IDS Magazine Volume I, Issue I (Fall 2023)

CONTENTS

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Ronan Zwa

Emelie Nguyen

Vanessa Vu

Phages: Nature’s Antibiotics

Wastewater Surveillance: A Case Study from the COVID-19 Pandemic

Automated C Systems in H

Elisa Dong

Julia Rodriguez

Global Disease Eradication

Where Does US Policy Stand on Telehealth?

Cluster Alert Hospitals

Emily Mrakovcic

Ruviha Homma

PrEP Usage in Sub-Saharan Africa: Where Biotechnology Meets Social Intervention

Use of Mobile Phone Contract Tracing Apps for the COVID-19 Pandemic and Beyond

Ruviha Homma

Ronan Zwa

Challenges to Global Polio Eradication

How Poverty Plagues Global Health

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EDITOR’S NOTE

D

ear Reader,

variants of SARS-CoV-2? What burdens has the COVID-19 pandemic placed on marginalized populations? Such questions continue to be a topic of debate throughout the world. Evidently, with the overwhelming increase in conversations regarding topics like “lessons learned from COVID,” we would like to initiate dialogue regarding the role of biotechnology in COVID and other pandemics alike through this issue of IDS magazine.

Such questions could include how biotechnology has worked to mitigate the spread of disease and how the development of mRNA vaccines has contributed to the anti-vaccination movement.

With the presentation of our first issue, we would like to give thanks to everyone that has made this possible. As such, we want to begin by acknowledging the hard work of the IDS Magazine team–our writers, editors, design editors, and communications chair–who collectively worked together to make the production of this magazine feasible. This magazine would also not be possible without the help of the IDS Executive Board and larger IDS community. We would like to conclude with the hope that this magazine will serve to not only promote discussion but build a community of individuals passionate about infectious diseases beyond its current and future pages.

We are so excited to introduce and welcome you to our newly found community through the Fall 2023 Issue of the Infectious Disease Society (IDS) Magazine. Initially founded as a group of individuals who are passionate about infectious diseases, IDS has evolved into a vibrant With kind regards, community of students holding interests ranging from biological outcomes of disease to social determinants of health. Wanting to create a platform through which topics in infectious disease could be brought forth and a medium by which discussion about issues traversing from disease to health could be fostered, we created the IDS Magazine and are excited to present our first issue.

Sean Park and Alvaro Uribe As we progress out of the COVID-19 pandemic, the discussion regarding infectious diseases from both a biological and societal standpoint are coming into play. What prophylactic measures can be implemented to combat disease caused by new

Editors-in-Chief

Our Staff: Editors-in-Chief Sean Park Alvaro Uribe Editors Dylan Lai Lisa Miyazaki Alexia Sanchez Contreras Writers Vanessa Vu Ronan Zwa Emelie Nguyen Emily Mrakovcic Ruviha Homma Julia Rodriguez Design Editors Katharine Knowles Kiara Anderson

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MAGAZINE

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“Biotechnology is the key to solving many of the world’s most pressing problems, from food security to climate change to disease.”

–Bill Gates “The promise of biotechnology is the ability to discover and develop new medicines and therapies that can cure previously untreatable diseases.”

–Janet Woodcock

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From Vaccines to Contact Tracing: Exploring Biotechnology’s Fight Against Infectious Diseases

Source: Adobe Stock https://stock.adobe.com/images/

Phages: Nature’s Antibiotics By: Ronan Zwa

T

he issue of antimicrobial resistance has sparked major concerns regarding the efficacy of modern medicine. Some researchers fear that humankind may soon re-enter a sort of “pre-antibiotic” age

is that no amount of new antibiotics will be able to put down these super-bacteria once and for all. The cure, then, will have to come from the joint effort of scientists and nature itself.

human target, phages can also target specific strains of bacteria, making them a vast improvement over antibiotics. Precision, though, is not the sole reason many hold phages in such high Meet the bacteriophage, or phage esteem. The true value of if you’re in a hurry. These virus- these creatures is their astonishing ability to defeat antibiotic-resistant superbugs.

“Many groundbreaking cures come with bank-breaking costs, and even if safe phage therapy is achieved, there is still the problem of equity in global health.”

— not because we’ll misplace the formulas for medicines, but because the target bacteria will have evolved to resist whatever our labs can muster. The stark reality 8

es are essentially the terminators of the microscopic world: they hunt and kill bacteria with incredible efficiency. Just as their silver screen counterparts might hunt a single

One inspirational example of phage therapy is the story of Tom Patterson, a researcher at UC San Diego, who developed a bacterium-induced pancreatic pseudo cyst (a collection of fluid around

the pancreas) while vacationing in Egypt in 2015. All attempts at treatment failed, and even a potent trifecta of kidney-damaging antibiotics ceased to work after less than a week. Patterson would soon go into a septic shock-induced coma after bacteria-infested fluid slipped past attempts to halt the spread of infection. With all options exhausted and little time to spare, it would come down to Patterson’s wife, Stephanie Strathdee, to save her husband’s life. Strathdee had encountered bacteriophages in passing as a student; now, as a researcher, she would turn to them for a miracle. With the help of various teams from across the nation, Strathdee and her colleagues managed to isolate a cocktail of multiple phages that they hoped would finally clear the infection. With no time to properly test the concoction, the team had no idea if their product would work; they had no choice but to administer the phages intra-

venously and hope that the intended effect would come to fruit. Amazingly, after three days of IV phage therapy, Patterson awoke. After being

comatose for nearly two months, he would finally see his wife and daughter once again.

They are also a reminder that even most basic life forms hold power beyond our imagination.

Patterson’s story exemplifies the potential of phage therapy. Despite this success, the bacteriophage is not a panacea. These viruses come in two main types: lytic viruses immediately begin replicating inside a target bacterium, causing it to explode and spread more phages, while lysogenic viruses integrate with a target’s DNA, sometimes granting the bacterium greater resistance. Furthermore, some phages can transition between the two classifications. Only lytic phages that are also incapable of being lysogenic are fit for use in therapy.

This distinction makes it difficult to find the right phage for a certain species of bacterium. In the same vein, administering the incorrect combination of phages can be ineffective at best and devastating at worst. Human testing is thus a nightmare for clinical researchers, making progress in this field glacial. Other concerns pertain to the production and distribution of new samples. Many groundbreaking cures come with bank-breaking costs, and even if safe phage therapy is achieved, there is still the problem of equity in global health.

References: LaFee, S., & Buschman, H. (2017, April 25). Novel Phage Therapy Saves Patient with Multidrug-Resistant Bacterial Infection. UC San Diego Today. Retrieved November 10, 2023, from https://today.ucsd.edu/ story/novel_phage_therapy_saves_patient_with_multidrug_resistant_bacterial_infect Barron, M. (2022, August 31). Phage Therapy: Past, Present and Future. American Society for Microbiology. Retrieved November 10, 2023, from https://asm. org/Articles/2022/August/Phage-Therapy-Past,-Present-and-Future#:~:text=Bacteriophages%2C%20 or%20phages%2C%20are%20viruses,are%20thousands%20of%20different%20types Anomaly J. (2020). The Future of Phage: Ethical Challenges of Using Phage Therapy to Treat Bacterial Infections. Public health ethics, 13(1), 82–88. https:// doi.org/10.1093/phe/phaa003

Ethics and policy aside, bacteriophages are fascinating little creatures that could revolutionize antibiotic treatments and stop super-bacteria dead in their tracks.

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From Vaccines to Contact Tracing: Exploring Biotechnology’s Fight Against Infectious Diseases

Wastewater Surveillance: A Case Study from the COVID-19 Pandemic Genomic Epidemiology Toolkit from the CDC’s Office of Advanced Molecular Detection, has uring the relentless battle against proven to be an extremely accurate early warning system for increased community transmission. Its COVID-19, the year 2020 witnessed the crucial role of innova- non-invasive nature and precision could render tions in tracking and containing it a practical tool for surveillance in future public health crises. the virus. One such strategy—a Analyzing wastewater to track infectious disseemingly strange one— involved using wastewater surveil- ease agents is not a new concept. In fact, a similar lance for the detection of SARS- system has been employed in the United Nations’ Polio Eradication Program since 1988. The basis CoV-2 RNA. This method, for sewage surveillance of poliovirus is derived under the broader COVID-19 from the characteristics of poliovirus infections. Over 95% of individuals infected with poliovirus excrete substantial quantities of the virus in their feces for up to several weeks, which remain detectable and infectious wastewater for days to weeks.

The traditional difficulties in tracking COVID-19 arise from the prevalence of asymptomatic and unreported infections.

Nevertheless, similar to the poliovirus, a 2020 study in the Netherlands revealed that 50% of both symptomatic and asymptomatic COVID-19 patients excrete the SARS-

By: Emelie Nguyen

“Wastewater ana from individuals lack access to me ing a unique per particularly valu underserved com

Source: Dave O’Connor and Marc Johnson https://openresearch.labkey.com/_webdav/Coven/human10

source-cryptic-SARS-CoV-2-lineages/%40files/SPHERES-wastewater/index.html

CoV-2 virus in their feces during the early stages of infection.1 Consequently, following the precedent set by wastewater surveillance for the poliovirus, scientists in 2021 applied the same system to the COVID-19 pandemic.2 Researchers at the University of Wisconsin–Madison and the University of Missouri explored wastewater surveillance further by employing the strategy to identify a novel variant of SARS-CoV-2. Throughout much of 2022, virologist Dave O’Connor and his colleagues had been monitoring a highly mutated variant of SARSCoV-2, initially detected during routine testing of Wisconsin wastewater sourced from over 100,000 individuals. In late 2021, before virologist Marc

rare, non-Omicron lineages that might have infected just a single individual. Illustrated in the diagram below, Johnson successfully traced this variant from the main wastewater plant to a specific business in Wisconsin with fewer than 30 employees, a pursuit spanning five months.

Wastewater testing presents notable advantages over clinical testing by providing an impartial assessment of viral spread within communities. This sampling method is unique for its autonomy from healthcare-seeking behavior, eliminating the reliance on individuals seeking medical attention or presenting symptoms to be effective. This independence allows researchers, such as Johnson and his team, to sift through extensive databases to identify hazardous variants of infectious diseases. Similarly, wastewater analysis captures data from individuals who may avoid or lack access to medical care, providing a unique perspective that proves particularly valuable in medically underserved communities. The collective nature of wastewater sampling is also an efficient strategy for monitoring large populations, yet its methodology is adaptable, Johnson and his team at the allowing for increased granuUniversity of Missouri could larity and more targeted testing trace the wastewater lineage of in response to the detection of this variant, the emergence of SARS-CoV-2 RNA. AdditionalOmicron cases overwhelmed the ly, wastewater testing has proven wastewater, obscuring the variits agility as a fast-responding ant. To address this challenge, measure, with laboratory results Johnson developed an innovative typically available in less than sequencing approach to identify two days. It also possesses the

alysis captures data s who may avoid or edical care, providrspective that proves uable in medically mmunities”

Future Outbreaks/ Instructions: 1. Medema, G., Been, F., Heijnen, L., & Petterson, S. (2020). Implementation of environmental surveillance for SARS-CoV-2 virus to support public health decisions: Opportunities and challenges. Current opinion in environmental science & health, 17, 49–71. https:// doi.org/10.1016/j.coesh.2020.09.006

2. https://www.nature.com/articles/d41586-0223. Module 2.7 - Wastewater based variant tracking for SARS CoV 2

predictive capacity to precede reported symptoms by approximately four days, enabling public health officials to anticipate and respond to outbreaks with greater speed and effectiveness.3 In anticipation of potential future health crises, wastewater surveillance emerges as an innovative and powerful tool that has demonstrated its efficacy in disease detection and monitoring. The integration of advanced molecular techniques and the adaptability of these methods to respond to new challenges, as proven by researchers like Johnnson, point towards a future where such surveillance could evolve into a routine early-warning system.

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From Vaccines to Contact Tracing: Exploring Biotechnology’s Fight Against Infectious Diseases

Automated Cluster Alert Systems in Hospitals spread of diseases. However, this manual process requires a significant amount of human resources and can be time consuming. Because of this, hosne of the most important aspitals often limit cluster detection to certain high pects of patient safety in hospirisk areas or certain pathogens, meaning pathogens tals is infection prevention and can slip under the radar in other areas.1 Automatcontrol, often called IPC. IPC is ing this process can simultaneously allow for cluster a field that has witnessed signifidetection programs in all parts of the hospital and cant advancements in computer alleviate the resource burden, which is especially science innovations and new important in situations like COVID-19, when hosalgorithms.3 While areas like pitals were short-staffed and overworked.1 identifying high-risk patients and One of the greatest advantages of automated prescribing antibiotics have bencluster alert systems is that it can utilize real time efited from these developments, data to detect clusters. In traditional contact tracthe subfield of outbreak detection ing, due to the incubation period of a given disease within infection control has not or the time needed to wait for a test result, there is progressed as much, despite its often a delay between cases that could be related to critical role in IPC.3 an outbreak.2 Even after receiving a positive result, Typically, hospitals employ a hospital staff member must fill out a case report manual cluster detection to pinform and notify the health department.2 In conpoint pathogens and trace the trast, the automated system is able to use electronic health records to utilize data that is already collected, and the algorithm can piece individual cases into clusters.2 In addition to its role in outbreak detection, automated cluster alert systems contribute to the overall quality of patient care. With potential clusters and outbreaks identified earlier, hospital staff are enabled to respond to them more quickly, thus minimizing the spread of a disease.1 The automation of a previously time consuming task also leaves hospital staff with more Source: Adobe Stock https://stock.adobe.com/images/infected-city/344864372

By: Vanessa Vu

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Source: Adobe Stock https://stock.adobe.com/images/ time to attend to patients’ other needs. supplement to the existing manuHowever, like any technological al methods.2 advancement, there are certain In summary, the incorpo1. Aghdassi, S. J., Kohlmorgen, B., Schröder, C., Peña downsides to automated cluster ration of automation into outDiaz, L. A., Thoma, N., Rohde, A. M., Piening, B., alert systems. An automated sys- break detection presents both Gastmeier, P., & Behnke, M. (2021). Implementation of an automated cluster alert system into the routine tem can only view data without opportunities and challenges. work of infection control and hospital epidemiology: nuance. It cannot consider enviAutomated cluster alert systems Experiences from a Tertiary Care University Hospital. ronmental factors such as politioffer efficiency and a chance to BMC Infectious Diseases, 21(1). https://doi.org/10.1186/ s12879-021-06771-8 cal/economic climate or neighlessen the responsibilities of hosboring outbreaks, and therefore pital staff, but fully adopting this

References:

“With potential clusters and outbreaks identified earlier, hospital staff are enabled to respond to them more quickly, thus minimizing the spread of a disease.” cannot detect causality.4 Automated systems also often exhibit higher rates of false positives and redundant alerts.2,4 As a result, it is possible that automated contact tracing will never completely replace manual contact tracing.

Instead, it will likely be used as a

system means compromising on false positives and the ability to identify causality.2 With the abundance of recent advancements in AI, there is no doubt that this system will continue to develop and will play an increasingly prominent role in IPC.

2. DeWitt, M. E., & Wierzba, T. F. (2023). Automatic case cluster detection using hospital electronic health record data. Biology Methods and Protocols, 8(1). https://doi.org/10.1093/biomethods/bpad004

3. Leclère, B., Buckeridge, D. L., & Lepelletier, D. (2019). Evaluation of a web-based tool for labelling potential hospital outbreaks: A mixed methods study.

Journal of Hospital Infection, 103(2), 210–216. https:// doi.org/10.1016/j.jhin.2019.05.004

4. Martischang, R., Peters, A., Guitart, C., Tartari, E., & Pittet, D. (2020). Promises and limitations of a digitalized infection control program. Journal of Advanced Nursing, 76(8), 1876–1878. https://doi.org/10.1111/ jan.14390

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“There is no one size that fits all. There is no one size that fits all. We must work country by country, region by region, community by community, to ensure the diversity of needs are addressed to support each reality.”

–Amina J. Mohammed, Deputy Secretary-General UN

“We cannot have an equitable recovery from the pandemic if we leave the most vulnerable in our communities behind. This includes the zero-dose children who have not received a single vaccine shot. We need strong collaboration across agencies and with countries so that we can reach zero dose children, and expand access to families who are missing out on crucial primary health care services.”

– Dr Seth Berkley, CEO, Gavi, the Vaccine Alliance

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From Vaccines to Contact Tracing: Exploring Biotechnology’s Fight Against Infectious Diseases sub-Saharan Africa, the way HIV/AIDS is viewed, proliferated, prevented, and treated is heavily reliant on cultural norms and stigma. There are heavy inequalities and discrimination surrounding the disease,¹ including treatment. Pre-exposure prophylaxis, more commonly known as PrEP, is a daily pill medication that significantly reduces an individual’s risk of HIV.² This prevention tool, however, fell into a net of stigma after introduction in sub-Saharan Africa, rendering its availability ineffective in reducing HIV incidence in this popuBy: Emily Mrakovcic lation. For PrEP to reach the tudying infectious diseases from levels of success it is capable a biological perspective may lead of producing in sub-Saharan to assumptions that diseases are Africa, the medication must experienced similarly across all be implemented alongside affected populations. Molecular social interventions that elimiproperties determining how a nate barriers to treatment. disease is transmitted and exPrEP itself has been tested perienced in the human body and proven to be effective in typically remain constant, yet reducing HIV transmission—reducing the risk of why does the burden of disease contracting HIV by 99% through sexual contact and differ across varying populaby 74% through injection drug use.² Currently, two tions? Factors that lie outside the approved pills are available: Truvada, which prevents realm of scientific fact, such as infection from both sex and injection drug use, and beliefs and behaviors of populaDescovy, which prevents infection from sex.² There is tions, may cause the same infecalso a new injectable form of PrEP, Apretude, that is tious disease to be experienced also available, expanding consumer options for HIV differently across the world. The prevention.² The medication, regardless of form, HIV/AIDS epidemic showcases fends off HIV by producing antibodies that hinthis—in ders the virus’s replication.⁴ It contains two drugs, tenofovir

PrEP Usage in Sub-Saharan Africa: Where Biotechnology Meets Social Intervention

“This populatio highest inciden the world, yet m about PrEP”

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and emtricitabine, that block the activity of necessary enzymes for HIV to replicate.⁴ PrEP users who adhere to their treatment regimens are able to almost completely eliminate their risk of contracting HIV after exposure.

Despite PrEP’s effectiveness, its prevention strategy is lagging behind its treatment counterparts. Young women in southern Africa are particularly affected by the shortall of prevention.

This population has one of the

on has one of the nce rates of HIV in many are hesitant highest incidence rates of HIV in the world,³ yet many are hesitant about PrEP. In sub-Saharan Africa, taking PrEP is often associated with promiscuity. It is common for male partners of women who are on PrEP to assume that their partner has been unfaithful.¹ This assumption often leads to domestic violence from the male partner, deterring women

from taking PrEP¹. Additionally, many women are afraid that their community will mistake PrEP for antiretroviral therapy, a medication used by individuals living with HIV. In a culture where HIV is highly stigmatized, many fear that community members might spread false information about their HIV status,¹ which will result in discrimination and isolation from the community.. For PrEP to become an impactful prevention tool, interventions addressing harmful stereotypes and assumptions must be implemented in these communities.

Several community-level interventions have been proposed to improve PrEP uptake, many of which revolve around education and the diffusion of knowledge.

Educating men and women on the use and benefits of PrEP may reduce the medication’s harmful stigma and allow people to distinguish between PrEP and ART.¹ Living testimonies from PrEP users¹ may also strengthen trust, encouraging potential consumers to begin PrEP regimens.

To specifically address barriers surrounding women when seeking preventative care interventions must be designed to encourage cooperation from male partners to their female partners to prevent violence.⁵ Rectifying PrEP’s usage image from promiscuous and unfaithful to empowering and responsible has

the potential to alter the medication’s constructive framework.

Addressing the cultural mechanisms that dictate behavior within a community is an extensive and lengthy process, but it is one that cannot be ignored.

Simply providing PrEP without considering the cultural context it is placed in is hardly a solution to sub-Saharan Africa’s HIV epidemic. Efforts that aim to provide new information while simultaneously breaking down existing stigma will ensure that the products of today’s ever-improving biotechnology, such as PrEP, are put to meaningful use.

References: 1. Bergam S, Harrison AD, Benghu N, et al. Women’s Perceptions of HIV- and Sexuality-Related Stigma in Relation to PrEP: Qualitative Findings from the Masibambane Study, Durban, South Africa. AIDS and behavior. Published online February 26, 2022. doi:https:// doi.org/10.1007/s10461-022-03632-6 2. Centers for Disease Control and Prevention. PrEP. Centers for Disease Control and Prevention. Published 2019. https://www.cdc.gov/hiv/basics/prep.html 3. Harrison A, Colvin CJ, Kuo C, Swartz A, Lurie M. Sustained High HIV Incidence in Young Women in Southern Africa: Social, Behavioral, and Structural Factors and Emerging Intervention Approaches. Current HIV/AIDS Reports. 2015;12(2):207-215. doi:https:// doi.org/10.1007/s11904-015-0261-0 4. Institute WH. What is PrEP and How Does it Work?

Washington Health Institute. Published February 16, 2021. https://dc-whi.org/what-is-prep-and-howdoes-it-work/ 5. Morgan R, Ayiasi RM, Barman D, et al. Gendered health systems: evidence from low and middle-income countries. Health Research Policy and Systems. 2018;16(1). doi:https://doi.org/10.1186/ s12961-018-0338-5

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From Vaccines to Contact Tracing: Exploring Biotechnology’s Fight Against Infectious Diseases

Source: Adobe Stock https://stock.adobe.com/images/

Use of Mobile Phone Contract Tracing Apps for the COVID-19 Pandemic and Beyond of COVID-19 transmissions By: Ruviha Homma happen asymptomatically.5 In that sense, the quick spread of ontact tracing during COVID-19 throughout comthe COVID-19 pandemic was a struggle for munities warranted a much many nations, including more effective, rapid contact high income countries. Wealthier tracing method. To address this countries like the United States, problem, a handful of countries successfully developed and imcertainly had the technological plemented similar technologies capabilities to succeed in one for contact tracing during the of the most basic public health COVID-19 pandemic, ushermeasures for containing infecing in a new era of tracking the tious diseases - contact trac4 spread of infectious diseases ing. However, when using the through a different, more constandard technique of contact tracing, public health officials in venient method. This groundthe United States had difficulties breaking contact tracing tool is, in fact, right within arm’s reach: reaching out to each and evour mobile phones. ery person who had contracted As the COVID-19 pandemic COVID-19 and their contacts. progressed, countries, especially Thus making the purpose of those in East and Southeast Asia, contact tracing—to prevent began developing smartphone the further spread of infectious 4 apps for contact tracing. These diseases–futile. The nature of apps collect Bluetooth and GPS COVID-19 also worked against data from mobile phones to the standard method of tracktrack the locations of individuals ing contact as around 50%

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over time.3 GPS data, along with a timestamp, is collected automatically from mobile phone operators, while Bluetooth data collects informations on interactions between Bluetooth-enabled devices that are close in proximity.3 With both of these datasets, individuals’ locations can be tracked and realtime information on physical clusters of people can be recorded for contact tracing purposes.3 When a case of COVID-19 is identified, the user is added to a list of others who are also infected.3 Other devices will then query this list, and if an infected individual is found to have been in contact with a particular user, then that user and their contacts will be alerted for further action.3 This technology proves to be particularly useful for counteracting COVID-19’s asymptomatic transmission. For instance, there may be an individual who

References: 1. Akinbi, A., Forshaw, M., & Blinkhorn, V. (2021).

Contact tracing apps for the COVID-19 pandemic: A systematic literature review of challenges and future directions for neo-liberal societies. Health Information Science and Systems, 9(1), 18. https://doi.org/10.1007/ s13755-021-00147-7 2. Anderson, M., & Auxier, B. (2020, April 16). Most Americans doubt tracking cellphones will help limit COVID-19, divided on whether it’s OK. Pew Research Center. https://www.pewresearch.org/shortreads/2020/04/16/most-americans-dont-think-cellphone-tracking-will-help-limit-covid-19-are-dividedon-whether-its-acceptable/ 3. Grantz, K. H., Meredith, H. R., Cummings, D. A. T., Metcalf, C. J. E., Grenfell, B. T., Giles, J. R., Mehta, S., Solomon, S., Labrique, A., Kishore, N., Buckee, C. O., & Wesolowski, A. (2020). The use of mobile phone data to inform analysis of COVID-19 pandemic epidemiology. Nature Communications, 11, 4961. https://doi. org/10.1038/s41467-020-18190-5 4. Lewis, D. (2020). Why many countries failed at COVID contact-tracing—But some got it right. Nature, 588(7838), 384–387. https://doi.org/10.1038/d41586020-03518-4 5. Parker, M. J., Fraser, C., Abeler-Dörner, L., & Bonsall, D. (2020). Ethics of instantaneous contact tracing using mobile phone apps in the control of the COVID-19 pandemic. Journal of Medical Ethics, 46(7), 427–431. https://doi.org/10.1136/medethics-2020-106314 6. Sato, M. (2020, December 14). Contact tracing apps now cover nearly half of America. It’s not too late to use one. MIT Technology Review. https://www. technologyreview.com/2020/12/14/1014426/covid-california-contact-tracing-app-america-states/

does not present any symptoms while taking public transportation, but later tests positive for COVID-19. Using manual contact tracing, it would be difficult to identify all those who were using public transportation and were also in close contact with the individual. These apps, however, store records of exactly where that asymptomatic individual has been. This allows contacts, even those who may have been in brief contact with the individual in passing, to be quickly identified and alerted.

With this potential for rapid

and effective contact tracing, it is no wonder that many countries developed and implemented this technology from early on in the pandemic. In China and Taiwan, these contact tracing apps were deemed mandatory for all citizens to download. Since they had proven to be effective at identifying and reducing cases of COVID-19, alongside the manual contact tracing method.1 Some countries went a step further and used these mobile phone apps to enforce public health measures such as lockdowns or home quarantines, during the pandemic. For example, the Hong Kong government required citizens to download a “StayHomeSafe” app and to wear electronic tracker wristbands that would alert officials if an individual left their home quarantine.1 This close government vigilance of citizens’ location and movements raises the concern of data privacy, which has deterred many from embracing this particular technology. A mobile phone app that records the location of individuals, which public health authorities and other officials can use to track citizens in close to realtime, may be viewed as concerning.5 In addition, if governments use this app to enforce certain public health measures, like isolation and quarantine, or if all citizens are mandated to download this app, the liberty and autonomy of individuals may be compromised.5 In neoliberal societies, including the United States and

United Kingdom, controversies surrounding these apps focus on such privacy and governmental surveillance concerns.1 Although around half of the states in the U.S. attempted to implement these contact tracing apps, there was no coordinated national effort.6 As a result, these apps arrived too late into the pandemic and not without doubt and controversy.6 In fact, in April of 2020, 60% of Americans believed that tracking locations through people’s phones would not do much to stop the spread of the virus, while 48% of Americans believed that it was not acceptable for the U.S. government to do this at all.2 However, some argue that these infringements on privacy and liberty are justified. Using people’s phone locations for contact tracing purposes can help mitigate the spread of disease, save lives, and improve the overall health of the population.5 With these conflicting perspectives, use of these contact tracing apps certainly has to be weighed against the potential public health benefits in the long run.

There is no doubt challenges and concerns related to these contact tracing apps must be addressed before the implementation of this technology worldwide.

However, there is also potential for this technology to become the most effective method of contact tracing for future outbreaks of infectious diseases. With this in mind, more research and further development of the use of contact tracing apps in mobile phones must be considered so that, when the next pandemic arrives, societies worldwide are prepared to successfully implement it.

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From Vaccines to Contact Tracing: Exploring Biotechnology’s Fight Against Infectious Diseases was the first disease to be eradicated— and, as of now, the last.

It’s thrilling to imagine that our technologies will become capable of taking out life-threatening organisms wholesale, but it turns out eradication is deafeningly complex.

While any disease can be eradicated in theory By: Elisa Dong with the right tools and investments, there are n 1796, Edward Jenner exmany biological factors at play that make certain perimented with the very first organisms more likely than others to successfully vaccine, finding a way to counter be eliminated. Firstly, there needs to be a proven a terrible infectious disease— treatment, which is rather self-explanatory—and smallpox—that had been ravyet, in the case of ever-evolving diseases, a criteria aging humanity for over three that must be met again and again with each new thousand years. From then on form of resistance. Secondly, the disease needs to spanned a battle lasting nearly be detectable. Asymptomatic transmission makes two centuries, crowned by the infection hard to diagnose, dealing a critical hit to WHO’s Intensified Smallpox eradication efforts (Dowdle, 1999).

Eradication Program in 1967.

Perhaps less intuitively, eradication also requires By 1977, the last case of smalla single-host disease. If an animal reservoir can pox was reported in Somalia. simply return the infection back into a human Once universally feared as a population, eradication efforts will never end until deadly and disfiguring disease, this secondary factor is addressed as well. This was the virus had been banished to seen with the guinea worm eradication effort, in freezers in high-security labowhich the discovery that dogs could transmit the parasite back into human hosts jeopardized WHO’s projects and forced the 2020 eradication target to be postponed.

Beyond biology and pathology, successful eradication also involves the complexities of social implementation and political will.

“Top-down” eradication efforts can apratories and formally declared pear paternalistic and even violent to those they eradicated (CDC, 2021). claim to help. In the final stages of the WHO’s WHO was emboldened. It smallpox eradication campaign in South Asia, looked like other infections were officials resorted to intimidation and coercion to soon to follow—metaphorical obtain universal inoculation, fostering resentment rows of soon-to-be extinct disin these communities toward subsequent health efeases, lined up on the shelves forts (Greenough, 2000). In Nigeria, cases of polio away from vulnerable human surged after rumors that vaccination efforts were bodies. However, since smallpox a covert operation to cause infertility and spread was declared eradicated in 1980, HIV in local communities (Larson and Ghinai, no other human disease has yet 2010). Successful eradication cannot simply operto meet that criteria. Smallpox ate on a national scale through the will of distant

Global Disease Eradication

“It is within the power of man to eradicate infection from the earth.” —Louis Pasteur

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officials, but also require the local scale with the consent and cooperation of the communities experiencing these interventions.

While infectious disease eradication is the idealized solution, it is not the end-all be-all. Thomas McKeown’s famous hypothesis suggested that the decline of deaths by infectious disease in the 1700s was not due to life-saving advancements in the medical field, but improved standards of living generated by economic conditions (Colgrove, 2002).

Successful global health is inseparable from political change and amelioration of social inequality.

Malaria and tuberculosis are no longer endemic to the US due to successful elimination efforts as a result of dedicated efforts in the 1950s involving insecticides, swamp drainage, wire screens, and surveillance by the CDC, despite global eradication of the disease remaining out of reach.

Even without complete eradication, the threat of a given infectious disease can be mitigated through non-biological social changes.

Let us view our current pandemic through the lens of infectious disease eradication.

As it stands, in 2022/2023, COVID-19 does not clearly meet any of the three criteria listed above: the effectiveness of vaccines and treatment seems to be variable depending on the virus strain, the disease can be transmitted asymptomatically, and zoonotic transfers remain

Source: Adobe Stock https://stock.adobe.com/images/variola-virus-a-virus-from-orthopoxviridae-family-that-causes-smallpox-highly-contagious-disease-eradicated-by-vaccination-3d-illustration/177676236 a constant threat. However, the forever, or does it come down lines of what makes a disease to the development of effective feasible to eradicate continue to tools and successful public health blur. Despite the high technical efforts? Until the day comes, barrier of poor vaccine accepcontrolling future outbreaks will tance and large upfront costs, remain the primary line of dethe reinfection rate from animal fense against infectious disease. to human is low. And, importantly, a high global interest in controlling COVID-19 activates Centers for Disease Control and Prevention. (2021, the powerful potential of public February 20). History of smallpox. Centers for Disease Control and Prevention. Retrieved May 3, 2022, from health and social measures— https://www.cdc.gov/smallpox/history/history.html which have already, in many Colgrove, J. (2002). The mckeown thesis: A historical regions, been used to almost controversy and its enduring influence. American completely mitigate the threat Journal of Public Health, 92(5), 725–729. https://doi. of COVID-19, like in New org/10.2105/ajph.92.5.725 Zealand. Eradication may be Dowdle, W. R. (2000, January 3). The principles of closer in reach than it seems—it disease elimination and eradication. The Principles of Disease Elimination and Eradication. Retrieved May just takes the right tools, social 3, 2022, from https://www.cdc.gov/mmwr/preview/ changes, and time (Wilson et al., mmwrhtml/su48a7.htm#:~:text=Elimination%20of%20 2021). disease%3A%20Reduction%20to,continued%20intervention%20measures%20are%20required Despite the clear criteria presented in this article, what qualGreenough, P. (1995). Intimidation, coercion and resistance in the final stages of the South Asian smallpox ifies as an eradicable disease eradication campaign, 1973–1975. Social Science & remains malleable—especially Medicine, 41(5), 633–645. https://doi.org/10.1016/0277under the force of time. The 9536(95)00035-6 lines change as new technologies Wilson, N., Mansoor, O. D., Boyd, M. J., Kvalsvig, A., forge new possibilities for elimi& Baker, M. G. (2021, August 1). We should not dismiss the possibility of eradicating covid-19: Comnation and detection. Will some parisons with smallpox and polio. BMJ Global Health. diseases remain ineradicable Retrieved May 3, 2022, from https://gh.bmj.com/con-

References:

tent/6/8/e006810

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“Our current privatized and fragmented commodity-based healthcare system costs more than public healthcare for other countries around the world. I must repeat this; we are already paying for the cost of Universal Health Care and then some.”

–Kat Lahr, What the U.S. Healthcare System Doesn’t Want You to Know, Why, and How You Can Do Something About It

“If access to health care is considered a human right, who is considered human enough to have that right?”

–Paul Farmer

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From Vaccines to Contact Tracing: Exploring Biotechnology’s Fight Against Infectious Diseases (Lee et al., 2023).

The people who use telehealth services the most are Medicaid (28.3%) and Medicare (26.8%) beneficiaries, African Americans (26.1%), and those whose income is lower than $25,000 (26.4%) (Lee et al., 2023). Telehealth clearly is still an important method of providing care, especially to those who are at an increased risk of experiencing disparities in care, such as people of color, the elderly, those with a lower income, and the disabled. Now that it appears telehealth is here to stay, what are states doing to address the issue of providing care across state lines?

During the COVID-19 pandemic, all states plus Washington, D.C. declared an emergency to waive certain parts of their licensing rules and allow doctors to provide care to their patients who may have been in other states (Health Resources & Services Administration, 2023b). After the public health emergency was declared over, some states stopped allowing waivers that permitted providers to practice in other states, while other states have passed laws to extend these waivers or set them in stone (Health Resources & Services Administration, 2023b). Arizona, for example, has permanently allowed providers to provide telehealth services to their patients on the

Where Does US Policy Stand on Telehealth?

By: Julia Rodriguez

R

ight before I left my last in person appointment with my provider before going back to Brown for the new semester, my provider told me she would not be able to provide telehealth services to me while I am in Rhode Island – she could only see me in person or do telehealth while I was in my home state. As a Texan, it is not feasible to go home every so often, which meant I would only be able to receive care from her during winter and summer breaks. Telehealth is one of the beneficial adaptations emerging from the pandemic, but now that the pandemic is subsiding, more students like me are experiencing discontinuity in care as we head off to college.

Most of us may not have heard about telehealth until we had to stay in our houses during the early days of the COVID-19 pandemic. Now, 3 years later, we are in a much different place, but we are still using telehealth.

Telehealth usage rates are still above pre-pandemic rates based on a study conducted from 2021 to 2022, finding that an average of 22% of American adults claimed they had used telehealth services in the past four weeks

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condition that they are registered with Arizona and their license from their state of licensure is in “good standing” (Appleby, 2021).

Some states allow providers to continue their patient-provider relationship for a short amount of time, typically no longer than 30 days, if their patient is located in another state (Health Resources & Services Administration, 2023b). Otherwise, their provider must obtain a license for the state they are residing in, which is difficult, timely, and costly. Most states require the provider to pass a background check, complete that state’s education and supervision requirements, and take (and pass) the required exams (Health Resources & Services Administration, 2023b). Providers also have to pay for their registration and license renewal and complete further education to keep their license (Health Resources & Services Administration, 2023b).

A license can cost up to $800 and the fees vary by state and the provider’s specialty (Health Resources & Services Administration, 2023a).

But not all hope is lost – there are some exceptions and solutions to this problem. Some states allow providers to treat their patients if the state they are licensed in shares a border with the state. Some states allow providers to treat their patients if a patient-provider relationship is established and the patient has seen the provider in person within the past year (Health Resources &

state (Appleby, 2021). On the federal level, certain providers are allowed to practice across Appleby, Julie. (2021, September 2). Telehealth’s Limits: Battle Over State Lines and Licensing Threatens state lines, such as licensed (in Patients’ Options. US News. https://www.usnews. their home state) sports medicine com/news/health-news/articles/2021-09-02/telehealths-limits-battle-over-state-lines-and-licensingproviders. Additionally, health threatens-patients-options providers working in the Department of Veterans Affairs, the Health Resources & Services Administration. (2023a, April 20). Getting started with licensure. telehealth.

Indian Health Service, and the hhs.gov. https://telehealth.hhs.gov/licensure/getDepartment of Defense, may ting-started-licensure provide care across state lines for Health Resources & Services Administration. (2023b, certain patients, such as athletes, May 11). Licensing across state lines. telehealth.hhs. veterans, American Indians and gov. https://telehealth.hhs.gov/licensure/licensingacross-state-lines Alaska natives, and Department of Defense employees, respectiveLee, E. C., Grigorescu, V., Enogieru, I., Smith, S. R., Samson, L. W., Conmy, A. B., & De Lew, N. (2023, ly (Health Resources & Services April). Updated National Survey Trends in Telehealth Administration, 2023a). The Utilization and Modality: 2021-2022 (Issue Brief federal government also allows No. HP-2023-09). Office of the Assistant Secretary for Planning and Evaluation, U. S. Department providers to provide care across of Health and Human Services. https://aspe.hhs. state lines by allowing states to gov/sites/default/files/documents/7d6b4989431f4c70144f209622975116/household-pulse-survey-teleenact the Uniform Emergency health-covid-ib.pdf Volunteer Health Practitioners Services Administration, 2023b). Act if the state has declared a There’s also a nurses’ compact, state emergency. However, it is up involving 37 states and Guam, to state whether they want to enin which all the states within act the act (Health Resources & the compact recognize a nurse’s Services Administration, 2023a). license that was earned in one State medical boards are relucof the compact states (Appleby, tant to allow providers to provide 2021). There is also an Interstate telehealth services across state Physician Licensure Compact, lines, as state medical boards started in 2017. 33 states, Washclaim licensing and their abilington D.C., and Guam are with- ity to discipline – which they in the compact, which is designed cannot do if the provider is to make it easier for physicians not licensed in their state – is to become licensed in multiple essential to maintaining pastates (Appleby, 2021). This com- tient safety (Appleby, 2021). pact, however, still requires the Plus, the state earns money physician to be licensed in every through licensing (Appleby, state they intend to practice in 2021). If providers were and requires the physician to able to pracgo through the required education and pay the required fees to maintain their license in each

References:

tice in any state without being licensed, states would lose out on money and have a harder time keeping track of who is treating their residents. There is also some resistance among healthcare providers due to the fear of losing patients to other doctors outside their state if states loosen requirements (Appleby, 2021).

As of now, providers’ ability to provide telehealth services across state lines depends on the state in which the patient is located.

Although there are federal rules, the ability to practice out of state is primarily a state issue, which can become confusing for both patients and providers. Compacts like the nurses’ compact and the Interstate Physician Licensure Compact can streamline these rules and make it easier for Brown students to continue their provider-patient relationship.

Whether these compacts will expand in the United States remains to be seen, but telehealth is and will continue to be an invaluable tool for continuing care for Americans.

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“Disease only treats humans equally when our social orders treat humans equally” –John Green, The Anthropocene Reviewed

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From Vaccines to Contact Tracing: Exploring Biotechnology’s Fight Against Infectious Diseases

Challenges to Global Polio Eradication

been imported to other countries, causing outbreaks in Malawi and Mozambique in recent years.8 However, since polio has technically been eradicated in olio is a highly infectious disease caused by the transmission of the almost all countries through continued immunizapoliovirus from person-to-person tion efforts, the global community certainly has the means to eliminate it everywhere else. Yet, there are and largely affects young children, causing paralysis through its certain challenges in eradicating polio completely in all regions of the world. invasion of the nervous system.7 One barrier is the type of vaccine that continIn the 1980s, polio was present ues to be used throughout many countries. In 121 in more than 125 countries and countries, the live attenuated oral poliovirus vaccine paralyzed 350,000 people each (OPV) continues to be used instead of the inactiyear.6 In response to this public vated poliovirus vaccine (IPV), although both have health emergency, the Global effectively helped eradicate polio.3 Some reasons Polio Eradication Initiative was the OPV is used instead of IPV include that OPV launched in 1988 to eliminate costs significantly less than IPV, forms better intesthe disease globally through the tinal immunity, and is more easily administered, as distribution of polio vaccines it is an oral vaccine rather than the IPV injection.3 around the world.6 This immuAlthough OPV has been effective in aiding the nization effort has largely paid off, as the number of polio cases eradication of polio, OPV can cause rare cases of 3 has decreased by over 99% since vaccine-associated paralytic poliomyelitis (VAPP).

In addition, this live virus in the vaccine can mu1988, with just 6 cases of polio tate, transforming into circulating vaccine-derived being reported in 2021.7 While polioviruses (cVDPVs).3 cVDPVs can lead to furtwo strains of the wild poliovither polio outbreaks, which is an issue, especially in rus—type 1 and type 3—were under-vaccinated areas.2 In fact, around 76 cases eradicated in 1999 and 2020, respectively, through these vacci- of cVDPVs have been reported annually between 3 nation efforts, wild poliovirus type 2005 and 2013. Therefore, if total global eradication of wild polioviruses occurs, the use of OPV 1 continues to affect children in would still continue to produce cVDPVs, which Pakistan and Afghanistan.7 Due to its circulation throughout these would essentially negate this so-called “eradication” 1 two countries, wild poliovirus has of the poliovirus.

By: Ruviha Homma

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To address this, many experts believe that once wild poliovirus cases have been completely eliminated, OPV cessation is necessary to eliminate cVDPV cases and is the final step to complete polio eradication.1 However, there are challenges in stopping the use of OPV and instead introducing IPV by low and middle income countries. On top of needing to eliminate wild poliovirus cases completely first, there is also the increased cost of the IPV vaccine, the manufacturing capacity needed to produce IPV, and other related logistics that will prove to be challenging for many countries.3 In addition, many countries that use OPV currently, and are considering the introduction of IPV, are burdened by other infectious diseases and public health priorities.3 Therefore, complete OPV cessation may have to hold off for some time.

Another challenge of eliminating polio is the political, economic, and social climates of certain countries.4 In Afghanistan and Pakistan, for example, there has been widespread mistrust of the West and its vaccination programs. Since 2012, 70 polio immunization workers have been targeted in Pakistan, while 8 polio vaccination workers were killed in Afghanistan in February 2022.4 Militant groups in Pakistan and Afghanistan have also enacted bans on polio vaccinations, oftentimes due to misinformation regarding these vaccines.4 Exacerbating this hostile climate with

regards to polio vaccinations, the COVID-19 pandemic and other political, economic, and social conflicts occurring in Afghanistan and Pakistan have caused children to miss routine vaccinations, including those necessary for polio immunization.4 In general, war, conflict, and instability in Afghanistan and Pakistan have no doubt disrupted the countries’ health systems, thus causing decreased vaccination rates and continued circulation of polio.

In response to the ongoing efforts to eradicate polio, UNICEF launched a campaign in 2022 to vaccinate 23 million children across Malawi.4 In Afghanistan, 2.6 million children were vaccinated against polio in late 2021, although the 2022 attack on vaccination workers has posed security challenges to this effort.4 In addition, the European Commission, the European Investment Bank, and the Bill & Melinda Gates Foundation have raised $1.1 billion dollars to fund polio vaccinations for 370 million children annually, to deliver vital health services to children, and to make vaccines and therapeutics more accessible to low and middle income countries.5 These efforts by global organizations aid in addressing disparities in polio immunization across the globe.

There are certainly barriers that have prevented the eradication of polio sooner. However, it is necessary to continue the implementation of vaccination campaigns, to develop and implement

safer, more effective vaccines, and to engage with all communities–specifically in Pakistan and Afghanistan–in an effort to reach the global community’s goal of eradicating polio for the health and wellbeing of all.

References: 1. Aylward, R. B., Sutter, R., & Heymann, D. (2005).

OPV Cessation--the Final Step To a “Polio-Free” World. Science, 310(5748), 625–626. https://doi. org/10.1126/science.1115547 2. Backman, I. (2022, August 26). Is Polio Making a Comeback? Yale School of Medicine. https://medicine. yale.edu/news-article/is-polio-making-a-comeback/ 3. Bandyopadhyay, A., Garon, J., Seib, K., & Orenstein, W. (2015). Polio vaccination: past, present and future.

Future Microbiology, 10(5), 791–808. https://doi. org/10.2217/fmb.15.19 4. Klobucista, C., & Renwick, D. (2022, August 22).

Why Hasn’t the World Eradicated Polio? Council on Foreign Relations. https://www.cfr.org/backgrounder/ why-hasnt-world-eradicated-polio 5. New funding to ensure 370 million children receive polio vaccinations and to boost health innovation in low-income countries. (2023, October 11). World Health Organization. https://www.who.int/news/ item/11-10-2023-new-funding-to-ensure-370-millionchildren-receive-polio-vaccinations-and-to-boosthealth-innovation-in-low-income-countries 6. Polio. (n.d.). Bill & Melinda Gates Foundation.

Retrieved November 3, 2023, from https://www. gatesfoundation.org/our-work/programs/global-development/polio#:~:text=In%201988%2C%20when%20 the%20Global 7. Poliomyelitis (polio). (n.d.). World Health Organization. Retrieved November 3, 2023, from https://www. who.int/health-topics/poliomyelitis#tab=tab_1 8. Why CDC is Working to End Polio Globally. (2023, September 27). Centers for Disease Control and Prevention. https://www.cdc.gov/polio/why-are-weinvolved/index.htm vv

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From Vaccines to Contact Tracing: Exploring Biotechnology’s Fight Against Infectious Diseases

Source: Adobe Stock https://stock.adobe.com/images/dirty-homeless-woman-sits-under-a-gray-wall/335828077

How Poverty Plagues Global Health By: Ronan Zwa ealth and medicine are often considered in a sterile, academic light. Indeed, clinical and experimental research are key to the advancement of the modern medical field. Yet, the tendency to focus solely on the scientific facets of health neglects the social issues that can render even the most brilliant treatments useless on a global scale. Poverty, in particular, has a severe and multifaceted impact on health equity and societal wellbeing.

Statistics present a grim image: nearly four billion people live on less than two dollars a day; around 2.7 billion lack basic san30

itation; six million children will die before turning five due to malnutrition, with nearly 300 million suffering from long-term nutrient deficiency. The list is as extensive as it is disturbing, and each element profoundly increases the danger presented by infectious diseases. An example of this comes from the 2010 Haitian cholera outbreak. The epidemic is often characterized as an inevitability in the context of Haiti’s recent natural disasters (a magnitude 7.0 earthquake and severe flooding due to Hurricane Tomas). However, such a perspective fails to consider the deeply rooted vulnerabilities in the Haitian economy—the real reason cholera, a disease rarely seen in the developed world, was able to ravage the nation.

Haiti traces its roots to a successful slave revolt against France, with the French relinquishing military control in 1804. However, post-war, Haiti was far from a paragon of freedom. France demanded an exorbitant sum of gold as “reparations’’ for the uprising. As a result, Haiti’s development was entirely stunted by debt, leading to an inability to

administer even basic sanitation and public health services to its population. Clearly, Haiti’s struggles grew from a much deeper place than hurricanes and earthquakes alone. In 2005, the state owed about a fourth of its GDP in national debt while simultaneously dedicating a mere 1.2% of said GDP to health care funding.

Even prior to the aforementioned natural disasters, Haiti was the poorest nation in the western hemisphere with nearly 80% of its citizens living on less than two US dollars daily. Thus, while Hurricane Tomas and the 2010 earthquake exacerbated sanitation deficits and allowed cholera outbreaks to spread, it is clear that extreme poverty was a root cause of the epidemic.

There is no simple solution to poverty. Even in developed nations, where poverty reduction measures have been implemented, there remain grave inequities.

For instance, wealthier patients in many countries access specialized care far more easily than individuals with lower incomes. Despite the seemingly widespread ideal of making healthcare a human right, medicine remains a privilege tied closely to economic status. What, then, can be done?

Many proposed solutions entail vast political, economic, and social restructuring that would be glacial in practice—if local and global politics even allow for such implementation. While politicians hash out the details of such a plan, one should consider

the responsibility of primary care providers to combat the impact of poverty on health. At the physician level, there have been increasing initiatives to train doctors to reduce health inequities on an individual and community basis. Such a revolution of thought has given rise to Community-Oriented Primary Care (COPC) in the United States. The evolution of payment plans towards relying more heavily on government and commercial payers, as well as the creation of alternative payment models for economically disadvantaged populations, are core tenets of this movement.

There is also a growing shift towards acceptance and adaptation to low-income patients.

Those with low socioeconomic status have historically been seen as “noncompliant” (missing appointments, failing to follow instructions, waiving tests, etc.), resulting in said patients being turned away by staff. It is crucial for doctors and care teams to create a welcoming and trusting environment that accounts for how poverty prevents patients from complying with medical treatment, regardless of their personal wishes.

Poverty does not divest a person of their dignity; treating all patients equitably, regardless of status, can do as much to combat the effects of poverty on health just as much as instituting revolutionary policies. It is crucial that all parties, from national governments to individual health profes-

sionals, work towards understanding, accepting, and combating the restrictions poverty places on medicine.

References: UN Development Group. (n.d.). Fast Facts: The Faces of Poverty [PDF]. https://www.youngfocus.org/PDF/ POVERTY_FACTS.pdf Alsan, M. M., Westerhaus, M., Herce, M., Nakashima, K., & Farmer, P. E. (2011). Poverty, global health, and infectious disease: lessons from Haiti and Rwanda.

Infectious disease clinics of North America, 25(3), 611–ix. https://doi.org/10.1016/j.idc.2011.05.004 American Academy of Family Physicians. (2021, April).

Poverty and Health - The Family Medicine Perspective (Position Paper). AAFP. Retrieved November 10, 2023, from https://www.aafp.org/about/policies/all/ poverty-health.html#:~:text=Poverty%20and%20 low%2Dincome%20status%20are%20associated%20 with%20various%20adverse,14%20leading%20causes%20of%20death.&text=Individual%2D%20and%20 community%2Dlevel%20mechanisms%20mediate%20 these%20effects]

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