The Public Health Advocate: Ignite (Spring 2021)

the

PUBLIC HEALTH ADVOCATE SPRING 2021

IGNITE

the

PUBLIC HEALTH ADVOCATE

TABLE OF CONTENTS

A UC BERKELEY UNDERGRADUATE PUBLIC HEALTH JOURNAL

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7

SPRING 2021 ISSUE

EDITORIAL BOARD EDITOR-IN-CHIEF Subeksha Sharma

PRINT MANAGING EDITORS Kahyun Koh Raneem Rayes

Sex Bias in Pharmacological Studies

Burning for Change 10

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ONLINE MANAGING EDITOR Manisha Sahoo DECAL MANAGER Haley Chen EXTERNAL RELATIONS MANAGER Jenny Kwon

Un-Natural Selection 16

STAFF

COPY EDITORS Caroline Kim Jandy Le Kaavya Venkat Annie Yang CONTRIBUTING WRITERS

High-Risk CA Residents May Be Eligible for COVID-19 Vaccine

Anna Fang Mahathi Kandimalla Alishah Khan Jonathan Kuo Keerthana Ramaswamy Erika Rizal Sonia Vaze

WITH SPECIAL THANKS TO UC Berkeley School of Public Health Alumni Association 2 | SPRING 2021

I Feel It In My Gut 20

Understanding Women

22

Pandemic Preparedness

24

Plants and Performance

LETTER FROM THE EDITOR Dear readers, Throughout the production of this issue, we have witnessed a whirlwind of change. As the world adapts to the on-going impacts of the COVID-19 pandemic, one thing has become clear: things are not going back to “normal.” The pandemic has both unearthed and exacerbated problems in our society that run deeper than this virus. Not only have there been over three million deaths worldwide, but we have also seen how low-income countries and communities of color are both hit the hardest and are the least supported by healthcare. Political polarization and competition around patents have shifted the focus of innovation from saving lives to making money.

Skepticism around vaccines and poor scientific literacy have raised concerns about whether we can reach herd immunity.

The turmoil of the past year has ignited movements across the globe and we are moving forward from our stumbles. At the time of writing, over 890 million covid vaccines have been administered worldwide. The progress has not been restricted to high income countries, as the COVAX program has made headway in providing 92 low and middle-income countries with vaccine supply. In the political world, the United States not only inaugurated the first female, Black, Asian American vice president, but also rejoined the Paris Climate Accord and the World Health Organization. Scientific breakthroughs

have not been limited to vaccine development, as NASA landed the Perseverance rover on Mars.

“Ignite’’ reflects the work of our writers to address the deeply rooted public health issues that touch us all.

In “Burning for Change’’ Jonathan Kuo demonstrates how igniting fire through prescribed burning can, quite literally, change California’s land to a healthier state and prevent wildfires. Anna Fang’s “Sex Bias in Pharmacological Studies” unearths the sex differences in clinical drug trials and the consequences for womens health. Alishah Khan in “Pandemic Preparedness” explores reasons for failures in the United States’ response to the pandemic.

As you make your way through this issue, we hope you reflect on what sparks your passion. What fires will you ignite?

Your advocate,

Subeksha Sharma

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A FIREFIGHTER (Frank Brown Jr.) from the Viejas Fire Department conducts a pile burn, a type of prescribed burning where brush is mechanically cleared, gathered, moved to a safe area, then burned.

IMAGE CREDIT | FRANK BROWN JR./ VIEJAS BAND

BURNING FOR CHANGE

Prescribed burning has become the de facto magic bullet for people thinking about how to solve California’s wildfire problem. But how does this magic bullet work in practice?

BY JONATHAN KUO

W

illiam T. Valentine had never seen such a strange sight during his 21 years living in Alameda. And as former chief of the Fire Department, he was pretty used to dealing with peculiar situations.

But nothing could have prepared him for the millions of butterflies that swarmed Alameda on the evening of September 25th, 1889. And as the insects swept through the streets for two hours, coloring the air dark brown with speckled gold motes, normal life seemed to pause. Birds pounced on the creatures as they flew by. Dogs and cows looked “apparently in wonder,” mimicking their human owners, as the butterflies danced

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around noses and tails and hands and paws. And horses neighed and stamped their feet as they were battered by soft touches of thousands of flapping wings.

As the residents of Alameda were witnessing this historical miracle, other residents in the southern part of the state were witnessing a historical tragedy, one Valentine was probably better-equipped to handle: the Santiago Canyon Fire. This fire was not your average blaze. While official records on fire size weren’t maintained until the 1930s, historical accounts place the Fire at a size of over 300,000 acres. It was one of those fires that destroyed cities, wrecked towns, and ruined lives.

Fortunately, thanks to a national attitude toward land management that prioritized fire prevention and suppression, fires like the Santiago Canyon Fire are few and far between in California’s history. And for a century, that policy seemed to work fine.

But things started to change with the turn of the millennium. In 2003, a wildfire burned nearly 275,000 acres of land in San Diego. “A fire of this type is not usual,” said one official in response, explaining that “this is an epic fire for San Diego County.” The blaze would be recorded as “the largest fire in the state” since 1932 (and unofficially, since 1889).

That record didn’t last for very long.

240,000 acres in July 2007. 200,000 acres in October 2007. 272,000 acres in August 2012. 257,000 acres in August 2013. 280,000 acres in December 2017.

690,000 acres in July 2018, in 2 separate fires. And just last year, over 4,000,000 acres in at least six fires spread across the state, 1,000,000 of which burned in the August Complex Fire alone. With the buildup of dry, dangerous brush across the state—a consequence of suppressing fire for a century—California’s lands are overdue for change through fire, and even deluges of water and firefighting chemicals won’t delay fire season any longer.

One solution, however, may lie in an increasingly popular indigenous technology that starts fires, rather than suppressing them: prescribed burning.

equipped with hundreds of gallons of water, a contemporary safety provision.

Strategy, too, plays an important role.

“One of the most important lessons in learning how to burn . . . is to start at the top of the brush,” Robbins says. Doing so limits the spread of fire, she explains, because it creates a barrier of charred material that fire can not bypass.

For the Yurok and many other tribes, however, burning doesn’t only prevent wildfires—it also has cultural meaning. “Cultural burns increase the health and availability of culturallyimportant species, restore the land to a healthy state, and improve the water quality,” explains Robbins. Location and history also endow burns with cultural significance. “Cultural burns have to do with the connection to a place,” continues Robbins. “Here in our country, we have been here since the beginning of time. We are connected to the land physically and spiritually.”

Fire is also important for tribes when it’s not applied to the land.

According to Valentin Lopez, chair of the Amah Mutsun Tribal Band, fire is part of their people’s creation story.

“The hummingbird brought fire to our people,” Lopez says, explaining that the

“WE HAVE BEEN HERE SINCE THE BEGINNING OF TIME. WE ARE CONNECTED TO THE LAND PHYSICALLY AND SPIRITUALITY.“ hummingbird’s throat is red because it got burned while carrying fire to humans. The Amah Mutsun band also uses fire in ceremonies. The smoke from fire, explains Lopez, “carries prayers up to Creator,” as well as “messages, pain, and the need for healing, and the wants that are in our hearts, and our bodies, and our minds, and our spirits.” “We pray,” summarizes Lopez, “with our whole body,” prayer that is aided by the gift of fire.

Burning the Land Regional Divides There isn’t one clear sign that points But cultural and prescribed burning to a burn day for the Yurok Tribe, don’t seem to be as widespread in located in the northernmost sector of Southern California compared to California. Sometimes, hunters might the North.

The Indigenous People’s sense that a storm is coming, giving Burn Network, for instance—one of them a natural extinguisher for any fires the largest groups dedicated toward they ignite. Sometimes, it might simply promoting “fire-related cultural be the right time of year, when the wind restoration”—does not currently operate isn’t so strong that it will catapult fire far away, and the land has enough moisture to burn slowly, but not so much that it won’t burn at all. And sometimes, a tribal member might notice that brush is growing too close to their home and request a burn on their land the next time conditions are right.

As President of the Cultural Fire Management Council and a member of the Yurok Tribe, Margo Robbins helps determine when the time is right for fire and trains community members to conduct prescribed burns safely. “They’re called prescribed fires because you must follow a prescription that’s written into a burn plan,” explains Robbins. These prescriptions outline certain conditions that allow fire managers to do burns: temperature, wind speed, equipment available, and other factors.

While prescribed burning may have ancient roots, today, it intermingles the present with the past. Most burns, for MARGO ROBBINS (right), teaching her grandson, Joe Joe (left), how to culturally IMAGE CREDIT | MARGO ROBBINS example, are accompanied by fire engines burn on Yurok land.

THE PUBLIC HEALTH ADVOCATE | 5

size-fits-all solution. Methods of burning

VIEJAS BAND Fire Department (top) and Tribal Council (bottom). Bob Pfohl is vary from tribe to tribe, and even from the center figure in the top row; Gabriel TeSam is the second figure from the family to family; different biomes across right in the bottom row.

IMAGE CREDIT | MORNINGSTORM BROWN / VIEJAS BAND the state respond differently to fire; and,

in Southern California. And while tribes may certainly burn small patches of their own land, there aren’t any broader efforts to encourage prescribed burning in the region.

Gabriel TeSam, Councilman of the Viejas Band of Kumeyaay Indians, puts the scope of their prescribed burning practices in perspective. According to TeSam, the Band, which owns one of sixteen reservations in San Diego County, does burns through their Fire Department about five to ten times per year, primarily with a technique called pile burning. As the name suggests, pile burns involve collecting dry brush and debris into large piles—for the Band, about 12 feet wide and tall max, or the size of a rather cramped dorm room— away from other flammable material and setting the piles on fire. In practice, these burns help clear fuel for only a small fraction of the 1,600 acres the Viejas Band directly manages.

But the Viejas Band has other tricks up their sleeve to manage their land. In the past, explains Bob Pfohl, Fire Chief of the Viejas Reservation, cattle herds roamed the entire reservation, grazing substantive portions of the undergrowth as they wandered. Families manage the land surrounding their homes,

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sometimes by moving brush away from their borders, other times by doing small burns. And since the Viejas Reservation is surrounded by national forests on all sides, the Fire Department regularly works with the U. S. Forest Service to help with managing the land.

The ecology of the Viejas Reservation might also contribute to the lower demand for prescribed burning. The reservation consists of an open grassland surrounded by chaparral brush, some oak trees, and hills—much different than the Yurok Reservation, which consists of a long river flanked by grassland and forests. According to the California Chaparral Institute, chaparrals need fire no more frequently than every 30 years, and efforts to prescribe burning too frequently can damage the ecosystem.

And unlike cities in northern California, San Diego hasn’t experienced a large wildfire since 2003. Without recent memories of wildfires, communities are reluctant to introduce fire to the land again.

To Burn Or Not To Burn It’s hard to predict what the future of fire management will look like in California. While prescribed burning is an alluring path, it isn’t exactly a one-

for many, an internal fear of fire hinders efforts to encourage prescribed burns.

But for Native American tribes, at least, cultural burning seems once again on the rise, even after being suppressed for over 100 years. TeSam and Pfohl seem poised to take a careful, incremental approach to bringing fire back to the land of San Diego, recognizing that the arid climate and built up fuels make tasks particularly daunting. “Both burning and animal grazing are both effective,” says Pfohl, but fuel still needs to be mechanically removed to prevent structure fires and “give firefighters a fighting chance.”

With the prospect of restoring the land on the horizon, Lopez feels compelled to bring fire back to Amah Mutsun lands.

“Our creation story tells us that we have a responsibility to take care of Mother Earth and all living things,” says Lopez, “and Creator never rescinded that obligation.” And for Robbins, the right to burn on her own land was always her right to begin with. “We never gave up our right to use fire,” she says. “We still hold that sovereign right.” 

ABOUT THE AUTHOR

Jonathan Kuo is a third year double majoring in Molecular and Cell Biology and Rhetoric. He is involved in research on the history of anti-vaccination and is broadly interested in the history of public health.

In the future, he hopes to use the medical humanities to inform his work on solving the social problems that have affected and continue to affect the medical field today.

SEX BIAS IN PHARMACOLOGICAL STUDIES Women have been historically excluded from drug trials, which causes a dangerous lack of data and calls for increased regulation of pharmaceutical companies.

BY ANNA FANG

W

omen have mainly been excluded from studies in pharmacology. This manifests in the exclusion of subject sex in the data parameters/summary and lack of separate analyses between male and female data. Possible dangers

of sex exclusion within pharmacological studies include disporportionate burden of adverse side effects and a lack of drug educational materials, all of which call for increased discussion, accountability and regulation within research.

Researchers mention the female

reproductive cycle and hormone differences as potential reasons for the lack of female experimentation in pharmacological studies. During the stages of menopause, women experience changes in reproductive hormones (mainly estrogen) and physical state,

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which is perceived by researchers as a change in baseline conditions and increased difficulty for accurate study.

Additionally, at least 26.1% of women aged 15-49 in the United States from 2015 to 2017 were using some form of hormonal birth control, which disrupts natural hormone levels in those women.

The most popular form of birth control, the oral contraceptive pill, contains and releases estrogen and/or progestin to prevent pregnancies. Thus, women using hormonal contraception may also be classified as suboptimal for study, similar to menopausal women.

Pregnant women are especially difficult to study because the clinical trials only account for a small window of time in the individuals’ lives, from a couple of months to a few years. The subsequent effect on their offspring and their development cannot be studied within the confines of the study. Professor Emeritus Irving Zucker—a researcher

in integrative biology and the author of multiple articles on pharmacological inequality—explains that the “duration of the studies is not such that you are able to pick up things that happen 4 or 5 years later. Most of the adverse effects in humans come from post-marketing reports, and sometimes it can take as long as 15 years. So, for example, a woman who is taking antidepressants during pregnancy–her offspring may be at much greater risk for depression when they’re 20 years old.”

Because of these reasons, women are underrepresented in Phase 1 clinical trials, which is the first part of drugtesting on a smaller group of human subjects, mostly to evaluate for drug safety, longevity in the blood, and possible side effects. Sex differences in the pharmocological effects of one-third of all drugs are unknown.

Failing to conduct separate clinical trial data analyses for either sex and,

more specifically, extrapolating one sex’s data for the other’s usage causes various problems. For one, there are innate biological differences between the two sexes, or sexual dimorphism, in components as basic as cells or tissues. Males and females express their metabolic enzyme systems differently, which leads to a different timeline of drug-clearance. For example, women have a lower glomerular filtration rate, so drugs that exit the body through the kidney exit slower in women than in men. Assigning the same dosage to all adults, after conducting most clinical trials on males, increases the risk of toxic effects and overmedication in females.

The history of drug trial regulations begins with the blatant removal of female trials. In 1977, the FDA passed the General Considerations for the Clinical Evaluation of Drugs which barred women of child-bearing potential from participating in early clinical trials. This

THE GRAPH BELOW depicts the sex participation trend from 2008 to 2017 in critical Cardivascular and Diabetes Mellitus clinical drug trials according to the year of drug approval. Women are consistently underrepresented.

% Participants

Percentage of Men and Women Participating Overall in Cardiovascular and Diabetes Clinical Drug Trials

Year of Drug Approval DATA SOURCE: JOURNAL OF THE AMERICAN HEART ASSOCIATON (VOLUME 9, ISSUE 11)

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sparked as a result of the then-recent birth defects linked to thalidomide drug usage during the mother’s pregnancy.

Consequently, clinical drug researchers erred on the side of caution, and ended up excluding or misrepresenting women in general.

Many women’s advocacy groups publicly disapproved of the legislation, arguing that it deprived women of their autonomy in the realm of informed consent. This conversation was accelerated by the AIDS epidemic in the 1980s. When researchers began studying AIDS, they focused on male subjects because the disease was thought to mostly affect men, even though AIDS was a rapidly increasing cause of death among women in the U.S. Moreover, a study published by the General Accountability Office in 1990 revealed that federally funded studies routinely excluded women.

Motions to balance the representation in drug studies include the 1993 Study and Evaluation of Gender Differences in the Clinical Evaluation of Drugs guidance, which underscored the

“SEX DIFFERENCES IN THE PHARMOCOLOGICAL EFFECTS OF ONE-THIRD OF ALL DRUGS ARE UNKNOWN.” analysis of drug safety and efficacy by sex. In 2000, the Amendment to Clinical Hold Regulations permitted the FDA to halt drug trials that excluded either sex on the basis of their reproductive potential.

While some legislation exists, oversight by the FDA concerning the fair representation for drug trials is limited. To illustrate, data submitted by the drug companies to the FDA are not publicly shared and do not undergo any peer review processes. In addition, the implementation of these guidelines have not completely eliminated the sex bias in Phase 1 trials, although women’s participation has increased from the 2225% range to 31% from 2002 to 2007.

At this point in time, the ethical and

scientific basis of including women, regardless of their pregnancy status, in clinical trials continues to present problems. This is effectively illustrated by the recent COVID-19 vaccine trials and administration, as well as their effect on women of both child-bearing and non-child-bearing status.

Because of COVID’s negative effects on the health of mothers and newborns during delivery (e.g. increased hospitalization and Cesarean delivery rates), pregnant individuals have been approved for COVID vaccine administration; however, there is less evidence for its safety and efficacy compared to what is available for nonpregnant individuals. For vaccination advice, pregnant women are encouraged to consult their primary care physicians, many of whom “don’t have the training or knowledge to answer those kinds of questions,” Professor Zucker says. Even as pregnant women are integrated into vaccine trial designs, it will still be a complex process, because ultimately, the professor emphasizes, “it is an individual decision.”

Moving forward, to increase the accountability of drug companies by the greater science community, data from every step of the drug trial process should be made publicly available for peer review. Stakeholders from similar disciplines and within healthcare systems can continue to monitor the post-market effects of drugs and collaboratively contribute to FDA databases. The personal initiatives of these stakeholders, along with more recent legislation like the FDA Amendments Act, will create a more comprehensive understanding of drug effects on all users.

Additionally, as suggested by the Task Force on Research Specific to Pregnant Women and Lactating Women, government agencies should instate a proactive protocol that outlines the early and intentional integration of pregnant women in clinical trials. Professor Zucker also suggests that behavioral studies of lactating rodents should be conducted in parallel to drug development and continue during human Phase 1 clinical trials. “The beauty of doing animal work

“GOVERNMENT AGENCIES SHOULD INSTATE A PROACTIVE PROTOCOL THAT OUTLINES THE EARLY AND INTENTIONAL INTEGRATION OF PREGNANT WOMEN IN CLINICAL TRIALS.” is that it doesn’t take as long, because they have a short life span,” he reasons.

With the use of animal models, drug companies would have more data to prove the safety of–or caution against– future drugs for women of child-bearing potential and their children.

Although the exclusion of women from clinical drug studies began as a safety precaution, the lack of accurate drug information could lead to even more long-term adverse effects. Using data collected from male drug trials could be toxic due to innate molecular differences between the biological sexes.

Generally, regulations should require more nuanced studies, such as those that include pregnant women or utilize rodent models, to study treatment effects on women regardless of their reproductive state. With the implementation of a few of these suggestions, it is hopeful that future pharmacological treatments will be safe and supported with evidence for all parties, including all women, before hitting the market. 

ABOUT THE AUTHOR

Anna is a third-year majoring in Molecular and Cell Biology and minoring in Data Science. She is interested in improving health equity through outreach and epidemiology research. In her free time, she likes to play with her dog and try new niche activities with friends.

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UN-NATURAL SELECTION: FEMALE FETICIDE IN INDIA India’s skewed sex-ratio due to mass sex-selective abortions is based on the perception that women should be valued less than men in society.

BY SONIA VAZE

A

pregnant woman sits alone with her thoughts inside the cold, empty hospital consultation room in India. She simply wants to make sure her baby is okay, but in the back of her mind, she knows there is a lot riding on whether the baby is a boy or girl. She knows it is illegal to ask the doctor to disclose information about

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the sex of her baby, but is desperate to please her husband and in-laws with the news of a son. In the United States, finding out the sex of a baby is simply another regular milestone that parents undergo during pregnancy. Normally, the moment is filled with excitement and love, but that is not the case for women in India.

A poll by the Thomson Reuters Foundation found that India is ranked the most unsafe country for women. Their culture of perpetuating female inferiority and subordination contributes to a vicious cycle of mass sex-selective abortions and female feticide, which has exacerbated crimes against women. Sex-selective abortions,

also known as female feticides, occur when female fetuses are aborted due to a cultural preference for sons. In India, the cause for female feticide is the overwhelming belief that women have less societal value than men. A lack of education among women, insufficient female leadership, and negative perceptions of women as “economic burdens” contribute to this view.

“SEX-SELECTIVE ABORTIONS AND FEMALE FETICIDE ARE ROOTED IN INDIAN PATRIARCHAL PERCEPTIONS.” History of Female Feticide Professor Anibel Ferus-Comelo, a professor at the UC Berkeley Goldman School of Public Policy specializing in labor and gender studies in India, explained that “before technology, it used to be that births were just ‘hidden’ because of female infanticides. Baby girls were killed, and it continues among the population that cannot afford or do not have access to technology or medical clinics.”

In the 1970s, medical diagnostic testing using ultrasounds became available to determine the sex of a fetus during pregnancy. Using highfrequency sound waves, ultrasounds can display accurate images of a fetus within the mother’s uterus to understand fetal health, positioning, and visualize potential problems during pregnancy.

However, a tool meant to help families prepare for a new life exacerbated India’s existing infanticide issue. Since sex determination technology became available in the 1970s, India is estimated to have about 63 million fewer women.

Female feticide based on sexdetermination testing is a relatively new practice. It skyrocketed in India around the 1990s when ultrasound technology became widespread among upperclass and upper-caste society members.

When the Indian government became aware of this technology, they passed the Pre-Conception and Pre-Natal Diagnostic Techniques Act (1994),

which made it illegal to determine the sex of a fetus unless it was necessary for urgent medical reasons. Despite the illegality of sex determination testing in India, this policy’s efficacy varied upon jurisdictional enforcement, which resulted in the continuation of mass sex-selective testing and abortions. As a result, it is estimated that there will be 6.8 million fewer female births by 2030, precisely due to the consistent practice of sex-selective abortions.

Root Causes Behind Female Feticide Sex-selective abortions and female feticide are rooted in Indian patriarchal perceptions. From a cultural standpoint, Indian boys maintain the family legacy as they carry the family name and typically perform funeral rites for their parents, allowing their souls to have safe passage.

These perceptions have bolstered the mentality that parents should value their sons and treat them with more pride and respect than Indian girls who are less valued in society. Although this view has become outdated among more globalized nations, India’s urban and rural areas continue to believe that women should be confined to their roles as caretakers and mothers.

Economically, boys have always been viewed as the “breadwinners” of the family. They have held the burden of getting a job and providing for their family. However, girls have continually been viewed as an economic burden, especially during marriage. In India’s rural areas, it is still common for girls to get married at a very young age.

According to Girls Not Brides, a global partnership that aims to end child marriage, about 27% of girls in India are married before turning 18. When girls are married, their parents are expected to pay a “dowry” to the groom’s family, which is essentially a payment in cash, food, household items, and clothes.

Professor Ferus-Comelo mentioned that dowries are “a very degrading practice.

It almost symbolizes that you have to pay someone to take your daughter.”

She further elaborated that the practice continues to be maintained, except that “Dowries are not necessarily called

‘dowries,’ but sometimes they are called ‘gifts,’ and that there are many other nomenclatures and euphemisms for them.” Once married, daughters are expected to take their husbands’ last name and move in with their family to begin their role within the home. As a result, young girls are often not wellinformed, confident, or financially independent enough to make educated decisions about pregnancy and children.

The political culture in India further exacerbates the perception that women should be treated inferiorly.

In the 1980s, political propaganda in India and the United States portrayed slogans such as “Pay 5,000 now, save 50,000 later” directed towards SouthAsian communities to encourage them to pay the cost of sex-determination technology than having a daughter and bearing an economic cost in the future.

Professor Ferus-Comelo remarked that, “The same ads, now decades later, have come back with the clinics offering the same possibilities, and it shows that there is still a market for sex-selective abortions even in the United States.” She also explained that the rise of the Hindu political right has furthered, “notions of womanhood tied exclusively to the heteronormative wife and mother roles.

This then restricts women’s abilities to break out of these molds.”

Objectively, the preference for sons over daughters is further supported by data. Boys are more likely to receive higher quality medical treatment and food. On the contrary, girls have less access to quality healthcare, education, and work. The problem of female feticide in India is multifaceted with cultural, economic, and political factors, and each aspect reinforces the attitude that womens lives should be valued less than mens.

“THE PROBLEM OF FEMALE FETICIDE IN INDIA IS MULTIFACETED WITH CULTURAL, ECONOMIC, AND POLITICAL FACTORS.“ THE PUBLIC HEALTH ADVOCATE | 11

A SIGN in an Indian hospital states the ban against sex-selection.

Although sex-selective abortions are illegal, many families seek alternative options.

The Legality of Abortion in India Both government and private entities provide healthcare services in India.

However, government services are rare and lack the high quality of treatment, while private services provide a high standard of care but are not affordable to most of the population. Furthermore, Indian health insurance is not mandatory, and employers do not have a legal obligation to provide insurance to their employees. As a result, 70% of the population does not have health insurance, meaning that they have to pay for most services and procedures out-of-pocket.

Abortion is one of these procedures.

Abortion is legal in India, but sexselective abortions, abortions solely based on the sex of the fetus, are illegal.

Legal abortions are performed strictly at the discretion of the physician. The woman does not have the right to choose whether she would like to have an abortion. A physician can perform a legal abortion if the fetus has any

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abnormalities, if the pregnancy is lifethreatening to the mother or the fetus, if pregnancy occurred due to the failure of contraception in married women, and if the pregnancy resulted from instances of sexual assault or rape. In India, legal abortions can be performed within the first seven weeks of pregnancy using an abortion pill in the presence of a medical professional. However, after the first seven weeks have passed, surgery is required to abort a fetus to maintain the safety of the woman’s life.

Insurance companies would cover some medical costs only if the pregnancy were terminated due to a medical threat to the woman’s life. Otherwise, the woman has to bear the total economic cost.

This raises an important question: why do women not have the autonomy to make decisions about having an abortion? Autonomy is not simply about making individual choices, but it also involves economic autonomy or independence. Even if a woman wants to have an abortion for medical reasons but cannot afford to, she may have to turn to unsafe or illegal options. Obviously, due to the illegal nature of sex-selective abortions, a woman’s only option is to use illegal or unsafe methods.

Exacerbation of Life-threatening, SexSelective Abortions by the COVID-19 Pandemic Although abortion in India is legal, illegal abortions currently outnumber them because most abortions in India are solely based on the fetal sex preference for boys. Almost ten women die every day of unsafe, illegal abortions in India.

According to India’s health ministry, nearly half of abortions are conducted in hazardous and unhygienic conditions and are often performed by untrained physicians or healthcare professionals.

Since sex determination tests are illegal within India, many women optin for diagnostic testing (conducted illegally by gangs), take sex selection drugs (SSDs), or try “old-wives tale” remedies to change the sex of the fetus after conception. Still, many women are unaware that the fetus’s sex is determined during the fertilization of the egg by

sperm and cannot be changed after that. The mother donates an egg, which always contributes an X chromosome to the fetus’s genome, while the father’s sperm can contribute either an X or a Y chromosome. If the sperm contributes an X chromosome, the fetus will be a girl, while a Y chromosome indicates that it will be a boy. Not only are many women uninformed about this concept, but they take harmful drugs containing synthetic chemicals and heavy metals that often result in congenital disabilities and stillbirths.

Social Impact of a Skewed Sex Ratio Studies show that countries with imbalanced sex-ratios tend to have a more violent culture. According to Professor Ferus-Comelo, “crimes against women, particularly by upper-caste on the lower-caste, continues when the signal goes out from the top-down that violence is okay and that they deserve it because they are beneath our level.” This can be observed in India’s north and northwestern states where the highest gender disparities exist and power is centralized among criminal gangs called goondas. Studies have shown that when there is an enormous surplus of men within countries with a skewed sex ratio (30+ million within India), they are unlikely to obtain stability economically through labor or socially through marriage. To gain economic stability, men are more likely to join criminal gangs. In order to gain social stability, men seek out marriage. However, in some areas where the ratio of women to men is alarmingly low, men cannot find girls to marry. As a result, brides are

“ALTHOUGH ABORTION IN INDIA IS LEGAL, ILLEGAL ABORTIONS CURRENTLY OUTNUMBER THEM BECAUSE MOST ABORTIONS IN INDIA ARE SOLEY BASED ON THE FETAL SEX PREFERENCE FOR BOYS.”

“purchased” from other areas leading to forced marriages and human trafficking.

Professor Ferus-Comelo remarked that, “one would think, logically, that if there are fewer women, their value actually rises. Their value in the marriage market should increase. But, that is not the case.”

COVID-19 has exacerbated this issue as women are more likely to seek unsafe or illegal abortion options since medical professionals and resources have been redirected to help combat the pandemic.

Even before the pandemic, domestic violence has been an immense problem in India. In 2018, “Cruelty by Husband or His Relatives” accounted for 32% of all crimes against women registered by the police amounting to over 100,000 cases. Due to quarantine orders, women are more likely to be trapped with abusive partners or lack access to contraception. Many Indian women who are victims of domestic violence have limited education and are usually unable to be financially independent.

They have inadequate options and

“INDIA SHOULD WORK TO ALLOCATE MORE RESOURCES TO BETTER ENFORECE THE PROIBITION OF SEX SELECTION ACT.” resources because they cannot turn to their parents due to social stigmas, or their parents cannot take them in due to financial burdens. However, the future looks optimistic as more organizations such as Shakti Shalini, Rise Up, and SNEHA Crisis Helpline are working to provide health and sexual education to girls and women in India to inform them about safe sex practices, contraception, and resources for domestic violence survivors.

Solutions Professor Ferus-Comelo explained that as more young people become exposed to other cultures and lifestyles, “people have higher expectations of one’s own culture.” She continued to explain that, “there has been a very positive,

inspiring awakening of women when their worlds have been constrained, and they know there is greater potential.”

The only way to combat the issue of such a complex problem of femalefeticide is to solve the root causes: skewed political propaganda, and a lack of economic opportunities, and unenforced legislation.

South Korea, which also faced a severely skewed sex-ratio, implemented solutions that have shown promising results, and many Indian government officials are looking to emulate their approach. They improved, enacted, and strictly enforced laws that prohibited female feticide, encouraged and provided opportunities for more women to enter the labor force, and used the media to mobilize support for their initiatives.

India should work to allocate more resources to better enforce the Prohibition of Sex Selection Act. Although the government launched a similar campaign in 2015, it was unsuccessful. To improve their efforts, experts recommend that the government should charge doctors who conduct illegal sex determination testing with hefty fines and strengthen detection for illegal clinics and services provided by gangs.

Most importantly, the government should promote women’s education, provide better opportunities for women to enter the labor force, enable more women to serve political positions, and enact equal inheritance laws.

Furthermore, health education on domestic violence awareness and safe sex practices should also be provided for men. Female education is one of the most influential factors in reducing gender discrimination and sexual violence. Studies prove that exposure to female leadership leads to a significant decrease in the gender gap for educational attainment (32%).

Moreover, introducing cable television to India’s rural areas and playing shows that had strong female characters or women in power caused preference for sons to decrease by 12% and school enrollment for children to increase by 5%. If women have better access to

“IF WOMEN HAVE BETTER ACCESS TO QUALITY EDUCATION, THEY CAN HAVE BETTER OPPORTUNITIES TO ENTER THE WORKFORCE.” quality education, they can have better opportunities to enter the workforce and become financially independent.

Professor Ferus-Comelo expressed that, “economic independence leads to less discrimination. If girls and women had equal access to wealth and income and legal inheritance rights, they could have a sense of economic independence, then these kinds of norms are going to change.” 

ABOUT THE AUTHOR

Sonia is a sophomore intending to double major in Public Health and Molecular Cellular Biology and is passionate about exploring the intersections between medicine, policy, and research within the healthcare field. At Berkeley, she is involved in the Global Leadership Organization, the American Medical Women’s Association, California Health Professional Student Alliance, and the Alpha Chi Omega sorority.

In her free time, she loves to watch movies, play board games, and travel.

THE PUBLIC HEALTH ADVOCATE | 13

I FEEL IT IN MY GUT

Crucial lifestyle interventions that address gut health also impact mental health.

BY KEERTHANA RAMASWAMY

I

n the mid 1880s, Austrian pediatrician Theodor Escherich discovered the gut flora, noting the impact of Escherichia coli on children’s diarrheal health—a discovery that would forever shape our understanding of human disease and the organisms residing in our guts.

Picture thousands of single-celled bacteria, fungi, and viruses exchanging materials in a hot, varyingly acidic set of pipes—this is essentially your gut microbiome.

The average human’s gut consists of an astronomically high number of microbes—1,014 resident

14 | SPRING 2021

microorganisms, approximately the size of an entire football field. Remarkably, the average individual only shares 10 percent of their microbiome bacteria with the next individual. Thus, in many ways, gut bacteria is a fingerprint, uniquely curated to individuals from birth and constantly transformed through the food we eat, our sleeping habits, and other lifestyle factors specific to ourselves.

Even bacteria within your microbiome vastly differ from the next. In fact, according to researcher Michael Snyder of Stanford Medical School, “while two humans typically

differ by about 1 in 1,000 DNA bases, bacteria of the same species may differ by as many as 250 in 1,000 bases.” As Mary Horton, a PhD student at UC Berkeley currently studying the effects of the microbiome on Multiple Sclerosis explains, “[bacteria] may share the same order, class, or genus but might have opposite effects, so studying the species or substrain level is how we’re going to learn [about the microbiome].”

This diversity of microbes has spurred interest among several in the scientific community to sequence and explore the role of microbes in regulating body functions. The microbiome has been

found to aid in food digestion and vitamin production, providing a barrier against pathogens and regulating the immune system. Recent research has revealed a correlation between gut bacteria and mental illness, illuminating the presence of a gut-brain axis, with mice models confirming associations between gut bacteria and depression, anxiety disorders, Multiple Sclerosis, and other neuronal diseases.

The precise mechanisms for how gut bacteria might alter brain function is still an area of several unknowns. Yet, researchers typically agree on three primary mechanisms of gut-brain exchange: neuronal, immune-mediated, and metabolite-mediated pathways.

In each pathway, the brain and gut function symbiotically; gut bacteria alter stress and hormone expression in the brain, while the brain influences motility and nutrient transport to the gut bacteria. In depression, researchers theorize that microbiota of the genus Bacteroides alter brain function through the first mechanism, neuronal activation of stress circuits. Gut microbes produce

“RESEARCH REVEALED A CORRELATION BETWEEEN GUT BACTERIA AND MENTAL ILLNESS, ILLUMINATING THE PRESENCE OF A GUT BRAIN AXIS...” neurotransmitters that make their way to the vagus nerve, a nerve connecting the brainstem to other organs in the body, and can accordingly shape brain activity. Gut bacteria may also alter the brain through immune-mediated pathways; several scientists have found elevated cytokine levels in people suffering from depression. Gut bacteria may also impact the brain through a third pathway, metabolite-mediated signalling. Through this mechanism, bacterial imbalances or pathogenic bacteria in the gut may reduce the number of metabolites, which can consequently trigger depressive behaviors.

Research on the gut-brain axis is of particular significance amidst the

COVID-19 pandemic, during which dramatically “high rates of symptoms of anxiety, depression, post-traumatic stress disorder, psychological distress, and stress” have been reported by people across the world. In light of the pandemic’s severe impacts on mental health, the gut microbiome potentially amplifies or alters the adverse impacts of mental health experienced by individuals depending on the makeup on their guts.

The gut-brain axis is of particular interest to medical professionals because, as Horton explains, “your gut microbiome is a potentially modifiable area of your body ... that might be easier to access.” Individuals can actively alter their microbiome through lifestyle changes. This presents potentially transformative nutritional interventions that may improve overall health. Take prebiotics, dietary fibers in food that fuel bacteria in the body, for example. Fibers and fermented foods like Kimchi, Miso, and Tempeh, which are fermented by bacteria in the gut, produce crucial metabolites like short chain fatty acids, which may induce beneficial impacts on the brain. In recent years, several studies have shown that the Meditteranean diet, which is composed of several prebiotic, fiber-rich foods such as fruits and legumes, can play a critical role in the health of the gut microbiome precisely through this mechanism. Furthermore, probiotics, live microorganisms, can promote good gut health. According to The Food Revolution Network, vegetables, grains, and beans cultivate a positive gut environment as opposed to meat and junk food, which generally negatively impact gut health. In quarantine, where people are likely to consume carbohydrate and sugar-heavy foods and not enough micronutrients, turning to plant based foods and Mediterranean diets may provide the crucial nutritional intake needed for overall health, upon digestion by the gut.

As research on the gut bacteria is still ongoing, there is a lack of concrete developments by healthcare researchers on mental health interventions via gut bacteria. In spite of much inaccessible mental health infrastructure including

“YOUR GUT MICROBIOME IS A POTENTIALLY MODIFIABLE AREA OF YOUR BODY... THAT MIGHT BE EASIER TO ACCESS.” unaffordable fees for medical care, psychologists recommend accessing counselors, medical professionals, and therapy for people struggling with their mental health. During the pandemic, students at UC Berkeley have access to the Tang Center’s facilities, which include group therapy sessions as well as one-on-one counseling. Furthermore, health professionals recommend regular good nutrition and exercise, which can boost endorphin production and ease symptoms. The Basic Needs Center and student cafeterias provides reliable guides to health nutritional intake that can boost beneficial gut bacteria activity.

Ultimately, the gut-brain axis can not be neglected when it comes to mental health. Health professionals must take a holistic perspective on evaluating their patients’ mental wellness, considering gut health in the process. One cannot exist without the other. 

ABOUT THE AUTHOR

Keerthana is a first-year intending to major to MCB and Social Welfare. She is interested in examining the intersection between public health and public policy as well as infectious disease and climate change! She enjoys curating new music and spending time with friends.

THE PUBLIC HEALTH ADVOCATE | 15

HIGH-RISK CA RESIDENTS MAY BE ELIGIBLE FOR COVID-19 VACCINE After pushback from activist groups, high-risk Californians may be eligible for the COVID-19 vaccine starting mid-March, depending on various restrictions.

BY JENNY KWON 16 | SPRING 2021

O

n February 11, 2021, the California Department of Public Health (CDPH) updated their guidelines on allocating COVID-19 vaccines to include highrisk individuals. Starting on March 15, healthcare providers “may use their clinical judgment” to vaccinate 16 to 64-year-old individuals at the highest risk of complications or death from COVID-19 who have at least one of the “severe health conditions” or a “developmental or other severe highrisk disability” listed on CDPH’s provider bulletin.

These severe health conditions include cancer, chronic kidney disease (stage 4 or above), oxygen-dependent chronic pulmonary disease, down syndrome, weakened immune system due to organ transplant, pregnancy, sickle cell disease, certain heart conditions, severe obesity and type 2 diabetes.

CDPH defines having a “developmental or other severe high-risk disability” as being either likely to become extremely ill or die due to COVID-19, unable to receive vital care or services due to COVID-19 and/or unable to get on-time and adequate COVID-19 care otherwise due to a disability.

This update would increase the number of individuals vaccinated between 4 million and 6 million people aged 16 to 64-years-old, bringing the total number of California residents eligible for the vaccine to 17 to 19 million by March 15.

The Pushback That Led to Updated Vaccination Guidelines for March 15 These revisions in the vaccine rollout plan stem from immense pushback from disabled citizens and advocates after Governor Gavin Newsom announced on January 25 that California would be switching from a plan that prioritized both healthcare workers and “people at increased risk for severe illness or death from COVID-19” in Phase 1 to an agebased vaccination eligibility framework.

In the press release, Governor Newsom’s office stated that the change in vaccine distribution would be “simplifying and standardizing” the process, even though

this new plan would leave out younger disabled individuals who are at higher risk of getting COVID-19.

The collective response from disabled communities and leaders was swift.

Disability Rights California Holds Press Conferences Highlighting Disabled Perspectives On January 28, a press conference featuring disabled and non-disabled experts on their concerns with the agebased framework was held by Disability Rights California, a non-profit legal organization advocating for disability rights and a member of the Community Vaccine Advisory Committee (a committee that gives feedback and input to the “planning efforts” and resolves “barriers to equitable vaccine implementation and decision-making”) since its creation in late November.

In the conference, Alice Wong, founder and director of the Disability Visibility Project, called the switch in plans an “act of violence and erasure toward groups disproportionately impacted by the pandemic.” Engracia Figueroa from Communities Actively Living Independent and Free, an advocacy non-profit and independent living center serving disabled communities in Los Angeles County, spoke candidly on how necessary it is to frame the de-prioritization of disabled individuals from the plan as a human rights issue. “We’ve stayed home since March,” she remarked. “All we’re asking—and we shouldn’t have to ask—is that we at least be seen for the sacrifice that we’ve given as well and that we’re just given our same regular spot of [Phase] 1c. That we are included in the right to live.”

Elena Escalera, PhD., and founder of the #NoBodyIsDisposable coalition, underscored the urgent and lifethreatening consequences of being unable to receive basic healthcare due to the de-prioritization of disabled people in Governor Newsom’s new plan. “As I’m waiting for medical care, I’m becoming more and possibly permanently disabled to the point where I can’t even stand,” she said, talking about being unable to

even straighten her leg enough to get the CT scan necessary for her prosthetic.

“I can’t get in to get my surgery...because I can’t get vaccinated.”

As someone who has multiple marginalized identities, Escalera noted the cruel irony in qualifying for the vaccine not as “a member of fat, disabled BIPOC communities’’ but as a teacher—one of the sub-groups prioritized in Phase 1B of the current vaccination rollout plan—even though she’s “teaching online this semester.” Fat people and people with certain medical conditions like diabetes, she said, are the “first to be blamed for COVID vulnerability but then last for vaccines.”

Speakers Sondra Solovay, J.D., and Alyssa Burgart, M.D., M.A., a clinical pediatric anesthesiologist, bioethicist and professor at Stanford University, clarified the importance of not “pitting one high-risk group against another high-risk group.” As Solovay put it, “everyone who is high-risk for whatever reason needs access.”

When asked what she thought about the state’s claim that there were ample data showing that “people over 75 and over 85 are more likely to die from COVID” and not enough data on the experiences of “people under 65 with disabilities,” Burgart argued that this was actually a symptom of the larger, systemic issue of ableism in healthcare.

The system’s bias against disabled people means that “we don’t even collect data necessarily in a strategic way to ensure that we actually have that information,” she said. “You don’t have the data that you need...then you punish that population because...that data does not exist to the degree you expected [and] that’s just one more form of erasure of our disability community.”

There is growing evidence that those with developmental and intellectual disabilities are “at least a three-fold risk” compared to other disabled individuals, she continued. “Unfortunately, some of that data won’t be apparent until after we can get folks vaccinated, and that is not a good reason to de-prioritize folks with disabilities.”

For Governor Newsom’s vaccination

THE PUBLIC HEALTH ADVOCATE | 17

rollout plan to truly fulfill its promise of “achieving equity,” speakers argued, it has to include multiple ways of vaccinating high-risk individuals, such as creating a “mobile, traveling vaccine” that would reach disabled Californians in rural areas and others who are confined and immunocompromised, unable to travel to big vaccination locations.

Two weeks after the first conference and a few days after Governor Newsom publicly acknowledged the pushback against his plan from disabled communities and activists and promised to “figure this out,” Disability Rights California held a second press conference calling on Governor Newsom to “prioritize people with disabilities and high-risk health conditions,” this time featuring individuals who lost loved ones at high-risk to COVID-19.

Burgart also spoke at this conference, calling once again for the state to “do everything it can to prioritize all high-risk Californians,” not just “folks who might be included in the CDC guidelines.” Arguing against defining disability and determining eligibility through categories, she emphasized that vaccination eligibility for disabled individuals “should not be limited by the CDC list.” If someone is at highrisk based on information “by their community,” by updated data, or “by their healthcare provider,” she stated, the vaccination rollout needs to include them “regardless of their age.”

Burgart also mentioned that the deprioritization of disabled individuals in receiving the vaccine causes them to be at risk of “systemic discrimination when they appear at hospitals for treatment,” especially at hospitals that lack adequate resources to care for the large surge in COVID-19 patients. She attributed both the de-prioritization and discrimination to the inherent ableism present in healthcare and society as a whole.

Not only does ableism disproportionately impact individuals like Escalera who identify not only as disabled but also Black, Indigenous and/or a person of color (BIPOC) and/ or low-income, but ableist, racist and classist structures all interact to make

18 | SPRING 2021

low-income BIPOC more likely to become disabled. “People of color who lack access to healthcare will have more comorbidities,” or two or more health conditions or disabilities, Burgart said, and “people don’t realize that disability spans across multiple identities including race.” Ableism is a public health issue and combating ableism is crucial in improving health equity.

“There’s also a sense that disabled people are seen as socially less valuable,” Burgart said in a phone interview.

In pushing for re-prioritization and inclusion of individuals with all kinds of disabilities and needs, “we want to preserve inherent human dignity,” she insisted. “We have to make sure we’re not devaluing them in any way.”

Burgart was incredibly cognizant of the inherent power and privilege she and other physicians hold as people with “the power to diagnose.” “There’s always room to improve,” she said determinedly.

Disabled Individuals Protest Using Hashtags Such As #HighRiskCA and #NoBodyIsDisposable Outside of press conferences like these, much of the activism and efforts to push the state to prioritize disabled, high-risk Californians has been through social media.

Immediately after Governor Newsom’s announcement on the switch in plans, disabled residents, advocates and allies launched a huge social media campaign using the hashtags #HighRiskCA and #NoBodyIsDisposable protesting the age-only based vaccine distribution.

Users such as @Morgan_Coburn tweeted, “I was lucky enough to get my first dose because I work in a lab no thanks to my diabetes & 3-4 fold risk of severe COVID,” echoing the similar sentiment expressed by Escelera in Disability Rights California’s first press conference. User @queer_spice tweeted out a call to other disabled Twitter users to contact Governor Newsom’s office and state assembly members and senators and give testimonies about their COVID-19 experiences.

On January 31, only three days after

the first press conference, Burgart herself tweeted out a call for public health experts and healthcare workers to sign an open letter to CDPH co-written with Disability Rights California and Disability Rights Education and Defense Fund (DREDF), another original member of the Community Vaccine Advisory Committee representing disabled voices. The letter was addressed to Dr. Tomás Aragón, Director and State Public Health Officer of CDPH; Dr. Erica Pan, Deputy Director of the Center for Infectious Diseases and state epidemiologist; Dr. Nadine BurkeHarris, Surgeon General of California and Dr. Mark Ghaly, Secretary of Health and Human Services.

Within the letter, Burgart, Disability California Rights, DREDF and hundreds of other signatories called for the vaccine proposal to include disabled individuals who “receive long-term services” through different programs regardless of age and provide a “safety valve” for all individuals with high-risk conditions and disabilities. In the phone interview, Burgart defined the safety valve as a “safe path” that ensured that those who don’t “clearly fit into one disability category” would still be prioritized. “This is what it means to not treat disabled residents as disposable,” she said.

By February 2, over 400 people had signed the letter. This letter likely helped influence the recent update reprioritizing individuals in high-risk with certain conditions in the vaccination rollout, even if this prioritization begins a month later. It also likely pushed Governor Newsom to finally publicly acknowledge and confront the backlash.

Governor Newsom Addresses Disabled Communities’ Concerns Last Friday in San Francisco at the Moscone Center, a major vaccination site that very recently announced it would pause vaccinations due to limited supply, Governor Newsom spoke about how his office would be “advancing [their] efforts to be more inclusive to those with disabilities.”

“I want the disability community to know we’ve heard you and we’re

going to do more and better to provide access even with the scarcity... [to] 16 to 64 [year olds],” he announced. “We recognize those with IDD and...physical [and] intellectual disabilities [are] uniquely vulnerable.” The phrase “IDD” refers to intellectual and developmental disabilities.

“We will be announcing more formally what we anticipate over the next 30 days,” he continued, “in terms of achieving some results and making sure that we’re prioritizing and allowing access for the special needs of our community leaders with IDDs.” The Re-prioritization Of High-risk Disabled Californians is Not Drastic Enough While high-risk Californians are re-listed as a priority in the vaccine rollout, not everyone feels satisfied.

Many also have issues with the updated plan’s narrow categories, requirement of medical proof and relative tardiness.

Policy Director of Asian Pacific Environmental Network (APEN) Sylvia Chi tweeted, “As someone [below the age of 65] with poorly-controlled hypertension, I’d like to know why California is excluding hypertension as a condition eligible for vaccine prioritization and how racial equity concerns were considered in making this decision.”

San Francisco Senior and Disability Action (SDA) tweeted, “We need a vaccine NOW for ALL #HighRisk CA, without a doctor’s note. Then poor disabled ppl, BIPOC, unhoused ppl will have won.”

Alice Wong commented on Twitter that “there are still many people left off [the] list that are #HighRiskCA” and that “it seems like the burden will be on the individual” to get approval from their physician if they have one rather than the state healthcare system. “It *is* something and I’m still processing everything,” she tweeted, “but it doesn’t feel like a win for ALL of us.”

Charis Hill, leader of the #HighRiskCOVID19 and #BeingDisabledDoesDefineMe campaigns, pointed out on Twitter

how the March 15th date is merely “15 days before it’s expected that anyone may be eligible for vaccines across the USA.” “I’m high-risk, but not high-risk enough?” they asked. “A month more of waiting is a month more of disabled people unnecessarily dying.”

At the time of publication, Governor Newsom has yet to make a public comment addressing these concerns regarding the updated vaccination rollout plan.

Continuing the Conversation on Ableism, Bioethics and Eugenics Beyond the COVID-19 Pandemic COVID-19 has only further exacerbated deeply-rooted health disparities and the societal conversation on ableism, bioethics and eugenics must extend beyond the scope of the pandemic. News about the creation of a COVID-19 Health Equity Task Force under the Biden-Harris administration clash with the implementation of ableist policies like Newsom’s age-based vaccination rollout plan that forces disabled individuals like Alice Wong to advocate for themselves and mobilize disabled and abled communities and with headlines highlighting COVID19-motivated discrimination against disabled individuals.

Even the language used by Governor Newsom and his administration calls for concern. The clause in the March 15 update allowing clinicians to “use their clinical judgment” raises concerns of doctors’ internalized ableism and bias towards disabled people and people of color. In a study published by Medical Education, researchers found that “health professionals are unconscious bearers of implicit social biases” such as perceiving disabled individuals as incompetent and (edit: helpless). These biases “affect the quality of professional interventions” regardless of physicians’ “intentions, personal goals and normative expectations.” Basing the dire need for vaccinations on the inherently biased clinical judgements of doctors will not ensure that high risk individuals aged 16 to 64-years-old who need the vaccine have access to life-saving health

services.

Additionally, in his announcement last Friday, Governor Newsom labeled the prioritization of vaccines and healthcare services to disabled Californians as “special needs,” indicating how deeply embedded ableism is in the language we use that shapes discussions surrounding disability and accessibility. A study conducted in 2016 concluded that using the phrase “special needs” to describe disabled individuals actually caused study participants to perceive them more negatively, and the researchers recommended against using “special needs,” predicting that the phrase would likely “become a slur” if it hadn’t already.

Two things are clear. First, discussions surrounding societallyembedded ableism, bioethics and eugenics must continue long after the COVID-19 pandemic subsides. Second, the movement to structurally combat ableism with policies to improve health equity should not only include disabled perspectives but also be led by disabled individuals themselves.

If the community-driven campaigns using hashtags like #HighRiskCA and press conferences run by disability rights and advocacy organizations have shown non-disabled individuals anything, it’s that disabled individuals and communities know their needs best. 

ABOUT THE AUTHOR

Jenny is a junior majoring in Public Health and hoping to minor in Journalism, Data Science and Global Poverty & Practice. They currently serve as external relations and multimedia manager on the executive board.

They aspire to work as a health-focused investigative data journalist after they graduate!

THE PUBLIC HEALTH ADVOCATE | 19

Understanding Women: A Look Into Endometriosis The misdiagnosis and mismanagement of pain-related diseases, such as endometriosis, can lead to a plethora of different physical, mental, and public health problems.

BY MAHATHI KANDIMALLA

W

omen who suffer from severe abdominal pain have to wait, on average, 65 minutes in the ER to receive care.

Men, on the other hand, only have to wait 49 minutes. Often women who come in with abdominal pain, even when admitted to the ER, are seven times more likely to be misdiagnosed.

20 | SPRING 2021

One of the most misdiagnosed diseases, primarily due to a poor understanding of women’s pain levels, is endometriosis.

Endometriosis affects around 10% of women above or at reproductive age.

Dr. Kathy Huang, a Gynecologist at NYU Langone, says endometriosis is often misdiagnosed for many diseases, from urinary tract infections to weight-

related hormonal issues. In one instance, a woman was criticized for claiming to have endometriosis and was told to stop being a google doctor. A deeper understanding of the public health issue behind endometriosis — a condition characterized by uterine tissue growth outside of the uterus — indicates that the primary reason for misdiagnosis

and negligence is a poor understanding of women’s pain levels and a lack of awareness.

According to a study done by the American Medical Association’s Journal of Ethics, women may be more susceptible to pain than their male counterparts due to numerous biological and hormonal differences. Hence, due to them being more attuned to their pain tolerance, they are more likely to seek treatment for their pain. According to Dr. Mike Fox, a Florida Board of Medicine certified Endocrinologist, the problem is that male and some female physicians often mistake women’s pain to be an emotional response to external or internal stimuli. Hence, when a woman comes into the ER reporting abdominal pain, many doctors internally decrease the amount of pain they think the women are going through. On the other hand, people also see women as having higher pain tolerances. This belief is rooted in several physicians believing that since women go through pain (menstrual cycles, labor, etc.) and do not continuously complain about it, they must have higher tolerances than men.

Therefore, women who stray away from this norm tend to disorient physicians away from their inert understandings.

Hence, women who report pain, even though they do it more than men, are said to be “anxious.”

Endometriosis is a good example of an often misdiagnosed and misunderstood disease. An early diagnosis can, in many cases, lead to better pain management.

Therefore, a better understanding of pain, combined with an increase in awareness amongst the general public for illnesses like endometriosis, polycystic ovary syndrome, lipoedema, etc., can help provide care to women before the conditions reach a more severe stage. However, many obstacles are standing in the way of a quick diagnosis. Firstly, women experience a plethora of different symptoms. Some suffer from depression, pelvic pain, anxiety, and high blood pressure; while others have abdominal pain, irregular menses, and cannot walk for months due to pelvic pain. If a health professional

suspects that someone may have the disease, they can perform a pelvic exam, laparoscopy, or transvaginal ultrasound.

Unfortunately, for most women, pelvic exams are not diagnostic enough to confirm endometriosis; laparoscopy and transvaginal ultrasounds are only done in extreme cases as they are expensive.

Therefore, there is a significant lag in diagnosis, leading to a painful progression of disease and symptoms.

As a result, doctors are resistant to diagnosing endometriosis and will often look at alternative disease, ignoring the pain and pleas of many women.

Endometriosis is not a small-scale, individual problem. Rather, it is a public health issue. According to Dr. Fox, not only is endometriosis physically taxing, but it also has both enormous economic and social impacts. 50% of women who suffer from the disease stay home during their menstrual period every month. For women earning hourly wages, this can increase the difficulty of making ends meet. Meanwhile, salaried women may be overlooked for managerial positions due to their monthly absences. Many women with endometriosis are forced to frequent gynecology offices, leading to 2.6 million dollars being spent annually by patients to relieve symptoms such as abdominal pain, irregular bleeding, increased blood pressure, etc. This places patients who have endometriosis at an economic disadvantage.

Furthermore, in severe disease cases, women are given hysterectomies: a potentially harmful procedure as it causes premature menopause and speeds up aging. This leads to several mental (depression, anxiety, etc.) and physical (hot flashes, pain, etc.) side effects.

While hysterectomies stop women from having periods, the severe perturbations to the hormonal cycles can lead to many abnormalities such as elevated blood pressure and urinary tract infections.

Additionally, complete recovery may take up to two months, further affecting the patient’s work life.

Many steps can be taken at a public health stage to help aid diagnosis at an earlier stage. Increasing awareness and funding for the illness can improve

“THERE IS A SIGNIFICANT LAG IN DIAGNOSIS, LEADING TO A PAINFUL PROGRESSION OF DISEASE AND SYMPTOMS.” research behind better diagnostic measures. Increased insurance coverage or access to birth control can also decrease the buildup of endometrial tissue. Additionally, standing against misinformation and raising physician understanding on pain tolerance can help women suffering from endometriosis.

According to Dr. Huang, increased training on pain detection, willingness to listen to patient narratives, and frequent bias testing may help fight against the misdiagnosis of endometriosis and other painful disorders.

Funding, awareness, and a more nuanced pain measurement scale can help fight against severe pain disorders for both men and women. Doctors need to make sure that their patients’ minor pain concerns are being heard and managed. Instead of dismissing patient concerns based on gender stereotypes, we should attempt to build a more nuanced understanding of illness and suffering. Diseases impact all aspects of life, from a person’s physical to their economic well-being. Hence, it is crucial to continuously update and improve our understanding of diagnosis, symptoms, and disease. 

ABOUT THE AUTHOR

Mahathi is a second year intended Public Health major. When she is not not attending virtual classes, you can find her biking around South-East Minnesota, recording podcasts, and reading books. She also loves to cook spicy food!

THE PUBLIC HEALTH ADVOCATE | 21

PANDEMIC PREPAREDNESS: WHERE AMERICA FELL SHORT Deciphering the reasons why the US is playing a constant game of catch-up with controlling the coronavirus outbreak.

BY ALISHAH KHAN

T

he 2020 coronavirus outbreak is not the first outbreak in America. Over a century ago, the 1918 H1N1 influenza sent the world into lockdown. After a grim 675,000 deaths, the pandemic finally slowed, but strains of the influenza frequently returned . Nothing was as devastating to America as the original “Spanish”

22 | SPRING 2021

influenza. These returning strains of influenza, particularly the 2009 H1N1 outbreak, caused the government to create pandemic preparedness plans.

This detailed plan is updated every few years, with updates in 2006, 2009, and most recently 2017. With such an indepth plan (including objectives related to surveillance, community mitigation

measures, vaccines, health care system preparedness, public outreach, scientific infrastructure, and more), why was the government so unprepared to deal with the coronavirus outbreak?

The coronavirus and the “Spanish” influenza are not comparable as diseases; with coronavirus having a higher mortality rate, the government could

not react in an identical way to their previous influenza response. Influenza outbreaks never called for a shutdown of the economy, and recent influenza outbreaks have had an efficient vaccine distribution process due to previous research on influenza vaccines.

As for the previously established general plans for pandemic preparedness, underfunding on behalf of the government led to the debilitation of any organized response to the outbreak.

Government public health agencies were severely underfunded, thanks to both Democratic and Republican parties.

“There was essentially no robust public health system in the United States,” comments John Swartzberg, MD of the UC Berkeley School of Public Health.

In actuality, there was a plan. After the SARS-CoV-1 outbreak in 2002, there was work on a pandemic preparedness plan under the Bush administration, which was continued and developed under the Obama administration. The main issue came when the plan was significantly dismantled during the Trump administration. “The plan had

“TAIWAN, SOUTH KOREA, AND JAPAN WERE ALL HIT HARD

BY SARS-COV-1, BUT THEY CONTINUED TO REVISE A ROBUST PLAN.” been undercut and underfunded. We had a continuation of the underfunding of public health. Our hands were tied in this game,” says Dr. Swartzberg.

What stopped America’s pandemic preparedness plan from being developed into a safety net from the coronavirus outbreak?

In November 2019, the Trump administration received an information briefing regarding coronavirus.

Immediately afterward, the vital information was essentially disregarded.

With continuous budget cuts to public health in the past years, dismantling of the previously established plan, and neglect of the briefing, all the pieces were in place for coronavirus to cause disaster

in America. The US was extremely behind in preparation, especially compared to Asian countries. Taiwan, South Korea, and Japan were all hit hard by Sars-CoV-1, but they continued to revise a robust plan. So, when this pandemic began in South Asia, most countries were prepared with a better public health system. According to Swartzberg, “This particular pandemic had the perfect storm for the decades of under-preparedness, due to a pandemic plan that had essentially been put on the shelf… this virus could not have picked a better time to emerge in the US.” Other main culprits in the lackluster CDC response? Politicization and hubris. According to Swartzberg, the politicization of the CDC and FDA lead to a slow, ineffective response to the coronavirus outbreak. One CDC scientist even predicted an upcoming pandemic, but was “muzzled” by the Trump administration. Not long after the Trump presidency came to an end, the CDC halted its politicallybased statements and began releasing more science-based announcements.

However, a lack of preparedness cannot be blamed only on the Trump administration: the CDC’s internal issues share the stage. The CDC, when presented with the opportunity to use a diagnostic test for coronavirus created by the Germans, turned it down.

Instead, the agency was adamant about creating their diagnostic test, which fell flat. Through revisions upon revisions of the test, time was wasted in obtaining an effective test.

A third, less obvious party also played a role in politicization of the pandemic.

According to Dr. Swartzberg, media outlets have strayed from science-based reporting and choose instead to purvey a political perspective. “because they [the media] are not scientists, physicians, or public health officials, they have difficulty translating what is important.

They can magnify things that aren’t important, or move on from things too quickly. The media has its own time course; the pandemic has been going on for a year, but a media cycle is one week.

That doesn’t work well together.”

“THE POLITICIZATION OF THE CDC AND FDA LEAD TO A SLOW, INEFFECTIVE RESPONSE TO THE CORONAVIRUS OUTBREAK.” With a lacking public health system and a collection of misinformation, America continues to fall short in its pandemic preparedness. 

ABOUT THE AUTHOR

Alishah is a sophomore studying public health and public policy. She is passionate about infectious disease research, and discovering disparities in healthcare policy.

You can find her taking pictures of the beautiful views on campus or on a run!

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PLANTS AND PERFORMANCE The benefits of plant-based diets in athletic performance.

BY ERIKA RIZAL

T

oday, there are several elite athletes who successfully compete and win while eating a plant-based diet. From tennis player Venus Williams to basketball player Kyrie Irvine to ultramarathoner Scott Jurek, athletes who compete at high levels in different sports proudly support and talk about the importance of their plant-based diets. Because of these correlations, researchers in recent years have been studying how nutrition plays a role in optimizing athletic performance. Researchers want to know if these athletes have better results in performance because of their plantbased diets, and if so, how these diets actually improve athletic performance.

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Recent research shows that plant-based diets can help athletes improve their performance by decreasing weight, creating leaner bodies, and improving stamina. While better performance is not dependent on a complete plantbased diet and can also be achieved by eating meat products, athletes who particularly require weight restrictions, speed, and endurance should consider the benefits of plant-based diets.

Several research studies have shown that plant-based diets reduce body fat.

One clinical study by Barnard et. al researched the effects of a plant-based diet in postemenopausal women after 14 weeks. From this study, it was reported that the adoption of a plant-

based diet had a statistically significant mean weight loss of 5.8 kg compared to a weight loss of 3.8 kg in the control group which adopted a meat-inclusive diet following the National Cholesterol Education Program guidelines. One could argue that perhaps the women who had the plant-based diets ate less food than the individuals who were on a diet plan that included meat. Looking further into the study, the women had no absolute limit to the amount of food they could eat, and both the intervention and control groups had similar caloric intakes throughout the study.

While Barnard’s study was done in postmenopausal women to control for hormonal changes that occur in pre-

menopausal women, other studies using different populations have also showed similar results. For example, a one study found that male and female participants aged 35-70 who followed a plant-based diet had a significant reduction in mean BMI (body mass index) compared to the control group of participants who did not use a plant-based diet, a 4.4 BMI point reduction versus 0.4 point reduction respectively. Plant-based diets not only reduce an individual’s weight and BMI scores, but they also are associated with overall leaner bodies, which can be measured by adiposity throughout one’s body.

In a large, prospective, populationbased study performed in the Netherlands over a period of seven years, researchers found that a greater adherence to a plant-based diet resulted in a statistically significant decrease in BMI as well as

“RESEARCHERS FOUND THAT A GREATER ADHERENCE TO A PLANT-BASED DIET RESULTED IN A SIGNIFICANT DECREASE IN BMI.” a statistically significant decrease in waist circumference, fat mass index, and body fat percentage. For the study’s analysis, the researchers stratified 9,633 individuals into quintiles according to how plant-based their diets were.

Findings highlighted that the higher the quintile - or the more plant-based the individuals’ diets were - the greater the change in BMI, waist circumference, fat mass index, and body fat percentage over time.

One potential counter argument is that individuals who ate less meat were individuals who naturally led healthier lifestyles. In order to try and address such variables, the authors built two models that assessed for confounders, including lifestyle behaviors like smoking status and physical activity.

The article did show that individuals with more plant-based diets were more educated and exercised more overall, which could contribute to the findings.

Nevertheless, as the research suggests, even a relative decrease in meat-based foods and increase in plant-based foods can help decrease body fat composition, and thus leaner body mass.

Leaner body mass is desirable for improved athletic performance. One of the first published studies of the body composition of U.S. Olympians showed that they had lower body fat percentage and higher lean body mass compared to college athletes. More recent studies have been conducted to examine the body composition of elite athletes. In several studies of collegiate athletes, body fat percentage and lean body mass differed across different sports, but athletes still had less overall body fat percentage than other college students.

A weakness of these studies is that they did not show specifically a causation between leaner bodies and athletic performance; these studies did not prove whether leaner bodies result in better athletic performance, or if elite athletes spend more time and energy practicing and thus have leaner bodies. However, the fact that these athletes are collegiate athletes and Olympians implies that these are some of the most elite athletes in their respective sports, and at the very least, that leaner bodies are desirable for top athletic performance.

Other national sports organizations also discuss the benefits of achieving greater lean body mass. For example, the National Strength and Conditioning Association states that athletes who compete in weight classes, such as boxers and weightlifters, benefit from leaner bodies because they can improve strength and power while maintaining their weight classes. Other than making the cut for weight classes, “body weight can influence an athlete’s speed, endurance, and power… and body composition can affect an athlete’s strength, agility and appearance.” The Nutrition and Performance position paper written by the American College of Sports Medicine recognizes that measuring ideal body fat composition depends on age, gender, sex, and sport of an individual athlete. But, the position paper does mention that the United

“IF AN INDIVIDUAL WERE TO EAT AN EQUAL NUMBER OF PLANT-BASED CALORIES VERSUS MEAT-BASED CALORIES, THE INDIVIDUAL CAN EAT TWICE AS MUCH VEGETABLES THAN RED MEAT.“ States Olympic Committee uses the sum of seven skinfolds (measured in mm) as a standard for measuring percentage of body fat, and suggests “the range of values for the athletic population is 30-60 mm for males and 40-90mm for females” if you use the sum of seven skinfolds measurement as a guideline for elite athletes and their coaches.

One can argue that there are several other ways to reduce body fat percentage other than plant-based diets. Human physiology shows that body fat increases because our bodies store extra calories.

As stated in the Harvard Medical School’s Website, “excess calories are stored throughout your body as fat. Your body stores this fat within specialized fat cells (adipose tissue).” If this is the case, then athletes can also decrease their body fat percentage through other methods of decreasing calories, such as other diets.

For example, a recent large study DIETFITS (Diet Intervention Examining the Factors Interacting with Treatment Success) concluded that both low-fat and low-carb diets were successful in weight loss. Similarly, studies also show significant reduction in weight, BMI and waist circumference when individuals used the Italian Mediterranean Diet and Paleolithic Diet, which both include animal products. However, several meats are unhealthy and are loaded with saturated fat, making it more likely for individuals to gain weight given a similar intake of food. This is because fat has more than twice the amount of calories per gram compared to carbohydrates and proteins. In other words, eating one gram of red meat will have a greater percentage of fat, and thus contain more

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than twice as many calories than if you ate 1 gram of vegetables. If an individual were to eat an equal number of plantbased calories versus meat-based calories, the individual can eat twice as much vegetables than red meat.

While some athletes make it a goal to decrease body fat percentage, it is important for athletes to also get enough calories in order to optimize their athletic performance.

Since athletes are doing more physical activity each day than the average person, they also need to consume more calories to match their energy expenditure. As Dr. Theodore Shybut at the Baylor College of Medicine explained, “for an average person, the daily caloric intake might be 1,800 to 2,000 calories. An athlete who is a competitive heavyweight rower or training for long distance running races, for example, may need to eat two or three times that amount of calories daily.” It’s important to note that athletes need to consume the right kind of calories, and the foods that athletes consume determine that types of calories his or her body receives. Not all calories are the same.

Carbohydrates are important sources of our body’s energy and are necessary for athletes. A review article by Murray and Rosenbloom stated, “a highcarbohydrate diet remains the evidencebased recommendation for athletes who engage in hours of physical activity on a daily basis.” There are two types of carbohydrates: simple carbohydrates which naturally occur in small amounts in foods like fruits, and complex carbohydrates found in whole grain foods, fruits, and starchy vegetables.

More specifically, complex carbohydrates are important for enhanced athletic performance, particularly for endurance training lasting more than 90-minutes. First, because simple carbohydrates are often digested more easily and quickly, individuals experience a “sugar rush,” which provides the body with an immediate but short-lasting source of energy. Because competitive athletes practice for multiple hours per day, it is important for them to have a constant

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supply of energy rather than having short energy spikes. Thus, plantbased diets are beneficial because they contain a significant portion of complex carbohydrates and will help athletes have a longer, more stable, and more constant supply of energy throughout the day. Second, complex carbohydrates are important for glycogen storage.

Glycogen synthesis is a slow process, taking hours to days to replete glycogen storages after an intense workout.

In fact, Murray and Rosenbloom summarized, “if daily carbohydrate intake is insufficient to fully replace the glycogen metabolized during hard labor or training, muscle glycogen concentration in active muscles will fall progressively over a period of days.” In order to maintain glycogen stores, athletes need to consume a highcarbohydrate diet that contains complex carbohydrates so that there is a longerlasting supply of carbohydrates that will be available for on-going glycogen repletion.

Recently, competitive athletes have been promoting high-fat diets contributing to their elite performance.

Some individuals misconceive that eating a high-fat diet leads to high levels of fat stores, which can be utilized for long-distance efforts or endurance sports. However, as mentioned earlier, eating fats does not equal increased adipose tissue. high-fat, low-carb diets are actually found to be detrimental to athletic training because they impair normal energy breakdown pathways and limit energy in the form of “highintensity ATP production.” Given this evidence, athletes should aim to have enough glucose and glycogen stores in their bodies, and plant-based diets are helpful in achieving those goals.

Nutrition is an important factor that helps athletes reach peak athletic performance. Other behavioral health factors that are important include muscle strengthening, endurance training, sleep, and mental health. Research studies have found that plant-based diets are effective in decreasing weight, creating leaner bodies through decreases in body fat percentage, and enhancing athletic

endurance. However, there is still a lot of research that needs to be conducted to further clarify the specific beneficial effects of plant-based diets on athletic performance. For example, researchers can look at the effect of plant-based diet on individual sports. Or, researchers can conduct studies to see if plantbased diets impact competition results, such as athletes’ times during track competitions. Different individuals may seek out different benefits from plantbased diets; some individuals may desire to have leaner bodies while others may desire to increase stamina. However, for athletes who are trying to gain a competitive edge on all aspects of health that contribute to their performance, they should at least consider trying a plant-based diet because of its potential benefits. 

ABOUT THE AUTHOR

Erika is a second year intended Public Health major. She is passionate about medicine, community outreach, and helping children.

In her free time she likes to snowboard, go to cute cafes, and spend time with friends and family.

MEET THE EDITORIAL BOARD SUBEKSHA SHARMA, EDITOR-IN-CHIEF Subeksha is a senior studying Public Health and Molecular and Cell Biology. On the weekends, she can be found trying out new recipes with friends, listening to true crime podcasts, and hiking around the Bay Area. After graduation, she hopes to pursue a career in reproductive healthcare.

KAHYUN KOH, PRINT MANAGING EDITOR Kahyun (Kai) Koh is a second-year majoring in Public Health and English. A pre-law student, she is passionate about advocating for health equity and food security through her writing. Kai enjoys figure skating, food vlogging, and listening to NPR podcasts.

RANEEM RAYES, PRINT MANAGING EDITOR Raneem is a senior studying Public Health. Besides PHA, she is involved in MEBA and works as a Research Assistant analyzing infectious disease epidemiology of countries in conflict. In her free time, she enjoys hiking, finding new music, and exploring the city! After graduation, she hopes to work in health care administration.

MANISHA SAHOO, ONLINE MANAGING EDITOR Manisha is a junior majoring in Public Health and minoring in Data Science. She loves being nerdy about pop culture and exploring new music genres. Outside of school, she is either napping or reading Jurassic Park, again. After graduation, she hopes to pursue a career in health analytics and strategy.

JENNY KWON, EXTERNAL RELATIONS MANAGER Jenny is a junior majoring in Public Health and hoping to minor in Journalism, Data Science and Global Poverty & Practice. In their free time, they enjoy going on sunny walks and hikes, listening to long commentary videos and making digital art and music. They aspire to work as a health-focused investigative data journalist after they graduate!

HALEY CHEN, DECAL MANAGER Haley is a senior studying Environmental Economics and Policy. In her free time she can be found doing yoga, exploring new places in San Francisco, and snacking on lemon bars. After graduation, she plans to take a gap year doing research in her field of interest.

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