typhoons, and similar water-based natural disasters wreak havoc wherever they land, causing flooding and mudslides that often lead to severe infrastructure and public health damages. Accordingly, health, safety, and the environment are all inextricably linked; government agencies must support the health of both their people and environment to promote a more complete wellness of their nations’ populations. For information on supporting relief efforts in the areas affected by natural disaster, please visit redcross.org, crs.org, or globalgiving.org. www Indira is a junior in Grace Hopper College majoring in Molecular, Cellular, and Developmental Biology. This article was written her sophomore year. She can be contacted at indira.flores@yale.edu.

The Challenges of Trump’s Plan to Eradicate HIV/AIDS By Vanessa Blas

Although the amount of HIV/AIDS cases has declined since the onset of the epidemic and stabilized in the United States throughout the past four years––as a result of advances in medical treatment, preventive resources, increased education about the disease, and early diagnostic testing––the effects of the virus and its lethal companion has yet to be obliterated from our country. In fact, each year 40,000 Americans find out they are living with HIV. 1 in 7 people are unaware that they have the virus or of their ability to transmit the silent killer to others.1 Yet what does the United States government currently do to combat this problem? Do they even have a solution to prevent another 40,000 from receiving the news that they have HIV in the coming year? President Donald Trump recently took on this issue in his 2019 State of Union Address. But his proposals and promises seem to leave more confusion than clarity among common citizens and expert health advisors, the latter now having to scrap their previous plans for combating HIV/AIDS.

During his speech, President Trump called for an end to HIV by 2030, as his budget will “ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years.” He ended with the firm conviction that “together, we will defeat AIDS in America and beyond.”2 Despite this optimistic outlook the president possesses, it would be a grave mistake to naively believe that HIV will be eradicated under his administration’s initiative. In this case, the classic quote “actions speak louder than words” has never rung truer.

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y the time you finish reading this article, 1 person will be diagnosed with HIV in the United States. When you’re getting ready for bed later tonight, 27 more people across the country are restless knowing the dreadful news that the HIV virus lives inside them. HIV, short for the Human Immunodeficiency Virus, isn’t like the common cold that goes away with fluids and rest. This virus, which leads to an immune-system related disease called AIDS, kills immune system cells that defend your body against infections. AIDS is one of the deadliest diseases in the world, claiming 35.4 million lives since the start of the HIV/AIDS epidemic in 1981.1

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It would be a grave mistake to naively believe that HIV will be eradicated under the Trump administration’s initiative.

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In order to fully understand this ambitious project, Trump’s (sudden) motive for eradicating AIDS in America and how it compares to his administrative decisions should first be discussed. Ever since the start of the 1980s United States epidemic, HIV/AIDS has been largely been pilloried as a “disease of the gays,” since a large proportion of people diagnosed with the virus and disease were men who had sex with men. Although current HIV/AIDS advocacy groups attempt to reverse this stigma, over 66% of all HIV diagnosed cases in the

country are gay and bisexual men, and African American men are the hardest hit in this group at 43%.1 With such a key population being affected by this devastating disease, one would assume that any person who pushes to end AIDS would also advocate ending the unnecessary suffering of all patients. Ironically (and unsurprisingly) enough, the Trump administration isn’t the strongest ally of the LGBTQ community: the President instated a ban on transgender people from joining the military, appointed judicial nominees with anti-LGBTQ records, and has often taken the anti-LGBTQ discrimination side in legal cases such as Masterpiece Cakeshop Ltd. V. Colorado Civil Rights Commission (2018), in which the “Trump administration in court argued in favor of Masterpiece Cakeshop, a bakery who claimed their right to discriminate against same-sex couples.”3 Trump also failed to recognize LGBTQ Pride Month and cut $3 million from the HIV/AIDS U.S. Department of Health and Human Services. The president then proceeded to fire all of the members on his HIV/AIDS Advisory Council.3-5 Needless to say, Trump seems more like a foe of the LGBTQ community than a friend. Then why is he so headstrong on defeating AIDS? Well, that’s when looking at the 34% of people affected by the virus and disease, rather than the 66%, shares a different story. States in the south, which are primarily conservative in ideology and hold many Trump constituents, composed more than half of the 40,000 new HIV diagnoses in 2017. And 23% of these new diagnoses occurred in rural or suburban areas, making it increasingly difficult for such

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patients to find nearby clinics and receive the vital resources to treat HIV/AIDS.6 Suddenly Trump’s basis for wanting to win the fight against AIDS becomes clear: he doesn’t care about the 1.1 million people living with the disease. He’s only worried about the 1.1 million votes he’d lose in the 2020 presidential run if he doesn’t mention anything about the virus plaguing his constituents.1 The U.S. Department of Health & Human Services elaborated on Trump’s plan to end AIDS. Their long-term goal is to “reduce new infections by 75% in the next five years and by 90% in the next ten years”. They hope to achieve this by channeling more funds into creating better treatment, preventive resources like the medication pre-exposure prophylaxis (PrEP), and clinics in the hotspots and rural places most affected by the disease.7 The problem, however, is the fact that no one has mentioned how much the budget for this massive-scale initiative will be. Not to mention that “creating better treatment and clinics” is a pretty vague statement. How will such tasks be implemented, especially if there is no set amount of money to spend? Trump and his administration vow to end AIDS, but how will that happen without a solidified plan? Anyone who has taken a global health class knows the importance of having a concrete budget to work with, especially if the budget requires the approval of another organization or institution. Trump is already failing on both parts: many of Trump’s radical budget proposals, such as his $5.7 billion wall construction proposal, frequently get shut down by Congress’s House of Representatives and Senate.8 Also, any detailed budget factors in the need to hire workers, buy treatments, build various clinics, and support many other components of a public health project in order to get anywhere near completing objectives. Healthcare is expensive, and the president shouldn’t vow to reduce over 90% of HIV infections in the next ten years if he doesn’t actually have the money or specific plan to support it. This isn’t like playing Monopoly: he’s actually dealing with the lives of people who depend on the government for their promised support. With all the evidence piling against him, it’s highly improbable that Trump will follow through his plan. There’s no concrete budget, the current White House remains quite hostile against a huge group of people affected by HIV/AIDS, and we all know that this isn’t the first time Trump has backed out on his promises to ‘Make America Great Again.’

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Where President Trump wants to target his initiative.

Of course, I’d love to be proven wrong—I want America to be AIDS-free by 2030, if not sooner. And this can be a feasible achievement, according to assistant professor of the Yale School of Public Health and former HIV/ AIDS activist Gregg Gonsalves. According to Gonsalves, we have the brains to coordinate a successful HIV/AIDS-eradication initiative, but Trump needs to “stays out of the way of experts and keeps the ideologies that have marked the past two years from interfering.”9 As a guest lecturer in a Yale Global Health class in 2019, Gregg Gonsalves underscored the importance of reducing the amount of HIV/ AIDS infections through the implementation of syringe exchange programs, as people who inject drugs through shared, unclean needles hold “the greatest risk for infectious disease outbreaks.“ Such programs show much success, as one of the first needle exchange programs in the country, located in New Haven, Connecticut, decreased the incidence of HIV infection “among needle exchange participants by 33%.”10

more than one perspective and share ideas, or a sense of distrust or feeling of inferiority from the ‘neglected side’ can occur.

Neither Trump nor the Health and Human Services (HHS) document detailing his plan mention a needle-exchange program, perhaps in fear of drawing a link between HIV/AIDS infection rates and the current opioid crisis our country is ashamed of tackling on. Gonsalves asserted both in the guest lecture and his opinion piece that if the Trump administration stays out of the way and allows the scientists to establish adequate protocols, the 2030 deadline could actually be within reach.

To avoid this, the United States needs cooperation, not separation. The Trump administration must learn from global health experts on how to best end HIV/AIDS, and scientists must learn how to best transfer this knowledge to ordinary citizens and patients who may not know the intricacies of viruses or illnesses affecting the complicated immune system. In a country that seems to become more polarized day by day, there must be a need to seek common ground to truly end HIV/AIDS.

I respectfully disagree. Yes, the Trump administration doesn’t have a good track record…yet that can change. I support giving scientists and HIV/AIDS health experts a voice in this initiative; if anything, their voices are one of the most critical components in pushing this project forward. But it’s also crucial to hear

For example, many parts of our country are currently facing measles outbreaks, partly due to a large proportion of children whose parents chose to not vaccinate them. One of the reasons for refusing to vaccinate? These parents have lost their confidence in scientists and the scientific field in general; they don’t believe in the effectiveness of vaccines and how they work, and thus, ignore the messages about vaccinating their kids. And they’re not alone. Only 14% of Americans “show a great deal of confidence in academia” and a mere 35% of citizens greatly trust scientists.11 Therefore, if we were to give only scientists the power to control the HIV/AIDS initiative, who says any everyday citizen would adhere to their plan and treatments? Once a sense of trust is lost, respect and credibility diminish as well, no matter how high the person’s ranking or social status may be.

www Vanessa Blas is a sophomore in Timothy Dwight College. She wrote this article her first year. She can be contacted at vanessa.blas@yale.edu.

JUUL LABS

Public Health Initiative or Tech Startup?

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BY MATTHEW PETTUS YALE GLOBAL HEALTH REVIEW

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leek,” “high-tech,” “modern,” and “colorful.” No, these is not describing the newest iPhone model, but the e-cigarette product from a Silicon Valley based company called Juul. Juul has dominated the e-cigarette market, becoming the most popular e-cigarette company in the United States by the end of 2017.1 However, its business model and subsequent success are largely contingent on an underage demographic, creating a public health epidemic of nicotine addiction in minors that rivals that of the 1950s.2 These unconventional marketing tactics have been deemed as unethical by the Food and Drug Administration and the larger public health community.3 Presenting a long and trying history, the tobacco epidemic has caused the premature deaths of more than 14 million Americans since 1964. The combination of this and the fact that using tobacco, and by extension cigarettes, can cause nicotine addictions, lung cancer, heart disease, respiratory disease, and smoke pollution, has led to widespread public health campaigns to curb tobacco use in the United States. For example, raising tobacco prices, implementing smoke-free air laws and policies, creating mass media campaigns, legislating to hold the industry responsible for misdeeds, and providing the option of e-cigarettes have all been successful ways in initiating smoking cessation.4 The electronic cigarette, or e-cigarette is a vaporizer that simulates the process of smoking. Primarily publicized as a method of harm reduction, it serves to help wean smokers off smoking tobacco or regular cigarettes. While most e-cigarettes still contain nicotine, albeit less than cigarettes, they do not pose as many health risks as smoking tobacco. The problem that e-cigarette initiate is that when used by non-smokers, e-cigarettes can lead to addiction, even though they have a smaller amount of nicotine. This is where Juul Labs comes into play.5 While public health organizations and nonprofits have made significant progress in curbing smoking behavior since the mid-20th century, smoking and nicotine rates are inexplicably growing at an alarming rate, especially in minors. Researchers and public health officials attribute this increase to new e-cigarette companies that are unconventional in their advertising and marketing strategies. Launched in 2015, Juul Labs aimed to design a solution to a public health problem but ended up worsening it. Taking up 70% of the e-cigarette market share, this $16 billion dollar company focused more on product design and innovation, making their e-ciga-

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The sleek Juul e-cigarette.

rettes very appealing to younger people. Its visual draw is that it looks like the newest Apple product, coming in both a variety of colors and flavors. Moreover, customers can vaporize with their Juul inconspicuously because Juuls do not produce large clouds or plumes of vapor, and they are the size of a small flash drive--essentially, they do not look or function like a real cigarette.6

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Genericization creates an unprecedented transparency for Juul and decreases awareness that Juul is a potentially harmful e-cigarette.

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Another reason that Juul is especially appealing to adolescents stems from Juul’s print and video advertising strategies. An analysis of cigarette marketing from the 1930s shows that advertisements for Juuls are similar to those of old cigarettes: adults and models demonstrating relaxation, happiness, sex appeal, travel, and freedom. These suggestive advertising themes are illegal for cigarette brands to use, but e-cigarette companies’ ads are not regulated in this way. Juul, and other e-cigarette companies, utilize celebrity endorsements, brand ambassadors, and social media to appeal to their audience, a lot of which are minors.7 In doing this, Juul is cultivating a lifestyle brand; “Juuling” is a neologism that has undergone a process of genericization, that is, a trademark that due to its popularity has become synonymous with its corresponding purpose (e.g., Xerox, Kleenex). In this case, genericization creates an unprecedented transparency for Juul and decreases awareness that Juul is a potentially harmful e-cigarette.

The aforementioned marketing tactics ranging from advertisements to product design contribute to Juul’s appeal in adolescents. Consequently, underage adolescents who theoretically had no experience with cigarettes are becoming addicted to nicotine. A recent study from the Schroeder Institute shows that 25% of 15-24 years olds recognized a Juul on sight, while 19% of the adolescents did not know that Juuls have nicotine. Currently, the Food and Drug Administration is trying to figure out if Juul is knowingly marketing to adolescents or not.8 The FDA recently rolled out their Youth Tobacco Prevention Plan, a public health initiative to decrease the rising smoking rates in adolescents.9 A key component of this plan involves demanding Juul Labs to submit documents about their marketing strategies and business model. In doing this the FDA is trying to determine if Juul is intentionally or unintentionally marketing to minors, with the former elucidating more consequences than the latter. Smoking is still the leading cause of preventable death, causing approximately 6 million deaths worldwide, per year.10 This implies that harm reduction initiatives and public health policies have the potential to directly combat rising smoking rates. Juul has actually reversed a lot of the public health progress that has been made on this issue. The conflict between Juul and the FDA is just one example of the longstanding debate between corporate interests and public health. The FDA’s measures might make more progress on the public health side of this debate, however it is uncertain as to what Juul will do next. www Matthew is a junior in Saybrook College studying Neuroscience. He can be contacted at matthew.pettus@yale.edu.

A CASE STUDY

To b a c c o U s e i n Indonesia By Debbie Dada

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Indonesia has the highest adult male tobacco use rate in the world of 76.2%, with a national adult average of 39%.

obacco contributes to the death of 225,700 Indonesians annually; nonetheless, over 53 million adults and 469,000 children (under the age of 15) still partake in its use.¹ Tobacco use is most common among adult men, living in rural areas, with less wealth. Those who live with smokers share the burden of disease. Tobacco use contributes to Disability-Adjusted Life Years (DALYs) mainly through chronic respiratory diseases, cancers, and cardiovascular diseases. The purchase of tobacco and treatment of the diseases it causes consumes much of Indonesian household and national resources. The Ministry of Finance of Indonesia has the power to work with the economic sector to ban the advertisement of tobacco products, impose higher excise taxes on tobacco products, and increase the amount of public smoke-free zones. Nature and Magnitude Tobacco use is the third leading risk factor for disease in Indonesia, accounting for 8.2% of national DALYs and 14.2% of deaths.¹ Indonesia has the highest adult male tobacco use rate in the world of 76.2%, with a national adult average of 39%.1,2 The current product of choice in over 80% of households is kreteks, a locally sourced form of the cigarette made with cloves, which replaced the very popular

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consumption method of chewing betel in the 1950s.³ Indonesia’s position as the fifth largest national producer of tobacco—an estimated 342 billion tobacco products were made in 2016 alone—has cemented the tobacco industry in Indonesian society, making the work of limiting its harm in society of paramount importance.¹ Affected and At-Risk Populations Adult men of low economic status are significantly more likely to use and abuse tobacco products than any other subset of the population. Men are more likely to use tobacco because Indonesian culture stigmatizes female smokers, who are viewed as “morally flawed,” as is well-documented in the Javi-Bali region.³ The female tobacco use rate is only 3.51%.¹ However, with the increased influence of Western nations on Indonesian society, there is a decrease in the social stigma around women smoking, leading to a recent upward trend of smoking rates among women.³ Poverty also has a positive correlation with smoking rates as men in the lowest wealth group smoke at a rate of 81.6%, while only 57.9% in the highest wealth group smoke.³ There could be many factors contributing to this problem, including tobacco industry marketing, historical

lack of education concerning risks, etc. This results in a cycle of poverty wherein poor families are more vulnerable to tobacco use, so they use more of their limited budget on tobacco (devoting less to education, nutrition, etc.), then the breadwinner (most often the male) becomes ill due to tobacco (incurring treatment costs) and dies prematurely, resulting in the family remaining in poverty. The most significant risk factors associated with tobacco usage are living with smokers and living in rural areas. Smoking has significant effects on the loved

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Rokok Indonesia

ones of smokers. Non-smoking women who are regularly exposed to secondhand smoke in the home are 25% more likely to develop lung cancer and 23% more likely to develop heart disease.³ This also affects children as 175,000 homes located in urban slums showed paternal smoking contributed to short-term and chronic child malnutrition.³ Men living in rural areas have a tobacco consumption rate of 67%, which is eight points higher than their urban counterparts.¹ This increased vulnerability to smoking in rural areas is especially debilitating as rural economies are more often predicated on agricultur-

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al manual labour—which decreased lung capacity and other health outcomes from smoking negatively affects.⁴ Economic, Health and Social Consequences Tobacco use has devastating effects on household and individual health, as

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well as economic and social well-being. Treating diseases attributable to tobacco use costs the Indonesian government an estimated 319 million USD per year.³ This is due to the premature death of many smokers, lost worked days due to chronic conditions, and the decreased efficiency at work of smokers even with attempts

Poverty also has a positive correlation with smoking rates as men in the lowest wealth group smoke at a rate of 81.6%, while only 57.9% in the highest wealth group smoke.

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Flickr

Top: Elderly men smoking handmade kreteks in Yogyakarta, Indonesia Bottom: Community members drying tobacco in a village near Borobudur, Indonesia

at managing chronic conditions—all contributing to a decrease in potency of the Indonesian labor force. In addition, families that smoke have an average household expenditure on tobacco products of 11.5%, with only 3.2% remaining for education and 11% for food.³ This speaks greatly to the decreased social welfare of children growing up in such homes (who are also more likely to have a parent die prematurely). Furthermore, the individual health effects of tobacco usage are well-documented as putting individuals at increased risk of heart disease, stroke,

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lung cancer, coronary heart disease, chronic obstructive pulmonary disease, etc. Kreteks specifically contain the chemicals eugenol (a carcinogen), coumarin, and arethol, which have been shown to be deleterious to human health.³ Priority Action Steps In order to decrease the negative consequences of tobacco usage to Indonesia society, the Ministry of Finance can work to decrease the initiation and reuptake of cigarette smoking and decrease the prev-

Families that smoke have an average household expenditure on tobacco products of 11.5%, with only 3.2% remaining for education and 11% for food.

alence of secondhand smoke. In order to decrease the extremely high smoker rate in the country, there must be an immediate ban instituted on the direct advertisements of tobacco. This is the concern of the Ministry of Finance as this is only feasible through the provision of monetary incentives to the large tobacco industries since they have a great amount of political power due to their significant stake in Indonesian society. There are currently zero laws governing tobacco’s presentation on national TV, radio, magazines, newspaper, billboards, the Internet, and in stores at the point of sale.² The implementation of comprehensive laws banning tobacco products has been proven to be greatly successful, as it reduced tobacco consumption by 5.4% and cigarette smoking by 7.4% on average in 22 countries.⁵ Additionally, the World Health Organization (WHO) minimum for the percentage of the retail price of tobacco products that should go towards the excise tax is 70%, but Indonesia’s percentage is only 48.7%; therefore, the excise tax should be increased to reach the WHO minimum.¹ Furthermore, currently 85.4% of people report having been exposed to tobacco smoke at restaurants, bars, and cafes, while 70% report having been exposed on public transportation.³ Considering that, as of 2017, for every 8 deaths due to direct tobacco usage, there was one death due to secondhand smoke, there must be increased protections put in place for the vulnerable non-smoking populations. This should take the form of implementing smoke-free zones in all business offices, government offices, restaurants, bars, cafes, and on public transportation as recommended by the WHO framework to combat tobacco-related deaths.² Vulnerable populations are disproportionately harmed by the tobacco industry in the form of economic, health and social consequences. It is the responsibility of the Indonesian government, especially the ministry of finance, to combat this issue by banning of direct advertisements, increased excise taxes and the creation of smoke-free zones. www

Debbie Dada is currently a junior in Pierson College majoring in the History of Science, Medicine and Public Health.

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She can be contacted for questions at debbie.dada@yale.edu.

YALE GLOBAL HEALTH REVIEW

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CA Cancer J Clin. 2012;62(3):147–172. doi:10.3322/caac.21139 23. Juckett G, Hartman-Adams H. (2010). Human papillomavirus: clinical manifestations and prevention. Am Fam Physician. 82(10):1209-1213. 24. Centers for Disease Control and Prevention, Human Papillomavirus (HPV) Vaccination: What Everyone Should Know. (2016). Retrieved from: https://www.cdc.gov/vaccines/ vpd/hpv/public/index.html The Elusive Antidote to Rising Prescription Drug Prices – Nishanth Krishnan 1. Presidential Statements George W. Bush – 2003. (2003). Social Security Administration. Retrieved from: https://www.ssa.gov/history/gwbushstmts3.html 2. Bush signs landmark Medicare bill into law. (2003). CNN. Retrieved from: http://www. cnn.com/2003/ALLPOLITICS/12/08/elec04.medicare/ 3. Grassley Leads Committee Action on Medicare Prescription Drug and Rural Equity Plan. (2003). grassley.senate.gov. Retrieved from: https://www.grassley.senate.gov/news/ news-releases/grassley-leads-committee-action-medicare-prescription-drug-and-rural-equity-plan 4. Pear, B. Bill to Let Medicare Negotiate Drugs Prices is Blocked. (2007). The New York Times. Retrieved from: https://www.grassley.senate.gov/news/news-releases/grassley-leads-committee-action-medicare-prescription-drug-and-rural-equity-plan

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5. Pollack, A. (2015). Drug goes from $13.50 a pill to $750, Overnight. The New York Times. Retrieved from: https://www.nytimes.com/2015/09/21/business/a-huge-overnight-increasein-a-drugs-price-raises-protests.html 6. Johnson, C. Y. (2017). What happened to the $750 pill that catapulted Martin Shkrelli to infamy? The Washington Post. Retrieved from: https://www.washingtonpost.com/news/ wonk/wp/2017/08/01/what-happened-to-the-750-pill-that-catapulted-pharma-bro-martinshkreli-to-infamy/?utm_term=.b1ac5c079bc3 7. Duhigg, C. (2017). Outcry Over EpiPen Prices Hasn’t Made Them lower. The New York Times. Retrieved from: https://www.nytimes.com/2017/06/04/business/angry-about-epipen-prices-executive-dont-care-much.html 8. Collier, R. (2013). Drug Patents: the evergreening problem. Canadian Medical Association Journal, 185(9), 385 – 386. 9. Insulin: a life-saving drug too often out of reach. (n.d.). Retrieved from: https://diabetescaucus-degette.house.gov/sites/diabetescaucus.house.gov/files/Congressional%20Diabetes%20Caucus%20Insulin%20Inquiry%20Whitepaper%20FINAL%20VERSION.pdf 10. Sable-Smith, B. (2019). How Much Difference Will Eli Lilly’s Half-Price Insulin Make? Kaiser Health News. Retrieved from: (https://khn.org/news/how-much-difference-will-elilillys-half-price-insulin-make/ 11. Grassley, Wyden Launch Bipartisan Investigation into Insulin Prices. (2019). grassley. senate.gov. Retrieved from: https://www.grassley.senate.gov/news/news-releases/grassley-wyden-launch-bipartisan-investigation-insulin-prices 12. Davio, K. (2018). 5 Things to Know about the CREATES Act. AJMC Managed Markets Network. Retrieved from: https://www.ajmc.com/newsroom/5-things-to-know-about-thecreates-act 13. Health Insurance Coverage in the United States: 2017. (2017). United States Census Bureau. Retrieved from: https://www.census.gov/library/publications/2018/demo/p60-264. html 14. Drug Pricing in America: A Prescription for Change, Part II. (2019). United States Senate Committee on Finance. Retrieved from: https://www.finance.senate.gov/hearings/drugpricing-in-america-a-prescription-for-change-part-ii 15. Medicare Enrollment Dashboard. (2019). Centers for Medicare and Medicaid Services. Retrieved from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMSProgramStatistics/Dashboard.html 16. Cubanski, J., Neuman, T. (2018). Searching for Savings in Medicare Drug Price Negotiations. Henry J. Kaiser Family Foundation. Retrieved from: https://www.kff.org/medicare/ issue-brief/searching-for-savings-in-medicare-drug-price-negotiations/ 17. Doggett, Brown Announce Bicameral Medicare Drug Price Negotiation Bill. (2019). doggett.house.gov. Retrieved from: https://doggett.house.gov/media-center/press-releases/ doggett-brown-announce-bicameral-medicare-drug-price-negotiation-bill Wellness Makes the World Go ‘Round – Tomeka Frieson 1. The United Nations High Commissioner for Refugees. (2018). Global Trends: Forced Displacement in 2017 [PDF file]. Retrieved from http://www.unhcr.org/5b27be547.pdf. 2. Beauchamp, Z. (2017). 9 maps and charts that explain the global refugee crisis. Vox. Retrieved from https://www.vox.com/world/2017/1/30/14432500/refugee-crisis-trump-muslim-ban-maps-charts. 3. Refugees, Asylum Seekers & Migrants: A Crucial Difference. (2016). Habitat for Humanity: Great Britain. Retrieved from https://www.habitatforhumanity.org.uk/blog/2016/09/ refugees-asylum-seekers-migrants-crucial-difference/. 4. Kopan, T. (2018). What are sanctuary cities? CNN. Retrieved from https://www.cnn. com/2017/01/25/politics/sanctuary-cities-explained/index.html. 5. Griffith, B. & Vaughan, J. M. (2017). Maps: Sanctuary Cities, Counties, and States. Center for Immigration Studies. Retrieved from https://cis.org/Map-Sanctuary-Cities-Countiesand-States. 6. Krogstad, J. M. & Radford, J. (2017). Key facts about refugees to the US. Pew Research Center. Retrieved from http://www.pewresearch.org/fact-tank/2017/01/30/key-facts-aboutrefugees-to-the-u-s/. 7. The United Nations High Commissioner for Refugees: Lebanon. (n.d.). Refugees and asylum-seekers. Retrieved from http://www.unhcr.org/lb/refugees-and-asylum-seekers. 8. Yee, V. (2018). In Lebanon Town, Refugees and Locals Agree on 1 Thing: Time for Syrians to Go. The New York Times. Retrieved from https://www.nytimes.com/2018/08/08/world/ middleeast/lebanon-syria-refugees-arsal.html 9. Saliba, I. (2016). Refugee Law and Policy: Lebanon. US Library of Congress. Retrieved from https://www.loc.gov/law/help/refugee-law/lebanon.php. 10. Blanchet, K., Fouad, F. M., & Pherali, T. (2016). Syrian refugees in Lebanon: the search for universal health coverage. Conflict and Health, 10(12). doi: 10.1186/s13031-016-0079-4. 11. Dadzie, G. M. (2017). Healthcare Accessibility for Syrian Refugees: Understanding Trends, Host Countries’ Responses and Impacts on Refugees’ Health [PDF file]. Retrieved from https://www.albany.edu/honorscollege/files/GertrudeMorganDadzie.pdf. 12. Lebanon Support. (2016). Access to Healthcare for Syrian Refugees. The Impact of Fragmented Service Provision on Syrians’ Daily Lives [PDF file]. Lebanon Support. Retrieved from https://civilsociety-centre.org/sites/default/files/resources/accesshealthcaresyrianrefugees-ls2016.pdf. 13. The United Nations High Commissioner for Refugees: USA. (2018). Survey finds Syrian refugees in Lebanon became poorer, more vulnerable in 2017. Retrieved from http://www. unhcr.org/news/briefing/2018/1/5a548d174/survey-finds-syrian-refugees-lebanon-poorer-vulnerable-2017.html. 14. Policy Framework for Refugees in Lebanon and Jordan. (2018). Carnegie Middle East Center. 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Journal, 23(6). 16. Sleiman, D. & Atallah, D. (2016). With Syria refugee crisis, Lebanese health services improve. The United Nations High Commissioner for Refugees: USA. Retrieved from http:// www.unhcr.org/news/stories/2016/9/57ce7e7d4/syria-refugee-crisis-lebanese-health-services-improve.html. 17. Warren, R. (2015). Why Are Refugees Going To Germany—And Will They Stay? BuzzFeed News. Retrieved from https://www.buzzfeed.com/rossalynwarren/why-are-refugeesgoing-to-germany-and-will-they-stay. 18. Rietig, V. & Müller, A. (2016). The New Reality: Germany Adapts to Its Role as a Major Migrant Magnet. Migration Policy Institute. Retrieved from https://www.migrationpolicy. org/article/new-reality-germany-adapts-its-role-major-migrant-magnet. 19. Borgschulte, H. S., Wiesmüller, G. A., Bunte, A., & Neuhann, F. (2018). Health care provision for refugees in Germany – one-year evaluation of an outpatient clinic in an urban emergency accommodation. 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Retrieved from https://www.vox.com/science-and-health/2018/12/6/18126338/crispr-babies-china-gene-editing. 13. Topol, E. (2018). Editing babies? We need to learn a lot more first. The New York Times. Retrieved from https://www.nytimes.com/2018/11/27/opinion/genetically-edited-babies-china.html?action=click&module=RelatedLinks&pgtype=Article. 14. Cyranoski, D. (2018). CRISPR-baby scientist fails to satisfy critics. Nature. Retrieved from https://www.nature.com/articles/d41586-018-07573-w. Psychosis and Possession – Sam Brakarsh 1. Patel, Vikram. 2003. Where There Is No Psychiatrist: A Mental Health Care Manual / Vikram Patel; Illustrations by Wilson DSouza. 2. Heaton, Matthew M. 2013. Black Skin, White Coats: Nigerian Psychiatrists, Decolonization, and the Globalization of Psychiatry. Athens, OH: Ohio University Press. 3. Kapya, John Kaoma. 2016. African Religion and Colonial Rebellion: The Contestation of Power in Colonial Zimbabwe’s Chimurenga of 1896-1897. Boston, Journal for the Study of Religion. 4. Conrad, Peter, Schneider, Joseph W. 2013. Professionalization, Monopoly, and the Structure of Medical Practice. In Sociology of Health and Illness: Critical Perspectives. 5. Light, Donald. 1981. Countervailing Power: The Changing Character of the Medical Profession in the United States. In Sociology of Health and Illness: Critical Perspectives. New York: Worth Publishers, pp.260-269. 6. Ciccarelli, S. K., & White, J. N. (2014). Psychology: DSM 5. Boston: Pearson. 7. Luhrmann, T. M., R. Padmavati, H. Tharoor, and A. Osei. 2015. Differences in Voice-Hearing Experiences of People with Psychosis in the USA, India and Ghana: Interview-Based Study. British Journal of Psychiatry 206, no. 1. 8. Foucault, Michel. 2011.Discipline and Punish the Birth of the Prison. New York: Vintage

Books. 9. Skaggs, Sherry Lynn. "Labelling Theory." Encyclopædia Britannica. October 09, 2016. Accessed November 25, 2018. 10. Conrad, Peter. 2005. The Shifting Engines of Medicalization. Journal of Health and Social Behavior. 11. West, Harry G. 2007. Ethnographic Sorcery. Chicago: University of Chicago Press. 12. Larøi, Frank, Luhrmann, Tanya Marie, Bell, Vaughan, William A. Christian, Deshpande, Smita, Fernyhough, Charles, Jenkins, Janis, Woods, Angela. 2014. Culture and Hallucinations: Overview and Future Directions, Schizophrenia Bulletin, Volume 40, Issue Suppl_4, 1 July 2014, Pages S213–S220, https://doi.org/10.1093/schbul/sbu012. 13. Kirmayer, Laurence J., Ryder, Andrew G. 2016. Culture and psychopathology. Current Opinion in Psychology. 14. Mental Health Innovation. n.d. The Friendship Bench. Accessed November 22, 2018. http://www.mhinnovation.net/innovations/friendship-bench?qt-content_innovation=0#qt-content_innovation 15. 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The Congressional Representation of Muslim-American Constituents. Politics and Religion,2(2), 230-246. doi:10.1017/S1755048309000212 7. Trump v. Hawaii https://www.supremecourt.gov/opinions/17pdf/17-965_h315.pdf 8. Trump v. Hawaii https://www.supremecourt.gov/opinions/17pdf/17-965_h315.pdf 9. Madara, James L. “AMA Urges Trump Administration to Clarify Immigration Executive Order.” AMA Urges Trump Administration to Clarify Immigration Executive Order | American Medical Association, American Medical Association, 1 Feb. 2017, www.ama-assn.org/ama-urges-trump-administration-clarify-immigration-executive-order. 10. Altorjai, Szilvia, and Jeanne Batalova. “Immigrant Health-Care Workers in the United States.” Migration Policy Institute, 19 July 2017, www.migrationpolicy.org/article/immigrant-health-care-workers-united-states. 11. 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Altorjai, Szilvia, and Jeanne Batalova. “Immigrant Health-Care Workers in the United States.” Migration Policy Institute, 19 July 2017, www.migrationpolicy.org/article/immigrant-health-care-workers-united-states. 16. Belluz, Julia, and Sarah Frostenson. “How Trump's Travel Ban Threatens Health Care, in 3 Charts.” Vox, 26 June 2018, www.vox.com/2017/2/1/14470746/trump-travel-ban-healthcare-doctors. 17. Hauslohner, Abigail. “Coveted Exemptions from Trump's Travel Ban Remain Elusive for Citizens of Muslim-Majority Countries.” The Washington Post, 22 May 2018, www. washingtonpost.com/national/coveted-waivers-for-trumps-travel-ban-remain-elusive-for-citizens-of-muslim-majority-countries/2018/05/22/d48cc8d8-48b6-11e8-827e190efaf1f1ee_story.html?utm_term=.6c524ed00283. 18. Belluz, Julia, and Sarah Frostenson. “How Trump's Travel Ban Threatens Health Care, in 3 Charts.” Vox, 26 June 2018, www.vox.com/2017/2/1/14470746/trump-travel-ban-healthcare-doctors. 19. 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The Health Consequences of the War in Yemen – Ben Grobman 1. How Yemen became the most wretched place on earth. (2017, November 30). Retrieved October 14, 2018, from https://www.economist.com/briefing/2017/11/30/how-yemen-became-the-most-wretched-place-on-earth 2. Laub, Z. (2016, April 19). Yemen in Crisis. Retrieved October 14, 2018, from https://www. cfr.org/backgrounder/yemen-crisis 3. Watson, B. (2018, February 03). The War in Yemen and the Making of a Chaos State. Retrieved October 14, 2018, from https://www.theatlantic.com/international/archive/2018/02/ the-war-in-yemen-and-the-making-of-a-chaos-state/551987/ 4. Al Jazeera. (2018, March 25). Key facts about the war in Yemen. Retrieved October 14, 2018, from https://www.aljazeera.com/news/2016/06/key-facts-war-yemen-160607112342462.html 5. Laub, Z. (2015, February 25). Who Are Yemen's Houthis? Retrieved October 14, 2018, from https://www.cfr.org/interview/who-are-yemens-houthis 6. Batati, S. A. (2015, March 29). Who are the Houthis in Yemen? Retrieved October 14, 2018, from https://www.aljazeera.com/news/middleeast/2014/08/yemen-houthis-hadi-protests-201482132719818986.html 7. Juneau, T. (2013). Yemen and the Arab Spring: Elite Struggles, State Collapse and Regional Security. Orbis,57(3), 408-423. doi:10.1016/j.orbis.2013.05.004 8. Ghobari, M. (2014, August 18). Tens of thousands of Yemeni Houthis protest against fuel reform, Retrieved from https://www.reuters.com/article/us-yemen-protests/ tens-of-thousands-of-yemeni-houthis-protest-against-fuel-reform-government-idUSKBN0GI1O420140818 9. Yemen crisis: President Hadi flees as Houthi rebels advance. (2015, March 25). Retrieved from https://www.bbc.com/news/world-middle-east-32048604 10. Yemen: The forgotten war. (n.d.). Retrieved from https://www.amnesty.org/en/latest/ news/2015/09/yemen-the-forgotten-war/ 11. Bayoumi, M. (2018, August 25). US bombs are killing children in Yemen. Does anybody care? | Moustafa Bayoumi. Retrieved from https://www.theguardian.com/commentisfree/2018/aug/25/us-bombs-yemen-children-humanitarian-disaster 12. Ferguson, J. (2018, July 11). Is Intentional Starvation the Future of War? Retrieved from https://www.newyorker.com/news/news-desk/is-yemen-intentional-starvation-the-future-of-war 13. Crisis in Yemen: Reflections on the world's largest humanitarian emergency. (n.d.). Retrieved from https://www.oxfamamerica.org/explore/stories/crisis-in-yemen-reflections-from-the-worlds-largest-humanitarian-emergency/ 14. Yemen crisis: Who is fighting whom? (2018, January 30). Retrieved from https://www. bbc.com/news/world-middle-east-29319423 15. Associated Press. (2018, September 14). Yemenis turn to boiled leaves as famine grips the region. Retrieved from https://www.mercurynews.com/2018/09/14/yemenis-turn-toboiled-leaves-as-famine-grips-the-region/ 16. Go inside a Yemen hospital. (2018, October 12). Retrieved from https://www.rescue.org/ video/go-inside-yemen-hospital 17. Fahim, K. (2017, December 21). Hospital Aided by Doctors Without Borders Is Bombed in Yemen. Retrieved from https://www.nytimes.com/2016/01/11/world/middleeast/hospital-aided-by-doctors-without-borders-is-bombed-in-yemen.html 18. In Latest Offensive, Saudi Arabia Destroys Hospital and Maternity Ward in Yemen. (2018, October 12). Retrieved from https://www.mintpressnews.com/in-latest-offensive-saudi-arabia-destroys-hospital-and-maternity-ward-in-yemen/250673/ 19. Mahmood, A. (2018, September 15). Houthis bar civilians from Hodeidah hospitals to keep beds for fighters. Retrieved from https://www.thenational.ae/world/mena/houthisbar-civilians-from-hodeidah-hospitals-to-keep-beds-for-fighters-1.770446 20. T. (2018, June 21). A Rare Look at Yemen's War, Where Children Starve and Hospitals Are on Life-Support. Retrieved from https://theintercept.com/2018/06/21/yemen-war-humanitarian-crisis/ 21. Frontieres, M. S. (2017). SAVING LIVES WITHOUT SALARIES Government health staff in Yemen. Retrieved from https://www.msf-me.org/sites/default/files/msf-yemen-salaries-lr-def.pdf 22. Raghavan, S. (2018, August 06). Dying babies and no doctors: A look inside a Yemeni hospital. Retrieved from https://www.washingtonpost.com/world/dying-babies-and-nodoctors-a-look-inside-a-yemeni-hospital/2018/08/05/8bcf87d4-8f7e-11e8-b769-e3fff17f0689_ story.html 23. Yemen war a 'living hell' for children: UNICEF. (2018, September 13). Retrieved from https://www.reuters.com/article/us-yemen-security-malnutrition/yemen-war-a-living-hellfor-children-unicef-idUSKCN1LT21M 24. Toyin Owoseje. (2018, September 19). Five million children face starving to death in Yemen, Save the Children warns. Retrieved from https://www.independent.co.uk/news/ world/yemen-crisis-conflict-children-famine-starvation-death-a8545666.html 25. YEMEN: Hunger & disease could kill at least 50,000 children. (2017, November 15). Retrieved from https://www.savethechildren.org.uk/news/media-centre/press-releases/ yemen--hunger---disease-could-kill-at-least-50-000-children-this 26. Lyons, K. (2017, October 12). Yemen's cholera outbreak now the worst in history as millionth case looms. Retrieved from https://www.theguardian.com/global-development/2017/ oct/12/yemen-cholera-outbreak-worst-in-history-1-million-cases-by-end-of-year 27. Camacho, A., Bouhenia, M., Alyusfi, R., Alkohlani, A., Naji, M. A., Radiguès, X. D., . . . Luquero, F. J. (2018). Cholera epidemic in Yemen, 2016–18: An analysis of surveillance data. The Lancet Global Health, 6(6). doi:10.1016/s2214-109x(18)30230-4 28. Analysis | 1 million people have contracted cholera in Yemen. You should be outraged. (2017, December 22). Retrieved from https://www.washingtonpost.com/news/worldviews/ wp/2017/12/21/one-million-people-have-caught-cholera-in-yemen-you-should-be-outraged/?utm_term=.4f3db9332261 29. Gladstone, R. (2017, May 10). Cholera Compounds Suffering in a Yemen Torn by

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War. Retrieved from https://www.nytimes.com/2017/05/09/world/middleeast/cholera-yemen-war-humanitarian-crisis.html 30. Miles, T. (2018, August 03). WHO warns of new Yemen cholera surge, asks for ceasefire to vaccinate. Retrieved from https://www.reuters.com/article/us-yemen-security-cholera/ who-warns-of-new-yemen-cholera-surge-asks-for-ceasefire-to-vaccinate-idUSKBN1KO18R 31. Yemen cholera outbreak accelerates to 10,000 cases per week: WHO. (2018, October 02). Retrieved from https://www.reuters.com/article/us-yemen-security-cholera/yemen-choleraoutbreak-accelerates-to-10000-cases-per-week-who-idUSKCN1MC23J 32. Yemen could be 'worst famine in 100 years'. (2018, October 14). Retrieved from https:// www.bbc.com/news/av/world-middle-east-45857729/yemen-could-be-worst-famine-in100-years Lessons from Chicago – Parmida Zarei 1. Alvarez, L., & Buckley, C. (2013, July 14). Zimmerman Is Acquitted in Trayvon Martin Killing. Retrieved October 27, 2018, from https://www.nytimes.com/2013/07/14/us/ george-zimmerman-verdict-trayvon-martin.html 2. Peralta, E., & Chappell, B. (2014, November 24). Ferguson Jury: No Charges For Officer In Michael Brown's Death. Retrieved October 18, 2018, from https://www.npr.org/sections/ thetwo-way/2014/11/24/366370100/grand-jury-reaches-decision-in-michael-brown-case 3. Williams, T., & Smith, M. (2015, December 28). Cleveland Officer Will Not Face Charges in Tamir Rice Shooting Death. Retrieved October 18, 2018, from https://www.nytimes. com/2015/12/29/us/tamir-rice-police-shootiing-cleveland.html 4. Smith, M. (2017, June 16). Minnesota Officer Acquitted in Killing of Philando Castile. Retrieved October 18, 2018, from https://www.nytimes.com/2017/06/16/us/police-shooting-trial-philando-castile.html 5. Park, M. (2018, October 03). Police shootings: Trials, convictions are rare for officers. Retrieved October 19, 2018, from https://www.cnn.com/2017/05/18/us/police-involved-shooting-cases/index.html 6. Gelman, A., Fagan, J., & Kiss, A. (2007). An Analysis of the New York City Police Departments “Stop-and-Frisk” Policy in the Context of Claims of Racial Bias. Journal of the American Statistical Association,102(479), 813-823. 7. Lowery, W. (2016, July 11). Analysis | Aren't more white people than black people killed by police? Yes, but no. Retrieved October 19, 2018, from https://www.washingtonpost.com/ news/post-nation/wp/2016/07/11/arent-more-white-people-than-black-people-killed-bypolice-yes-but-no/?utm_term=.6044e2d0fd2 8. Edwards, F., Esposito, M. H., & Lee, H. (2018). Risk of Police-Involved Death by Race/ Ethnicity and Place, United States, 2012–2018. American Journal of Public Health,108(9), 1241-1248. 9. Kalven v. City of Chicago, 2014 IL App (1st) 121846 (Illinois Appellate Court March 10, 2014). 10. Heinzmann, D. (2014, March 12). Court: Misconduct complaints against Chicago police should be public. Retrieved October 19, 2018, from http://www.chicagotribune.com/news/ local/breaking/chi-court-rules-citizen-complaints-about-chicago-police-misconduct-arepublic-20140311-story.html 11. Bor, J., Venkataramani, A. S., Williams, D. R., & Tsai, A. C. (2018). Police killings and their spillover effects on the mental health of black Americans: A population-based, quasi-experimental study. The Lancet,392(10144), 302-310. 12. Geller, A., Fagan, J., Tyler, T., & Link, B. G. (2014). Aggressive Policing and the Mental Health of Young Urban Men. American Journal of Public Health,104(12), 2321-2327. 13. Gomez, M. B. (2016). Policing, Community Fragmentation, and Public Health: Observations from Baltimore. Journal of Urban Health,93(S1), 154-167. 14. Bui, A. L., Coates, M. M., & Matthay, E. C. (2018). Years of life lost due to encounters with law enforcement in the USA, 2015–2016. Journal of Epidemiology and Community Health,72(8), 715-718. 15. Peck, J. H. (2015). Minority perceptions of the police: A state-of-the-art review. Policing: An International Journal of Police Strategies & Management,38(1), 173-203. 16. Futterman, C. B., Hunt, C., & Kalven, J. (2016).’'They Have All the Power': Youth/Police Encounters on Chicago's South Side. University of Chicago Public Law & Legal Theory Working Paper No. 573, 1-76. 17. Krieger, N., Kiang, M. V., Chen, J. T., & Waterman, P. D. (2015). Trends in US deaths due to legal intervention among black and white men, age 15- 34 years, by county income level: 1960-2010. Harvard Public Health Review,3, 1-5. Retrieved October 19, 2018. 18. Jones, T. (2018, September 27). How Chicago's Public Schools Are Teaching the History of Police Torture. Retrieved October 17, 2018, from https://www.newyorker.com/news/dispatch/how-chicagos-public-schools-are-teaching-the-history-of-police-torture 19. Rahr, S., & Rice, S. K. (2015). From Warriors to Guardians: Recommitting American Police Culture to Democratic Ideals(Rep. No. 248654). Washington, D.C.: U.S. Department of Justice, National Institute of Justice. Facing the Heat – Indira Flores 1. Willingham, A. (2017, November 21). A look at four storms from one brutal hurricane season. Retrieved from https://www.cnn.com/2017/10/10/weather/hurricane-nate-mariairma-harvey-impact-look-back-trnd/index.html 2. Japan floods: At least 100 dead after record rainfall. (2018, July 09). Retrieved from https://www.bbc.com/news/world-asia-44762110 3. Japan floods: 155 killed after torrential rain and landslides. (2018, July 10). Retrieved from https://www.bbc.com/news/world-asia-44775627 4. Negishi, M. (2018, July 09). Japan Flooding, Mudslides Kill More Than a Hundred People. Retrieved from https://www.wsj.com/articles/japans-disastrous-rain-mudslideskill-more-than-a-hundred-1531117089 5. 2018 Hurricane Florence: Facts, FAQs, and how to help. (2018, October 11). Retrieved from https://www.worldvision.org/disaster-relief-news-stories/2018-hurricane-flor-

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ence-facts 6. C. (2018, September 15). Florence by the numbers: More than 30 inches of rain reported in Swansboro, North Carolina. Retrieved from https://www.cbsnews.com/news/ florence-tropical-storm-hurricane-by-the-numbers-north-carolina-south-carolina-today-2018-09-15/ 7. Atkin, E. (2018, September 13). Hurricane Florence Is a Public Health Emergency, Too. Retrieved from https://newrepublic.com/article/151180/hurricane-florence-public-health-emergency 8. The New York Times. (2018, September 14). Wreaking Havoc, Deadly Storm Cuts Through the Philippines. Retrieved from https://www.nytimes.com/2018/09/14/world/asia/ ompong-typhoon-philippines-mangkhut.html 9. Yap, C., Sullivan, B. K., & Colanzo, A. (2018, September 14). Hong Kong On Lockdown as Typhoon Mangkhut Arrives. Retrieved from https://www.bloomberg.com/news/articles/2018-09-14/super-typhoon-mangkhut-slams-philippines-with-category-5-power 10. CRS. (2018, September). Typhoon Mangkhut- Philippines. Retrieved from https://www. crs.org/sites/default/files/usops-resources/crs_emergency_factsheet_philippines_typhoon_ mangkhut_u.s.pdf 11. George Washington University. (2018). ASCERTAINMENT OF THE ESTIMATED EXCESS MORTALITY FROM HURRICANE MARÍA IN PUERTO RICO. Retrieved from https://prstudy.publichealth.gwu.edu/sites/prstudy.publichealth.gwu.edu/files/reports/ Acertainment%20of%20the%20Estimated%20Excess%20Mortality%20from%20Hurricane%20Maria%20in%20Puerto%20Rico.pdf 12. CDC. (n.d.). Waterborne Illnesses. Retrieved from https://www.cdc.gov/nceh/vsp/training/videos/transcripts/water.pdf 13. University of Arizona. (2017, October 16). The impact of climate change on hurricanes and how it affects public health. Retrieved from https://mphdegree.arizona.edu/resources/ articles/the-impact-of-climate-change-on-hurricanes-and-how-it-affects-public-health/ 14. Cook, J., Ebbs, S., & Theodorou, C. (2018, September 13). How the federal government is poised to respond to Hurricane Florence. Retrieved from https://abcnews.go.com/US/ federal-government-poised-respond-hurricane-florence/story?id=57806869 The Challenges of Trump’s Plan to Eradicate HIV/AIDS – Vanessa Blas 1. HIV/AIDS, CDC (2018). Basic Statistics: HIV Basics. 2. Goldstein, A. (2019, February 5). Trump announces goal of ending HIV/AIDS epidemic by end of next decade. The Washington Post. 3. Lopez, G. (2018). Trump promised to be LGBTQ-friendly. His first year in office proved it was a giant con. 4. Matt Stevens (2017). Trump Ends Terms of Remaining Members of H.I.V. and AIDS Council. The New York Times. 5. II, A. M. A. (2018). Department of Health and Human Services’ Fiscal Year 2018 Funding. 6. HIV/AIDS, N. C. f. (2018). HIV in the United States by Region. 7. Azar, A. (2019). Ending the HIV Epidemic: A Plan for America. 8. Ella Nilsen, L. Z. (2018). The government is headed to a partial shutdown after the Senate rejected Trump’s $5 billion in border wall funding. 9. Gonsalves, G. (2019). The U.S. really could end AIDS – if the Trump administration gets out of the way. The Washington Post. 10. Junge, V. a. (1998). The role of needle exchange programs in HIV prevention. Retrieved from Public Health Reports 11. Tsipursky, G. (2018). (Dis)trust in Science. Juul Labs – Matthew Pettus 1. Haubursin, C. (2018). How Juul made nicotine go viral. Vox Media. 2. Framework Convention on Tobacco Control. (2014). Electronic nicotine delivery systems. World Health Organization. 3. Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems. (2018). Public Health Consequences of E-Cigarettes. National Academies of Sciences, Engineering, and Medicine. 4. Giovino, GA. (2007). The tobacco epidemic in the United States. State University of New York at Buffalo. 5. Glynn, S. (2012). Electronic Cigarettes - Can They Help People Quit Tobacco Cigarettes? Medical News Today. 6. Belluz, J. (2018). FDA: we might have to ban some e-cigarettes to stop teens from vaping. Vox Media. 7. Brodwin, E. (2018). $15 billion startup Juul used 'relaxation, freedom, and sex appeal' to market its creme-brulee-flavored e-cigs on Twitter and Instagram — but its success has come at a big cost. Business Insider. 8. Willett, J. (2018). Recognition, use and perceptions of JUUL among youth and young adults. Schroeder Institute. 9. Youth and Tobacco. (2018). US Food and Drug Administration. 10. Smoking and Tobacco Use. (2018). Center for Disease Control. Tobacco Use in Indonesia – Debbie Dada 1. Indonesia. (2018). Tobacco Tobacco Atlas. Retrieved from www.tobaccoatlas.org/country/ indonesia/. 2. Cherukupalli, R. & Perucic, A. (2017). Affordability of cigarettes products in the WHO report on the global tobacco epidemic, 2017. Tobacco Induced Diseases, 2(1), 696. 3. Barber, S. & Ahsan, A. (2009). The tobacco excise system in Indonesia: hindering effective tobacco control for health. Journal of Public Health Policy, 30(2), 208-225. 4. GBD Profile: Indonesia. (2015). Institute for Health Metrics and Evaluation. Retrieved from www.healthdata.org/sites/default/country_profiles/GDB/ihme_gbd_country_report_indonesia. 5. Saffer, H. & Chaloupka. (2000). Journal of Health Economics, 19(6), 1117-1137.