Volume 16, Spring 2019 by Epidemic Proportions

EPIDEMIC PROPORTIONS the johns hopkins university public health research journal | volume 16 | spring 2019

reflections

About

Johns Hopkins University's premier undergraduate public health research journal. Designed to highlight students' research and fieldwork in the realm of public health; combines research and scholarship; seeks to capture the breadth and depth of the undergraduate public health experience.

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Table of Contents

Letters 8

Letter From the Editors

Featured Letter

Kain Kim & Soonmyung Hwang Susan Baker

Research

12 A Systematic Review Exploring Housing Firstâ€™s Effectiveness at Reducing Homelessness and Substance Use Andrew Cho

18 Relationship Between Familiarity with the #MeToo Movement and Gender of Survivors and Perpetrators on Judgement in Response to Vignettes Lee Clyne

Policies 28

Opioid Crisis and Stigma

Nuri Ha

Features

36 Exploring Uganda Through the Lens of Water, Sanitation, and Hygiene Faith Atai, Sofia Milosavljevic, Stone Streeter

44 Pharmaceutical Advertising: Restrictions that Inspire Creativity Jeanne Lee

Editorials

48 Instagrams and Instapounds: In Favor of Body Neutrality Kathleen Li

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52 Should Public Health Include the Well-Being of Animals? Lana Weidgenant

LETTERS

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Letter from the Editors Dear readers, Welcome to the Epidemic Proportions Undergraduate Public Health Journal, Johns Hopkins’ premier undergraduate public health journal. Epidemic Proportions aims to highlight varied student perspectives on critical conversations regarding public health. In this year’s volume, you will find personal accounts of public health fieldwork, essays on public health policy, opinion pieces, and discussions of student-conducted research. Each article highlights a unique perspective or experience that offers meaningful insight to the state of public health in today’s society. This year, we present the 16th volume of our journal, an effort made possible by the contributions of our talented and dedicated team of undergraduate staff and authors. This issue of Epidemic Proportions is devoted to the theme of “Reflections.” The field of public health is constantly witnessing the need for improvement on a global scale, with diverse issues ranging from that of maternal health to communicable diseases. Even so, modern public health interventions have substantially

improved the health and quality of life across communities. Epidemic Proportions believes it is imperative to be as forward-looking in public health as it is to be retrospective. Through this theme of “Reflections” in our 16th volume, we hope to highlight these milestones, redress any gaps in conversations we feel deserved more attention, and use lessons of the past as a tool in building the future. In this collection, our writers delve into a broad repository of issues including body neutrality, the opioid crisis, housing initiatives, and health advertising. These writers tasked themselves with assessing and interrogating past advancements in these areas, and in so doing, lay the foundations for charting a more progressive future. We hope you enjoy this issue and that these pieces take hold in helping you envision what public health means to you. As we share these articles, we invite you all to remember that our current experiences are, after all, ultimately the root of our future memories.

Sincerely, Kain Kim &

Soonmyung Hwang Epidemic Proportions Editors-in-Chief

pages.jh.edu/~ep/

Featured Letter

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Maximizing Safety in the Design Process: Need for a Cultural Change By Susan Baker, Professor Emeritus (Johns Hopkins Bloomberg School of Public Health)

Susan Baker is a renowned epidemiologist who specializes in the sector of injury prevention, making significant contributions to counter the high number of injuries in the United States. She is the creator of the Injury Severity Score, which is still widely used in trauma centers; author of a number of influential books such as the Injury Fact Book; and the founding director of Johns Hopkins University’s first Center for Injury Research and Policy. Dr. Baker has played a prominent role over the decades in influencing a number of notable public policy changes, such as the requirements for the use of child safety seats that have significantly reduced infant mortality in motor vehicle crashes.

During the past half-century, there has been an amazing shift in the way we think about injury– from a focus on ‘accidents’ and human behavior (finding fault, attributing hazardous actions to ‘stupidity,’ emphasizing who was to blame) to a focus on injury and how to best prevent it. The word ‘accident,’ with its implication of randomness and non-preventability, has largely been replaced with words describing the injury event, such as ‘crash’ or ‘fall.’ Focusing on injury has made it possible for us to address it scientifically through studying the epidemiology of injury events and evaluating preventive approaches.

spreading the word throughout the world, starting new programs, developing teaching programs, and finding ways to prevent many injuries.

A lot of the credit for this shift goes to Dr. William Haddon, Jr., whose models have generated interest in injury control and stimulated new ideas. His ten basic strategies for injury prevention1 have been applied productively to many kinds of injuries, ranging from asphyxiation by food to burns and rape. His popular nine-cell matrix, originally applied to the prevention or reduction of injuries in crashes2, helps to identify countermeasures applicable to pre-event, event, and post-event phase periods of injury, with examples related to the injured person, the agent or vector of injury, and the physical or social environment.

This shift in culture will start at academic institutions such as Johns Hopkins University and Cornell University, where today’s students will begin to spread the word. At Hopkins, we have started a new undergraduate course titled “Killer Designs: Maximizing Safety in the Design Process, ” and at Cornell, the Department of Design and Environmental Analysis will be sponsoring a lecture series on Safety by Design and supporting faculty and student travel to conferences where they are featuring this topic.

The focus on injury and its control, rather than on ‘accidents,’ also has been largely responsible for attracting physicians and other health professionals to the field of injury control. In particular, pediatricians and surgeons have been active in promoting and testifying for measures that will prevent injury. In the past several decades, our students have been pages.jh.edu/~ep/

Now, we need another cultural change: a change in the mindset of designers of products, structures and environments, so that in addition to focusing on form and function and innovation, esthetics and money, safety will be an essential consideration from the beginning of any design -- rather than regret for a design after people have been injured or killed because safety was not adequately considered initially.

The change will not occur overnight, but hopefully designers will take ownership of what they design, for the life cycle of their creations, from toys and clothing to vehicles and the built environment. references 1. Haddon W. Jr. “On the Escape of Tigers, an Ecologic Note.” AJPH 60 (1970): 2229-2234. 2. Haddon W. Jr. “”The Changing Approach to the Epidemiology, Prevention, and Amelioration of Trauma.” AJPH 58 (1968): 1431-1438.

RESEARCH

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A Systematic Review Exploring Housing First’s Effectiveness at Reducing Homelessness and Substance Use By Andrew Cho | Public Health, JHU ‘21

abstract

ousing First was first developed by Dr. Sam Tsemberis in 1992 to house individuals experiencing homelessness and mental illnesses concurrently in New York City. Housing First is an approach that emphasizes granting homeless individuals with permanent housing without any admission criteria like sobriety or treatment; it addresses an individual’s need for housing stability first and then treats other concurrent symptoms second. This literature review seeks to bridge the knowledge gap in Housing First’s effectiveness as a solution to homelessness and its effectiveness as a harm reduction policy in reducing substance-use dependence. The literature review included published studies within the 2008-2018 time period that reported on housing stability rates and substance use dependence among individuals who went through a Housing First site in the United States or Canada. The literature review also included studies reporting on the reduced public use costs (such as emergency department visits) incurred by formerly homeless individuals after they were given housing through a Housing First site. The reduced public use costs were included in the literature review to study the economic benefits of Housing First. Housing First sites showed consistent success rates at promoting long term housing stability, and these

success rates are greater in comparison to traditional Treatment First programs. However, its effectiveness in reducing substance use dependence showed varied results. The current literature supports Housing First’s effectiveness in reducing homelessness, but more research must be done to possibly alter its program to address the needs of homeless individuals experiencing addiction concurrently.

introduction In 2017, the U.S. Department of Housing and Urban Development (HUD) estimated that approximately 553,742 individuals were experiencing homelessness on a single night.1 Furthermore, a systematic review conducted by Fazel, et al. on homeless populations in Western societies found that homeless individuals were

substantially more likely to experience substance use addiction.2 Substance use addiction serves as an additional barrier to finding housing stability, and there have been limited reviews on the effect of Housing First as a rehabilitative measure.2 As such, this study aims to establish homelessness as a problem that must be approached at a systems level and to explore the Housing First approach as a viable and sustainable practice model for rehabilitation. Housing First was initially developed by Dr. Tsemberis to meet the housing and treatment needs of individuals suffering concurrently from homelessness and mental illnesses.3 While the traditional model sought to specifically rehabilitate homeless and mentally ill individuals, the contemporary Housing First model seeks to rehabilitate those also suffering from substance use addiction. Housing

While the traditional model sought to specifically rehabilitate homeless and mentally ill individuals, the contemporary Housing First model seeks to rehabilitate those also suffering from substance use addiction. pages.jh.edu/~ep/

First is an approach to rehabilitating homelessness by providing stable and permanent housing first, as opposed to the Treatment First approach to prioritizing substance use among this population.3 The Treatment First approach mandates a sobriety requirement for individuals to receive housing; individuals applying for housing must either prove prolonged sobriety or submit to a sobriety contract where their housing is dependent on the maintenance of complete sobriety. In contrast, Housing First prioritizes housing, regardless of continued substance abuse. The rationale behind this practice is that Housing First views housing stability as the most effective pathway for individuals to successfully recover from their substance use.3 The cycle of poverty is often perpetuated by the barriers faced by individuals experiencing housing insecurity: individuals experiencing homelessness are not able to find housing because they suffer from substance use addiction, and they turn to substance use because they do not have the stability and support system to cope with the stresses of housing insecurity. Housing First introduces a stable foundation for individuals to recover and treat their substance use addiction at their own discretion. Not only is this treatment plan more effective than coerced sobriety, as it is based on intrinsic motivation to recover, it also addresses the humanistic side of homelessness intervention. Housing First has been lauded by advocates as a best practice model; however, its slow progress in becoming a standard practice used by the HUD can be attributed to the general public’s overall wariness about seemingly funding substance use addiction, a belief called the “enabling hypothesis.”4 The enabling hypothesis stems from the continued social stigma against poverty and drug use, wherein the burden of blame is placed on individuals for pages.jh.edu/~ep/

their vulnerability to poverty and drug dependence.4 Rather than seeing these two vulnerabilities as a product of systemic inequities, the American cultural emphasis on individualism and the economic beliefs of “pulling oneself up by the bootstraps” mentality places the blame on the individual for their poverty and drug dependence. This literature review seeks to bridge the gap between Housing First’s effectiveness in achieving housing stability and to solidify the literature’s understanding of Housing First’s effectiveness in reducing substance use. Since substance use is often a concurrent problem with homelessness, the study is necessary to approach homelessness in a more multifaceted manner.

methods participants

Peer-reviewed studies that enrolled individuals who were American or Canadian adults aged 18 or older and who were experiencing homelessness, substance use addiction, or both conditions concurrently were considered. Studies that explored Housing First’s impact on individuals suffering from homelessness, substance use addiction, and mental illnesses concurrently were also included in this review. However, studies that explored Housing First’s impact on homeless individuals suffering solely from mental illnesses were excluded from this review. The reason for the inclusion of the individuals experiencing homelessness, substance use addiction, and mental illnesses concurrently was because it fell within the scope of the research question’s exploration of housing stability, whereas the latter focused solely on the medical impact of Housing First. Homelessness was defined to include individuals without permanent housing. Substance use was defined to include alcoholism and any other illicit substance dependence.

In addition, all of the studies were published within 2008-2018. target populations

All of the studies targeted individuals experiencing homelessness or homelessness and substance use addiction concurrently. One study specifically studied the experiences of ethnic minorities at a Housing First site in Toronto, Canada, while two studies explored the effectiveness of Housing First sites in the United States for military veterans.5,6,7 The rest of the studies explored the overall effects of Housing First for all participants.4, 8-13, 14-19 outcome variables

The principal outcome variable measures used in this review were self-reported and measured levels of housing stability and substance use. Additionally, certain studies evaluated the differences in outcome data in terms of archival data, housing stability, and substance use. As such, these outcome variables were the principal comparison variables for studies comparing Treatment First and Housing First program results. study designs

The studies included in this review implemented multiple comprehensive study designs. The studies used naturalistic observation designs, randomized control designs, pre-post, quasi-experimental, and survey methods.4-13, 15-19 Studies that did not provide housing stability rates or substance use reduction rates were excluded from the study. Periodicals and systematic reviews were also excluded from the literature review. Studies that explored the elements of a successful Housing First site were excluded because they did not provide quantitative data on housing stability rates and substance use.

study selection, collection

The titles and abstracts of the studies after using the set of search terms on Academic Search Complete, PubMed, and Journal

identification screening

Records identified through database searching

Duplicate records removed (n = 1)

(n = 140)

Records excluded by screening relevance by title and article type

Records screened (n = 139)

(n = 121)

eligibility

This literature review included literature sources from PubMed, Academic Search Complete, and the Journal of the American Medical Associations. The initial search terms on Academic Search Complete included “housing first” and “housing first programs.” Subsequent searches on Academic Search Complete included “impact housing first” “housing first model,” “housing first effective model,” “housing first homeless,” “housing first minority,” “Housing First HUD,” and “housing first substance.” 88 published papers in total were found through these searches with one duplicate removed, and fifteen articles were selected after screening the titles and abstracts of each study. All fifteen articles were read in its full text form, and two articles were removed from the literature review as one was a secondary source and another was a qualitative study. As such, thirteen published and peer-reviewed articles were selected from this database. Papers that were not published within the 2008-2018 period were also screened and excluded from the literature review selection. Next, the following term was used on PubMed: “housing substance admission criteria.” A total of twelve articles were found, and one article was selected after all of the studies were screened by the title and abstracts. Finally, the term “housing homeless public costs” was used in the Journal of the American Medical Associations. A total of 40 published pieces were found. Viewpoint, opinion, and editorial articles were excluded, and two original articles were selected.

Full-text articles assessed for eligibility

Full-text articles excluded*

(n = 18)

(n = 2)

included

information sources

Studies included in quantitative synthesis (meta-analysis) (n = 16)

*One article was a qualitative study and the other was a secondary source

FIGURE 1: Study selection and data collection process. of the American Medical Association were screened to eliminate studies that did not provide the aforementioned relevant data to the literature review. Acceptable studies included those providing data on housing stability rates and substance use. Additionally, studies that included archival data on those two elements and medical costs were included. The data extracted from each study included the participants’ locations, their housing stability rates, substance use reduction rates, public use costs of medical services, inclusion criteria, study design, and the limitations of the studies.

results settings

Two studies were conducted in United States hospitals: one in Seattle and one in Chicago.8,9 Two studies were conducted in Housing First sites in New York City.10,11 Two studies were conducted through Housing First sites provided by the United States Department of Veterans Affairs.6,8 Of these two, one study did not specify its location, but one specifically cited conducting its study in “Cleveland, Los Angeles, Philadelphia, Miami, and Baltimore.”6,8 Five studies were conducted in major cities in Canada (Vancouver, Toronto, and pages.jh.edu/~ep/

Ottawa), and two studies were conducted in Housing First sites located in Seattle.7, 12-17 Moreover, one study was conducted in a Housing First site located in Phoenix, Arizona, and two studies were conducted in an unspecified city in the Pacific Northwest.4,18,19 primary outcomes

The primary outcomes measured in 14 of the studies were the reduction of substance use and the rate of housing stability. Two of the studies explored the reduction of public services such as emergency department visits.8,9

72% of Housing First participants found long term housing stability in comparison to 19% of the sample that did not go through the Housing First program.6 A study conducted in Toronto explored the effects of Housing First for ethnic minorities in Canada; it was found that 75% of Housing First program participants were able to find long term housing stability as opposed to 41% of the comparison group following a 2 year period.10 Furthermore, Housing First clients in Ottawa, Canada were able to find housing stability quicker and had longer housing stability in comparison to Treatment First clients.15

measurement

Two studies measured the reduction of use in emergency departments visits, hospitalizations, and hospital days after participants were placed into a Housing First program.6,8 These studies used electronic surveillance, medical records, and interviews to measure these variables. The remaining studies reported on housing stability rates of participants after they went through the Housing First program.4-6, 8-19 public service cost reduction

Housing First participants in Seattle, Washington saw a decrease in median public medical costs from $4066 to $958 per month after 12 months of housing.8 In Chicago, Housing First participants saw reductions of about 29% in hospitalizations, 29% in hospital days, and 24% in emergency department visits.9 housing stability

A study conducted in a major city in the Pacific Midwest reported that only 23% of Housing First participants relapsed into homelessness after a period of two years.16 In Vancouver, pages.jh.edu/~ep/

substance use reduction

In a study conducted in NYC, only 30% of Housing First participants used substances during the duration of the study whereas 65% of Treatment First program participants used substances during the duration of the study. Additionally, only 11% of Housing First participants dropped out of the Housing First program in contrast to 54% of Treatment First participants prematurely leaving the program.10 A study also found that both groups showed improvements on substance use reduction.8 For example, in the 12-month follow-up result, only 0.34% of Housing First participants reported using alcohol in the past month after treatment and only 0.28% of sobriety required housing participants reported using alcohol.8 A comparison of a Treatment First program and Housing First also found that Housing First participants had fewer days of problems at the 6 months follow-up, fewer substance use problem symptoms at the 12 months follow-up, but not at 24 months.13 Two more studies found significant decreases in substance use for Housing First participants.4,11 At baseline, a particular set of Housing

First participants consumed about 24.39 drinks per day along with an intoxication frequency of 19.82 days per month.19 A significant decrease through Housing First is shown when comparing baseline data to the results found in the previous study.4 One study conducted in Vancouver, however, found that there was no significant reduction of daily substance use in Housing First participants compared to Treatment First programs after 12 or 24 months period during these follow-ups.14

discussion key findings

The studies included in this systematic review consistently displayed Housing First reducing homelessness and promoting housing stability among individuals experiencing housing instability. The success rate of Housing First was especially pronounced in comparative studies between Housing First programs and the traditional Treatment First programs. All of the studies reviewed reported high success rates and those that compared housing stability rates between Housing First and Treatment First found Housing First to be more successful. The papers studying reduced substance use reported varied success rates. A key finding was that a very small percentage of Housing First program participants dropped out of the program prematurely, whereas about half of Treatment First program participants dropped out of the program prematurely; the higher retention rate of Housing First should be considered as an influential factor for the reducing substance use rates.7 The majority of studies that observed substance use after Housing First found that Housing First program participants had lower rates of substance use and a lower odds ratio of relapsing into using substances.4,8,13

All of the studies reviewed reported high success rates and those that compared housing stability rates between Housing First and Treatment First found Housing First to be more successful. One study in Vancouver, in contrast to the previously mentioned studies, found no statistically significant difference in reducing substance use when comparing Housing First and Treatment First program participants in a 1 year and 2 year follow-up after their exits from the program.14 This study cited that while Housing First program participants have higher rates of housing stability, higher quality of life, and fewer emergency department visits, Housing First did not reduce substance use substantially more than Treatment First programs.14 While this study did conflict with the existing literature on Housing First’s effectiveness at reducing substance use dependence, the study continued to support Housing First’s effectiveness at reducing homelessness and promoting housing stability.14 implications and interpretations

Housing First’s remarkable success at promoting long term housing stability demonstrate that Housing First is an effective intervention measure. The retention rate of Housing First can be attributed to its success; Treatment First programs focus on individuals attaining sobriety first before giving participants housing, which can lead to higher drop-out rates as the sobriety admission criteria ignores the quality of life experienced by individuals without

housing stability. When individuals are granted a basic human need such as housing, they are at a better position to achieve sobriety and find employment which can contribute to continued sobriety. Furthermore, without housing, individuals experiencing homelessness face additional obstacles in finding employment. Thus, the endless cycle of substance abuse and unemployment continues because these individuals fail to find employment due to their substance dependence. Conversely, they are more vulnerable to illicit substance use because they lack the stability and support system designed to address their needs. The one study that questioned Housing First’s effectiveness at reducing substance use dependence is a valid observation that calls for a modification of the Housing First model.14 Housing First programs were originally developed to treat individuals experiencing homelessness and mental illness concurrently. As such, a modification of the program’s practical model may be pertinent to include this sub-group of the homeless population, specifically those experiencing substance use dependence. Future research is warranted to determine what characteristics of certain Housing First sites lead to its success at reducing substance use dependence. Additional-

ly, all of the studies were conducted in major metropolitan areas, and all except one study were conducted on politically liberal, metropolitan areas of the United States and Canada.18 As such, Housing First’s effectiveness in politically conservative, rural areas must be looked into to encompass more individuals experiencing homelessness. One possible revision might be an inclusion of peer support programs like the one included in the Housing First site located in Arizona. A peer support model akin to the Alcoholics Anonymous group might be a positive factor in influencing continued sobriety rates. The peer support model may help individuals find emotional support from peers who are experiencing similar obstacles and lead to better reduction rates.18 limitations and strengths

The limitations of the studies included in this review are that they display limited generalizability in addition to the fact that the studies selected primarily relied on self-reported data for measuring substance use. Self-reported data have limited validity because they are susceptible to self-report bias; participants may underreport their substance use dependence. Another limitation was that thirteen of the studies did not use an experimental design and thus could not explain causality between Housing First and housing stability.4-7, 9-12, 15-19 The strengths of the articles included that they were mostly able to maintain high follow-up retention rates among the participants. As such, attrition biases were greatly reduced in these studies. Additionally, all of the selected articles focused on providing measurable and quantitative data on Housing pages.jh.edu/~ep/

First experiences rather than qualitative analyses. Thus, the key findings were easily discernible and facilitated an easier identification of Housing First’s effectiveness at reducing housing instability. Additionally, three studies used a randomized and controlled experimental design and could determine causality between Housing First and housing stability rates.8,9,13 Another strength of this literature review was that it included analyzing the economic benefit for the general public in implementing Housing First. Most studies did not include elements that could sway the general public’s wariness of seemingly paying taxes to support illicit behavior (i.e. enabling hypothesis). Since this literature review also included studies that observed a marked decrease in public use service costs primarily in terms of emergency medicine costs, Housing First’s added economic benefit is included to further advocate for its implementation as an intervention method.

ness, but further research on Housing First program elements must be conducted to better address the needs of individuals experiencing homelessness and substance concurrently.

10.1001/jama.2009.561.

references

11. Davidson C, Neighbors C, Hall G, et al. Association of housing first implementation and key outcomes among homeless persons with problematic substance use. PS. 2014;65(11):1318-1324. https://doi. org/10.1176/appi.ps.201300195. doi: 10.1176/ appi.ps.201300195.

conclusion

6. Montgomery AE, Hill LL, Kane V, Culhane DP. Housing chronically homeless veterans: Evaluating the efficacy of a housing first approach to hud-vash. J Community Psychol. 2013;41(4):505-514. http:// search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=86213553&site=ehost-live&scope=site. doi: 10.1002/jcop.21554.

While an overwhelming majority of current literature supports Housing First’s effectiveness at reducing homelessness and promoting long term housing stability, its effectiveness at reducing substance use is varied. These varied results may be an indication of different measurement techniques, or could be a byproduct of an intrinsic element of Housing First programs that is missing. For example, a peer support model might be necessary to further address the needs of homeless individuals experiencing substance use dependence. As such, it can be concluded that Housing First consistently demonstrates effectiveness at reducing homelesspages.jh.edu/~ep/

1. United States Department of Housing and Urban Development. The 2017 Annual Homeless Assessment Report to Congress. https://www.hudexchange. info/resources/documents/2017-AHAR-Part-1.pdf. Published December, 2017. Accessed April 4, 2018. 2. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: Systematic review and meta-regression analysis. PLOS Medicine. 2008;5(12):e225. https://doi.org/10.1371/journal.pmed.0050225. 3. Tsemberis S, Gulcur L, Nakae M. Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004;94(4):651-656. http:// search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=12667292&site=ehost-live&scope=site. 4. Collins SE, Malone DK, Clifasefi SL, et al. Project-based housing first for chronically homeless individuals with alcohol problems: Within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012;102(3):511-519. http:// search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=71917871&site=ehost-live&scope=site. 5. Tsai J, Rosenheck RA, Kasprow WJ, McGuire JF. Sobriety as an admission criterion for transitional housing: A multi-site comparison of programs with a sobriety requirement to programs with no sobriety requirement. Drug and Alcohol Dependence. 2012;125(3):223-229. http://www.sciencedirect. com/science/article/pii/S0376871612000683. doi: //doi.org/10.1016/j.drugalcdep.2012.02.016.

7. Stergiopoulos V, Gozdzik A, Misir V, et al. The effectiveness of a housing first adaptation for ethnic minority groups: Findings of a pragmatic randomized controlled trial. BMC Public Health. 2016;16(1):111. http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=119037468&site=ehost-live&scope=site. doi: 10.1186/ s12889-016-3768-4. 8. Larimer ME, Malone DK, Garner MD, et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009;301(13):1349-1357. http://dx.doi. org/10.1001/jama.2009.414. doi: 10.1001/ jama.2009.414. 9. Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: A randomized trial. JAMA. 2009;301(17):1771-1778. http://dx.doi.org/10.1001/jama.2009.561. doi:

10. Padgett DK, Stanhope V, Henwood BF, Stefancic A. Substance use outcomes among homeless clients with serious mental illness: Comparing housing first with treatment first programs. Community Ment Health J. 2011;47(2):227-232. http:// search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=59316502&site=ehost-live&scope=site. doi: 10.1007/s10597-009-9283-7.

12. Palepu A, Patterson ML, Moniruzzam A, Frankish J, Somers J. Housing first improves residential stability in homeless adults with concurrent substance dependence and mental disorders. Am J Public Health. 2013;103:e36. http://search.ebscohost.com/login. aspx?direct=true&db=s3h&AN=92519751&site=ehost-live&scope=site. 13. Kirst M, Zerger S, Misir V, Hwang S, Stergiopoulos V. The impact of a housing first randomized controlled trial on substance use problems among homeless individuals with mental illness. Drug & Alcohol Dependence. 2015;146:24-29. http://search.ebscohost.com/login.aspx? 14. Somers JM, Moniruzzaman A, Palepu A. Changes in daily substance use among people experiencing homelessness and mental illness: 24-month outcomes following randomization to housing first or usual care. Addiction. 2015;110(10):1605-1614. http:// search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=109323720&site=ehost-live&scope=site. doi: 10.1111/add.13011. 15. Cherner RA, Aubry T, Sylvestre J, Boyd R, Pettey D. Housing first for adults with problematic substance use. Journal of Dual Diagnosis. 2017;13(3):219229. http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=124481147&site=ehost-live&scope=site. doi: 10.1080/15504263.2017.1319586. 16. Collins SE, Malone DK, Clifasefi SL. Housing retention in single-site housing first for chronically homeless individuals with severe alcohol problems. Am J Public Health. 2013;103:S274. http:// search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=92518802&site=ehost-live&scope=site. 17. Brown MM, Jason LA, Malone DK, Srebnik D, Sylla L. Housing first as an effective model for community stabilization among vulnerable individuals with chronic and nonchronic homelessness histories. J Community Psychol. 2016;44(3):384-390. http:// search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=113638142&site=ehost-live&scope=site. doi: 10.1002/jcop.21763. 18. Bean KF, Shafer MS, Glennon M. The impact of housing first and peer support on people who are medically vulnerable and homeless. Psychiatr Rehabil J. 2013;36(1):48-50. http:// search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=110146011&site=ehost-live&scope=site. doi: 10.1037/h0094748. 19. Collins SE, Clifasefi SL, Dana EA, et al. Where harm reduction meets housing first: Exploring alcohol’s role in a project-based housing first setting. International Journal of Drug Policy. 2012;23(2):111119. http://www.sciencedirect.com/science/ article/pii/S0955395911001332. doi: //doi. org/10.1016/j.drugpo.2011.07.010.

Relationship Between Familiarity with the #MeToo Movement and Gender of Survivors and Perpetrators on Judgement in Response to Vignettes By Lee Clyne | Postbaccalaureate Premedical Student, JHU ‘19 abstract

introduction

his study sought to determine the relationship between familiarity with the #MeToo movement and the gender of perpetrators and survivors of sexual violence situations with how participants might judge a vignette describing a situation of alleged sexual harassment. The study included 108 participants of mostly college-aged, white females. Participants completed online questionnaires that presented them with vignettes which they were then asked to judge. The investigator evaluated responses through an assessment of their agreement with certain statements. A primary effect of familiarity with the #MeToo movement was identified, but no main effect of the gender of perpetrators and survivors. Exploratory variables of the age of participants, gender of participants, and participants’ feelings towards the goals of the #MeToo movement were statistically significant. The results suggested that people who are more familiar with the #MeToo movement are likely to judge perpetrators of alleged sexual harassment more harshly than participants who are less familiar with the movement.

Famed psychologist B.F. Skinner conducted studies that focused on the consequences of development in our current understanding of operant conditioning. The term operant conditioning refers to how behavior can be changed or maintained through reinforcement. Through the use of a “Skinner Box,” Skinner demonstrated that animals are more likely to repeat actions, such as pressing a lever, that offer reinforcement, and less likely to repeat behaviors that might earn them punishment. Providing reinforcement in response to a behavior increases the likelihood of someone repeating that behavior. In contrast, punishment in response to a behavior decreases this likelihood.1 Bandura and Walters (1977) found that people learn behavior not only by directly experiencing the consequences, the reinforcement, or punishment for their actions, but also through observing them externally. Bandura’s famous Bobo Doll Experiment involved children watching adults attacking a Bobo Doll and either being reinforced, punished, or given neutral feedback in response to their actions. Bandura found that children are more likely to mirror

the actions of someone whom they see being reinforced or not facing any consequences than they are to mirror the actions of someone who they see punished for their behavior. People learn to understand consequences of actions vicariously through people they observe who act as models (Bandura & Walters 1977). There is a wealth of research demonstrating that consumption of media impacts social learning in behavior.3,4,5 A longitudinal study of 450 adolescents involving three surveys administered over five years found that exposure to sexual media content had an influence on adolescents’ own sexual behavior.6 Celebrities are prominent figures within media who serve as models of behavior, from whom observers can vicariously learn. Just as consumers of media observe celebrity behavior, and as celebrity behavior has an impact on public behavior,7 the consequences of celebrity behavior are also observed and incorporated as an aspect of social learning. Pitsula reported that many young people learn about social issues through the promotion of issues by Hollywood celebrities and through other forms of media consumption.8 An initial study by Gerber and Jackson requested that community members rank how pages.jh.edu/~ep/

strongly they agreed that lawbreakers deserve harsher sentences.9 Gerber and Jackson found that whether community members knew someone who had been affected by the crime and whether participants perceived the incidence of the crime to be high were significant factors in how strongly participants agreed on the need for harsher punishments. They concluded that how harshly people think offenders should be punished is influenced by institutions and participants’ ideas of obedience to authority.9 In another study, Roberts and Doob found that when participants read a newspaper article coverage of a court case, as compared to reading court materials, participants were more likely to suggest harsher punishment for the accused.10 Much information regarding cases involved with the #MeToo movement have been conveyed to the public through media coverage. The “contact hypothesis” describes that conflict between groups can be reduced through contact with members of another group. People may be more likely to empathize with people of marginalized communities when they know more members of that group. One study found that second-hand exposure to marginalized communities can reduce prejudice, even through consumption of media and pop culture, such as reading a novel like Harry Potter in which the reader empathizes with a protagonist interacting with out-groups.11 Survivors of sexual violence are members of a social group that faces a great deal of stigma in our society, but has gained more media attention as a result of the #MeToo movement. The #MeToo movement has highlighted the number of survivors that exist, making it pages.jh.edu/~ep/

Survivors of sexual violence are members of a social group that faces a great deal of stigma in our society, but have gained more media attention as a result of the #MeToo movement. more likely that people will become aware of survivors around them. The #MeToo movement has brought attention to cases of sexual violence in the media recently, with sensationalized stories detailing alleged assaults. Celebrities have been advocating for justice in cases of sexual violence, and perpetrators of sexual violence have been facing punishment as consequences for sexual misconduct more than what has previously been seen in cases of assault or harassment. People learn which type of punishment a person deserves for an action based on observational learning. The consequences faced by celebrities in response to their actions—seeing their television shows canceled or being forced to step down from their jobs, for instance—have contributed to vicarious social learning of the public that sexual harassment behaviors will be punished. Compared to the past, punishment may be more common in response to allegations since individuals who have followed the movement through observational learning have come to expect punishment in response to sexual misconduct. Punishment in response to sexual misconduct however corresponds to perception of the situation involving a victim and perpetrator. This perception can be

influenced by several variables, including the genders of victims and perpetrators detailed in vignettes and the genders of participants who read the vignettes. Numerous studies utilizing vignettes describing sexual harassment scenarios in an academic setting have found a significant relationship between the judgments of the situation, the gender of participants, and the gender of perpetrators and victims portrayed in vignettes detailing situations of sexual harassment. Male participants are less likely to find fault and expect harsh punishment in response to vignettes than female participants, who are more likely to recognize situations as sexual harassment and expect that situation to be reported and disciplined. Vignettes commonly described situations with a professor perpetrator and student victim. Vignettes detailing a situation with a male professor perpetrator and female victim are more easily recognized as a situation of sexual harassment with a harsher punishment expected for the perpetrator, compared to vignettes containing situations where a female is the perpetrator. Most of these studies finding a main effect of gender have utilized vignettes with male and female participants assigned randomly to either a vignette involving a situation of

sexual harassment between a male professor perpetrator and female student or a female professor perpetrator and male student.12,13,14,15 As #MeToo is a recent movement, no studies currently exist, however, that examine the influence of familiarity with the #MeToo movement on perceptions of situations of sexual harassment. In addition, previous studies have only included self-identified male and female participants while researching the effect of participant gender on bias in how severely a perpetrator of sexual harassment should be punished. The current study includes transgender participants to investigate whether greater gender diversity within participants may influence the main effect of gender on the judgments participants make in response to vignettes, and it compares familiarity with the #MeToo movement with participant responses to sexual harassment in vignettes. The current study hypothesized that students who would rank themselves as more familiar with the #MeToo movement would, in response to a vignette detailing a situation of sexual harassment, rate that the perpetrator of harassment in the vignette should be more harshly punished than students who are less familiar with the movement. A second hypothesis predicted that the gender of professors and students detailed in these vignettes would affect participants’ judgments of the situations, corresponding to findings of previous studies. Assessing the effectiveness of any kind of violence prevention program is essential to securing resources for its continuation or for understanding how to improve programs in the future. Al-

though the #MeToo movement was widespread, as it was sustained by individuals across social media, the movement was begun by Tarana Burke, a woman running a non-profit who wanted to create spaces of solidarity for survivors of sexual violence and prevent occurences by raising awareness of the possibility that perpetrators could face consequences for their actions. Her organization did not receive widespread recognition until actress Alyssa Milano tweeted using her hashtag. Comparing the significant relationship between familiarity with the #MeToo movement and judgment to familiarity with other anti-violence organizations that have not received the same level of media attention and judgment of sexual harassment situations could indicate that nonprofits should try to partner with celebrities or focus on Twitter as a platform for their activism.

methods participants

Participants in the current study were taken from a convenience sample of students online who utilize Facebook. Participants completed the questionnaire on computers in locations of their choosing through an online link shared to Facebook. The current study included a sample of 120 participants in their early 20’s (M= 21.99). The only demographic information collected from participants was their age, race, and gender. procedure

Questions were phrased using wording that was objective and non-judgmental in order to eliminate as much experimenter bias as possible. In an effort to decrease social desirability bias, participants completed the online questionnaire anonymously. Participants were

first asked whether they consented to their answers being recorded and used in the study, then informed of the anonymity of their responses, and finally were told what the questionnaire would entail. Students confirmed their ages, with participants under the age of 18 excluded as a vulnerable population. Vignettes were presented, with participants’ opinions about how harshly the perpetrators of harassment in each of the scenarios should be punished being recorded. Lastly, information about familiarity with the #MeToo movement, exploratory variables such as participants’ feelings toward the goals of the #MeToo movement, and demographic information were recorded. materials

Questionnaires. The current study utilized anonymous online written questionnaires through the program Qualtrics. Questions asked about participants’ familiarity with the #MeToo movement, ranked on a scale of one to seven with one being the “least familiar” and seven being “most familiar.” Participants disclosed the harshness of punishment that they felt the scenario’s perpetrator should receive, also on a scale of one to seven, with one being the “least harsh” and seven being “the harshest.” An explanation was provided of what numbers one to seven stand for to ensure the validity of participant responses. Each questionnaire provided information to the participant about what the study contained, and then asked for a confirmation of participants’ informed consent before allowing any other answers to be recorded. For each vignette, participants were asked to rate the harshness of the punishment that the perpetrator of harassment should receive. Vignettes. Two vignettes were used, one involving a student named Marpages.jh.edu/~ep/

cus and the other involving a student named Alana. Only the names and pronouns of the students and professors were changed between the two groups. The professors in the scenarios were not given names, but their gender was indicated through the pronouns used for them. Vignettes were originally written for this study by the researcher. The vignette was presented as follows: the parentheses indicate both options for participant name and pronouns, although only one would be used per participant, depending on the group they were randomly sorted into. “Every time (Marcus/Alana) interacts with (his/her) professor, (he/ she) feels like (she/he) is trying to take advantage of (him/her). After being asked into (his/her) professor’s office to discuss a paper, (Marcus/Alana) confided to a friend that ‘(She/He) kept moving closer to me as (she/he) talked, and (she/he) kept finding opportunities to be touching me, which made me feel really uncomfortable.’ (Marcus/Alana) now feels uncomfortable going to this professor’s class because (he/ she) is worried about the ways that (she/he) interacts with (him/her).”

results

Extremely familiar Very familiar Moderately familiar Slightly familiar Not familiar at all (%)

pages.jh.edu/~ep/

FIGURE 1: Participant familiarity with #MeToo Strongly agree Agree Somewhat agree Neither agree nor disagree Somewhat disagree Disagree Strongly disagree (%)

FIGURE 2: Responses to "The professor should be reported" Strongly agree Agree Somewhat agree Neither agree nor disagree Somewhat disagree Disagree Strongly disagree (%)

Analysis came from examinations of data collected through the Qualtrics survey and analysis through the program SPSS. Data was eliminated before analysis for participants who did not complete the questions for the dependent variable and for participants who failed a manipulation check. All participants were familiar with sexual violence, as 48.08% of participants claimed that they were extremely familiar with the issue of sexual violence in general on a scale from “extremely familiar” to “not familiar at all.” No participants stated

FIGURE 3: Responses to "The professor is guilty of sexual harassment" Strongly agree Agree Somewhat agree Neither agree nor disagree Somewhat disagree Disagree Strongly disagree (%)

FIGURE 4: Responses to "The professor should be punished"

that they were “not familiar at all” with the issue of sexual violence. When asked about familiarity with the #MeToo movement, again most participants were familiar, and none said they were “not familiar at all” with the movement (see Figure 1). From participants’ judgements, it was apparent that participants tended to be harsher rather than more lenient with perpetrators of sexual harassment in response to reading the vignettes. With one indicating “strongly agree” and six indicating “strongly disagree,” in response to statements, participants showed a tendency overall toward agreement. For “The professor should be reported,” the mean of responses on a scale of one to six was 1.90 (see Figure 2). Most participants felt that the professor should be punished, and “strongly agree,” the most extreme response possible, was selected by the most participants. No participants selected “strongly disagree.” In response to “The professor is guilty of sexual harassment,” the mean was 2.49 on the scale of one to six (see Figure 3). In response to this statement “agreeing” was more popular than “strongly agreeing,” although again no one strongly disagreed. In response to “The professor should be punished,” the mean score was 2.60 (see Figure 4). As with the other statements, no participants selected “strongly disagree,” and similar to responses to the statement, “The professor is guilty of sexual harassment,” “agreeing” was the most popular response. Along with most participants seeming to be more familiar than not familiar with the #MeToo Movement, there also was a lack of diversity in the ages, genders, and races represented in this study’s sample. The mean age of this study was 21.99. The sample was 76.47% female, 16.67% transgender, and

only 6.86% male. Regarding race, 78.95% of participants were white, suggesting a lack of racial diversity. More specifics regarding data can be found in the index. recording of data

In the manipulation of data, the independent variable, “familiarity with #MeToo” was re-coded from a continuous variable to a categorical variable. As the original scale held the options “extremely familiar,” “very familiar,” “moderately familiar,” “slightly familiar,” or “not familiar at all,” options were coded into two groups, with “extremely familiar,” and “very familiar,” as one group, and “moderately familiar,” “slightly familiar,” and “not familiar at all” as another. The decision to group these categories was reached after consulting the collected data. None of the participants selected “not familiar at all” as their familiarity with #MeToo, which necessitated the allocation of options into two groups. People less familiar with #MeToo were compared to those more familiar with the movement as no one completely unfamiliar with the movement could be found. The dependent variables were a series of related statements tapping similar constructs and using similar scales, “The professor should be reported,” “The professor is guilty of sexual harassment,” and “The professor should be punished,” in response to which participants were asked to choose from the following options: “strongly agree,” “agree,” “somewhat agree,” “neither agree nor disagree,” “somewhat disagree,” “disagree,” or “strongly disagree.” In using Cronbach’s alpha to test the internal consistency of these three measures, the three statements that participants responded to, Cron-

bach’s alpha was equal to 0.884. As Cronbach’s alpha was greater than 0.8, internal consistency was good and data was re-coded to create a single dependent variable “Judgment” from participants’ responses to all three statements, scored by the sum of points given to responses to each question. Information about gender was collected through free responses in an attempt to avoid limiting the ways in which participants could identify, and free responses were coded as either Male, Female, or Transgender/Nonbinary, represented by one, two, or three. hypotheses

The primary hypothesis was that students who would rank themselves as more familiar with the #MeToo movement would, in response to a vignette detailing a situation of sexual harassment, rate that the perpetrator of harassment in the vignette should be punished more harshly. This was operationalized through participants’ responses of agreement or disagreement to statements presented. Students who were less familiar with the #MeToo movement were predicted to rate that perpetrators of sexual harassment should be less harshly punished than what more familiar participants would recommend. A significant effect of participants’ familiarity with the #MeToo movement was expected to correlate with a harsher response towards perpetrators. A secondary hypothesis predicted that participants would judge a male professor who perpetrates sexual harassment against a female student more harshly than female professors harassing male students in the same scenario. In comparing the two indepages.jh.edu/~ep/

pendent variables, familiarity with #MeToo and the genders of students and professors in the vignettes, with the dependent variable, “Judgment,” the two-factor analysis of variance showed no significant main effect for the group, which gave the gender of a professor perpetrator, (p=0.960), but showed a significant main effect for #MeToo familiarity (p=0.048) since p was less than 0.05. This p of less than 0.05 allowed for rejection of the null hypothesis, indicating a statistically significant relationship between #MeToo familiarity and the harshness of participant judgments of perpetrators. There was no significant interaction between genders of participants and their #MeToo familiarity. (p=0.763) The r-squared for this analysis was 0.040. exploratory variables

There was also significance through the analysis of a few exploratory variables. Age, gender, and feelings towards the #MeToo movement were all statistically significant. An analysis of variance (ANOVA) analyzing the relationship between age and the dependent variable “Judgment” found p=0.004, indicating a significant relationship. A test of between-subjects effects which analyzed the relationship between genders of participants and “Judgment” yielded p=0.041, a significant result indicating that gender identities of participants were associated with the harshness of their judgments of perpetrators. A Pearson correlation of participants’ levels of agreement with the three statements was significant on all accounts. “R” represents the Pearson correlation coefficient which acts as a measure of the linear relationship between compared variables. The relationship between “The professor pages.jh.edu/~ep/

should be reported,” and participants’ feelings towards the goals of the #MeToo movement was found to yield r=0.349, p=0.000. This indicated a slight positive correlation, and statistical significance with p<0.05. A Pearson correlation of agreement with the statement, “The professor is guilty of sexual harassment,” and participants’ feelings towards the goals of the #MeToo movement found r=0.328, with a p-value of p=0.001, also indicating a slight positive correlation between agreement with the statement and positive sentiment towards #MeToo’s goals. Lastly, the Pearson product-moment correlation of participants’ responses to “The professor should be punished,” and participants’ feelings towards the goals of the #MeToo movement was found to be statistically significant (r=0.265, p=0.007). There was statistical significance of feelings towards #MeToo’s goal on the dependent variable with p<0.05.

discussion The study’s first hypothesis— that participants’ familiarity with the #MeToo movement would have a significant effect on their judgments in response to a vignette detailing an alleged situation of sexual harassment– was supported by the data. The secondary hypothesis, that the gender of the professor perpetrator would influence participants’ judgements in response to a vignette, was not supported. There was no main effect of changing the gender of perpetrators and victims in vignettes. limitations of study

This study utilized anonymous questionnaires to limit the effect of social

desirability bias, but this bias may still have influenced the results. Data showing that no participants were unfamiliar with #MeToo or sexual violence may have been accurate, as these are common discussion topics, but the data also may have been influenced by desirability bias if participants felt a preference describing themselves as informed over ignorant of current social issues. It can be uncomfortable to admit to ignorance in an area, but knowledge of the #MeToo movement was an important part of the research. As the #MeToo movement is relatively recent, it was difficult to find similar previous studies. A lack of precedent can make it more difficult to understand which questions to ask, and to learn from the conclusions drawn and the recommendations for future study that other researchers have suggested. The sample used in this study was not completely representative of the general population, which limits the external validity of the study. Participants were mostly white, of college age, and female or transgender, with few male participants. This demographic information may have influenced why the secondary hypothesis of this study was unsupported by the data. Of the sample, 16.67% participants identified as transgender. About 0.6% of adults in the United States are transgender. Washington, D.C., where a majority of participants resided, has one of the highest concentrations of transgender people, with about 2.8% of its citizens identifying as transgender.16 Transgender involvement was especially high in this study. Gender information was collected through free response. Although responses were re-coded as either Male, Female, or Transgender, the ways that many participants chose to respond indicated information not represented in that data alone. Participants who were categorized as female often wrote responses such as “cisgender female,” “femme,” “feminine-oriented person,” “woman using the pronouns ‘she/her/

hers’”, or other such terms that indicated femininity but which also suggested participants possessed an understanding of the construction of gender, perhaps from taking courses in gender studies, that the general population likely would not. These responses, along with the 16.67% of participants who identified as transgender, especially using terms to describe their gender identities such as “non-binary,” “agender,” “genderqueer,” or even “whatever, I don’t know,” might indicate that these were participants who may view gender as less of a binary. Many perceptions of sexual violence regard it to be only a woman’s issue, which might influence people to be more likely to recognize a situation of a female victim and a male perpetrator as sexual harassment. This perception stems from views of a gender binary which frame men as dominant aggressors and women as passive victims.12-15 Participants more fluent in conversations about gender binaries may be less likely to make gendered assumptions. The study utilized convenience sampling. Due to the limited time in which this study was conducted, participants were recruited through posts in social media, available mostly to Facebook friends of the researcher, and especially American University students. Participants tended to be younger, and transgender people and women were overrepresented compared to the general population. Familiarity with the #MeToo movement as well as other variables examined such as age, race, or gender are quasi-experimental variables. There was some overlap between variables. Passion for sexual violence prevention is not a variable that was considered. It is likely that people who are very familiar with the #MeToo movement are also people who feel strongly about preventing sexual violence. And it was impossible to ask participants to respond to vignettes before and after exposure to the movement as it has been a far-reaching, unanticipated social movement. Therefore, although

correlation was supported, one cannot conclude that it was exposure to the #MeToo movement that caused people to more harshly judge perpetrators of sexual violence. conclusions, future directions

This data is significant because it lends an understanding of a correlation: that people who are more familiar with the #MeToo movement tend to also be more willing to harshly judge a person who perpetrates sexual violence. Information that this study’s secondary hypothesis was not supported indicates that these participants– people who were mostly familiar with the #MeToo movement and mostly young, white, female or transgender individuals– did not treat perpetrators as significantly more or less guilty and deserving of punishment depending on whether they perpetrated violence against a male or female survivor. This represents a shift, because as previously mentioned, sexual violence is often perceived as a “women’s issue,” with shelters for survivors of domestic abuse or other resources sometimes exclusively serving women, and research in the past has indicated a gender bias in perceptions of situations of sexual harassment.12-15 Significant findings came from exploratory variables. Age was found to be strongly correlated with the harshness of participants’ judgments. Feelings towards the #MeToo movement was correlated with judgments of vignettes. And although the gender of perpetrators and victims described in the vignettes were not found to have a main effect, there was a significant correlation between gender identities of participants and their judgments of vignettes, which was consistent with previous research.12-15 Gender was examined as a potential factor of influence in situations of sexual harassment, but something left

unexplored in this study was sexual orientation. Participants were assigned randomly to either a vignette detailing a situation of sexual violence between a male professor perpetrator and female student or a female professor perpetrator and male student. Same-sex sexual harassment situations, or situations involving identities other than male and female were not examined. Further research could explore the effect of more diverse gender combinations between perpetrators and victims in vignettes and how that might influence participant responses to the situations. It would be important to continue this research with a more diverse sample population. Only 6.86% of the population identified as male, and no participants were unfamiliar with sexual violence or with the #MeToo Movement. This was not surprising, as #MeToo has been far-reaching as a movement, but it would be interesting to see if participants who were entirely unfamiliar with the #MeToo movement might respond to these situations differently. This study sought to explore the relationship between familiarity with #MeToo and participant responses to situations of sexual harassment. Sexual harassment, and sexual violence overall, are public health issues. The use of social media to address health issues is an increasingly popular intervention, and is one that has yet to be much researched. This research supports that the #MeToo movement aided in participants’ recognition of situations as sexual harassment and lends evidence that increased familiarity with a movement such as #MeToo correlates with increased likelihood of requiring accountability for a perpetrator. This supports the importance of a social movement such as #MeToo and the potential impact of a social media movement on public perception of the issue of sexual violence. pages.jh.edu/~ep/

references 1. Skinner BF. About Behaviorism. New York: Knopf; 1974. 2. Bandura A. Social Learning Theory. General Learning Press; 1971. 3. Heath L, Kruttschnitt C, Ward D. Television and Violent Criminal Behavior: Beyond the Bobo Doll. Violence and Victims. 1986;1(3):177. doi:10.1891/08866708.1.3.177. 4. Cantor J. Media violence. Journal of Adolescent Health. 2000;27(2):30-34. doi:10.1016/s1054139x(00)00129-4. 5. Dill KE, Brown BP, Collins MA. Effects of exposure to sex-stereotyped video game characters on tolerance of sexual harassment. Journal of Experimental Social Psychology. 2008;44(5):1402-1408. doi:10.1016/j. jesp.2008.06.002. 6. Bleakley A, Hennessy M, Fishbein M, Jordan A. Using the Integrative Model to Explain How Exposure to Sexual Media Content Influences Adolescent Sexual Behavior. Health Education & Behavior. 2011;38(5):530-540. doi:10.1177/1090198110385775.

appendix TABLE 1: Participant age.

RANGE

MIN

MAX

MEAN

103

21.99

TABLE 2: Participant gender.

7. Smith KC, Twum D, Gielen AC. Media Coverage of Celebrity DUIs: Teachable Moments or Problematic Social Modeling? Alcohol and Alcoholism. 2009;44(3):256260. doi:10.1093/alcalc/agp006.

GENDER

FREQUENCY

PERCENT

8. Pitsula P. Hollywood and human rights in the curriculum. Education Law Journal. 2008;17(3):275-290. https:// search.proquest.com/docview/212959110?accountid=11752.

Female

76.47

Male

6.86

Trans

16.67

TOTAL

102

100

9. Gerber MM, Jackson J. Authority and Punishment: On the Ideological Basis of Punitive Attitudes towards Criminals. SSRN Electronic Journal. 2012. doi:10.2139/ ssrn.1800481. 10. Roberts JV, Doob AN. News media influences on public views of sentencing. Law and Human Behavior. 1990;14(5):451-468. doi:10.1007/bf01044222. 11. Vezzali L, Stathi S, Giovannini D, Capozza D, Trifiletti E. The greatest magic of Harry Potter: Reducing prejudice. Journal of Applied Social Psychology. 2014;45(2):105121. doi:10.1111/jasp.12279. 12. Baker, D. D., Terpstra, D. E., & Larntz, K. (1990). The influence of individual characteristics and severity of harassing behavior on reactions to sexual harassment. Sex Roles, 22(5), 305. 13. Mckinney, K., & McKinney, K. (1990). Attitudes toward Sexual Harassment and Perceptions of Blame: Views of Male and Female Graduate Students. Free Inquiry in Creative Sociology, 18(1), 73â€“76. 14. Pryor, J., Day, J., & Pryor, J. (1988). Interpretations of sexual harassment: an attributional analysis. Sex Roles: A Journal of Research, 18(Apr 88), 405â€“417. 15. Valentine-French, S., & Radtke, H. L. (1989). Attributions of responsibility for an incident of sexual harassment in a university setting. Sex Roles, 21(7), 545. 16. Flores, A., Herman, J., Gates, G., & Brown, T. (2016). How Many Adults Identify as Transgender in the United States. The Williams Institute. Retrieved from http:// search.proquest.com/docview/1918304413/?pq-origsite=primo

acknowledgements I wish to express my sincere thanks to my supervisor for this research, Dr. Laura Duval of American University. In addition, I am grateful to all of my participants in this research, who took time out of their days to aid in understanding the effects of an important social movement.

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TABLE 3: Participant race.

RACE

FREQUENCY

PERCENT

Caucasian

79.0

Black or African American

2.6

American Indian or Alaska Native

Asian

7.9

Native Hawaiian or Other Pacific Islander

Other

10.5

TOTAL

114

100

POLICIES

Photo by Michelle Chung

Damaging Effects of Adverse Stigmas on the Opioid Crisis By Nuri Ha | Public Health & Computer Science, JHU '21

abstract

s of 2019, more people are dying from opioids than breast cancer, motor vehicle crashes, and guns, demonstrating the need for a closer investigation of this societal dilemma.¹,¹³,¹⁴ Through an internship at Concerted Care Group (CCG), an addiction treatment center, and my own research, I found that the stigmas against opioid addiction are both rampant and destructive. The three main types of stigma are self-stigma, social stigma, and societal stigma. This paper will focus on structural stigma, which restricts the rights and opportunities of a group through institutional procedures. The effects of structural stigma are multifaceted and far-reaching. My first-hand interactions with patients painted a disturbing picture of insensitive health professionals and prejudiced treatments. Additionally, research has found that structural stigma impacts the quality of care, significantly decreasing the amount of empathy and personalization offered to patients with substance use addictions. Furthermore, this kind of unjust and flippant treatment contributes to an increasing reluctance to seek help, a major setback in terms of fixing the opioid epidemic. The Johns Hopkins University, an institution specializing in medicine and public health, has a high concentration of students who are

looking to go into the health sciences. Therefore, these students are the most likely to be impactful in reducing structural stigma in the fight against opioid addiction. As such, this proposal is focused on lessening stigmas in Hopkins health sciences students and in turn, minimizing structural stigma so as to combat the epidemic from a more unconventional angle. The proposed solution is to create a club focused on addiction stigma education. The club would work in a manner similar to that of a program that is already implemented by the university– the Bystander Intervention Training program. Through this club, peer educators would be able to raise awareness of and work to reduce the stigma against substance use disorders that is prevalent in the Hopkins community. Furthermore, the club would collaborate with CCG to offer a club-specific internship. This would not only increase involvement in the club, but also work to reduce stigma by exposing students to stigmatized patients. The club would begin addressing the structural stigma that is quietly plaguing the hundreds of thousands of people suffering from opioid addiction.

proposal What comes to mind when you think about heroin, morphine, and

oxycontin? What type of people do you imagine abuse these drugs? For the most part, society has very negative viewpoints toward opioids and assumes that only weakwilled people use these substances. However, even prominent figures such as Elvis or Demi Lovato have overdosed on opioids. Addiction to these substances is not something that only affects certain people; rather, it is an epidemic that is affecting the entire nation. In Maryland alone, there has been a 70% increase in opioid-related deaths between 2015 and 2016.² Nevertheless, the language used to describe opioid overdose and addiction is very much accusatory. For example, news of Lil Peep’s death was met with comments along the lines of “what did he expect,” “no one forced a needle into his arm,” and “it was his choice.” Even a famous YouTuber with over 87 million subscribers, Felix Kjellberg (PewDiePie), mocked Demi Lovato’s overdose hospitalization by posting an offensive meme. By abusing his platform, he made light of a serious issue and promoted negative thoughts towards opioid addiction. Such actions speak to a larger cultural stigma towards addiction, hindering the fight against the current opioid epidemic. In recent years, opioid addiction has become an omnipresent, pervasive issue, and the negative stigma against it is undermining pages.jh.edu/~ep/

efforts to curb this epidemic. To learn more about this public health crisis that is gripping the nation, I started by turning to Baltimore, a city that is rampant with opioid addiction. In a survey I created and disseminated to pre-med students at Johns Hopkins, 85.7% of participants thought opioid addiction was common in the Baltimore community, establishing that the participants recognized the pervasiveness of this issue.³ Unfortunately, nearly 40% of the survey participants claimed that negative stigma towards opioid addiction was common on campus.³ The notion that pre-health students, who live in an area where opioid addiction is rampant, have negative attitudes about a demographic they could one day be treating is frightening. My internship at Concerted Care Group, a comprehensive addiction treatment center in Baltimore, gave me the opportunity to confront and fight these stigmas. During my time at CCG, I worked to increase patient enrollment in different the CCG programs, and my team engaged with the community to create a bond between CCG and the inhabitants of that area. I was able to talk to many of the patients and passersby and learn more about opioid addiction from the CCG staff, which made me realize the extent of the opioid epidemic. More importantly, I was able to gain direct experience with both professionals working with addiction and opioid abusers themselves, which provided insight into how complex opioid addiction is and how dehumanizing it can be to be labeled a “drug addict.” Oftentimes, stigmas against people with addictions and against relapsing prevent potential patients from getting the treatment they pages.jh.edu/~ep/

need. My conversations with patients revealed that health professionals tended to blame ordinary problems on the patient and their addiction without regard for their circumstances. For example, staff at addiction treatment clinics would blame patients for not having their own form of photo ID, saying things like “of course she doesn’t have ID with that drug addiction,” or “he’s just making excuses again.” Therefore, new patients were surprised to hear that CCG had a free ID program in which patients who joined the treatment program could have their ID paid for by the clinic. The negative bias that the staff have at these addiction treatment centers prevents them from being empathetic and listening to the problems the patients face. Additionally, patients who relapse tend to be kicked out of their treatment program and/or are deemed unable to join a new program. Relapse is seen as an inability to recover and a moral failing; however, the National Institute on Drug Abuse says that “relapse rates for drug use are similar to rates for other chronic medical illnesses.”⁴ Therefore, the current attitudes associated with addiction when seen in the context of chronic illnesses, like cancer or Crohn’s dis-

ease, seem unfounded. Most people would not scold a cancer patient for relapsing, but substance abuse patients are shamed and deemed second-class citizens. The stigmas associated with drug addiction and relapse enforce the incorrect belief that addiction is a choice, which makes it difficult to see relapse as a normal step towards recovery and addiction as yet another medical condition to be treated. Not only are health professionals and distant strangers to blame for these stigmas, but I could also see that I myself harbored stigma towards opioid addiction. In my own experience working with this demographic, I came to understand that my stigmas were a product of my upbringing and the community I lived in. As such, I found myself surprised at how well-spoken some of the patients were and how motivated they were for their future. Talking to the patients directly helped me put faces and names to ominous words like “drug addict” and humanize them. My interactions with these people showed me that the preconceptions of drug addicts being “weak willed,” “irresponsible,” and “lazy” were not even close to the dynamic personalities of the patients I met at CCG. Although I did not consider myself to be someone who stigmatized opioid addiction, the experiences I had as an

Although I did not consider myself to be someone who stigmatized opioid addiction, the experiences I had as an intern helped me to realize and start correcting the stigmas I subconsciously harbored. 29

intern helped me to realize and start correcting the stigmas I subconsciously harbored. Furthermore, I noticed that community can have a significant influence with how you perceive drug addiction. While completing the internship, the safety of the ‘Hopkins Bubble’ constantly came to my mind. I began to see how being sheltered from the hardships of the Baltimore community was unintentionally promoting stigma, and I felt that it was important to bring attention to this issue. categorization of opioid stigma

In order to begin recognizing and addressing the problem of stigmas, it is important to know that stigmas may manifest themselves in numerous ways. Self-stigma is characterized “by negative thoughts and feelings that emerge from identification with a stigmatized group and their resulting behavioral impact”⁵, meaning that the negative social experiences the individual experiences because of their condition might make them feel hopeless and hostile. [SM1] While everyone perceives their condition differently, many of the patients at CCG were hyper-aware of their addiction and tended to self-handicap themselves. Instead of dreaming of the future, those who harbored self-stigmas tended to feel dejected and thought of themselves as a

burden. A female patient I talked to apologized every time she spoke because she was “just an addict” and did not want to “bother smart Hopkins students with her words.” This interaction was disheartening because the harsh stigma towards opioid addiction caused her to internalize that negativity. Social stigma is defined as “the phenomenon of large social groups endorsing stereotypes about and acting against a stigmatized group.”⁶ This is the stigma that most people are familiar with; it is the stigma created and perpetuated by everyday people and society. The negative connotations around addiction and the degrading preconceptions about drug addicts are all supported and furthered by society through movies, news, and conversation. Kjellberg’s meme is a great example of society sponsoring harmful stigma and marginalizing people with addictions. Furthermore, movies tend to portray addiction in unrealistic ways, which can be categorized into four different stereotypes: the tragic hero, the demonized user, the rebellious free spirit, and the comedic user.⁷ These terms, while complex, give a general description of the kinds of stereotypes media portrays about drug addicts. Substance addiction is sensationalized in media and though not all of these stereotypes are necessarily negative,

The negative connotations around addiction and the degrading preconceptions about drug addicts are all supported and furthered by society through movies, news, and conversation. 30

portraying inaccurate depictions of opioid addiction can either romanticize or demonize a relatively common, but serious illness. Finally, structural stigma “refers to the rules, policies, and procedures of institutions that restrict the rights and opportunities for members of stigmatized groups.”⁶ An example of this type of stigma is the negative attitudes of some people who work in medicine or law enforcement who, through their positions of power, are able to systematically oppress those who have opioid addictions by punishing them more harshly or by neglecting to treat their addictions adequately. I was able to experience this stigma first hand while talking to a couple of community members for outreach. Before I knew it, a police car pulled up next to us and the officer proceeded to stare at me and the two other people suspiciously until we cut off the conversation. Bewildered, I asked why the cop was idling next to us, and one of the men said that it was because the officer thought we were dealing drugs. Simply talking to two Black males on a street corner in a neighborhood with many drug problems presumably led the officer to jump to extreme and false conclusions. Furthermore, the language health professionals use when referencing addiction “intentionally and unintentionally propagates stigma: the mark of dishonor, disgrace, and difference that depersonalizes people.”⁸ Terms such as junkie, abuser, and habit keep the focus of the substance use addiction on the individual instead of framing the addiction in an unbiased, medical perspective. Structural stigma is an increasing problem in treating opioid addiction because, and according to many of the patients I talked to pages.jh.edu/~ep/

during my internship, numerous addiction treatment facilities act in rude and dehumanizing ways to their patients- systematically limiting patients’ access to good care. As mentioned earlier, those who relapse are kicked out of recovery programs, nurses and staff yell at patients as if they are animals, and patient complaints are not taken seriously. As such, addiction treatment centers are not doing their part in helping to minimize the mortalities caused by substance abuse, even though there has been a 66% increase in the deaths caused by drug and alcohol intoxication in Maryland between 2015 and 2016 and 88% of all intoxication deaths in Maryland in 2017 were from opioid use.² The patients said that they felt that the staff at these centers were judging them and influenced by the negative stigma surrounding substance abuse addiction. Because of the negative attitudes of the staff in these addiction treatment centers, the patients said they had less motivation to want to continue with treatment and felt that they were unable to get fair, beneficial treatment at these facilities. Furthermore, the people I talked to even stated that some of the medication dispensing nurses were corrupt, and allegedly diluteding the methadone (a synthetic opioid used to treat addiction) given to patients to sell the extra on the side. These horror stories paint a picture of the way people with addiction are treated by the system that was put in place to help them. The grievances of many opioid addiction patients I encountered areis telling of a larger culture of structural stigma. This type of stigma is everywhere, as evidenced by physician assistant students who “believed that stigma beliefs about pages.jh.edu/~ep/

FIGURE 1: Opioid stigma infographic by Nuri Ha.

substance use were common among health care professionals.”⁹ Further, research shows that health professionals that project their negative stigmas and attitudes about substance addiction onto their patients led to “diminished feelings of empowerment and subsequent treatment outcomes.”10 In addition, these health professionals tended to be less empathetic and had a “more task-oriented approach in the delivery of healthcare.”10 The

implications of these findings are alarming, meaning that even those who do seek medical interventions are shut down, with staff treating patients as a checklist of chores instead of a human in need of help and attention. Structural stigma is clearly an aspect of healthcare that can negatively impact treatment, and, because it is persistent, it must be stopped as early as possible. because it is persistent. In a study aiming to reduce substance use stigmas

among physician assistant students, the intervention did reduce stigma. However, the reduction was minor, attitudes towards substance use were still negative, and the students believed that their “own level and quality of care would not be influenced by these beliefs.”⁹ This study shows that even students who will soon enter the medical field are uninformed about the negative effects of stigma and have difficulty changing their beliefs. To tackle this issue as effectively as possible, it is important to consider why stigma against opioid addiction is not a larger part of the public discourse on this epidemic. A large reason why this is the case is because of a simple lack of information and education. People might not realize that stigmas exist, or they might think that they do not harbor stigmas when they actually do, just like I did. Furthermore, society as a whole is so focused on the actual opioid epidemic that they may have not thought about factors that contribute to and worsen the epidemic’s current state. Therefore, as an institution that has a high number of intelligent students who will eventually go into the health sciences fields, Johns Hopkins University has a responsibility to educate the next generation of professionals on the damaging effects of stigma. Stigma prevents patients from seeking real, sincere help and perpetuates a dangerous assumption that patients are addicted by choice and could get better at any time. This kind of incorrect thinking could further exacerbate the current opioid epidemic by not effectively treating those who suffer from opioid addiction. The Johns Hopkins University is a world-renowned public health and medical institu-

Opioid addiction is not a distant problem that only affects a certain subset of the population, instead it is a growing issue that can affect anyone. tion and, consequently, the school should work harder to help correct misconceptions against an epidemic that is essentially happening in our backyard. Hopkins is always trying to improve the Baltimore community, whether it be by sponsoring tutoring programs for inner city students or hosting HopServe50. That being said, it should make an effort to curb or at least educate students on the opioid epidemic that is ravaging the city. “Given how early in life discriminatory viewpoints and behaviors can appear,” it is not enough to just educate those currently in the medical field.¹¹ From the media portrayal of drug users to the word choice associated with addiction in medicine, negative connotations linked to substance abuse are omnipresent. Consequently, there should be an extra initiative to try to help combat this devastating epidemic as early as possible. In the survey I generated, 71.4% of students stated that they believed that the stigmas associated with opioid addiction must be changed.³ The students are already in agreement that the opioid epidemic is a problem, is relevant, and stigmas against it should be changed. And so, as a whole, it is necessary to address this problem in the fight against the opioid epidemic in order to output students who are informed and ready to break down the negative stigmas against opioid addiction.

potential intervention

Accordingly, I propose that a club dedicated to educating students about the opioid epidemic and, specifically, the stigma surrounding substance abuse be created. This organization would work to implement educational programs around campus and to internally arrange an internship with CCG so that interested students could learn about the opioid epidemic first- hand. Further, I see this club persuading school officials to implement an stigma education program, much like the current Bystander Intervention Training (BIT) on sexual violence, during orientation week. Ideally, this club would facilitate a relationship with the Public Health Studies department to provide an intersession class or sponsored program for students in this major. The educational program would be based off of previously implemented programs to reduce structural stigma in which participants had to answer questions about and reflect on stigma. This has been shown to be effective in a systematic review of the current literature on interventions to reduce stigma.⁶ To do this, I would pull questions from the SAMHSA anti-stigma toolkit which has probing questions like “what are your personal beliefs about why people become addicted,” and “do you accept certain types of addictions more than pages.jh.edu/~ep/

others?”¹² These questions coupled with an empathy-based curriculum and experiential activities will “engage students’ feelings and behavior, not just cognition-based points of view,” which is important in creating lasting changes to attitudes towards substance use.¹¹ The club would be structured so that club members would be educated intensively on stigmas so that they can be peer educators in the Hopkins community, much like the current program on sexual violence, BIT. Furthermore, the club would hold campus events to raise awareness. These events can be anything from food events, where students can come eat free food while the peer educators give a short presentation on stigmas surrounding opioid addiction, to more formal education workshops, where the education component is a lot more serious and comprehensive, or even fundraisers, where the club could sell baked goods to raise money for other club events. In addition, during my internship, I found that face- toface interaction and contact with members of the stigmatized group reduced bias and stereotypes. Likewise, an evaluation of school-based interventions, stated that “‘contact’ is likely necessary,” to produce effective results.¹¹ Therefore, I believe that an internship program would not only spark the interest of public health and pre-med students, but also help them to realize their own stigmas against opioid addiction. The internship program would be offered as a collaboration between the proposed club and CCG, and only those who have been trained as peer educators would be able to apply for the internship. This way, there would be more of an incentive to join the club and get involved. I think this program would be an enpages.jh.edu/~ep/

gaging way to reduce bias and teach students about the negative effects of stigma while also appealing to the needs of pre-health students. This club’s educational programs are very low cost, needing only an effective presentation and a room to present in. In addition, once the club is approved I plan on communicating with CCG to see if they would want to set up a Hopkins- specific internship in collaboration with the club. The likelihood of CCG working in partnership with the club is high, given that CCG is currently looking for more interns, and I have a good relationship with the upper management at CCG. In addition, the CEO of this addiction treatment clinic, Andrey Ostrovsky, is very progressive and always looking for new ways to improve. The implementation of this club would enable the university to send out educated, informed students into the medical fields, and this initiative could potentially help to curtail the opioid epidemic, a major public health concern.

references

conclusion

9. Crapanzano, K, et al. “Reducing Stigma towards Substance Users through an Educational Intervention: Harder than It Looks.” Academic Psychiatry : the Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry., U.S. National Library of Medicine, Aug. 2014, www.ncbi.nlm.nih.gov/ pubmed/24619913.

When considering this proposal, the universality of this issue should be remembered. Opioid addiction is not a distant problem that only affects a certain subset of the population, instead it is a growing issue that can affect anyone. Likewise, substance abuse disorder is something that can affect you or someone you care about around you and should be handled as such. Given the scope of this issue, it is not plausible for one person to reverse the opioid epidemic overnight, and so, as students, we must work to find our corner of the crisis to focus on and attempt to fix. This corner is the stigma against opioid addiction; as pre-med students who could one day be treating this very demographic, we cannot be complacent. We must act now.

1. “Cancer Facts and Figures 2016.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cancer.org/content/ dam/cancer-org/research/cancer-facts-and-statistics/ annual-cancer-facts-and-figures/2016/leading-sitesof-new-cancer-cases-and-deaths-2016-estimate.pdf. 2. “Overdose Data and Reports.” Data and Reports, bha.health.maryland.gov/OVERDOSE_PREVENTION/Pages/Data-and-Reports.aspx. 3. Ha, Nuri. “Opioid Addiction”. Survey. 30 September 2018. https://goo.gl/forms/uvRwSrJGF11vK8qB2. 4. National Institute on Drug Abuse. “Treatment and Recovery.” NIDA, National Institute on Drug Abuse, July 2018, www.drugabuse.gov/publications/ drugs-brains-behavior-science-addiction/treatment-recovery. 5. Luoma, Jason, et al. “An Investigation of Stigma in Individuals Receiving Treatment for Substance Abuse.” Addictive Behaviors, Pergamon, 7 Nov. 2006, www.sciencedirect.com/science/article/pii/ S0306460306002966. 6. Livingston, James D et al. “The Effectiveness of Interventions for Reducing Stigma Related to Substance Use Disorders: A Systematic Review.” Addiction (Abingdon, England) 107.1 (2012): 39–50. PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3272222/. 7. Cape, G. S. “Addiction, Stigma and Movies.” The Canadian Journal of Chemical Engineering, Wiley-Blackwell, 7 Feb. 2003, onlinelibrary.wiley.com/ doi/full/10.1034/j.1600-0447.2003.00075.x. 8. Broyles, Lauren, et al. Gordon (2014) Confronting Inadvertent Stigma and Pejorative Language in Addiction Scholarship: A Recognition and Response, Substance Abuse, 217-221. https://www.tandfonline. com/doi/abs/10.1080/08897077.2014.930372.

11. Schachter, Howard M et al. “Effects of SchoolBased Interventions on Mental Health Stigmatization: A Systematic Review.” Child and Adolescent Psychiatry and Mental Health 2 (2008): 18. PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2515285/. 12. Landry, M. (2001). ANTI-STIGMA TOOLKIT A Guide to Reducing Addiction-Related Stigma. [online] Central East ATTC. Available at: http:// attcnetwork.org/regcenters/productDocs/2/Anti-Stigma%20Toolkit.pdf. 13. Stewart, Ian. “Report: Americans Are Now More Likely To Die Of An Opioid Overdose Than On The Road.” NPR, NPR, 14 Jan. 2019, www. npr.org/2019/01/14/684695273/report-americans-are-now-more-likely-to-die-of-an-opioidoverdose-than-on-the-ro. 14. Pirani, Fiza. “Opioids Now Kill More Americans than Guns or Breast Cancer, CDC Says.” Ajc, The Atlanta Journal-Constitution, 29 Dec. 2017, www.ajc.com/news/health-med-fit-science/opioids-now-kill-more-americans-than-guns-breastcancer-cdc-says/DUx1KS33P4sbyzgj9T9rrN/.

FEATURES

Photo by Lauren Questell

Exploring Uganda Through the Lens of Water, Sanitation, and Hygiene By Faith Atai | Public Health, Makarere University '21 By Sofia Milosavljevic | Public Health, JHU '20 By Stone Streeter | Public Health & Molecular and Cellular Biology, JHU '21

introduction

n January 2019, our team of students from Johns Hopkins University joined students from Makerere University School of Public Health under the Johns Hopkins University Childhood, Health, and Society Intersession Program in Uganda. Our group was assigned the topic of water, sanitation and hygiene (WASH). We used WASH as a lens through which we could explore Uganda and come to understand how it impacts people’s day-to-day lives. It is estimated that nearly 10% of the global burden of disease is associated with lack of access to adequate sanitation, safe drinking water, proper hygiene, and effective water management.1 Uganda is no exception to the high burden of sanitation-related diseases that are common in developing countries. From drinking, to cooking, to showering, to watering plants, reliable access to clean water is essential. In areas of the country where

this access does not always exist, many communicable diseases such as diarrhea, cholera, dysentery, and typhoid are prominent. The situation is made worse by the lack of appropriate medical facilities and services, which in turn leads to high morbidity and mortality rates. Special emphasis should be placed on both quantity and quality of water, but with a greater emphasis on clean water. Uganda should not be experiencing water shortages because it borders the largest lake in Africa, Lake Victoria, which also hosts the origin of the Nile River. Despite Uganda’s location, many parts of the country still suffer from water contamination or lack access to clean water due to poor infrastructure.

methods Guided by a variety of informative site visits, we were able to discover the social, political, and environmen-

Despite Uganda’s location, many parts of the country still suffer from water contamination or lack access to clean water due to poor infrastructure. 36

tal factors that allow WASH issues to persist. We used both qualitative and observational methods of data collection during our site visits that were in both rural and urban areas of the Rakai and Kampala districts of Uganda. We visited households, health facilities, and held interviews with members of households, health facility staff, and other key informants affected by WSH related diseases.

results initial observations

Stepping off of the plane at Entebbe International Airport, the first thing that struck us was the dust in the air and the uncomfortable heat of the late afternoon. We collected our luggage from baggage claim and made our way to the resting area where we waited for our van to arrive. At that point, 24 hours into our travel itinerary, our group was dehydrated and on the lookout for something to drink. In preparation for the trip, we were instructed to only drink bottled water or to use iodine tablets to treat the tap water. Luckily, a small stand selling bottled water was nearby, and we happily bought all of the plastic water bottles they had. After loading everything into the van, we hit the road. The landscape was breathtaking. However, as we ventured further away from the tourist area surrounding the airport, at every corner of the road, rubbish covered the pages.jh.edu/~ep/

UNHYGIENIC CONDITIONS: This was a first glimpse of the dry, dusty climate and the bustling streets. Citizens used "boda bodas," a type of motorcycle, as their main method of public transportation. street. Masked in the soil, the trash was molded into the ground. It was everywhere. And we did not notice a single trash can the entire way. Upon arrival at the Ndere Cultural Center, where we would be spending a majority of our stay, we learned that the sink and shower water were unsafe for consumption and were even advised against using it to brush our teeth. For the next couple of days, we drank strictly bottled beverages with every meal and did not add ice to anything. This seemed wasteful and unnecessary, but it was our only option. Before going on our first site visit, we did some research to provide us with background knowledge on water and sanitation in Uganda. We learned that approximately 61% of people living in Uganda do not have access to clean water and that 75% are unable pages.jh.edu/~ep/

to use adequate sanitation facilities.2 The lack of access to clean water can be blamed on the contamination of water sources by way of open defecation, defective pit latrines, and improper dumping of waste. Pollutants that are inadequately disposed of are carried by runoff into local sources of water. Furthermore, nearly 90% of Ugandaâ€™s population lives in rural areas which are particularly at-risk for water-borne diseases.3 These diseases primarily affect small children under the age of five years old whose immune systems are not fully developed at the time of exposure. Due to lack of knowledge by parents, caretakers, and even local medical experts in rural cities, many children receive inadequate treatment and die as a result.4 With this information in mind, we now felt better prepared to properly engage

with the local community and understand their personal experiences with water, sanitation, and hygiene. home visits

After a few days at Ndere, we packed up our things and headed south to the Rakai District for a weeklong homestay. We are incredibly grateful for this opportunity during which we not only made tremendous leaps in our understanding of water, sanitation, and hygiene in a typical Ugandan household, but we were also introduced to a different way of life. Supper was served at 11pm, we were taught how to make fresh juice, and we even worked on our pronunciation of a few phrases of the Luganda language. Throughout the time we spent with our homestay families, we were sure to note anything that stuck out to us per-

taining to water and sanitation. In developing countries (and marginalized areas of developed countries) across the globe, human waste disposal is a major WASH hurdle. During our homestay, when we had to use the bathroom we used what are called latrines. Latrines are essentially a type of outhouse that features a rectangular opening on the surface of the ground that leads to a very deep hole. Latrines are designed to offer families or public venues that are without plumbing a more sanitary way to dispose of human waste. For some households, a “VIP” latrine had been installed. Ventilated Improved Pit (VIP) latrines use an intricate ventilation system to ensure better long-term disposal of the waste and are much preferred to ordinary latrines. VIP’s also require that the minimum depth of the pit is approximately 15 feet. The only downside is that they cost more money to install and for this reason are

not available to a majority of families. It was evident that the water and sanitation issues arose from a combination of lack of accessibility and insufficient funds. The wealthier hosts had access to private pipes from the National Water System (NWS) while less affluent hosts collected rainwater to use for cooking, drinking, and bathing. Unfortunately, neither water source was reliable. The NWS water had potential pollutants and the basins for properly collecting rainwater were expensive. All of our homestay families had to boil the water before drinking it, which glaringly highlighted the inaccessibility of clean drinking water to all members of society. Another cultural norm that surprised us was that animals were allowed to roam freely throughout one’s property. On many occasions, we saw both pigs and chickens wander into open doors that led to the main parts

of homes where people ate meals and slept. This was extremely unsanitary as animals can tread fecal matter and potentially very harmful bacteria into the home. Other sanitation concerns arose when we saw the children in our homestay not using utensils to eat their food, instead just using their hands. This is problematic as the children ate on the floor and would crawl around on the ground (where animals had walked mere hours before) in the middle of eating. Lastly, for the duration of the homestay, we could not find a single trashcan in the compound. We asked where our family disposed of the trash from meals and other activities and they said they simply made a pile in the backyard and occasionally burned it. Bacteria from these trash heaps can contaminate the food that many of the families grow for subsistence. After a week of making friends with our hosts, it was hard

SITE VISITS: Shocking image of a butcher's stand where meat was displayed, unrefrigerated in the beating sun (left). Main waste canal flowing through the middle of the slum (right).

pages.jh.edu/~ep/

for us to leave and return to a life of toilets and showers without thinking of the conditions we were leaving our hosts in. The families were so welcoming and loving and they taught us the invaluable lesson of human connection. The families put into perspective the issue of water and sanitation as they taught us about navigating everyday problems along with having to manage suboptimal access to water and sanitation facilities. site visits

The first site visit by the team was to Owino Market in the capital city of Kampala. This is the busiest and most crowded market in the city. The scene was quite overwhelming. We were surrounded by vendors selling anything and everything you could imagine. From dried fish to Louis Vuitton purses, the market had it all. As we inched our way through the crowded alleys, the lack of proper sanitation became evident. There were people everywhere and congestion was definitely a problem. We were bumped into many times and dust in the air made it hard to breathe. In between the vendors in the main alley, there was a steady stream of murky water, trash, and rotten food running through the market. To either side of the stream, vendors sat on blue tarps on the ground with their produce spread out around them. On several occasions, we watched a vendor, dissatisfied with a piece of fruit, toss it into the stream of water and then carry on with their work. The â€˜freshâ€™ produce was not only covered with dust from the ground, but it was also washed in buckets that looked like mud just moments before it was sold. As we emerged from the opposite side of the market, we saw a meat stand for the first time pages.jh.edu/~ep/

TABLE 1: Final water sample data. and our jaws dropped. Huge strips of steak and entire chickens hung from metal poles roasting in the blazing sun. Flies buzzed around the pieces of meat and blood could be seen dripping down the front of the counter. It was shocking to us that the meat would be put on display rather than refrigerated and kept fresh. We would come to learn later on that this was how all meat was treated in Uganda and that using refrigerators was reserved for the upper-middle class and above. Just a few miles away from Owino Market was Mulago Market. At Mulago Market we found relatively similar conditions. Animals were left to wander wherever they pleased, trodding over muddy water and piles of trash. However, produce here was sold from stands rather than on tarps and most of the trash in the market was collected into a large pile in one specific area. It was clear that improvements had been made and measures were being taken to improve sanitation, but proper organization was still lacking. The next site visit was to Kimwanyi Zone of the Katanga Slum, which we decided to visit in order to

see the water and sanitation amenities available to the least privileged level of society. We were greeted warmly and enthusiastically by the leader of the slum, and we were even given a guide who showed us around. We were led through the intricate network of narrow corridors and makeshift shelters used both as homes and storefronts. What was most striking to us was the vast accumulation of garbage. The slum looked to have been built on piles of trash. Despite the large amount of trash we saw, we were informed that the residents had to regularly pick up trash and place it outside of the slum for collection by the government. Various government infrastructure deficiencies made this process inefficient and inhibited proper sanitation in the slum. Specifically, we were told that there were only three garbage trucks for a ward with 113 zones. Subsequently, trash pickup was often times delayed or did not happen at all for long periods of time. Additionally, there was a haphazard drainage system consisting of open channels that drained into one large river of waste flowing through

the center of the slum. The river was most likely contaminated with human and animal fecal matter and other waste products that were more convenient to dump in the river than to dispose of properly. As for human waste management, the slum had public toilets which we found surprisingly modern. The advantage of toilets over latrines is that they are much more sustainable in the long run. Yet, despite the availability of toilets, open defecation remains prevalent, especially amongst small children. As we continued our tour we were led to the Public Stand Pipes (PSPs) that were the clean water source for the slum. We learned that both the PSPs and the toilets were supported by the National Water System (NWS), but we were alarmed to hear that at times the NWS ran out of water. This led to clean water shortages along with waste disposal crises when there was no water for the toilets to flush. Overall, the community was doing its best to maintain hygienic conditions, but the risk of communicable and water-borne disease remained high as there were 20,000 people packed into a 35-acre area with unreliable sanitation infrastructure. Despite the major challenges, the slum’s leader remains hopeful that through community engagement he can better the slum’s sanitation conditions. The leader told us that he has established a health council that facilitates weekly clean-ups and health information dissemination. The leader explained that though he is motivated to continue the community-led interventions, it is hard to keep the community motivated because there is no means of compensation for participating members. We were impressed by the youthful leader’s

ambitious plan for the slum and came to understand the frustration of trying to improve a community’s sanitation without proper governmental support. We next visited the National Health Laboratory Service (NHLS) in Luzira on the outskirts of Kampala city. The NHLS falls under the Ministry of Health (MOH) and is responsible for supervising and overseeing all laboratory services across the country. We were excited to learn more about the country’s epicenter of laboratory data collection. We were taken on a tour by a researcher who was very enthusiastic about the vast amount of data collected by the NHLS. This being said, he repeatedly mentioned that there was not enough skilled man-power to properly analyze all the data that was collected. Lack of human resources was a recurring theme that was interwoven in many of our site visits, but its effects became most evident at the NHLS. Our guide talked to us about the many longitudinal studies occurring and the extensive amounts of data collected, but it seemed as if the only data that was sufficiently analyzed was that related to HIV/ AIDS. The HIV/AIDS epidemic seemed to be such a great burden on the infrastructure of the lab that few other topics received any attention. This was especially prominent when we discussed the current Cholera outbreak. Our guide told us that the initial water samples were analyzed at NHLS in order to detect the outbreak, but that overall the outbreak was detected late because of a lack of communication. According to our guide, there is a team that does continuous testing of water in order to identify any potential water-borne diseases. However, due to a lack of manpow-

er, the testing was not thoroughly done. We asked what could be done to reduce the preventable spread of these communicable diseases and our guide said that properly trained workers could fix it, but that the resources were not there to enforce testing and reporting protocol for disease outbreaks. The difficulty of enforcing protocol without sufficient human resources became evident not only in the case of the Cholera outbreak, but in the case of general safety protocol as well. As we toured the NHLS, we saw several sanitation concerns such as biohazardous waste sitting in the main lobby, mold on lab ceilings, and people not wearing clean shoes or lab coats in areas designated as as ‘sterile.’ We greatly appreciated everything we were shown and we certainly developed a deeper understanding of obstacles such as a lack of skilled workers facing researchers in Uganda. Our next site visit was to a water supply plant in Kalisizo which is found in the central part of Uganda. In most developed countries the water distribution system is centralized and run by governmental agencies. In Uganda, the government is trying to implement a similar practice, but due to the difficulty of establishing a whole new infrastructure, the process of developing a functional National Water System (NWS) has proven difficult. During the homestay, our team made a site visit to the Kalisizo branch of the National Water System where we learned that clean water was such a precious resource that it had to be kept under lock and key and the supervision of an armed guard. We were educated on their water purification system that successfully turned swamp or well water into drinkable water. We also pages.jh.edu/~ep/

learned that the distribution infrastructure currently only supported water delivery to urban areas and that rural towns had to find their own supply of clean water. Similarly, water accessibility was heavily dependent on household income. For the rich, the NWS could install a private tap for the household, but for the poor, the NWS installed Public Standpipes (PSPs) which were communal taps that served around 200 residents. The PSPs were inconvenient as they required residents to walk significant distances in order get their water. In addition to the logistical difficulty of acquiring water, there were further barriers to safe drinking water. The most striking was that the residents were advised to boil any drinking water they got from the NWS pipes. We were very surprised by this recommendation, as we had learned that the water purification process done by NWS produced ready-to-drink water. When asked about the discrepancy between the clean water that comes from the NWS plant and the polluted water that arrives to the residentsâ€™ homes, the NWS representative told us that people frequently illegally tapped into pipes, creating sources of pollution. Furthermore, we were informed that the NSW does not do any pipe maintenance, leading to rusty and rotting pipes that propagate water pollution. Hopefully, logistical improvements can be made soon so that the NWS can meet its goal of â€œClean Water for Allâ€? in Uganda by 2021. water sample testing

Throughout our trip, we tested water using a portable device called a Total Dissolved Solids (TDS) Meter, which was provided to us by our instructor from Makerere Unipages.jh.edu/~ep/

KEY INFORMANT: Our water and sanitation research team alongside Dr. Muyodi after our interview. versity, Mr. Aloysius Mutebi. We used the TDS meter to measure the turbidity, or clarity, of the samples. On several occasions, we were told many facts about potential water contamination and how it impacts daily life, but we wanted to synthesize a more quantitative representation of this issue. We decided to do this by collecting water samples at the locations we visited so as to determine the status of the water we had access to. Because we had limited resources for testing, we decided to use empty water bottles to collect our samples. In order to improve our data collection method, we rinsed each sample bottle with the water to be stored in it prior to filling it up. We then looked for a way to test our samples for general potability and contamination. Dr. Fredrick Muyodi introduced us to Dr. Rosemary Nalwanga, a laboratory technician at the Microbiology Lab at Makerere University. She was incredibly welcoming and accommodating and ran cultures of several bacteria including Enterococcus and

E. Coli, both of which are found in fecal matter. Our specific results can be seen in the table. Overall, there was a high level of fecal matter contamination for almost all of the samples, as represented by the bacterial growth. The standard for potable water for these bacteria is 0 CFU (colony-forming units). Using this standard for contamination, it can be concluded that the only potable water is bottled water. This has several larger implications regarding the overall state of water and sanitation in the Kampala, Mburo National Park, and Rakai Districts where we visited. Primarily, our findings conclude that safe drinking water via a tap is inaccessible to locals. It is true that bottled water is clean, but it is not realistic for locals to use this as their only source of drinking water as it is expensive and environmentally unsustainable. Accordingly, we believe that one possible source of contamination in the regions we visited is human waste. Based on the results, public health workers in these regions

should recommend boiling all types of water before drinking. The fault in this method is that there is still a risk of contamination for locals because boiling water to ensure sterility is not foolproof. It is said that water must be brought to a rolling boil for 1-3 full minutes to kill all bacteria.5 This information is not well known by the public and can lead to improper boiling of water and thus unsafe drinking water. interview with key informant

Our final site visit was to the Makerere School of Public Health, where we were introduced by our instructor, Dr. Mieka Smart, to her colleague, Dr. Frederick Jones Muyodi. He studies water systems, water source preservation, and water pollution mechanisms. He provided a great conclusion to our study of water and sanitation, as he clearly summed up the complex mechanisms that lead to clean water insecurity in Uganda. During the interview, Dr. Smart posed to him the following question: â€œIf you had ten million dollars, what would you do to improve water and sanitation in Uganda?â€? His answer gave us a deeper perspective on the systemic inefficiencies that lead to improper monitoring of water and sanitation in Uganda. He also reaffirmed the sentiments of the other public health professionals we interviewed, such as the idea that community-based interventions are the most successful. Dr. Muyodiâ€™s response to our question began with setting funds aside to promote interventions that did not simply impose programs on communities, but that worked with the communities to develop ideas of their own. He emphasized that Ugandans should be made to feel in control of and responsible for their own water. Also, with some education and guidance,

From our experiences, we have not only learned about water insecurity at the household level, but also about the larger governmental and socioeconomic processes that perpetuate these issues. Ugandan communities can take control of their water, prevent pollution, build more latrines, and maintain a sustainable water system. Unlike in Northern Africa, Uganda has enough water, but people continue to pollute it and ignore open defecation bans. Furthermore, Dr. Muyodi would use the rest of the money to build water infrastructure within Uganda and increase latrine and well coverage. Lastly, Dr. Muyodi made sure to mention that simply providing resources to maintain a high level of water and sanitation cleanliness is insufficient. There must be a community-based push that normalizes the use of toilets, hand washing, and respect for water resources. He explained how many Ugandans do not fully understand water pollution and that successfully implementing any water and sanitation interventions requires education. Dr. Muyodi led us to consider the benefits of community-based interventions as they help create a sense of responsibility and respect for natural resources.

discussion Though we spent less than a month in Uganda, we feel as though our awareness of what public health is has expanded. From our experiences, we have not only learned about water insecurity at the household level,

but also about the larger governmental and socioeconomic processes that perpetuate these issues. A significant element of water accessibility has to do with wealth disparity. Though Uganda is a developing country, there seems to be a divide between the rich and the poor regarding access to clean water and proper sanitation facilities. In comparison, we found this wealth disparity dissimilar to that in the United States. In the United States most low-income citizens have access to clean water and sanitation facilities, while in Uganda the rich have exclusive access to these resources. As tourists, we were provided with bottled water, toilets, and showers, but in almost every place we went, these options are not financially feasible options for most residents. Both in the Rakai homestay and the Kimwanyi Zone of the Katanga Slum, people had insufficient access to clean water and suboptimal waste-management resources. Furthermore, the poor must dedicate a significant amount of time to fetching clean water, reducing the time they can spend on education or income-generating activities. This propagates the wealth gap and inhibits social mobility. This issue is troublesome on both an individual and national level as it reduces overall economic prosperity in the country and limits potential growth of the nation. pages.jh.edu/~ep/

In some developing countries such as Uganda, an authoritative governing body either does not exist or is incapable of making regulations that can be implemented and maintained. In these situations, the government is unable to control its people, and public health issues are nearly impossible to address. As we have learned, the issue of water accessibility is not mitigated by government efforts and the unreliable NWS cannot manage to provide consistent access to clean water for many of its patrons. Interestingly, this issue of national infrastructure development is more contentious than we originally thought as there is a current debate surrounding whether Non-Governmental Organizations (NGOs) should participate in building water and sanitation infrastructure in Uganda. In the current state of the country, in which government failure is followed by NGO intervention, a sustainable future is unlikely. According to Teddy Ruge, a Ugandan writer, activist,

and entrepreneur we had the privilege of speaking to, it is more important for the government to develop than for NGOs to step in and fix water and sanitation temporarily. Overall, we were grateful to have the opportunity to delve into a smallscale analysis of water and sanitation in Uganda, and it would be interesting to view water and sanitation through a more global and political perspective in the future. Throughout our journey, we cultivated a new appreciation for the complexity of establishing a functional water and sanitation system in a developing country. We witnessed that despite short-lived success in some areas, a lack of communication, cooperation, and centralization throughout the nation stunts sustainable growth. Individual efforts can only go so far to provide clean water for an entire country. We look forward to applying the many lessons we learned to future engagements both abroad and domestically.

FINAL PRESENTATION: Our team after giving our final presentations to professors and students at Makarere University School of Public Health.

acknowledgements We would like to thank all of the individuals who helped us put this article together. Our instructors, Dr. Mieka Smart, Dr. Roland Thorpe, and Mr. Aloysius Mutebi, were essential in providing us with the materials we needed to thoroughly explore the topic of water, sanitation, and hygiene in Uganda. Their knowledge of the local culture and their connections with public health officials were indispensable. Furthermore, Dr. Frederick Jones Muyodi provided a vital overview of the longterm issues pertaining to water, sanitation and hygiene in Uganda, which was made possible by his years of experience and intimate knowledge of local issues. He also introduced us to his colleague, Dr. Rosemary Nalwanga, who kindly accommodated us by utilizing her expertise in microbiology to run rapid tests on our water samples. Given the time constraints of our project and our limited resources, we would not have been able to get any quantitative results without her help. Lastly, we would like to thank the students from the Makerere University School of Public health for allowing us to navigate each site visit with ease and for inspiring us to share our experience with the Johns Hopkins community. Additionally, to our classmates at Johns Hopkins who went on this journey with us, thank you for your support along the way.

references 1. Mortality and burden of disease from water and sanitation. World Health Organization. https://www. who.int/gho/phe/water_sanitation/burden/en/index2. html. Published 2019. Accessed February 1, 2019. 2. Uganda's Water Crisis - Water In Uganda 2019 | Water.org. Water.org. https://water.org/our-impact/ uganda/. Published 2019. Accessed February 3, 2019. 3. Clean Water for Rural Uganda. Ifc.org. https:// www.ifc.org/wps/wcm/connect/news_ext_content/ ifc_external_corporate_site/news+and+events/news/ clean+water+ppp+for+uganda. Published 2016. Accessed February 3, 2019. 4. Lรถfgren J, Tao W, Larsson E, Kyakulaga F, Forsberg B. Treatment patterns of childhood diarrhoea in rural Uganda: a cross-sectional survey. BMC Int Health Hum Rights. 2012;12(1). doi:10.1186/1472698x-12-19 5. Emergency Disinfection of Drinking Water | US EPA. US EPA. https://www.epa.gov/ground-waterand-drinking-water/emergency-disinfection-drinking-water. Published 2017. Accessed February 3, 2019.

pages.jh.edu/~ep/

Pharmaceutical Advertising: Restrictions that Inspire Creativity By Jeanne Lee | Public Health, JHU '19

ot a lot of people think of the pharmaceutical advertising industry as a creative field. In fact, it is an industry convoluted with strict regulations that usually stifle artistic freedom. From the complicated chemical names to the disturbingly long lists of harmful side effects, pharmaceutical drugs have traits that make them difficult to stir enthusiasm in buyers. When I was interning at imre Health last semester, however, I learned that this assumption was wrong. Twice a week I would find myself walking into a colorful office teeming with innovative ideas, sharp graphics, and artistic photoshoots dedicated to informing patients and doctors about medications that would improve lives. imre Health is an advertising agency of talented writers, coders, health experts, and account executives who work together to serve bigname pharmaceutical clients such as AstraZeneca and AMAG. They do everything from constructing social media campaigns to developing chatbot applications in order to better market drug products to consumers. As a public relations intern, I worked closely with the account and creative team to analyze marketing statistics and contribute to the artistic conceptualization of campaigns. Throughout the semester, I quickly learned that the strict regulations of the pharmaceutical industry were in fact proponents of creativity that inspired an artistic challenge and that finding the solution to these challenges yielded fruitful rewards.

medical, legal, regulatory review

So what exactly are the strict restrictions expected in pharmaceutical advertising? On the first day of my internship, my boss came to my desk with an intimidatingly thick packet of pages printed with legal regulations. She sat next to me to read out the list. First, she explained, any advertising content for medication required a warning of side effects listed clearly and boldly. If the text was too small or if it was difficult to read, the ads were not allowed to be published. Second, every piece of content used in the advertisements required rounds of revisions before they were published. A medical, legal, and regulatory review team, partnered with the Federal Drug Administration, would need to check every word, punctuation, and graphic for medical accuracy before the ads were uploaded onto public platforms such as Facebook or Instagram. Third, once the review team replied back to the agency with the specific revision requests, the finalized draft that the agency sends back would need to make only those specific changes; anything added to the new draft that was not included in previous drafts would mean that the revision process would have to start from the beginning. Even the addition of a single accidental

space, or a deleted apostrophe, would require the agency to start the revision process from scratch. One of my jobs was to print out old drafts and new drafts of a campaign and compare them side by side, checking every single comma and space, and work to make sure that the correct parts of the drafts were identical. During this mundane process, I realized that pharmaceutical ads need to start the creative brainstorming process months in advance to take into account the grueling review process before launch. Unlike conventional advertising content, each of the revisions for medicine could take days to weeks to be reviewed. Considering that the clients would want their campaigns to launch as soon as possible, this process would mean that creative content would need to be developed quickly. Pharmaceutical advertising was thus a challenge not only in terms of restricted content, but also restricted time.

a pharmaceutical photoshoot

These challenges eventually led to greater outcomes. After several weeks of working with the account team, I was asked to assist the creative team with a pages.jh.edu/~ep/

photoshoot for the conceptualization of an upcoming campaign. The artistic director had set up the office’s studio with cameras and pink lights to convey the look and feel that would fit the client’s product for women’s health. As I helped adjust the lights in the right place, I was able to connect the different aspects of the pharmaceutical industry together, from its creation stage to its review and implementation. I sat in front of the camera as the director adjusted the camera’s focus in preparation for the subjects that we would photograph. When I was asked to work behind the camera, I was responsible for selecting music that would compliment the mood so that guests we brought in to photograph reacted in the way that we wanted. When we snapped the pictures, they turned just the way we wanted. I sat along with the artistic director as she reviewed the images and edited them on Adobe Photoshop. She then set up the panels, text, and styling guides for fonts and colors into a PowerPoint deck that would be presented to our client. The result was a beautiful slideshow of designs and pictures of potential patients who would use the drug product. The presentation would be sent to the client for approval before starting the next steps of creating, revising, and implementing the campaign.

campaign results

Tying in the creative and account aspects together allowed me to understand how science and health intersected in pharmaceutical advertising. For my final projpages.jh.edu/~ep/

ect during my internship, I was assigned to analyze an entire year’s performance of a campaign for a drug that treated asthma. I looked at every post that was published on Facebook in the year of 2018 and compared which posts received the most views and most likes, and which posts were completely ignored by viewers. Everything from the color scheme, to the vocabulary used, to the timing of the posts impacted the results. After looking through hundreds of panels on my computer and asking my co-workers for advice, I noticed some interesting trends. Posts that showed people engaging in daily activities, such as participating in yoga, jogging with dogs, or cooking with friends, received the most views and likes. On the other hand, pictures showing doctors talking with their patients, or people in clinical settings, received much fewer likes and views. The fact that all of these posts advertised the same drug, but led to drastically different results, was surprising. Did the statistics suggest that consumers preferred images of the outdoors over being in hospitals? This seemed to be the case for most people. Perhaps for 2019, the campaign should create content solely showing people in their daily activities, omitting all posts relating to the hospital. However, there was a twist. Though the Facebook posts showing outdoor activities performed better overall, the clinical ads performed better among people who were already aware of the drug or specific asthma symptoms. The solution was to then target a campaign by dividing the target audience: one unaware of the drug and one familiar with it. This would result in an effective, well-rounded campaign that would convert those

interested in the drug into actually buying the drug. As I was writing up the report, I sent it to my manager for review. Building on top of my findings, the team revised only a few sentences before sending it directly to our client. I felt rewarded for my work and appreciated my learning curve throughout the semester.

health and creativity

As a senior studying English and Public Health, I was intrigued by the power of language: how nuances in language could compel patients to buy a product, or convince doctors to prescribe medications to their patients. Upon my graduation in a few months, I would like to continue building my skills in this unique niche industry. My internship at imre Health was a refreshing deviation from my experiences at Hopkins, where the STEM-heavy student population tends to focus on the scientific aspects of health rather than the humanistic aspects. Creativity in pharmaceuticals and health is a field that I believe is certainly underappreciated, considering the vital importance of human interaction in connecting the people it serves. In the future, I hope to encourage students to use their creative talents in the health industry where creativity might be least expected. I learned that using creativity in an industry that challenges its use actually encourages the blossoming of ideas that can inspire healthier lives.

EDITORIALS

Photo by Calvin Qian

Instagrams and Instapounds: In Favor of Body Neutrality By Kathleen Li | Public Health, JHU ‘22

n October of 2018, Cosmopolitan released a controversial cover featuring plus-sized model and body positivity activist Tess Holliday. This choice was in support of the body positivity (bopo) movement, a movement about embracing one’s own body that has just recently been adopted by the world of fashion and mainstream society. Almost immediately after the magazine’s release, writers like British columnist Piers Morgan and online media influencers released critiques about how this cover was part of a push to normalize obesity and bad health.1 This is hardly new. Ever since the conception of the body positivity movement, there has been a slew of articles theorizing that fat representation would encourage unhealthy behaviors. Despite and/or because of these criticisms, Holliday has a very interesting stance on her body. In an earlier interview with SELF, Holliday revealed that she felt “guilty saying I eat well and that I’m active and that I do all those things.”2 She didn’t want to succumb to societal pressures, like Morgan’s open letter, to lose weight. I believe that this discussion surrounding Tess Holliday’s weight is interesting because it demonstrates a conversation between the traditional idealization of thinness and two body image movements—fitspiration (fitspo) and body positivity. This interaction uncovers the flaws in all of the beauty movements involved. Holliday rightfully identifies

the harmful nature of the thin ideal and fitspo, but the bopo movement as integrated into mainstream culture currently fails to fully challenge existing beauty ideals and still is detrimental to body image. Both ways of thinking about female beauty still give value to beauty as part of female worth, intentionally or not. Keeping in mind all of these flaws, analysis of this conversation can be used to better understand the complex social restrictions surrounding female beauty, the disregard of which may make another movement called body neutrality the best approach. It builds on the self-compassion touted by body acceptance while also being cognizant of female body autonomy, which is infringed upon by previous beauty movements. Body neutrality is unique among the existing body image movements because it promotes acceptance of one’s body. Others seek

to redefine conventional beauty ideals; fitspiration and body positivity can currently be summed up with the ideas “fitness is attractive” and “every body is beautiful,” respectively. These two movements may have been created in response to the assumed “skinniness is beautiful,” but they inevitably create new beauty standards, mostly for women. (It should be noted that men also face the restrictive pressure of unrealistic beauty ideals, but I will mainly be discussing body image movements in relation to women because of the increased scrutiny our society currently places on female bodies.) To better understand body neutrality, we must first understand the history that led up to it. For decades, the thin ideal, the concept that thinness is a necessary component of feminine beauty, has been reinforced and propagated in traditional media to the detriment of the American

Holliday rightfully identifies the harmful nature of the thin ideal and fitspo, but the bopo movement as integrated into mainstream culture currently fails to fully challenge existing beauty ideals and still is detrimental to body image. pages.jh.edu/~ep/

woman’s mental health. Since the increased popularity of very thin models in the Sixties, discrepancies between the BMI of female models and those of the average American woman have steadily been growing, and an increasingly extreme thin ideal became firmly entrenched in American standards of beauty.3 Accordingly, it is also represented in American media. Such examples of this representation may include the stigmatization of fatness and fat characters as well as the positive portrayal of thinness and thin characters. In traditional media, this might manifest itself as comedy at a fat character’s expense or as the diet articles and pictures in a magazine, which was reported to have influenced 47% of girls to want to lose weight in a study conducted by Field et al.4 Meanwhile, on the internet, this desire is continually fed by the echo chambers of thinspiration and pro–ana (pro–anorexia) sites and tags. These decades spent with the thin ideal have shaped our current society into one where women inevitably feel the pressure to be thin, and their mental health suffers for it.5 Enter fitspiration and body positivity. These two movements have now been adopted by beauty and fashion companies and gained support worldwide, in no small part due to social media. Their appeal stems from a recognition of the harmful effects of the thin ideal and their opposition to it: body positivity pushing for acceptance and representation of all body types, and fitspiration supporting a new focus on fitness instead of thinness. Indeed, Tess Holliday wrote on a twitter post announcing her Cosmo cover: “If I saw a body like mine on this magazine when I was a young girl, it would have changed my life.”6 “Strong is the new skinny,” one popular fitspiration saying goes.7 pages.jh.edu/~ep/

BODY POSITIVITY: Tess Holliday’s Cosmopolitan Cover. Source: “This blogger pointed out the double standard of criticising Tess Holliday's Cosmopolitan cover,” article by Catriona Harvey-Jenner for Cosmopolitan.

Unfortunately, that fitspiration saying wasn’t quite true. One of the biggest flaws of fitspiration is that it predominantly features tall, thin women—the same sort of women who fit into the thin ideal in the first place.8 Similar to thinspiration and other thin ideal media, it continues to stigmatize fatness, objectify women, and promote dieting.9 And like thin ideal media before it, it is therefore horrible for body image.10 In its current state,

fitspiration and arguments in favor of healthy bodies may be accepted by society as a good alternative to extreme idolization of thinness, but skinniness still reigns supreme. This is the environment Holliday is fighting against, and one she fears succumbing to. For women, thinness is considered to be the ultimate goal or at least the final product of fitness; as discussed above, #fitspo images are almost invariably thin and lean. Our definition

of health fails to include larger but still undeniably healthy body types, like those gained from weight training or football. Therefore, as a rising star in the world of beauty and a body positivity activist, Holliday must consider how her actions will be contextualized with societal definitions of beauty. Some parts of the body positivity movement may interpret the changes in her exercise and diet regimen as a betrayal because Holliday is actively changing her body, possibly to align more with the thin ideal, instead of staying in her current state. Ironically, that is why the model feels “guilty.” At first, this seems like a catch-22. Whether they conform to societal beauty ideals or rebel against them, most people will not be able to fully achieve the goals of their side. The pursuit of the thin ideal leads to greater body dissatisfaction, while “loving your body” and not seeking to change it is impossible to do 24/7. In the words of MindBodyGreen Content Editor

Anne Rooney, “Body positivity is hard for me, and this fact actually makes me feel worse when it comes to my body image—I feel bad that I don’t love my aforementioned flaws.”11 Both the established beauty ideals and this new movement can thus reduce perceived female bodily autonomy because they attempt to control how a woman should interact with her body. Therein lies the problem and the solution. Body neutrality tempers the fiery self-compassion of body positivity with the understanding that women cannot always love themselves. It fights the pressures to be thin, and avoids the commercial warping that happened to body positivity. Body neutrality can do all of this because it separates female worth from beauty. One of the secrets to the success of body neutrality is that it adopts one of the most successful aspects of body positivity to combat negative body image—self-compassion. Self-compassion is defined as be-

ing kind towards oneself, realizing that everyone is imperfect, and being aware of negative emotions and thoughts without magnifying them. Some research suggests that this technique may be effective in combating body dissatisfaction because it allowed participants to stop judging themselves so much and recognize the exclusionary and narrow nature of beauty ideals.12 Body positivity and body neutrality closely resemble each other in this aspect. However, their main difference is that body positivity generally promotes a positive attitude towards one’s body, while body neutrality simply promotes acceptance. Both of these techniques technically fulfill the definition of self-compassion, and therefore could combat media influences that worsen body image. In this way, body neutrality and some more radical parts of the body positivity movement are going back to the roots of bopo. Just like in fitspiration, the integration of body positivity in mainstream culture has

REAL BEAUTY: An example of the Dove real beauty sketches. Source: Dove. From the Dove Self-Esteem Project page.

pages.jh.edu/~ep/

resulted in the movement bending to align with traditional beauty ideals, with less controversial aspects of its message turned marketable. Hence, the one-dimensional “you’re beautiful” attitude and conventionally attractive “plus sized” models. Consider the Dove Self-Esteem Project. In one video with a revealing title, “You’re More Beautiful than You Think,” women find out that strangers who meet them describe them as more beautiful than they had described themselves.13 The takeaway here is that the women should not put down themselves, but it also implies that they should think of themselves as beautiful. The pitfall in mainstream body positivity is that it assumes those two are one and the same. This pressure to be positive may likely backfire. According to research from the University of Waterloo and the University of New Brunswick, repeating and internalizing positive statements only really worked for individuals who already had high self esteem.14 People with low self-esteem, however, felt worse after repeating these statements. In the case of beauty, then, Dove’s suggestion that we think of ourselves as beautiful would only hurt the people who need to alleviate body dissatisfaction the most. Instead, according to the study, they would focus on the ways in which they are not beautiful. It is a bitter conclusion to come to, and these women might feel increasingly worthless from their perceived lack of beauty and inability to be positive about themselves...unless we remove beauty from our perception of female worth. Body neutrality and new waves of body positivity, like the one Holliday promotes, present the body as a non-issue. They argue that we should not have to worry about pages.jh.edu/~ep/

our attractiveness. They instead preach self-compassion. In an interview with Today, Holliday said that her view on body positivity is that “[it’s] all about accepting yourself the way you are now and loving who you are today. If you want to work towards a better you ... do it, but you’re OK just the way you are today.”15 This approach means going to the gym, or not, to be healthy. It means viewing your body as your vehicle, instead of decoration. Perhaps the new waves of body positivity would rather have that “OK” to be self-love, and perhaps body neutrality promotes simple acceptance, but they both agree on one thing: ignore the hate, both from British journalists and yourself, and you have a better chance at living a good life. Holliday’s brand of bopo may be something to ultimately strive towards, since thinking of oneself positively is the best outcome. However, achieving that mindset is complicated by existing self-loathing and body dissatisfaction. Rather than set an another unrealistic goal for women about self-love, we should accept body neutrality as a good stepping stone or as a realistic goal, depending on what the woman in question chooses. And even if women choose not to or find themselves unable to take up body neutrality, that’s fine too. Because in the end, we should adopt the underlying message of body neutrality: respect the woman, not the unachievable ideal. references 1. Morgan P. An open letter from Piers Morgan to Tess Holliday: Stop lying to yourself Tess you’re morbidly obese and it’s going to kill you. Daily Mail. September 20, 2018. https:// www.dailymail.co.uk/news/article-6190487/ PIERS-MORGAN-Stop-lying-Tess-youre-morbidly-obese-going-kill-you.html. Accessed January 10, 2019. 2. Ford A. Tess Holliday’s Health Is None of Your Business. SELF. https://www.self.com/ story/tess-holliday. Published June 25, 2018.

Accessed January 12, 2019. 3. Martin JB. The Development of Ideal Body Image Perceptions in the United States. Nutr Today. 2010; 45(3): 98-110. doi: 10.1097/ NT.0b013e3181dec6a2. 4. Field AE, Cheung L, Wolf AM, Herzog DB, Gormaker SL, Colditz GA. Exposure to the mass media and weight concerns among girls. Pediatr. 1999;103:e36. doi: 10.1542/ peds.103.3.e36, 1Y5. 5. Thompson JK, Stice E. Thin-Ideal Internalization: Mounting Evidence for a New Risk Factor for Body-Image Disturbance and Eating Pathology. Curr Dir in Psychol Sci. 2001; 10(5): 181–183. doi: 10.1111/1467-8721.00144 6. @Tess_Holliday. Phew, I’m literally a COSMO GIRL!! Can’t believe I’m saying that! Thank you @CosmopolitanUK for this incredible opportunity. If I saw a body like mine on this magazine when I was a young girl, it would have changed my life. 7. Issue hits stands 8/31! https://twitter.com/ Tess_Holliday/status/1034807072687177729. Posted August 29, 2018. 8. Kiberd R. Fitspo: how strong became the new skinny. The Guardian. April 20, 2015. https://www.theguardian.com/lifeandstyle/2015/apr/20/fitspo-strong-skinny-socialmedia-food-abs-better-living-body-fascism. Accessed January 5, 2019. 9. Carrotte ER, Prichard I, Lim MSC. “Fitspiration” on Social Media: A Content Analysis of Gendered Images. J Med Internet Res. 2017;19(3):e95. doi: 10.2196/jmir.6368. 10. Boepple L, Thompson JK. A content analytic comparison of fitspiration and thinspiration websites. Int. J. Eat. Disord. 2015;49: 98-101. doi:10.1002/eat.22403 11. Tiggemann M, Zaccardo M. “Exercise to be fit, not skinny”: The effect of fitspiration imagery on women's body image. Body Image. 2015;15. 61-67. doi:10.1016/j.bodyim.2015.06.003. 12. Rooney A. Forcing Myself To Love My Body Didn’t Work. Here’s What I Did Instead. mindbodygreen. https://www.mindbodygreen.com/ articles/what-is-body-neutrality. N.d. Accessed January 8, 2019. 13. Albertson ER, Neff KD, Dill-Shackleford KE. Self-compassion and body dissatisfaction in women: A randomized controlled trial of a brief meditation intervention. Mindfulness. 2015;6(3): 444-454. doi: 10.1007/s12671014-0277-3 14. Dove US [Dove US]. (2013, April 14). Dove Real Beauty Sketches | You’re more beautiful than you think (3mins) [Video file]. Retrieved January 11, 2019 from https://www. youtube.com/watch?v=XpaOjMXyJGk. 15. Wood JV, Perunovic EWQ, Lee JW. Positive Self-Statements: Power for Some, Peril for Others. Psychol Sci. 2009; 20(7): 860–866. doi: 10.1111/j.1467-9280.2009.02370.x 16. Dawn R. Model Tess Holliday doesn't worry about bullies, naysayers anymore. Today. https://www.today.com/style/size-22-supermodel-tess-holliday-has-her-head-straight-t22256. Published May 21, 2015. Updated May 21, 2015. Accessed January 12, 2019.

Should Public Health Include The Well-Being of Animals? By Lana Weidgenant | Public Health, JHU '21

rom factory farming to makeup testing on animals, issues of immense animal suffering have impacted human populations through the safety and transparency of the products we purchase. From the antibiotics in grocery store meat, dairy, and eggs, to the animal toxicology tests used to prove safety for our personal care products like mascara and shampoo,1 issues of animal health have become increasingly tied to issues of human health. But should public health always frame its concern in terms of the human impact? Or should public health itself include the well-being of other species outside our own? Some parts of the public health world certainly support that way of thinking. After all, the Johns Hopkins Bloomberg School of Public Health (JHSPH) houses the Center for Alternatives to Animal Testing (CAAT), which describes itself as working to “promote humane science” through the “three R method.” The three “R”s are as follows: reduce the number of animals used in research, replace ani-

mals with more effective non-animal methods, and refine practices with the purpose of making them “less painful or stressful to the animals involved.”2 The JHSPH also contains the Center for a Livable Future, which researches food systems and production, and infamously published the 2008 Pew Commission report on CAFOS (Concentrated Animal Feeding Operations or factory farms), which “concluded that the current method of producing food animals presents an unacceptable level of risk to public health and damage to the environment, as well as unnecessary harm to the animals we raise for food.”3 Animal suffering and a lack of animal welfare were considered in this well-known report, and may indicate that we should do the same. Inspired by these concepts, I scheduled an appointment this semester with my advisor in the Public Health Studies department to discuss completing the Applied Experience major requirement. As someone interested in animal welfare, I brought up the idea of aiding a campaign to pass a law

Public health has traditionally concerned itself with human well-being and several definitions of public health ... [are] in terms of only promoting and protecting the health of people ... 52

that would phase out makeup company testing on animals. My advisor expressed great concern over whether the experience would be approved and almost discouraged me from applying. I understand where this concern comes from. Public health has traditionally concerned itself with human well-being and several definitions of public health, such as the one provided by the American Public Health Association and the Future of Public Health text cited in many Johns Hopkins courses,4 have defined public health in terms of only promoting and protecting the health of people and their communities and of reducing human suffering.5 However, I decided to submit the Applied Experience proposal regardless of my advisor’s concerns. To my great surprise, it was approved! I strongly believe that this approval and the reason I am now working as the End Cosmetics Testing on Animals Assistant at the Humane Society of the United States is because I focused on the human impact of cosmetics testing. Rather than discussing the vast populations of animals facing painful conditions in makeup labs across the United States, I framed my Applied Experience in terms of consumer transparency and safety, talking about how most people were unaware of what happened before their makeup wipes or mascara made it to the store shelf. For example, I addressed that animal testing can act as a poor indicator of a product’s effects on a human being due to the differences between pages.jh.edu/~ep/

the body of a human and that of a mouse, rabbit, or dog. As the Humane Society of the United States specifies on their site, this has very much been the case with consumer safety at risk due to how “different species respond differently when exposed to the same chemicals.”6 Nevertheless, as with all of my co-workers, my motivation for campaigning against the practice of cosmetic animal testing is not by any means limited to concerns of consumer transparency and safety, but is instead always grouped with a mission to end unnecessary animal suffering occurring in the hands of cosmetic companies. After all, the campaign to pass the Humane Cosmetics Act is being conducted by The Humane Society Legislative Fund and The Humane Society of the United States—national animal protection organizations that largely operate on the basis of decreasing the suffering of non-humans. Going back to the Johns Hopkins community, it is important to contrast the definition of public health provided by the American Public Health Association above with the definition provided by JHSPH, which describes public health through a comparison with the medical field. JHSPH states that whereas doctors treat diseases and injuries on the individual level, public health works at the community and population level to identify the cause of the issue and work towards prevention.7 Within this definition, the work of animal protection organizations, such as The Humane League or The Humane Society of the United States, appear to perform a ‘public health role’ for non-humans, working at the community and population level of issues such as factory farming and makeup testing on animals. Whereas a veterinarian might individually treat a rabbit that has been exposed pages.jh.edu/~ep/

BEAUTY INDUSTRY: Humane Society poster against animal testing Source: Humane Society International and The Humane Society of the United States. From the campaign to End Cosmetics Testing on Animals.

to large amounts of chemicals or a dairy cow living under inhumane conditions, non-profit organizations such as the one I am completing my Applied Experience with raise awareness and pass legislation to impact the larger community issues. Both the Center for Alternatives to Animal Testing and the Center for a Livable Future are nestled within JHSPH, which has consistently been named the number one school for public health in the United States.8 Both of these public health centers have been acting as hubs for animal welfare developments and explicitly stating motivations to decrease animal suffering in their work. This should make us question where we draw the line of inclusion in public health. Looking briefly at the history of public health, Dr. John Snow and Henry Whitehead historically challenged

the belief of their time that the 1854 cholera epidemic could be contributed to the lifestyle and foul odors of lower income populations and instead reshaped public health to focus on the previously disregarded importance of sanitation. Afterwards, Rudolph Virchow introduced social justice activism for poorer populations into the sphere of public health as he realized the social causes which were bringing about the need for sanitation campaigns. Repeatedly, public health has increased its circle of concern, expanding to include infant and maternal health, occupational health, prevention of occupational injuries, and even environmental health.1 Many of these core aspects of public health, which we largely take for granted as students, were not included in the conception of public health that Dr. John Snow confronted. This question of what we include

in public health is crucial. After all, if public health aims to ultimately promote welfare and decrease suffering, then the criteria for being included in public health should be sentience (or the ability to feel pain and suffer). And if sentience or the ability to feel pain is not enough, and instead we consider a difference in mental capacity, then we must justify to ourselves why an infant or human with a disability who happens to be at the same mental level of various other species would be included under the umbrella of public health concern while a non-human of the same mental ability is not.

Photo by Grace Lee

So, should our modern understanding of what public health means include a concern for non-human species? And if not, what is our justification? references 1. Akhtar A. Animals and Public Health: why treating animals better is critical to human welfare. The Palgrave Macmillan Animal Ethics Series. https://www.worldcat.org/title/animalsand-public-health-why-treating-animals-betteris-critical-to-human-welfare/oclc/778696955. Accessed January 16, 2019. 2. Johns Hopkins Bloomberg School of Public Health. About us: Center for Alternatives to Animal Testing. Jhsph.edu. http://caat.jhsph.edu/about/index.html. Accessed January 16, 2019. 3. Pew Commission on Industrial Farm Animal Production. Putting Meat on the Table: Industrial Farm Animal Production in America. https://www.pewtrusts.org/en/ research-and-analysis/reports/0001/01/01/putting-

meat-on-the-table. Accessed January 16, 2019. 4. Institute of Medicine. A Vision of Public Health in America: An Attainable Ideal. Chapter 2 In: The Future of Public Health. Washington, DC: National Academy Press; 1988. 5. American Public Health Association. What is Public Health? apha.org. https://www.apha.org/what-is-public-health. Accessed January 16, 2019. 6. The Humane Society of the United States. Fact Sheet: Cosmetics Testing. Humanesociety.org. https:// www.humanesociety.org/resources/fact-sheet-cosmetic-testing. Accessed January 16, 2019. 7. Johns Hopkins Bloomberg School of Public Health. What is Public Health? Jhsph.edu. https://www.jhsph. edu/about/what-is-public-health/index.html. Accessed January 16, 2019. 8. Johns Hopkins Bloomberg School of Public Health Again Named No.1 Grad School of Its Kind [news release]. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health; March 10, 2015. https://www.jhsph.edu/news/news-releases/2015/johns-hopkins-bloomberg-school-of-public-health-again-named-number-1-grad-school-ofits-kind.html. Accessed January 16, 2019.

Photo by Grace Lee

ACKNOWLEDGMENTS The staff of Epidemic Proportions would like to thank the Public Health Studies Program, the Krieger School of Arts and Sciences, and the Johns Hopkins Bloomberg School of Public Health for making this journal possible. We would like to extend our appreciation and recognition to President Ronald J. Daniels; Dean Beverly Wendland of the Krieger School of Arts and Sciences; Dean Ellen MacKenzie at the Johns Hopkins Bloomberg School of Public Health; the members of the Public Health Studies Advisory Board: Colleen Barry, Laura Morlock, Joel Schildbach, Steven David, Andy Cherlin, Adam Sheingate, Marie Diener-West, John Groopman, James Yager, and Scott Zeger; and the members of the Krieger School of Arts and Sciences Public Health Studies Program: Maria Bulzacchelli, Katherine Henry, Natalie Boyd, Cara McNamara, Keri Frisch, and Caroline Barry.

Photo by Grace Lee

EDITORIAL BOARD Editors-in-Chief

Kain Kim Soonmyung Hwang

Research

Lydia Lee (Editor) Trisha Parayil (Editor) Joshua Woo Roshini Narayanan Ahimsa Aradhya Jesse Huang

Features

Noela Lu (Editor) Lisa Ha Courtney Harrington Daphne Moraga Caroline Wang

Editorials

Grace Ren (Editor) Olivia Chan Kristine Nyugen Kathleen Li

Policies

Sanjana Murthy (Editor) Lidya Tadesse Emily Lee Ananya Kalahasti Benjamin Laurin

Layout

Asim Dhungana (Editor) Ying Zhang Sarah Rosenberg Aileen Zhou

Copywriting

Anagha Ashokan (Editor) Laurence Okeke Anna Fiedor Hannah Bruckheim Aditya Bhave

Publicity

Caroline Aronin (Chair) Sharon Chow (Chair) Ying Zhang Michelle Chung Aileen Zhou Jamie Kim

Photography

Aileen Zhou Michelle Chung

Treasurer

Jamie Kim

Advisor

Natalie Boyd

Photo by Calvin Qian

Illustration by Aileen Zhou