Volume 19, Spring 2022

Page 1

In this Issue Letter from the Editors Featured Letter

4 6

Bringing to Light the Millions of Left-Behind Children in China

8 Connecting with Baltimore Through Alternative Medicine at the Joy Wellness Center


Eradicating the Potential Barriers Hindering Adherence to Antiretroviral Therapy in Southern India through Treatment Counseling


No More Slim Pickings: Time to Demand Quality Nutrition Standards in American Schools


Should Scientists Translate Their Own Research?


The Need for HPV Vaccination to be Mandatory and Accessible for Sixth Graders


Developing a Statistical Awareness of Racial Disparities in Health Care


Day at the Market: a Health Outreach Initiative


Incorporating Unintentional Childhood Injury Prevention in Federally Funded Home Visiting Programs

81 What We Can Learn from the Thailand Department of Public Health


An Illusion of Explanatory Depth in Public’s Understanding of COVID-19

94 The Hidden Epidemic: A Call to Reform Secondary School Education on the Opioid Crisis


Learning from a Pandemic: Mass Vaccination and COVID-19


On The Cover

Vaccination Patterns, Disparities, and Policy Among Asian Americans and Asians Living in the U.S.

106 An Ethical Analysis of Vaccine Prioritization

119 Baltimore Service Organizations


Cover Illustrations by Han Zhang "Through this piece, I hope to highlight the healing power of community resilience that is easily overlooked in the pandemic era. The difficult times have relayed the importance of uniting different voices and uplifting each other. Illustrating this cover led me to appreciate the ordinary people behind the extraordinary success we take for granted." Han Zhang Public Health Studies Class of 2023

Letter from the Editors Dear Readers, Welcome to the 19th edition of Epidemic Proportions, a collection of academic works highlighting the public health research and experiences of Johns Hopkins University students in Baltimore and beyond. Since our last issue, the world has once again entered a period of significant change. Just as we once adapted to the regulations put in place to limit the spread of the COVID-19 pandemic, we can now begin to appreciate the efforts to restore our society to a state of normalcy. To better highlight this momentum, our theme for the 19th issue of Epidemic Proportions is “Healing Communities.” We hope that this volume of Epidemic Proportions gives you an insight into the consequences the pandemic has had on communities in Baltimore. It has been a unique opportunity presenting student research and experiences from throughout the pandemic, and each of the following articles represent the coming together of numerous individuals to address the problems which affect us all. We are grateful for the resilience and adaptability of not only the Baltimore community but also of our authors and staff editors for working to better public health in any way possible throughout these difficult times. As we move forward in repairing our community, we should take care to remember the truly world-changing events that have led us to this point. Although a significant majority of our content is about COVID-19 and related issues such as disparities in mass vaccination and the public understanding of COVID-19, we would also like you to reflect on the plethora of unrelated factors that have impacted communities throughout the pandemic as well. Throughout this issue, we aim to highlight issues such as food insecurity, racial disparities, and the opioid crisis that have long been prevalent within Baltimore but have been significantly worsened by the effects of the pandemic. As you peruse the following pages, we invite you to reflect on how the pandemic has directly and indirectly impacted you, and ask in turn what you can do to help those around you. Most of all, we hope this journal inspires you, as it has inspired us, to better understand how our communities and humanity as a whole can begin to heal and learn from this experience. Lovingly yours,

Kriti Bomb 4

Jesse Huang Epidemic Proportions

Kriti Bomb

Kriti Bomb is a recent graduate with a B.A. in Public Health Studies and Psychology. She is currently a research assistant at a molecular & cellular pathobiology lab at JHMI and a MHS candidate in Epidemiology at the Bloomberg School of Public Health. She hopes to attend medical school after her gap year. Kriti has been a part of Epidemic Proportions for 4 years, and will greatly miss all of the wonderful people!

Jesse Huang

Jesse Huang is a recent graduate with a B.A. in Biophysics and Applied Math & Statistics. He currently works as a research assistant at the Johns Hopkins Center for Cell Dynamics and hopes to attend medical school after his gap year. He has been a proud member of Epidemic Proportions for all 4 years of college and will miss getting to know the other members of the team most of all. Edition 19 Spring 2022

Photo Courtesy of Mason Cole 5

Featured Letter The COVID-19 pandemic has radically changed all aspects of life. In our case, COVID-19 is responsible for bringing together a public health lawyer, an ex-probation officer, and a doctor of nanomedicine to address critical issues related to public health data infrastructure. Our work together on the Johns Hopkins Coronavirus Resource Center (CRC) – and its accompanying blog series within the Pandemic Data Initiative – has provided first of its kind, real-time public health data and analysis directly to individuals around the world for almost two years. This unprecedented public health service has only been successful due to an immensely collaborative and multidisciplinary team. Quickly after Professor Lauren Gardner and her team at the Whiting School’s Center for Systems Science and Engineering first launched the Johns Hopkins COVID-19 Global Map in January 2020, the University’s response became all-hands-on-deck, attracting expertise from all corners. Johns Hopkins President Ron Daniels envisioned the CRC as an interdisciplinary effort that would translate the depth and breadth of Hopkins expertise into information for policymakers and the general public alike, embodying the Hopkins mission, “knowledge for the world.” The data collection and technical expertise of teams from the Centers for Civic Impact/Center for Government Excellence, Sheridan Libraries, and the Applied Physics Laboratory became integral to scaling our work to meet the intense global demand for real-time information. In addition to data experts, this growing CRC team knew that we needed to leverage world class expertise from across the University. We brought together faculty experts from the Johns Hopkins Bloomberg School of Public Health and School of Medicine in contact tracing, testing, vaccination, and epidemiology to help direct our efforts and provide invaluable insight through public analysis and internal discussions. Our success in propelling these voices and data into such a prominent position in the public sphere is due in large part to the CRC’s communications team and support from University leadership and our philanthropic partners at Bloomberg Philanthropies and the Stavros Niarchos Foundation. We built a team that reflects the need to bring in diverse perspectives that could provide insights on the impact of the COVID-19 pandemic on all facets of society – from health care and public health, to economics, climate, mental health, and sociology. Public health is a broad field and benefits from collaborations. We have capitalized on this coalition approach to investigate many aspects of the COVID-19 pandemic apart from cases and deaths. The pandemic has highlighted that the cracks in our communities driven by institutional racism, wealth inequality, and political ideologies run deep. The CRC has been committed to pursuing data and analysis that explore these inequalities. Moving forward we will need a collaboration that spans divisions and institutions that represent diverse communities to begin discussing, researching, and solving these problems. Public health 6

Epidemic Proportions

cannot be solely a concern of public health experts. The social determinants of health derive from a multitude of sources and require groups of interdisciplinary subject-matter experts collaborating to address these health issues. Today, some of the most interesting, innovative, groundbreaking research is done at the intersection of disparate fields. Just here at Johns Hopkins we have engineers working with oncologists to investigate the processes of cancer metastasis, musicians working with neurologists to study fine motor skills, and teachers working with nurses and economists to redefine health education. Collaboration is key to the progress we pride ourselves on. We have personally seen how strong an impact we can have on public health problems when the team is broad, determined, and mission-driven with complementary expertise. Engineers can tackle public health issues. Economists can tackle public health issues. Lawyers can tackle public health issues. Historians can tackle public health issues. And, we don’t need the pressures of a global pandemic to make an incredible impact on public health. Long after this pandemic is over, we will continue to work together within Johns Hopkins to help improve the health and well-being of the global community. We hope you will join us.

Joshua E. Porterfield

Beth Blauer

Lainie Rutkow

Joshua E. Porterfield received his PhD in Chemical and Biomolecular Engineering from Johns Hopkins University in 2020, three days before campus closed for COVID-19. His research career has covered diverse fields including regenerative medicine, cancer biology, neuroscience, hepatology, ophthalmology, and nanomedicine. He is the Pandemic Data Initiative lead for the Johns Hopkins Coronavirus Resource Center.

Beth Blauer is the Associate Vice Provost for Public Sector Innovation. Blauer oversees the work of Johns Hopkins’ Center for Government Excellence and the Bloomberg Center for Government Innovation. Blauer is also an Associate Professor of the Practice at the Carey School for Business. Blauer believes strongly that the Government can transform lives for the better and that academic partners are critical to the public sector. She is the data lead for the Johns Hopkins Coronavirus Resource Center.

Lainie Rutkow is a Professor of Health Policy and Management in the Bloomberg School of Public Health and the University’s Vice Provost for Interdisciplinary Initiatives. She works at the intersection of public policy, law, and health using legal, qualitative, and quantitative methods to determine how law influences public health outcomes. She is the project lead for the Johns Hopkins Coronavirus Resource Center.

Edition 19 Spring 2022


Editorials | Gloria Li

Bringing to Light the Millions of Left-Behind Children in China


In high school, Li joined a non-profit that worked with students in rural China. This experience exposed her to the issue of leftbehind children in China, and provoked Li to learn about this underdiscussed situation that affects millions. In this article, Li shares some of the main elements she has learned about leftbehind children in hopes of spreading awareness on the issue; after all, awareness is the first step towards solving any problem. Epidemic Proportions

Photo Courtesy of Irfaan Karim


n my sophomore year of high school, I joined Education For All (EFA), a studentrun non-profit that teaches English to rural Chinese children. However, I had no idea how much it would impact me. Although I had only expected to improve my Mandarin when I first entered the organization, I instead found myself becoming close friends with a community of altruistic young adults across the world, fostering strong relationships with dozens of adorable children, and realizing the life-changing role an education could bring to impoverished individuals. Yet, the most eyeopening part for me has been learning about an issue that impacts a huge group of people but is talked about by so few. What I did not know when I first started teaching classes of rural Chinese children was

Edition 19 Spring 2022

that many of them did not have parents to go home to— they were “left-behind children.” According to the United Nations Children’s Fund, there are more than 69 million leftbehind children— rural minors with one or both parents working in urban areas—in China.1 That is more than 1.5 times the population of Canada! The sheer number of children who experience this situation motivated me to consult online resources so that I could gather an understanding of this issue. Why

There are more than 69 million left-behind children— rural minors with one or both parents working in urban areas—in China.1 " 9

do so many parents leave? What does the life of a left-behind child look like? What are the effects of being left behind? Based on my research, I hope to spread awareness about the struggles of being a left-behind child. Why do Parents Leave? In short, parents are migrating from rural areas to urban places to work. China’s rural to urban migration is one of the largest internal migrations in world history.2 Several factors contribute to this mass migration, especially the loss of rural land. Originally, Chinese rural citizens were prohibited from entering urban areas. To avoid the socioeconomic consequences of huge floods of rural migrants to cities, China established a household registration system called Hukou ( ) to control its population and prevent rural citizens from entering cities. However, as China began its economic reform during the late 1970s, these regulations became more relaxed. With the increasing demand for cheap labor in urban areas, the government gradually allowed the rural population to travel to cities and work. Accordingly, millions of rural citizens have migrated to pursue jobs since the beginning of the 1980s.3 Although rural migrant workers earn higher wages in cities, they are treated as inferior to the general population. Since their households are registered in rural places, these workers cannot access city resources such as free public education for their children.4 Thus, most children are left behind in rural areas with their grandparents so they can go to school. While some rural citizens decide to migrate to cities for economic reasons, migration is often not a choice. Many people are forced to migrate due to the loss of rural land.2 When China’s economic reforms began in the late 10

1970s, the rapid urbanization led to the loss of farmland at an unprecedented speed.5 This can be seen in the difference in farmland lost between 1978 to 2003 and 2003 to 2015. In the 25 years spanning 1978 to 2003, approximately 4.7 million hectares of farmland was lost, whereas during the 12 years between 2003 to 2015, this number was nearly tripled to 11.56 million hectares of farmland lost.6 By 2011, a total of 40 million Chinese farmers have lost their land, with projections showing that number to reach 110 million by 2030.7 As of 2009, an estimated 1 in 3 Chinese rural citizens live in non-rural areas.2 What Does the Child Think? In 2014, Oxford sociologist Dr. Rachel Murphy traveled to rural Jiangxi to interview left-behind children. A key finding from her study was that many of these children believe that their parents migrated to pay for their education, so these children feel obligated to study hard.8 Even in situations where children are not directly told why their parents were working in urban areas, the children inferred that their education was the main reason.8 Thus, most left-behind children believe their parents are working tirelessly for them and that they must do their part in achieving high grades. These beliefs are then confirmed when parents visit home looking exhausted.8 Feeling constantly indebted to their parents, however, causes left-behind children to put less emphasis on themselves.9 Compared to urban children, left-behind children are more group-oriented and less likely to care much about their individual well-being.9 How is the Child-Parent Relationship Affected? Even though left-behind children want to succeed academically for their parents, Epidemic Proportions

While many left-behind children are determined to succeed academically, research has shown that their educational performance tends to be worse than their non-left-behind peers." they still miss them. Left-behind children are unable to gain the care they crave from their grandparents, who are often appointed as left-behind children’s guardians.8 As fourteenyear-old Heqin explains: “Living with [my grandfather], I am independent and look after myself. [My grandfather] is in poor health, he is eighty‐eight. My parents are not here to look after me. I cook, wash clothes, clean and buy medicine for [my grandfather]”.8 Filial piety and self-sacrifice for the family, along with other traditional Chinese values, are highly emphasized in rural areas, and Heqin is clearly showing this through her care.9 When attempting to gain the care they crave from their parents, many left-behind children only receive more pressure to perform well in school. For example, thirteen-year-old Zhanglin explained that when he told his parents he missed them, his parents would always reply with “study hard”.8 Moreover, twelve-year-old Cuili disclosed that when she asks her older sister why their parents have still not returned, her sister says “Don’t worry. Study hard. They are earning money. Don’t disappoint them”.8 Even though a few of the children explained that they sometimes cried because they missed their parents, they expressed that their crying was unjustified since their parents were working so hard for their future. Eleven‐year‐old Jinhong recalls that one time, when her grandmother saw her crying, her grandmother scolded her by stating: “Your parents are out earning money for you. There is nothing for you to cry about.”8 Edition 19 Spring 2022

Some children, like thirteen-year-old Shenyi, can use their good academic performance to comfort them. Shenyi reported during his interview with researchers that although he wished his mother could come back, he consoled himself by imagining how happy she was that he was studying diligently in school.8 However, others who believed their academic performance was inadequate often avoided interacting with their migrant parents and reported intense feelings of shame and unhappiness when speaking with them. Regardless, many left-behind children experience feelings of abandonment from their parents and develop estranged relationships with them as those feelings linger throughout their lives.10 How are Left-Behind Children Affected Academically? While many left-behind children are determined to succeed academically, research has shown that their educational performance tends to be worse than their non-left-behind peers. For instance, Professor Hongliang Zhang of the Chinese University of Hong Kong found that left-behind children consistently perform worse on primary school exams.3 Another study confirmed that the longer the parents are absent, the poorer the left-behind child’s academic performance.11 Furthermore, schools in rural areas are considerably worse than schools in urban areas, inhibiting left-behind children and other rural children from obtaining a good education. Because rural education lacks proper funding, 11

teachers are often inexperienced, overworked, and underpaid, leading to a poor learning experience for students. Many rural educators have no formal teacher training; some have only completed middle school or high school.12 Moreover, some staff work for over 12 hours a day.12 Regardless, academics remains one of the top priorities for left-behind children. In China, admittance to university lies entirely upon students’ performance on the National College Entrance Examination (NCEE), a difficult standardized test where millions of Chinese high school seniors compete for one of the limited spots to higher education. In preparation for the NCEE, most parents want their children to succeed academically from a young age, emphasizing good study habits and high test scores. This especially includes left-behind children’s parents, who hope their children may achieve a better life than them. This, however, means that more emphasis is often put on academics than students’ wellbeing. What are the Mental Health Effects? Compared to other children, left-behind children have worse mental health overall. Leftbehind children have lower levels of subjective well-being, lower self-esteem, and higher levels of anxiety.11,13-16 Moreover, they are at a higher risk of mental disorders, are more likely to show symptoms of depression, and have more mental health problems compared to the general population of Chinese children.15-18 Not only do left-behind children perform poorer emotionally, but they also perform poorer socially.17 One study, which scanned Chinese children’s brains using Magnetic Resonance Imaging, found that the parts of the brain responsible for emotional regulation and processing are different in left-behind children, 12

suggesting that biological parental care can impact children’s brain development.19 Furthermore, the younger a child was when their parents left, the more symptoms of anxiety and depression the child displayed.20 However, left-behind children tend to report higher levels of happiness and selfesteem with time.14 This is perhaps because as left-behind children grow older, they develop a better understanding of their own circumstances and learn to appreciate their parents’ difficult decision. What are Some Established Support Systems For Left-Behind Children? Currently, the Chinese government and multiple organizations are working towards improving the psychological development of left-behind children. Children’s Club, a community-based intervention that allows leftbehind children to drop-in, play, and engage in educational activities, has been shown to bolster emotional well-being and is currently being integrated into numerous rural areas.21 The Global Youth Mentorship Initiative, a nonprofit public charity founded at Columbia University, aims to help foster emotional and social development in left-behind children by partnering them with undergraduate students. Stanford University’s Rural Education Action Program has been working with Chinese universities, rural schools, and the Chinese government to learn more about early childhood development and changing policy to improve the conditions for rural kids, including left-behind children. However, in a 2020 systematic review of interventions that promote the mental well-being of left-behind children, researchers agreed that more widespread dissemination is needed.22

Epidemic Proportions

Conclusion Informed by this research, I helped develop the Emotional Development Guarantees Excellence (EDGE) Mentorship program at EFA two years ago, which pairs left-behind children with a high school mentor who is regularly trained and advised by a certified psychologist. EDGE aims to develop “big brother”/“big sister” relationships between students and volunteers, and EFA hopes to eventually grow this program to reach the 1000+ students they work with. Currently, EDGE works closely with 36 students who spend an hour a week with their mentor online. Meanwhile, EDGE volunteers routinely practice their active listening and empathy through emotionally supporting others online and regularly checking in with EFA’s psychologist. Another idea I have proposed to EFA is implementing short positive psychology activities such as meditation, gratitude letters, and character strength identification which bolster mental well-being into lessons, but this is still a tentative initiative. Nonetheless, more action is needed to support the millions of left-behind children across China. The first step to solving any issue is awareness. I hope that this piece has been able to inform readers and spark some into action, whether through educating themselves further about this complex issue, volunteering at an organization like EFA (visit efaglobal.org for more information), or becoming involved with advocacy and policy. References

1. UNICEF. Country Office Annual Report: China. UNICEF website. https://www.unicef.org/about/ annualreport/files/China-2019-COAR(1).pdf. Accessed November 12, 2021. 2. Ye J, Wang C, Wu H, He C, Liu J. Internal Migration and Left-Behind Populations in China. The Journal Edition 19 Spring 2022

of Peasant Studies. 2013;40(6):1119-1146. doi: 10.1080/03066150.2013.861421 3. Zhang H, Behrman JR, Fan CS, Wei X, Zhang J. Does Parental Absence Reduce Cognitive Achievements? Evidence from Rural China. Journal of Development Economics. 2014;111:181-195. doi: 10.1016/j.jdeveco.2014.09.004 4. Chen Y, Feng S. Access to Public Schools and the Education of Migrant Children in China. China Economic Review. 2013;26:75-88. doi: 10.1016/j. chieco.2013.04.007 5. Jiang L, Deng X, Seto KC. The Impact of Urban Expansion on Agricultural Land Use Intensity in China. Land Use Policy. 2013;35:33-39. doi: 10.1016/j. landusepol.2013.04.011 6. Liu S. China’s Two-Stage Land Reform. International Economic Review. 2017;5:29-56. 7. Editorial Board of China Urban Development Report. China Urban Development Report (2011). China City Press; 2011. 8. Murphy R. Study and School in the Lives of Children in Migrant Families: A View from Rural Jiangxi, China. Development and Change. 2014;45(1):29-51. doi: 10.1111/dech.12073 9. Bond MH. Oxford Handbook of Chinese Psychology. Oxford University Press; 2010. 10. Ye J. Left-Behind Children: The Social Price of China’s Economic Boom. The Journal of Peasant Studies. 2011;38(3):613-650. doi: 10.1080/03066150.2011.582946 11. Zhou M, Murphy R, Tao R. Effects of Parent’s Migration on the Education of Children Left Behind in Rural China. Population and Development Review. 2014;40(2):273-292. doi: 10.1111/j.17284457.2014.00673.x 12. Elmer K, Crothall G. Over-Worked and Under-Paid: The Long-Running Battle of China’s Teachers for Decent Work. China City Press; 2011. 13. Zhou J, Hu F, Wu J, et al. Subjective Well-being and Family Functioning among Adolescents Left Behind by Migrating Parents in Jiangxi Province, 13

China. Biomedical and Environmental Sciences. 2018;31(5):382-388. doi: 10.3967/bes2018.049 14. Dai Q, Chu R. Anxiety, Happiness and Self-Esteem of Western Chinese Left-Behind Children. Child Abuse & Neglect. 2018;86:403-413. doi: 10.1016/j. chiabu.2016.08.002 15. Wang X, Ling L, Su H, Cheng J. Self-Concept of Left-Behind Children in China: A Systematic Review of the Literature. Child Care Health and Development.2014;41(3):346-355. doi: 10.1111/ cch.12172 16. Zhao X, Chen J, Chen M, et al. Left-Behind Children in Rural China Experience Higher Levels of Anxiety and Poorer Living Conditions. Acta Paediatrica. 2014;103(6):665-670. doi: 10.1111/apa.12602 17. Wang L, Mesman J. Child Development in the Face of Rural-to-Urban Migration in China: A Meta-Analytic Review. Perspectives on Psychological Science. 2015;10(6):813-831. doi: 10.1177/1745691615600145 18. Liang Y, Wang L, Rui G. Depression Among Left-Behind Children in China. Journal of Health Psychology. 2016;22(14):1897-1905. doi: 10.1177/1359105316676333 19. Fu Y, Xiao Y, Du M, et al. Brain Structural Alterations in Left-Behind Children: A Magnetic Resonance Imaging Study. Front Neural Circuits. 2019;13:33. doi: 10.3389/fncir.2019.00033 20. Liu Z, Li X, Ge X. Left Too Early: The Effects of Age at Separation from Parents on Chinese Rural Children’s Symptoms of Anxiety and Depression. American Journal of Public Health. 2011;99(11):20492054. doi: 10.2105/AJPH.2008.150474 21. Zhao C, Zhou X, Wang F, Jiang M, Hesketh T. Care for Left-Behind Children in Rural China: A Realist Evaluation of a Community-Based Intervention. Children and Youth Services Review. 2017;82:239245. doi: 10.1016/j.childyouth.2017.09.034 22. Wang M, Sokol R, Luan H, et al. Mental Health Service Interventions for Left-Behind Children in Mainland China: A Systematic Review of Randomized Controlled Trials. 2020;117:105304. doi: 10.1016/j. childyouth.2020.105304 14

Gloria Li Public Health Studies & Natural Sciences Class of 2025

Photo Courtesy of Irfaan Karim Epidemic Proportions

Features | Romina Rojas

Connecting with Baltimore Through Alternative Medicine at the Joy Wellness Center


Through her internship at the Joy Wellness Center, Rojas was able to witness firsthand the operations of a healthcare facility aiming to lower the barriers to accessing integrative healthcare in the Baltimore community. Her experiences helped her gain new insights on alternative medicine remedies and how they can be used to nourish both the body and mind. Here, she shares how her role as both an intern and a participant at the center gave her new perspective on the importance of community and cultivating personal wellness, a rare commodity in the ongoing pandemic.

iving through these unparalleled times, it’s almost impossible to think about anything other than the immediate concerns of COVID-19. Every conversation circles back to the virus variants, testing shortages, transitions to remote work, and which friend or relative recently tested positive. Constant worry about one’s health and that of loved ones leads to stressors and anxieties that some have never experienced before. The exhaustive measures that are taken to maintain good physical health make it increasingly difficult to nourish our mental

health. This is especially difficult for those living in marginalized communities suffering from long histories of healthcare and mental health disparities, which have been exacerbated by the pandemic. In the summer of 2021, I had the opportunity to intern at the Joy Wellness Center, as they work to ameliorate these disparities in the Baltimore community. Joy Wellness is a non-profit healthcare facility that works in conjunction with Shepherd’s Clinic to provide integrative health care to the Baltimore community free of charge. The center offers an abundance of wellness

The exhaustive measures that are taken to maintain good physical health make it increasingly difficult to nourish our mental health." Edition 19 Spring 2022


programs and services in areas such as movement education, stress reduction, nutrition education, and healing arts. Classes such as chair yoga, meditation, and gardening are held weekly and open to all adult residents in Baltimore, while other services like nutrition education and diabetes self-management are appointment-based. The majority of Joy Wellness’ client base is uninsured, African American women over the age of 45. Clients are often referred to Joy Wellness for alternative medicine services by their primary care provider at the Shepherd's Clinic. Together, Shepherd’s Clinic and Joy Wellness offer a holistic approach to medical care that includes standard medical treatment as well as nontraditional remedies, while limiting barriers to access to healthcare.

The “Joy” mosaic art piece sits at the entrance of the Joy Wellness facility. I got the opportunity to work with Joy Wellness through the Community Impact Internships Program (CIIP) at Johns Hopkins University. CIIP is a summer internship program run by the JHU Center for Social Concern that provides Hopkins undergraduates with an immersive experience in community work within Baltimore. Each CIIP intern is paired with a local non-profit organization or government agency to do an 8-week summer internship. 16

A highlight of the program is called “Bites of Baltimore”, consisting of weekly reflection sessions where CIIP interns come together to reflect on their experiences and learn about how the work they’re involved with is related to pressing societal issues within the community.

I was particularly intrigued by the opportunity to learn about different aspects of medicine, especially since I had very little knowledge of alternative medicine beforehand." The strategy behind the CIIP matching process remains a mystery to me. After listing “Healthcare/Health Policy”, “Environment and Sustainability”, and “Immigration & Refugee Services” as my top areas of interest on my application, I received my placement at Joy Wellness. I was immediately welcomed by my supervisors Tracy Holcomb (Joy Wellness Director) and Allison Revels (Program Coordinator), who took me on a tour of the facility when I first visited. As we passed the yoga and meditation room, massage room, kitchen, and outdoor garden I grew amazed at the work of this unique healthcare facility. It also became clear to me how Joy Wellness falls under all three interest areas. By hosting seasonal outdoor programs, like gardening and patio yoga, the center incorporates aspects of environmental wellness into healthcare. In addition, Joy Wellness provides many wellness services to Spanish-speaking immigrants, as they make up a large portion of the patients served by Shepherd’s Clinic. Realizing how interdisciplinary the health and well-being services are at Joy Wellness at Epidemic Proportions

limiting close contact with others. Despite these limits on normal operations, Joy Wellness alongside Shepherd’s Clinic continued to support the Baltimore community in other ways. For example, the unused massage room was turned into a food pantry to assist patients and community members facing food insecurity.

Tanya Ray, garden keeper and instructor of gardening club, hosting a demonstration for clients on the outdoor patio. the beginning of the summer excited me for the weeks ahead. I was particularly intrigued by the opportunity to learn about different aspects of medicine, especially since I had very little knowledge of alternative medicine beforehand. My experience with alternative medicine practices before my CIIP summer consisted of an expository writing course I took freshman year on Chinese Traditional Medicine and a few 10-minute yoga practice Youtube videos. As a result, I went into my Joy Wellness internship with an open mind and was interested in learning about integrative healthcare from the perspective of communitybased work. However, immediately following these initial feelings were concerns of how COVID would affect this summer experience and the work of community partners. Like many organizations, the operations of Joy Wellness look much different during COVID times. During my internship, Joy Wellness was working on a hybrid system as some wellness classes transitioned to Zoom and others were able to resume in-person activity but only if hosted outdoors. On the other hand, services such as acupuncture and massages were unable to return at all due to health precautions Edition 19 Spring 2022

A memorable day from my internship experience was when we hosted a covid vaccination clinic at the facility. It was one of the busiest days of the summer as personnel from different health departments in Baltimore worked hard to ensure the clinic ran as smoothly as possible. My roles that day included prefilling vaccination cards, directing people from the waiting room to the vaccination area, and promoting Joy Wellness services to people in observation. On the drive back to my apartment, I remember feeling so happy after witnessing the efforts made by the community to get vaccinated and getting to be part of this. On a typical workday at Joy Wellness, my roles as an intern were mainly focused on community outreach for the center’s wellness classes and services. After settling in at my working space, I’d start sending emails and making phone

The Joy Wellness garden grows a variety of fruit, vegetables, and native flowers. 17

calls to remind clients about the upcoming classes for that week. I would also reach out to clients to assist with scheduling private appointments, such as personalized nutrition consultations provided by nutrition interns from the Maryland University of Integrative Health. My role also included being a point of contact for our instructors and providers in preparation for their upcoming appointments or classes. When I first started my internship, it felt daunting having to communicate and coordinate with so many people daily. Initially, I attributed this feeling to the fact that restricted in-person

The (pre-pandemic) set up for Chair Yoga, a popular movement class at Joy Wellness. During COVID, the class is hosted virtually and on the outdoor patio at a reduced capacity. activity made it more difficult to meet and connect with many Joy Wellness community members. These feelings faded once I started getting the hang of things and becoming more comfortable on the phone. I found that some of my routine reminder calls would actually turn into meaningful conversations with our clients. By starting the call off with a standard “how are you doing today?”, some would tell me about their busy days and how much they were looking forward to their favorite wellness class to help them destress. At the end of the 18

call, clients would always thank me and give many heartwarming goodbyes such as “have a blessed day” or “stay cool and hydrated!” (in light of the hot summer weather). After a few weeks of making these routine calls, some clients would tell me that they recognized my voice and how they were even waiting for my phone call that day! I was constantly touched by how appreciative community members were for a simple reminder call. As the summer progressed, I began to realize the importance of these tasks, despite them seeming so minimal. Calling patients weekly to remind them that their favorite wellness class is coming up makes the experience more personable. It’s a way to provide another means of accountability and support to clients. Even if clients express that they cannot attend classes that week, they are still met with support and understanding. Through these calls, we show clients that we remember them each week and we hope to see them at the next yoga, meditation, or nutrition class. This personable form of community outreach is a means by which Joy Wellness attempts to tackle the challenge of how to motivate people to engage in wellness practices and self-care during COVID-19, even if it’s not their current priority. After finishing outreach and other administrative tasks related to wellness programming, I got the amazing opportunity to attend Joy Wellness classes alongside community members. This was a highlight of my summer, as it allowed me to have a hands-on CIIP experience while dedicating time to my personal well-being. A favorite class of mine is Yoga Nidra, held virtually on Thursday afternoons by meditation instructor Kerry Martinez. Yoga Nidra is a form of guided meditation that enables you to reach a deep Epidemic Proportions

Community nurse speaking to children at a local school after they have received routine immunizations. state of conscious relaxation. Kerry typically starts the class by checking in on everyone and discussing the themes or intentions of that day’s practice. Attendees are then asked to get into a comfortable position, either sitting or lying down, to carry out guided breathing exercises and full body scans. As someone who had never meditated before, I was in disbelief by how relaxed and rested I felt after my first time trying Yoga Nidra. Being able to participate in classes like this one throughout the summer allowed me to experience firsthand the benefits that alternative medicine has on the mind and body. In addition, seeing the same faces in class each week was evidence that several community members had also felt these benefits and have integrated these practices into their routine as an essential part of their healthcare. The commitment to regulary attend wellness classes is key to experiencing the health benefits of these practices as well as cultivating a strong community within Joy Wellness. Through alternative medicine, community members are able to connect with and uplift one another, which is especially meaningful during COVID times when feelings of isolation Edition 19 Spring 2022

My supervisor, Allison Revels, and I at the CIIP 2021 Closing Reception hosted in Mason Hall on the Homewood Campus. The closing reception celebrates the end of the CIIP cohort’s summer internship experience! are more common. The dedication that the Joy Wellness community has for integrative health inspired me to further pursue and learn about alternative medicine practices beyond my CIIP experience. Though I just began practicing yoga regularly during the summer through Joy Wellness as well as a local gym, it has now developed into a new hobby of mine. During the busy semester, I value the time I set aside in my schedule for yoga classes at Hopkins’ recreation center or through YouTube videos. Similarly, I’ve grown to better understand the powerful effects of meditation through daily practice. Although meditating consistently has been more challenging for me than yoga, I’m grateful that my internship at Joy Wellness helped introduce these well-being practices

Through alternative medicine, community members are able to connect with and uplift one another" 19

into my life. Someday, I hope to further connect these practices to my academic interests of science and medicine, whether it be through my pre-med curriculum or alternative medicine courses offered in medical school. Through my CIIP experience, I’ve gained new perspectives on holistic healthcare as well as community-based health that will stay with me as I pursue my aspirations of becoming a healthcare professional. I’ve learned that being able to incorporate alternative medicine remedies into one’s healthcare is a privilege. Not everyone has access to stress reduction and movement classes led by experts or even the time to engage in wellness classes. However, building a supportive community and limiting the barriers of access to alternative medicine provides a safe space for community members to take time for their health and well-being, especially during the challenging moments in our lives. Acknowledgements I wish to extend a special thanks to Tracy Holcomb, Allison Revels, and the CIIP 2021 staff and cohort for all the support and guidance throughout my summer internship, making it an incredible experience.

Romina Rojas Biophysics Class of 2023 20

Photo Courtesy of Mason Cole Epidemic Proportions

Photo Courtesy of Mason Cole

Research | Kriti Bomb

Eradicating the Potential Barriers Hindering Adherence to Antiretroviral Therapy in Southern India through Treatment Counseling

Adherence to antiretroviral therapy (ART) is an important factor in combatting the HIV epidemic in Southern India. In this research article, Kriti Bomb discusses the role of three primary, interrelated barriers: stigmatization, gender identity, and mental health, in limiting access and adherence to treatment for HIV. Antiretroviral therapy can help maximally suppress the viral load of HIV and significantly prolong life expectancy for people living with HIV. For the treatment to be effective, however, persons diagnosed with HIV must maintain optimal adherence to ART, which is not the case for the populations affected by HIV in Southern India. To further combat barriers to HIV treatment in India, Bomb also explores the feasibility and implementation of adherence counseling within these regions to increase adherence to ART. Edition 19 Spring 2022



he human immunodeficiency virus (HIV) has infected more than 2 million Indian citizens, 55% of whom live in rural and urban regions throughout the southern states in India.1 To combat this epidemic, antiretroviral therapy, or ART, was recently developed and globally implemented as the most efficient “treatment as prevention” approach against fighting the HIV/AIDS pandemic. HIV infects immune cells in humans through four broad phases of infection: entry, transcription, integration, and translation. During entry, HIV anchors to uninfected cells and penetrates their cell membrane. Reverse transcriptase is then used to transcribe a double-stranded DNA from viral RNA, which is transported to the cell’s nucleus and integrated into host DNA by the enzyme integrase. Integration is what causes life-long HIV infection and results in an expansive latent HIV reservoir within the host. Through the process of translation, this integrated proviral DNA is expressed as protein and thousands of copies of the virus are assembled and released from the cell using host cell machinery. Antiretroviral therapy uses various combinations of drugs to inhibit these different phases of HIV infection using drugs like entry inhibitors or integrase inhibitors.2 ART regimens help maximally suppress the viral load of HIV during chronic HIV infection to reduce transmission, restore immunological function, and prolong life expectancy for people living with HIV (PLHIV).2 For the treatment to be

effective, persons diagnosed with HIV must urgently begin initial drug regimens and adhere to treatment upon diagnosis to prevent the development of acquired immunodeficiency syndrome, caused by a high HIV viral load and low levels of immune cells. Suboptimal adherence to ART regimens, which is determined by the number of missed doses, can lead to increased transmission, drugresistance, and insufficient inhibition of HIV viral replication in infected persons, resulting in an increase in the viral load of latent HIV up to pre-treatment levels. Some protective factors for optimal adherence include an adequate social support network, positive perceptions towards HIV and medical treatments, trust in healthcare providers, and accessibility to and affordability of daily treatment. Based on national guidelines and multiple patient-centered HIV treatment studies in the US, an adherence level of at least 82% to 95% is required to achieve viral suppression with standard ART regimens.3 People living with HIV in southern India, however, have been found to have adherence levels to prescribed doses as low as 68% across multiple studies.1 Within the different states in Southern India, there are a multitude of barriers that may be limiting access to and adherence to antiretroviral therapy, despite the relative increase in ART delivery sites and improved regimens in the past few years.4 The effects of these barriers also vary across rural and urban regions in India, which have asymmetric

ART regimens help maximally suppress the viral load of HIV during chronic HIV infection to reduce transmission, restore immunological function, and prolong life expectancy for people living with HIV (PLHIV).2" 22

Epidemic Proportions

literacy rates and highly disproportionate accessibility to healthcare. Three primary, interrelated factors - stigmatization, gender, and mental health - have been found to have varying levels of association with sub-optimal adherence to ART in Southern India; however, adherence to ART may be improved through the efficient mobilization of accessible adherence counselling within these regions. Results Firstly, both the external and internal stigma associated with HIV as well as individuals’ perception towards ART can significantly affect adherence. HIV-related stigma in southern India, reinforced by cultural taboos surrounding drug use, sex work, and queerness, can present through two modes: external or enacted stigma, and internalized stigma. Enacted stigma involves direct experiences of discrimination as well as perceptions of stigma shaped by indirect discrimination, which have both been found to influence internalized stigma, or an individual’s perceived legitimacy of and negative attitudes towards their HIV status.5 A significant portion of enacted stigma against HIV prevails within the medical community in India itself. For instance, many people living with HIV in India have reported experiences of provider discrimination and breach of patient-provider confidentiality following diagnosis.6 Another study interviewed more than 1,000 healthcare providers in urban areas within southern India and discovered a high prevalence of stigma, discrimination, and misconceptions, even within different healthcare settings. 55% of providers advocated for prohibiting female PLHIV from having children, 94% endorsed mandatory testing for female sex workers and surgery patients [due to the risk of HIV transmission Edition 19 Spring 2022

through bodily fluids], and 50% believed that people who acquired HIV through sex or drugs “got what they deserved,” all of which are devastating perceptions that reinforce internalized stigma within PLHIV and that may significantly decrease treatment adherence in these patients.7 Adherence counseling, which would be provided pre-treatment, may help mitigate some of the stigma associated with HIV and help rebuild the relationship between healthcare providers and PLHIV. This will provide tangential and emotional support and factual information instead of the discrimination or misconceptions that result from enacted stigma. One qualitative study involving interviews and focus groups further examined the effect of stigma on ART adherence in rural southern India, discovering that most individuals affected by HIV had deep-rooted internalized stigma about their status, often characterized by feelings of guilt, shame, and fear of rejection.8 Much of this stigma and shame was also fueled by an individual’s perception of HIV and the influence of Western medicine, especially in regions with stricter sociocultural values and limited education. Strong negative perceptions surrounding HIV and ART may also be causing lower adherence in people living with HIV, because if individuals do not understand the drug regimens they are prescribed, trust their healthcare providers, or if they feel that they are at fault for acquiring the infection, they might not trust the efficacy of ART or feel worthy of receiving treatment. According to a study on HIV misconceptions in urban South Indian cities, “higher HIV transmission misconceptions (p<0.001), more traditional gender attitudes (p<0.01) and more negative feelings towards HIVpositive people (p<0.001) were related to 23

Indian men might be more susceptible to external and internalized stigma due to culturally reinforced toxic masculinity, and they may also have more negative perceptions towards queerness and HIV." higher avoidance intentions” in 2014.9 These negative perceptions of HIV and ART, along with enacted and internalized stigma, were found to be associated with self-isolation, avoidance of HIV testing, delayed treatment, and a lower quality of life.8 The stigmatization of HIV was also found to be associated with higher levels of negative coping strategies in PLHIV such as avoiding disclosing their HIV status with a support network, which limits the social support that serves as a protective factor during treatment.6 In multiple recent studies, people living with HIV who had adequate familial support have shown better adherence to ART than those who had inadequate support.10 Through these mechanisms, external and internalized stigma, lack of social support, and stigma-avoidant strategies such as avoidance of disclosure can directly decrease individuals’ adherence to ART and worsen the prognosis of PLHIV. Fortunately, however, with individualized or group treatment counseling, these negative attitudes can be mitigated, and adherence counselors can ensure that patients understand their ART regimen, its necessity, and feel void of any shame or guilt that may hinder optimal ART adherence. Along with stigmatization, multiple research studies have found a statistically significant association between demographic factors such as gender and ART adherence as well.9,10 This association between gender and ART adherence has been observed in many countries with high HIV prevalence, and there 24

are multiple possible mechanisms that may explain the role that gender plays in adherence. Persons who identify as male, including men who have sex with men (MSM), have been found to have lower rates of adherence than those who identify as female in multiple studies conducted throughout southern India.10 Indian men might be more susceptible to external and internalized stigma due to culturally reinforced toxic masculinity, and they may also have more negative perceptions towards queerness and HIV. Men in southern India also have lower rates of diagnostic testing for HIV than women, which means that less men are aware of their HIV status or seeking treatment for HIV, making it more difficult for them to adhere to treatment once they do begin it and possibly increasing transmission rates as well. Implementing adherence counseling within men may be a challenge, especially with increased rates of internalized stigmatization, but this may be the population that could benefit the most from HIV-related resources, testing, and adherence strategies. In comparison, women with HIV are significantly more likely to be diagnosed than men, according to a meta analysis of women living in rural areas in southern India.4 This may be due to higher rates of diagnostic testing in childbearing women to prevent vertical transmission, and subsequent adherence to treatment may be due to societal pressure to protect women’s health and their infants’ health. In one study from coastal southern India, people identifying as female were even found to be more adherent to their Epidemic Proportions

prescriptions than young males because many of them were widows and lived with their families, who regularly reminded them to take their medications.10 This further supports the importance of social support and status disclosure in optimal adherence, both of which may be higher for women living with HIV. However, even though men have lower adherence, women living with HIV in India still experience high rates of stigmatization, mental illness, and encounter countless barriers to accessing ART treatment, such as unemployment. In southern India, especially within farming and fishing-based cities, women only make up 20% of the entire country’s labor force and have higher rates of unemployment than men,11 even though the annual per capita cost of ART averages around 50,000 INR.12 Along with improving ART adherence and creating a comfortable and safe environment for women to learn about ART, adherence counselor teams composed of female healthcare providers and community outreach workers could help bridge this gender gap within employment in southern India as well. Along with this gender gap in adherence and the stigmatization of HIV, mental health disorders and substance use constitute other frequently reported risk factors for suboptimal adherence to ART in India, as reported by a recent meta analysis reviewing the specific factors associated with ART nonadherence.4 Psychological distress and mental illness present a major barrier for ART adherence by worsening quality of life for PLHIV, limiting social support, and increasing self-isolation. Poor mental health is a comorbidity for many injection drug users, MSM, and transgender women, who are the key populations at risk for HIV. When combined with the stigmatization against queerness and HIV in countries with Edition 19 Spring 2022

strict socio-cultural beliefs like in India, the mental health of many people living with HIV can significantly worsen. This may also result in increased substance use, which can in turn increase transmission. Further, as discussed previously, the enacted and internalized stigma surrounding a person’s HIV status can cause anxious and depressive symptoms, limiting affected persons from disclosing their HIV status to their support network and thus trapping them within a cycle of self-isolation and fear. In one study conducted in coastal cities across south India, more than 50% of participants diagnosed with HIV blamed themselves for infection and felt ashamed about their status, and almost 15% had suicidal ideations following diagnosis.6 Adherence counseling, along with providing information about ART, can help some of these heavily burdened populations understand the implications of their HIV diagnosis, inform them about routes of transmission, reassure their sexual and gender identities, and provide them with the necessary mental health support and social network to persevere and thrive despite their status. This social support may be crucial as factors like poor mental health and shame associated with a positive HIV diagnosis can significantly decrease adherence and cause many people to refuse or avoid treatment. In fact, among patients living with HIV in urban cities within northern India, severe depression was associated with four times the risk of non-adherence as compared to minimal depression,13 and these findings may also be applicable to similar regions in southern India. Multiple studies have also observed a statistically significant association between the consumption of alcohol and suboptimal adherence.4,6 This pattern may be used to 25

infer associations between all substance use and adherence to ART, but data regarding the use of other substances is limited due to sociocultural factors and minimal research into drug users within India. The association between poor mental health and suboptimal adherence to ART may also be due to the shortage of mental health care providers within India, especially for people living with HIV, with only an average of 0.75 psychiatrists

Eradicating the barriers discussed in this paper requires a multi-pronged approach targeted at the different regions and populations living within southern India.”

available for a population of 100,000 people, as of 2020.14 The lack of mental health support and the culturally reinforced stigma surrounding mental health in India has mediated this association and limited affected persons’ willingness to get tested for HIV, their adherence to ART, and their ability to seek help for mental health issues that may be limiting them seeking treatment. Treatment counselors, however, can help mitigate some of these factors affecting the mental health of people living with HIV by clearing misconceptions about HIV and providing an adequate support network for key populations in southern India. Discussion Eradicating the barriers discussed in this paper requires a multi-pronged approach targeted at the different regions and populations living within southern India. One solution to the problem of suboptimal adherence is multimodal adherence counseling. This approach 26

would mobilize both healthcare providers and other PLHIV as treatment counselors, and it has been shown to have a positive association with adherence to ART amongst people living with HIV in multiple countries. Along with helping PLHIV better understand their treatment regimens, adherence counseling can help reduce the stigmatization of HIV, bridge the gender gap amongst HIV prognoses in PLHIV, and improve mental health outcomes, which makes it an ideal approach to eliminating some of the barriers hindering optimal adherence to ART in southern India. One of the major prongs of multi-modal adherence counseling involves employing willing persons who have lived with HIV diagnoses for a long period of time as peer treatment counselors, along with healthcare providers. This approach could mitigate the distrust of and discrimination PLHIV may face from healthcare providers, and it could help provide an inbuilt network of social support amongst treatment counselors and their mentees. “Since older women and [people] who have lived with their diagnoses a longer time appear more likely to adhere to their regimens, they may make good peer educators for younger [people] who are newly infected, by sharing their adherence strategies.”8 In another study in southern India, these peer counseling techniques were actually implemented, “resulting in a significantly greater proportion of virally suppressed and optimally adherent participants” after a year of counseling.15 Post-assessment interviews from this study also revealed that the use of peer counselors along with trained adherence counselors accounts for some of the priorities that PLHIV may have in comparison to the ones their healthcare providers may have, such as access to local community resources, Epidemic Proportions

family management, or financial barriers. Moreover, in order to minimize the burden on these peer counselors, who may be struggling with their own diagnoses and adherence to treatment while managing their own health, trained adherence counselors and healthcare providers should also be mobilized to help eliminate some of the barriers against adherence within PLHIV. These counselors must follow standardized guidelines for counseling and assessment, such as those set by global non-governmental organizations like EngenderHealth.16 They must also use standardizing reporting measures such as the ACTG adherence self-reporting tool, CD4+ cell count, and HIV viral load to accurately portray the efficacy of this approach in improving adherence.17 Like any approach with the potential to influence HIV care, multi-modal adherence counseling is accompanied by some major limitations in its implementation and effectiveness within India. Firstly, the approach requires trained teams of willing community outreach workers and healthcare professionals, both of which may be limited in rural areas or restricted in action by socio-cultural values. Adherence counseling also largely depends on willing participation from PLHIV, and many patients may be lost to follow up or fail to adhere to the counseling itself, perhaps even due to the same barriers the approach is meant to eradicate. Thus, for the approach to be effective, there must be a reduction in stigma against counseling, there would need to be funding, and there would have to be enough treatment counselors and community outreach workers to provide individualized support in different regions. Another issue is that significant stigma against mental health counseling and mental illness still exists in India, along with a shortage of mental Edition 19 Spring 2022

health counselors, which might limit PLHIV from seeking out these resources. However, adherence counseling should be promoted as medical treatment counseling, which would allow it to serve both functions of improving direct treatment outcomes as well as mental health prognoses for people living with HIV. If it is advertised as a crucial part of ART itself, there may be reduced stigma associated with adherence counseling.

The mobilization of many innovative treatment and prevention approaches like multi-modal adherence counseling has helped reduce the burden of HIV in the country significantly in the past few years.” As mentioned before, this approach would also vary depending on which region of southern India it was being implemented in. The access to healthcare for PLHIV in rural regions of India is significantly limited in comparison to access in urban regions, as PLHIV in rural areas within India often must travel long distances to reach well-equipped hospitals and ART delivery sites. To account for this inequality in access to treatment, however, the engagement of lay health providers and village women has been used in the past to increase education, transportation, and social support for PLHIV in rural areas within India, which significantly increased adherence.13 While some studies have found that individuals who traveled a greater distance to receive ART show better adherence to treatment,10 supplementing this tendency with accessible treatment counseling could help account for unequal 27

access to healthcare by limiting the frequency of how often PLHIV have to access care at all. By accounting for limited access to healthcare resources and engaging PLHIV in rural and urban regions as peer counselors, standardized, multi-modal adherence counseling can be a useful tool in eradicating barriers to ART adherence by reducing HIVrelated stigma and improving mental health outcomes in PLHIV. Conclusion Despite the numerous challenges PLHIV face in southern India, the mobilization of many innovative treatment and prevention approaches like multi-modal adherence counseling has helped reduce the burden of HIV in the country significantly in the past few years. To combat the HIV epidemic affecting the country, the Indian government, the National AIDS Control Organization, and countless HIV/AIDS activists have worked resiliently to establish free ART delivery centers and HIV testing and counseling sites throughout the country. These efforts have resulted in HIV incidence declining by almost 50% within India. Multi-modal counseling can further supplement these improvements by reducing enacted and internalized stigma surrounding HIV and ART, by minimizing the disproportionate effects of gender on adherence, and by improving mental health outcomes in PLHIV. This approach will also help limit HIV transmission throughout key populations living in India and help meet the global 90-90-90 goal to eradicate AIDS. Minimizing these potential barriers can help maximize optimal adherence to antiretroviral therapy in all persons living with HIV in rural and urban areas throughout southern India, and ultimately reduce the prevalence and incidence of HIV within the entire country. 28


1. Heylen E, Chandy S, Shamsundar R, Nair S, Ravi Kumar BN, Ekstrand ML. Correlates of and barriers to ART adherence among adherence-challenged people living with HIV in southern India. AIDS Care. 2021;33(4):486-493. doi:10.1080/09540121.2020.17 42862 2. Farzadegan, H. Epidemiology and Public Health Impact of HIV/AIDS. Johns Hopkins University. 2021. 3. Byrd KK, Hou JG, Hazen R, et al. Antiretroviral Adherence Level Necessary for HIV Viral Suppression Using Real-World Data. J Acquir Immune Defic Syndr. 2019;82(3):245-251. doi:10.1097/ QAI.0000000000002142 4. Chakraborty A, Hershow RC, Qato DM, Stayner L, Dworkin MS. Adherence to Antiretroviral Therapy Among HIV Patients in India: A Systematic Review and Meta-analysis. AIDS Behav. 2020;24(7):2130-2148. doi:10.1007/s10461-020-02779-4 5. Steward WT, Herek GM, Ramakrishna J, et al. HIVrelated stigma: adapting a theoretical framework for use in India. Soc Sci Med. 2008;67(8):1225-1235. doi:10.1016/j.socscimed.2008.05.032 6. Kumar S, Mohanraj R, Rao D, Murray KR, Manhart LE. Positive coping strategies and HIV-related stigma in south India. AIDS Patient Care STDS. 2015;29(3):157163. doi:10.1089/apc.2014.0182 7. Ekstrand ML, Ramakrishna J, Bharat S, Heylen E. Prevalence and drivers of HIV stigma among health providers in urban India: implications for interventions. J Int AIDS Soc. 2013;16(3 Suppl 2):18717. Published 2013 Nov 13. doi:10.7448/IAS.16.3.18717 8. Ekstrand ML, Heylen E, Mazur A, et al. The Role of HIV Stigma in ART Adherence and Quality of Life Among Rural Women Living with HIV in India. AIDS Behav. 2018;22(12):3859-3868. doi:10.1007/s10461018-2157-7 9. Bharat S, Ramakrishna J, Heylen E, Ekstrand ML. Gender-based attitudes, HIV misconceptions and feelings towards marginalized groups are associated with stigmatization in Mumbai, India. J Biosoc Sci. 2014;46(6):717-732. doi:10.1017/ S0021932014000054 Epidemic Proportions

10. Banagi Yathiraj A, Unnikrishnan B, Ramapuram JT, et al. Factors Influencing Adherence to Antiretroviral Therapy among People Living with HIV in Coastal South India. J Int Assoc Provid AIDS Care. 2016;15(6):529533. doi:10.1177/2325957416661424

Photo Courtesy of Mason Cole

11. “Women in the Workforce.” Catalyst. https://www. catalyst.org/research/women-in-the-workforceindia/. Published 2020. 12. Sharma A, Prinja S, Sharma A, Gupta A, Arora SK. Cost of antiretroviral treatment for HIV patients in two centres of North India. Int J STD AIDS. 2019;30(8):769778. doi:10.1177/0956462419839852 13. Nyamathi, A., Ekstrand, M., Heylen, E., Ramakrishna, P., Yadav, K., Sinha, S., Hudson, A., Carpenter, C. L., & Arab, L. (2018). Relationships Among Adherence and Physical and Mental Health Among Women Living with HIV in Rural India. AIDS and behavior, 22(3), 867– 876. https://doi.org/10.1007/s10461-016-1631-3 14. Sandhu, G. India has 0.75 psychiatrists per 100,000 people. Can telepsychiatry bridge the gap between mental health experts & patients? The Economic Times. 2020. https://economictimes.indiatimes.com/ magazines/panache/india-has-0-75-psychiatristsper-100000-people-can-telepsychiatry-bridgethe-gap-between-mental-health-experts-patients/ articleshow/78572684.cms?from=mdr 15. Ekstrand ML, Heylen E, Pereira M, et al. A Behavioral Adherence Intervention Improves Rates of Viral Suppression Among Adherence-Challenged People Living with HIV in South India. AIDS Behav. 2020;24(7):2195-2205. doi:10.1007/s10461-02002785-6 16. “Adherence to Treatment for HIV A Training Curriculum for Counselors”. Engender Health Society. 2006. https://www.engenderhealth.org/files/pubs/ localized/india/counselor_facilitator_guide.pdf 17. Safren SA, Kumarasamy N, James R, Raminani S, Solomon S, Mayer KH. ART adherence, demographic variables and CD4 outcome among HIV-positive patients on antiretroviral therapy in Chennai, India. AIDS Care. 2005;17(7):853-862. doi:10.1080/09540120500038439

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Kriti Bomb Psychology & Public Health Studies Class of 2022 29

Photo Courtesy of Irfaan Karim


Epidemic Proportions

Policy | Ciaran Cole

No More Slim Pickings: Time To Demand Quality Nutrition Standards in American Schools

In this piece, Cole discusses the long-term causes of America’s increasingly privatized school meal system and its effects on educational institutions. Noting resultant declines in school nutritional standards and overall diet quality in American adolescents, Cole advocates for an expansion of nutrition education programs as well as limiting continued outsourcing of meal preparation.


mongst 17.5 million students dependent on free and reduced lunches, over one billion meals went unaccounted for during school shutdowns in 2020.1 In terms of COVID-19’s widespread impact on global sustenance systems, food supply shortages were yet another blow to the diets of American adolescents. Already burdened by declining national nutritional standards and pressure from the food industry corporations, attention to school cafeterias standards could not come at a more dire time. Though policy debates surrounding the National School Lunch Program (NSLP) date back to the 1940s, media coverage has largely shied away from government accountability. Ironically enough, the pandemic’s exacerbating effects on the program might finally produce a much-needed call to action for news outlets and researchers to promote reforms.

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Increasing social awareness surrounding food assistance programs raises concerns for the country’s most vulnerable populations across the board. Concurrently, two million more children live in food-insecure homes following the ramifications of the recent recession.3 Deteriorating health conditions furthermore are observed not only in adolescents, but several subpopulations dependent on government food services including inmates.4 In the best interest of citizens relying on government provided subsistence, immediate action is needed by public health officials to push for improved nutrition standards. Processed food overconsumption poses one of the largest health hazards to participants of NSLP, in addition to several other food assistance programs. The growing presence 31

of these products emerges as a result of budget cuts from different government services. Limited funding has forced schools nationwide to adopt cost-cutting measures, typically accomplished by outsourcing food preparation to third party corporations, such as Sodexo and Big Compass. Remarkably, this trend has followed suit of universities and incarceration facilities, indicating that the issue at hand extends beyond the scope of just education institutions. Thereby, grasping the full extent to which privatized food companies manipulate meal services is imperative in formulating a response. Historically, schools used to have their own employees directly prepare their constituents' meals in prior decades, which starkly contrasts current practices. Insourcing labor in such a way encouraged the usage of more local produce and reduced the need for food processing, leading to healthier meals.4 Unfortunately, gradual pressure under the federal government to increase meal cost efficiency eventually marked the cessation of

U.S. childhood obesity rates climbed from 19.3% to 22.4% in recent years, making the highest prevalence of any large country.2 " such methods. Initiated by former President Regan’s $1.5 billion cut to NSLP in 1981, a movement towards third-party food services swept through schools in the late 20th century.5 Immediately, this changeover presented itself as a major marketing opportunity for corporate food chains to partner with private food services, whose customer rapidly expanded. Tyson and Kellog both employ this strategy 32

through their associations with Aramark, one of the US’s largest food suppliers to both schools and universities.6 By offering cashback rebates to Aramark and its competitors, these corporations continuously maintain leverage for their products to remain on lunch trays versus healthier alternatives.6 Efforts from food retailers thereafter to expand their youth clientele increasingly intensified upon breaking into school markets. Indeed, several companies successfully built firsthand relationships with schools by setting up individual retail contracts and sponsoring school sports programs.7 These ramifications later climaxed in the early 2000s, at a time when national soda brands including Coca Cola and Pepsi subsidized schools for product exclusivity and sales quotas.5 By 2012, upwards of 50% of school districts served fast-food as a menu option.5 While some federal regulations have begun to eliminate such influences from cafeterias within the last decade, the food industry to date is working on and started succeeding in reversing such decisions. Altogether, this phenomenon has been a massive problem instigated by the tandem of corporate food manufacturers and providers, often referred to as “Big Food.” Beyond their involvement in manipulating markets and consumers, Big Food is extensively involved in lobbying. In addition to extensive spending to promote laws that make their products more marketable, these corporations relentlessly push for regulatory legislation to reduce transparency in nutritional information. Specifically, they aim to limit new nutrition regulations and pass bills that make food labels less informative. Their ties with legislators are a major reason that sugary, high-calorie foods are so prevalent in America today. Epidemic Proportions

One major line of defense within schools over the last decade has been the implementation of the 2010 Healthy Hunger-Free Kids Act (HHFKA). These nutrition regulations have led to a gradual decrease in obesity prevalence among low-income students, while also eliminating large portions of SSBs from vending machines." Major concerns with processed food intake, in addition to sugar sweetened-beverages (SSBs), involve associations between obesity and various other chronic health conditions. Several comprehensive studies and clinical trials have established SSBs as the leading contributor to long-term weight gain in comparison to all other dietary sources.8 In turn, ultra-processed foods contribute additional sources of starches and sugars, leading to health ailments such as type II diabetes.8 Systematic reviews, on the other hand, have been less conclusive in characterizing school meals as direct causes of health conditions due to confounding variables in students' diets. Since home eating habits influence adolescent health, measuring the impact of dietary choices made at school against those elsewhere has been difficult. This fails to exonerate educational institutions, nonetheless, from generating negative impacts on the populations they feed. While new nutrition policies have recently improved school lunches themselves, products available through separate sale at cafeterias are not as harmless. Here, corporations are able to exert their influence, by cutting out the middle-man (food services) and selling their products using alternative methods. Consequently, school districts with less healthy options added to vending machines have been shown to have higher obesity rates among their student bodies.9 Though Edition 19 Spring 2022

the presence of unhealthy snacks does not tend to encourage unhealthy eating habits in youth, they do appear to reinforce such habits among those who have already developed them at home.9 For students with a genetic predisposition for obesity, research suggests increased junk food availability in schools as a potential source of their weight gain.9 One major line of defense within schools over the last decade has been the implementation of the 2010 Healthy Hunger-Free Kids Act (HHFKA). These nutrition regulations have led to a gradual decrease in obesity prevalence among low-income students, while also eliminating large portions of SSBs from vending machines. HHFKA’s 2014 launch of its supplemental program, Smart Snacks, marked the first time that regulations were issued for foods sold outside of standard lunches and breakfasts.10 Overall, analyses concluded an annual 9% reduction in obesity risk for impoverished youth attributable to HHFKA.10 While it is clear that legislation such as HHFKA improves nutrition quality in targeted populations, efforts to improve nutrition must be further strengthened. Threats of the influence from Big Food remain pertinent after several cycles of government administration changes since HHFKA’s passage. In fact, attempts to weaken K-12 nutritional standards are currently on-going after regulation changes were instigated by the Trump administration 33

in 2018.11 New guidelines which allow more relaxed nutritional guidelines for à la carte entrees at schools have been put in place, effectively erasing steps taken forward with Smart Snacks standards. In a major setback, as many as 99% of newly added entrees now fail to meet previous regulations as a result.12

Thus, Americans urgently need to push for the adoption of such policies and decrease schools' dependence on privatized food services."

To combat the elimination of HHFKA regulations, innovative upstream public health interventions should target afflicted populations before the food industry sways them towards unhealthy options. Policies that attempt to stop non-nutritious foods from reaching students are vulnerable to corporations exploiting alternative pathways to introduce their products to them.

Michigan found an association between higher standardized test scores and schools forgoing third-party food vending,13 and districts that switched from outsourcing are now reporting budget savings.14 On a national level, this campaign overall constitutes a vital step for schools to restore guidance of their pupils' diets to health officials as opposed to companies with special interests.

This is the case with Big Food continuously lobbying for loopholes in new regulations enacted.

Special consideration should also be made for education and awareness programs that encourage adolescents to make healthy dietary selections on their own behalf rather than merely removing unhealthy products. While the 2010 NSLP overhaul has resulted in overall positive health outcomes for student populations, beneficiaries have exclusively been low-income students. To address the health of students who are purchasing unhealthy foods as ​​ à la carte options, students with broader meal options must be encouraged to choose more wisely.

Instead, more comprehensive approaches educate the public to recognize risk factors on their own, ensuring prevention does not merely just target the actions of the food industry. Firstly, garnering public support to pressure education institutions into terminating contracts with food services would reduce corporations’ stranglehold on cafeteria menus. This action would afford schools a choice to autonomously select healthy ingredients and products to use, while also minimizing transport-necessitated food processing. Critically, this also replaces attempts to continually restrict third party food providers from using unhealthy products, which largely fail when corporations clearly pressure them to promote them. Indeed, initiatives to restore inhouse meal preparation just recently emerged in a few states, and schools that succeed in doing so are beginning to reap benefits. 34

Evidence that nutrition education programs can produce positive results is more than hypothetical. Foreign country school lunch systems that have adopted such measures show promising results, including the Shokuiku program in Japan. “Shokuiku” translates to “nutrition education” in English. Originating from the teachings of a military doctor, Shokuiku emphasizes mandatory curriculum covering nutritional label literacy, seasonal eating benefits, and healthy food habits in all Japanese schools. Specifically, it Epidemic Proportions

was developed to help lower the prevalence of unhealthy eating habits among students, including skipping breakfast and unnecessary snacking. Since the nationalized enactment of Shokuiku in 2005 for all students, Japan has increasingly been viewed as the gold standard for school lunch systems globally. A study researching the impacts of Japan’s efforts has returned encouraging results when observing students' overall dietary changes. Based on the considered dietary habit metrics, 73% showed improvement in school groups overall after the completion of the program.15 These promising findings support the integration of similar programs in the United States and invoke optimism in tackling complex issues like increasing child obesity. With these strategies in mind, it is critical that nutritional standards are updated in accordance with public health guidelines. Privatized food companies increasingly detriment the quality of meals services in US institutions, leaving millions of children vulnerable to chronic health problems. Nonetheless, programs like HHFKA and Shokuiku demonstrate that reversal of this damage is possible when widespread enforcement is enacted. Once these strategies are implemented, the NSLP will finally get the fresh start it needs to actively encourage schools and students to take back control of their own diets. References

1. National School Lunch Program. USDA ERS National School Lunch Program. https://www.ers. usda.gov/topics/food-nutrition-assistance/childnutrition-programs/national-school-lunch-program/. Accessed November 13, 2021. 2. Obesity rates & Trend Data. The State of Childhood Obesity. https://stateofchildhoodobesity.org/data/. Accessed January 12, 2022. Edition 19 Spring 2022

3. Hunger deprives our kids of more than just food. Feeding America. https://www.feedingamerica.org/ hunger-in-america/child-hunger-facts. Accessed January 12, 2022. 4. Soble, L., Stroud, K., & Weinstein, M. (2020). Eating Behind Bars: Ending the Hidden Punishment of Food in Prison. Impact Justice. impactjustice.org/impact/ food-in-prison/#report 5. Soechtig, Stephanie. 2014. Fed Up. United States: RADiUS-TWC. 6. Kelloway C. Farmers, workers, and students rally outside Aramark for more ethical food sourcing. Food & Power. https://www.foodandpower.net/ latest/2019/10/24/farmers-workers-and-studentsrally-outside-aramark-for-more-ethical-foodsourcing. Published October 22, 2020. Accessed January 12, 2022. 7. Issue 15: Obesity crisis or soda scapegoat? the debate over selling soda in schools. Berkeley Media Studies Group. http://www.bmsg.org/resources/ publications/issue-15-obesity-crisis-or-sodascapegoat-the-debate-over-selling-soda-inschools/. Published November 17, 2018. Accessed November 15, 2021. 8. X. Gostin LO. "Big Food" Is Making America Sick. Milbank Q. 2016;94(3):480-484. doi:10.1111/14680009.12209 9. Sildén KE. Impact of competitive foods in public schools on child nutrition: effects on adolescent obesity in the United States an integrative systematic literature review. Glob Health Action. 2018;11(1):1477492. doi:10 .1080/16549716.2018.1477492 10. Kenney EL, A H, Al. E, et al. Impact of the Healthy, Hunger-Free Kids Act on obesity trends: Health Affairs Journal. Health Affairs. https://www.healthaffairs.org/ doi/10.1377/hlthaff.2020.00133. Published July 1, 2020. Accessed November 13, 2021. 11. Feldman C. Rollback proposed for Michelle Obama School Lunch Guidelines. AP NEWS. https://apnews. com/article/ap-top-news-child-nutrition-michelleobama-sonny-perdue-sam-kass-15c439239b86 b85663cd829f7395b952. Published January 17, 2020. Accessed November 13, 2021. 35

12. Cohen JFW, Schwartz MB, Leider J, Turner L, Chriqui JF. Meal Quality of Entrées That Can Be Sold as Competitive Foods in Schools and Potential Impact of the Proposed USDA Rollbacks. Nutrients. 2020;12(10):3003. Published 2020 Sep 30. doi:10.3390/nu12103003 13. Food for thought: Privatizing School Lunches may impair learning. University of Michigan News. https://news.umich.edu/food-for-thought-privatizingschool-lunches-may-impair-learning/. Published March 20, 2008. Accessed January 12, 2022. 14. Private Food Service: School Districts Eat Up Savings. Mackinac Center. https://www.mackinac. org/2138. Accessed January 12, 2022. 15. Kurotani, Kayo & Shinsugi, Chisa. (2020). Promotion of Shokuiku (Food and nutrition education) - Lessons learned from Japanese context.

Ciaran Cole Environmental and Health Engineering & Public Health Studies Class of 2025

Photo Courtesy of Mason Cole


Epidemic Proportions

Editorials | Manasi Nawathe

Should Scientists Translate Their Own Research?

In this article, Manasi Nawathe tackles the overarching question about the intentions and objectives of academic research and how scientists have often lacked accountability to scale their novel work up to a broader societal scope in this article. To explore this issue further, Nawathe asked several undergraduate students about their perspectives on this debate and discovered that most students agree that academic research should be performed with the intention of solving societal problems or improve quality of life. Nawathe further argues that scientific research should always have an applied aspect that impacts society, although determining the sole party responsible for translating scientific discoveries to benefit society remains a daunting task.


cience has become entangled with many societal aspects since the boom of technological, medical, and economic advances in the late twentieth century. We turn to research to explain natural phenomena, innovate new products and treatments, and form the basis for public policies.1 However, as professor and researcher Daniel Sarewitz argues in “Saving Science,” scientists and researchers often produce knowledge without providing applications to benefit the greater good.2 Particularly in academic research settings, there are limited policies that encourage researchers to use their work to address specific problems. A 2018 report from the National Science Foundation found that universities spend 63% of their research Edition 19 Spring 2022

funding on basic research, meaning that they focus more on fundamentals and the pursuit of knowledge.2,3 Contrary to this trend, I believe that scientific findings should progress society through technological advances, medical treatments, or consumer products. In theory, many scientists agree that research should be translated into tangible benefits, but the issue comes down to who is responsible for applying the work to a broader scope. Is a scientist accountable for their own work, should other experts build on the research to develop solutions, or should a diverse team of scientists and nonscientists collaborate to scale up the findings? In “Saving Science,” Sarewitz illustrates the story of physicist A.J. Kumar, who used his 37

Is a scientist accountable for their own work, should other experts build on the research to develop solutions, or should a diverse team of scientists and nonscientists collaborate to scale up the findings?"

background in physics and collaborated with other scientists at Harvard University to create an innovative diagnostic test for sickle cell anemia. Kumar conducted user-centered researcha with the goal to provide affordable blood tests for patients in sub-Saharan Africa.2 Kumar and his colleagues identified a crucial need for diagnostic tools in rural villages, so they developed a simple method to separate regular blood cells from sickle cells using their different densities. A basic physics concept was translated for use in a diagnostic test that produced results in 12 minutes and cost as little as 50 cents.4 A.J. Kumar’s innovation exemplifies what it looks like for academic researchers to apply their work to solve societal problems, rather than just add to the current knowledge of the topic.2 I was drawn to this example because of the lengths that Kumar went to ensure that his work had an impact on the world. In my experience, not all researchers are always thinking of how their findings can be used to solve societal problems. I was curious to see what people thought about this perspective on translational research, so I reached out to a few undergraduate peers to get their thoughts as future researchers. I asked them: “Is it scientists’ and researchers’ responsibility to apply what they discover to tangible benefits for society?” Respondents agreed that research should 38

ultimately be used to benefit society and make an impact, but some claimed that it is unfair to place the additional burden of translating the research back onto the scientists. Three people, all currently involved in research, mentioned that academic researchers tend to lack the resources and support to scale their findings up to a level where they can explicitly contribute to technological advances. Two others commented on how insufficient funding or conditional grants play a role in academic researchers’ ability to undertake projects with an end-user in mind. Oftentimes, scientists are pressured to use their resources to publish their findings and keep up with demands from their fields rather than spend time scaling projects up for future work.5 Respondents also commented on how academic and scientific institutions prioritize the production of knowledge and novel discoveries over application of the findings to benefit society.6 If scientific research is to be translational and more broadly applicable, institutions need to support their researchers both materially and culturally. This might look like increasing funding for research scale-up and shifting priorities to applied science, respectively. If institutions are not willing to make these changes to encourage scientists to apply their work, then there must be an alternative to help scientists to scale-up their findings. University researchers are often on the vanguard of scientific knowledge, but how can these breakthroughs be acknowledged if they do not make it into the public sphere? Many respondents proposed interdisciplinary collaboration, claiming that cross-functional teams involving experts from many different fields should be responsible for applying research findings. Several suggested that researchers should partner with engineers, applied scientists, and even communityEpidemic Proportions

based activists for the right guidance and expertise to build a pipeline of discoveries leading to societal benefits for end-users.b Collaboration between different scientists might be beneficial to bring new perspectives into the work. Teams including engineers who focus specifically on applying research could balance the responsibility of addressing problems with the principal scientists. Adding activists to these groups would hold the technical experts accountable to the broader goal of impacting end-users. Collaboration with advocates is essential to frame the findings to benefit interest groups or endusers who will be most impacted by the results.7 This push for collaboration is held by many respondents as the broadest and most feasible answer to who should be responsible for translating research findings to impact society. A scenario in which collaboration can be the key to translational science begins with cancer researchers studying a novel chemotherapeutic protein. The main goal of the scientists might be to isolate this protein, but if they frame their work with a clear objective to eventually develop a new cancer treatment, they can collaborate with more experts to scale-up their research to the treatment level. The scientists can work with a team of applied scientists to create a drug substance from the protein. To deliver the drug to the patients’ tumor site, the researchers can consult with engineers. When the drug is administered, patients and oncologists are involved to study the efficacy of the drug and the severity of side effects. Patient advocates or activist groups might also address treatment costs or other concerns that the users have with the treatment. Just from this simplified example of drug development, we see that if the researchers embrace translational science Edition 19 Spring 2022

in every step, they transform research into essential treatments for patients. While some research can be directly applied to consumer products, technology, or medicines, scientists also need to consider how science can be translated to policy. None of the respondents discussed the political use of research, but it is essential to utilize scientific findings for the creation of public policy. As we have seen throughout the COVID-19 pandemic, there is a heavy reliance on science to substantiate public health and policy decisions, so it is important that science is accessible to policy-makers.5 Of the many factors that policymakers consider when making decisions, science and research are revered as objective sources of evidence to justify policies. However, it is easy for nonscientists to misconstrue results or “cherry-pick” certain facts if the technical findings and nuances are not properly explained.1 To limit this misuse of facts and promote the responsible use of research, the results need to be well-communicated and widely available.5,6 Many researchers can impact policy-making, but there is a disconnect between how researchers present their findings and how politicians utilize the evidence to form policies.6 To bridge this gap, collaboration between policymakers and scientists is necessary to employ research findings as a basis for policies. It is difficult to frame a research question to directly solve a policy issue, so it is crucial that scientists

None of the respondents discussed the political use of research, but it is essential to utilize scientific findings for the creation of public policy" 39

consider the path of their research beyond the surface level and work with the right stakeholders to translate the findings to public policies, among other applications. When I asked my peers about translational research, they replied with thoughtful responses on how the intention of research should involve applying findings to a greater good. Respondents recognized that while scientists themselves typically lack support for work beyond initial discoveries, collaboration and developmental work can expand the scope of the findings. There were a couple of more extreme opinions, one being that scientists should only undertake a research project if they can guarantee the application of their work into a tangible benefit. Without this promised objective, the respondent claims that the research lacks purpose. Another claim was that academic researchers are experts in their fields because of the niche knowledge they have gained, and they should continue to use their expertise to produce more knowledge in their disciplines. This respondent also argues that research can be done for the sake of learning more about the natural world out of sheer curiosity rather than just transactionally for future benefit. The diversity of the responses and answers to the question highlighted the various ways that research can be imagined beyond the fundamentals and how scientists and nonscientists alike can solve problems using research. For most of the undergraduates I surveyed, research has been an integral part of their college careers. Initially, I thought that those involved in clinical research might have different views about direct applications of findings compared to those doing academic or industrial research. While I did not see much disagreement about this point, I did notice 40

that respondents pulled from different areas of expertise and perspectives to justify their ideas. For example, those that suggested collaboration among disciplines were primarily pre-medical and engineering students, while those who argued for more resources to do translational research were in social science focused majors. Seeing respondents weave their personal experiences into their answers indicated that translational research is of interest in many different fields, and that it is crucial to have these discussions as students at a research institution. I chose to have this discussion about translational science with undergraduate students because I was focused on how future scientists and researchers feel about the responsibility of using their expertise for the greater good. It is fascinating how these undergraduates seek to change the culture of their fields and can point out the faults in the current systems. Ultimately, research is a cornerstone of our society, so we must start each new scientific endeavor with the intention that it will positively impact our society.


Is it scientists’ and researchers’ responsibilities to apply what they discover to tangible benefits for society?

For example, physicist AJ Kumar applied his research on protein separation to creating a diagnostic test for sickle-cell anemia. As a fundamental physicist, he could have published papers and given presentationS on the physics of protein separation, but he chose to apply his work to a healthcare problem.

Epidemic Proportions

I think they should be in an ideal world but the field itself doesn't hold scientists responsible for doing anything with their work, because the only actual goal is to expand the knowledge base and earn the institutes/publishers/journals money. The goal of science might inherently be to better society, but I do not think that is what it is in a capitalistic society. However, it is pretty cool that scientists have the autonomy to apply their research in whichever fields they would like. So, it all comes down to the type of person the individual is. Plus, they rarely ever have the resources to actually be able to apply and see the effects of their research being used in the real world." I think they should be responsible for it because ultimately I think the purpose of scientific research is to benefit the community. I don’t think there’s anything wrong with giving presentations and publishing papers spreading their work, but in their papers/presentation they should definitely include a section on how it could be applied or what it means to society. And then they could work with others to help develop any necessary technology as well." Okay so I think that it’s not necessarily their job to apply the research because they’re doing the research for general findings and publishing papers to get that information out there- I think getting the information to the public is their main responsibility as scientists and researchers so that others (perhaps people with more funding or cross-functional groups with more abilities in different disciplines) can then take their findings and apply them to different situations." I currently work with an organization that prioritizes applying scientific research to better the world, and I think the question requires a nuanced answer. Of course, in an ideal world, all research would be able to be applied to benefit society, but to put that burden on the scientists themselves seems unfair, as they are rarely equipped with the institutional knowledge and skills required to translate their research into policy. I think, as a society, we need to put more emphasis on interdisciplinary collaboration so that people with the means and ability to implement policy or promote products can collaborate with these esteemed researchers so that the researchers themselves can focus on their fields, if that is what they want to do." I think that doing research that benefits the community should always be a goal when applicable. If you’re choosing to do presentations only, they should be done to groups of people that can use your research as preliminary data to take their own research in a more community based form." Edition 19 Spring 2022

Overall, I do think that researchers especially basic science researchers have a responsibility to the general public to make sure their research results in the greater good for humanity, especially over their own clout. But I also recognize that a lot of basic scientist, especially older white men, have no training or experience on making their findings translatable. So, I really think that institutions need to better facilitate collaboration between translational researchers, health policy makers, and basic scientists to make findings actually relevant to the public. I find too much emphasis on the individual lab or individual authors of papers and that really doesn’t get us anywhere and I think science (and all of academia) needs to make a stronger cultural shift towards collaboration."

I'm a huge fan of Sarewitz and his idea of doing research that's targeted at developing a technology or intervention that delivers tangible benefits to a soceity to solve a problem. But, I'm not necessarily sure if the scientists themselves should be responsible for applying their research. I think it's worth exploring the partnerships between researchers and others that could focus on applying scientific research, or worth exploring a new career field of not necessarily scientists that are dedicated to translating existing research into novel interventions that benefit society."

I think there is definitely a difference between translational research and basic science, of course, where researchers are specifically trained to have their findings be directly applicable (i.e., bench to bedside). I also find that a lot of basic scientists collaborate with translational researchers to make their molecularlevel findings applicable to the general public!"

Scientists should only be responsible for science. The people responsible for creating products to better the community should be the engineers. Ie not every Bio student is going to make a healthcare devices but when a BME design team is creating a device, they’ll rely on the scientific papers and research to back up their projects. I feel like it’s a lot of pressure to expect everyone in science to want to better the community because then there would be little incentive to study things for fun (like why study astronomy) also I feel like a lot of fields in science don’t necessarily have impact on the human condition." 41


a. User-centered research is research that is undertaken with a specific user in mind. In this example, the diagnostic testing tool was researched and developed with the objective that it should be quick and affordable for patients in communities lacking resources. b. In this case, an “end-user” is anyone who is affected by scientific findings through policies, consumer products, medical treatments, or technological advances 1. Howe N. 'Stick to the science': when science gets political. Nature News. https://www.nature.com/ articles/d41586-020-03067-w. Published November 3, 2020. Accessed November 11, 2021. 2. Sarewitz, D. (2016, Summer). Saving Science. Retrieved October 20, 2021, from https://www. thenewatlantis.com/publications/saving-science 3. “Chapter 5: Academic Research and Development.” National Center for Science and Engineering Statistics, Higher Education Research and Development Survey (HERD), National Science Foundation, 2018, https://nsf.gov/statistics/2018/nsb20181/report/ sections/academic-research-and-development/ expenditures-and-funding-for-academic-research 4. Ruell, Peter. “Faster, Cheaper Tests for Sickle Cell.” EurekAlert!, Harvard Research, Sept. 1AD, 2014, https://www.eurekalert.org/news-releases/691451. 5. Tseng V. Vol 26. 2nd ed. Society for Research in Child Development; 2012. 6. Weiss CH. The Many Meanings of Research Utilization. Public Administration Review. 1979;39(5):426. doi:10.2307/3109916 7. Christopherson, Elizabeth Good, et al. “The Civic Science Imperative.” Stanford Social Innovation Review, 2018.

Manasi Nawathe Chemical and Biomolecular Engineering Class of 2022 42

Epidemic Proportions

Photo Courtesy of Irfaan Karim Edition 19 Spring 2022


Photo Courtesy of Mason Cole 44

Epidemic Proportions

Policy | Kathleen Li

The Need for Mandatory and Accessible HPV Vaccination for Sixth Graders

In her policy piece, Li highlights the HPV Vaccine as a safe and effective way to prevent HPV infection and reduce risk of cervical cancer. She emphasizes the importance of vaccinating students early due to the vaccine’s efficacy being limited to patients without prior infection. Given the weight of the impact of HPV, Li strongly advocates for school-mandated HPV vaccination despite challenges that may arise from the policy.


hen they hear “HPV vaccine,” most people only consider how the vaccine protects against the sexually transmitted disease. They may believe that their child does not need to be vaccinated against human papillomavirus (HPV)—at least not at age 11.1 Most schools in the United States recognize this controversy and do not include HPV on their required vaccination lists. However, the HPV vaccine is an effective

Edition 19 Spring 2022


and safe way to prevent some cancers and protect the health of vaccinated children and the community as a whole. States therefore should protect children’s health by mandating students receive their first dose of the HPV vaccine by 6th grade and their second dose 6-12 months later. At the same time, these states should create HPV vaccination clinics at schools to make these vaccines accessible to all. HPV can harm peoples’ health not only because it is one of the most common sexually transmitted diseases, but also because HPV strains can cause cancer. These include genital and anal cancer, as well as cancers affecting the nose, mouth and throat; 36,000 new cases of cancer every year in the US are caused by HPV.2 These cases are easily preventable by the HPV vaccine, too. The vaccine has been found to be almost 100% effective for the decade after administration, with minor side effects similar to other vaccines.3, 4 If we proactively protected American boys and girls against HPV, we could safely prevent thousands from developing cancer each year. When and how should children be vaccinated? Children should be immunized against HPV before they become sexually active. Vaccines protect recipients from becoming infected, but there is no treatment for people who already have HPV. It might be hard for parents to accept, but their middle-school aged children may be sexually active and therefore be at risk for STIs. Almost all unvaccinated people become infected with HPV within a few years of becoming sexually active.2 Based on CDC guidelines, adolescents should therefore be vaccinated by age 12, before most people start having sex.5 46

The CDC also recommends 11-12 year old children to receive 2 doses of the HPV vaccine.5 The second dose should be administered 6-12 months after the first dose. However, this process becomes more complex for people who receive their first dose when they are 15 or older. The CDC recommends that these people receive 3 doses; there should be 1-2 months between the first and second doses and 6 months between the first and third doses. This added complexity may make it harder for families to properly and fully vaccinate children against HPV. Thus, children should be put on the 2 dose schedule around 12 years old.

If we proactively protected American boys and girls against HPV, we could safely prevent thousands from developing cancer each year" The Need to Intervene Despite all the benefits of HPV vaccination, less than half of teens aged 13 to 15 have received their recommended doses.6 In 47 states, there are no school requirements for HPV vaccination.7 Instead, parents are expected to talk with their doctor and make their own decisions about whether and when to vaccinate their children. Research has found that parents often defer or decline HPV vaccination because they do not believe it is necessary or because they are unsure about its safety. This may be due in part to a lack of strong and effective physician recommendations for children 11 or 12 years old to receive the HPV vaccine.8, 9 Doctors feel that discussions about HPV vaccination are longer and more difficult, and many do not recommend vaccination consistently Epidemic Proportions

or on schedule. Medical organizations like the American Medical Association should encourage doctors to advocate better HPV vaccination regimens, but states can also help by releasing HPV vaccination requirements. Parents and doctors will then place greater priority on getting children vaccinated and discussions about the vaccine may be simpler. The benefit of protecting children’s health through HPV vaccinations morally and politically outweighs the restrictions on personal freedom they may create. Governments have a responsibility to protect their citizens’ health, and school requirements can be an effective way to increase vaccination rates.10, 11 Furthermore, there is precedent for public schools to require vaccinations; for example, almost all states require children to receive the Tdap vaccine by 6th or 7th grade.12 The HPV vaccine should also be required by public schools and not be left to individual choice. In addition to protecting the health of individual students, schools should also require these vaccines to prevent the larger community from getting sick. As we have seen during the COVID-19 pandemic, vaccines can strongly affect public as well as personal health. The decision of whether to vaccinate yourself or your child can affect other people through herd immunity. Herd immunity is reached when enough people within a community are immune to a disease through vaccination or other means, and their immune status prevents illness from being spread between group members. This protects the members of the community who cannot become immune through vaccination. Though HPV is transmitted differently from the coronavirus, the HPV vaccine has also been shown to provide herd immunity—but only if enough Edition 19 Spring 2022

people within a group are vaccinated.13, 14 Accommodations to waive vaccination using the personal belief exemption put this system in jeopardy. Unfortunately, in the few areas that have HPV vaccine mandates, the effectiveness of these mandates is split among racial and socioeconomic lines. Low income girls and Black girls are more likely to start their HPV vaccination series, but are less likely to finish it.11 Knowledge or ability to navigate the vaccination timeline could be at fault--that is a barrier common to many different HPV vaccination efforts. Therefore, in addition to creating 6th grade HPV vaccination requirements, state governments should ensure students stay on track with their vaccination schedule. Furthermore, states could also create school-located vaccination (SLV) clinics for HPV, similar to existing flu clinics.15 This would remove major barriers to vaccination such as transportation and health literacy.

It might be hard for parents to accept, but their middleschool aged children may be sexually active and therefore be at risk for STIs" Creating HPV Vaccine Clinics Creating school-based programs to provide first and second HPV vaccine doses to children could greatly increase vaccine uptake. In the United States, there is a centuries-long history of mass vaccination clinics at schools and many schools have hosted SLV clinics for flu vaccination since 2006.16 These flu vaccination clinics have increased vaccination rates for elementary and middle schoolers.17 47

Governments can and should ensure that all adolescents and young adults stay on track for their vaccinations by creating requirements for subsequent school years and creating inschool vaccination clinics"

The clinics’ success in reaching adolescents is particularly striking, since this population accesses preventative health measures like vaccinations less frequently.18 This effectiveness in reaching adolescents may be especially important to increase timely HPV vaccination. There are still several major barriers to creating public school HPV mandates with schoolbased vaccination sites. First, most states only allow schools to set vaccine requirements for diseases that are related to children’s safety at school.19 Sexually transmitted infections like HPV have lower chances of being spread at school compared to airborne diseases like the flu. Another possible barrier is whether schools can house these vaccination clinics. Mass vaccinations like the flu clinics mentioned above are logistically challenging because guardians are not often on-site, so they must fill out permission forms ahead of time.20 It can also be complicated to communicate documentation of doses to primary care providers and insurance. Vaccination clinics create large work burdens for a school’s administrative staff, which can reduce the feasibility of a successful vaccination fair. However, there is legal and practical precedent to address both of these concerns. Despite HPV not being considered a health risk at school, governments are also given authority to 48

broadly protect the health of minors under the legal doctrine of parens patriae.21 Since school boards are governmental representatives of the local community, under the spirit of parens patriae they should be able to provide assistance to children unable to participate in the recommended HPV vaccination regimen, regardless of their parents’ beliefs. Furthermore, flu clinics can serve as a model for HPV clinic success. SLV Funding and Logistics Solutions Similar to flu vaccine clinics, HPV vaccination clinics could either bill insurance providers or waive all fees. If these SLV programs bill insurance, children can be insured under their guardian’s insurance or through other programs. Both private and public insurance plans must cover the HPV vaccine, and the Vaccines for Children program helps cover Medicaid-eligible, uninsured, and underinsured children across the nation.22 This option allows SLVs to be self-funding and sustaining. However, the coordination and paperwork for billing insurance may be a barrier to creating SLV programs. This barrier could be minimized by funding the clinic through government grants, though future changes to these grants could jeopardize the vaccine clinic. One major difference from flu vaccines is that the HPV vaccine requires multiple doses at set time frames and HPV vaccination clinics should provide both doses to minimize barriers to vaccination timeline adherence. Again, the CDC recommends for children under 15 to receive their second dose 6-12 months after the first dose.5 SLV clinics could achieve this schedule by holding a first dose clinic in the fall and a second dose clinic in the spring. Alternatively, schools can hold an annual clinic where sixth graders receive their first dose Epidemic Proportions

and seventh graders receive their second. The annual clinic may be more feasible than the biannual clinic, but also has its drawbacks. The spring clinic will need just as much planning and paperwork as the fall, and could cost more if all fees are waived. Having the annual clinic may be more logistically and financially feasible but may not protect as many children. Children would go half a year longer without full protection, though ideally 6th graders are at minimal risk for HPV infection. The relative advantages and disadvantages of these funding schemes and schedules may vary by school, so schools should be given the freedom to create individualized solutions following science-informed guidelines. Conclusion Requiring 6th graders to be vaccinated against HPV is a matter of both personal and public health. The vaccine is a safe and effective way to prevent cancers. Governments can and should ensure that all adolescents and young adults stay on track for their vaccinations by creating requirements for subsequent school years and creating in-school vaccination clinics. These clinics should provide both the first and second HPV vaccine doses to reduce barriers to vaccination timeline adherence. Through these school-mandated HPV vaccinations, we can prevent thousands of cancer cases a year. References

1. Perkins RB, Clark JA, Apte G, et al. Missed opportunities for HPV vaccination in adolescent girls: A qualitative study. Pediatrics. 2014;134(3). doi:10.1542/ peds.2014-0442 2. National Cancer Institute. HPV and cancer. National Cancer Institute. https://www.cancer.gov/aboutcancer/causes-prevention/risk/infectious-agents/ hpv-and-cancer. Published January 22, 2021. Accessed October 18, 2021. Edition 19 Spring 2022

3. Chatterjee A. The next generation of HPV vaccines: Nonavalent vaccine V503 on the Horizon. Expert Review of Vaccines. 2014;13(11):1279-1290. doi:10.15 86/14760584.2014.963561 4. National Cancer Institute. Human papillomavirus (HPV) vaccines. National Cancer Institute. https:// www.cancer.gov/about-cancer/causes-prevention/ risk/infectious-agents/hpv-vaccine-fact-sheet. Published May 5, 2021. Accessed October 18, 2021. 5. Centers for Disease Control and Prevention. HPV vaccine recommendations. Centers for Disease Control and Prevention. https://www.cdc.gov/ vaccines/vpd/hpv/hcp/recommendations.html. Published March 17, 2020. Accessed October 18, 2021. 6. US Department of Health and Human Services. Increase the proportion of adolescents who get recommended doses of the HPV vaccine - IID‑08 data. Increase the proportion of adolescents who get recommended doses of the HPV vaccine Data - Healthy People 2030. https://health.gov/ healthypeople/objectives-and-data/browseobjectives/vaccination/increase-proportionadolescents-who-get-recommended-doseshpv-vaccine-iid-08/data. Published n.d. Accessed October 18, 2021. 7. Sitler CA, Weir LF, Keyser EA, Casablanca Y, Hope E. Mandatory HPV vaccination; opportunity to save lives, improve readiness and cut costs. Military Medicine. 2021. doi:10.1093/milmed/usab232 8. Gilkey MB, Moss JL, Coyne-Beasley T, Hall ME, Shah PD, Brewer NT. Physician communication about adolescent vaccination: How is human papillomavirus vaccine different? Preventive Medicine. 2015;77:181185. doi:10.1016/j.ypmed.2015.05.024 9. Gilkey MB, Malo TL, Shah PD, Hall ME, Brewer NT. Quality of physician communication about human papillomavirus vaccine: Findings from a national survey. Cancer Epidemiology Biomarkers & Prevention. 2015;24(11):1673-1679. doi:10.1158/10559965.epi-15-0326 10. Barraza L, Weidenaar K, Campos-Outcalt D, Yang YT. Human papillomavirus and mandatory immunization laws. Public Health Reports. 2016;131(5):728-731. 49



11. Polonijo AN. The impact of school-entry mandates on social inequalities in human papillomavirus vaccination. SSM - Population Health. 2020;12:100647. doi:10.1016/j.ssmph.2020.100647

20. Cartmell KB, Young-Pierce J, McGue S, et al. Barriers, facilitators, and potential strategies for increasing HPV vaccination: A statewide assessment to inform action. Papillomavirus Res. 2018;5:21-31. doi:10.1016/j.pvr.2017.11.003

12. Immunization Action Coalition. State information. Tdap Vaccine Mandates for Elementary and Secondary Schools. https://www.immunize.org/laws/ tdap.asp. Published January 20, 2020. Accessed January 16, 2022. 13. Kahn JA, Brown DR, Ding L, et al. Vaccinetype human papillomavirus and evidence of herd protection after vaccine introduction. Pediatrics. 2012;130(2):e249-e256. doi:10.1542/peds.20113587

21. Wex Definitions Team. Parens Patriae. Legal Information Institute. https://www.law.cornell.edu/ wex/parens_patriae. Published July 2021. Accessed January 16, 2022. 22. Kaiser Family Foundation. The HPV vaccine: Access and use in the U.S. KFF. https://www.kff.org/ womens-health-policy/fact-sheet/the-hpv-vaccineaccess-and-use-in-the-u-s/. Published July 12, 2021. Accessed January 16, 2022.

14. Rosenblum HG, Lewis RM, Gargano JW, Querec TD, Unger ER, Markowitz LE. Declines in prevalence of human papillomavirus vaccine-type infection among females after introduction of vaccine — United States, 2003–2018. MMWR Morbidity and Mortality Weekly Report. 2021;70(12):415-420. doi:10.15585/mmwr. mm7012a2 15. Centers for Disease Control and Prevention. Influnza school-located vaccination (SLV): Information for Planners. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/pdf/school/SLV_ information.pdf. Published n.d.. Accessed October 18, 2021. 16. Mazyck D. School-Located Vaccination Clinics: Then and Now. The Journal of School Nursing. 2010;26(4_suppl):3S-6S. doi:10.1177/1059840510369231

Kathleen Li Biology & Public Health Studies Class of 2022

17. Shlay JC, Rodgers S, Lyons J, Romero S, Vogt TM, McCormick EV. Implementing a School-Located Vaccination Program in Denver Public Schools. J Sch Health. 2015;85(8):536-543. doi:10.1111/josh.12281 18. Limper HM, Burns JL, Lloyd LM, Atilano J, Alexander KA, Caskey RN. Challenges to schoollocated vaccination: lessons learned. Pediatrics. 2014;134(4):803-808. doi:10.1542/peds.2014-1339 19. Diekema DS. Personal belief exemptions from school vaccination requirements. Annual Review of Public Health. 2014;35(1):275-292. doi:10.1146/ 50

Photo Courtesy of Mason Cole Epidemic Proportions

Features | Amanda Ferber

Developing a Statistical Awareness of Racial Disparities in Health Care

In this feature, Ferber reflects on her research experience at the Johns Hopkins Center for Health Disparities Solutions, where she worked to bring light to the differing degrees by which different races in gentrifying neighborhoods of the U.S. employ the healthcare services available to them. Her work not only reveals the breadth of the varied struggles we each face in the aim of health, but she feels her involvement also helped her in developing her concept of what it means to work in a team and develop understanding.


uring the summer before my freshman year at Johns Hopkins, I had the privilege of conducting remote research at the Johns Hopkins Bloomberg School of Public Health at the Center for Health Disparities Solutions. I received this opportunity due in part to a lucky coincidence. In the winter of my junior year of high school, I applied to the Short Term Research Program for Underrepresented Students (STEPUP) offered by the NIH National Institute of Diabetes and Digestive and Kidney Diseases. The program was meant to match accepted students with local research mentors in the biomedical and health sciences in order to complete a summer research project. After submitting a personal statement and a description of my extracurricular involvement and accomplishments, I was delighted to learn Edition 19 Spring 2022

that I was accepted to the program in February 2020. However, three weeks following my acceptance, the program was postponed due to COVID-19. Luckily, my spot in the program was deferred to the summer of 2021 during which the program would be mainly remote. In the year that followed, I was accepted to Hopkins, and I also discovered my strong interest in Public Health after conducting computational biology research with a breast cancer research center where free mammograms and screenings are provided to women without insurance. I realized that I wanted to have a career wherein I could make healthcare more accessible and efficient for those with the greatest disadvantage. When my STEP-UP coordinator contacted me inquiring about my research preferences 51

We were all underrepresented minorities seeking to contribute to the body of knowledge of public health issues that affect other people who look like us” for the summer, I informed her that my ideal research placement would be with a Public Health researcher at Hopkins due to my impending matriculation at JHU in the Fall. She had placed students with researchers at the Center for Health Disparities Solutions in years past, so she was eager to match me with two mentors: Dr. Roland Thorpe and Dr. Genee Smith with whom I would spend the summer learning about racial health disparities and analyzing health survey data. My research experience actually began in early June 2021 before I had even graduated from high school. Our research team comprised Dr. Thorpe, Dr. Smith, myself, and two high school seniors from Franklin and Marshall College and Morehouse College, respectively. With enthusiasm and irony in his voice, Dr. Thorpe explained the goal for our summer in one sentence: “let’s write a paper in eight weeks!” Though his tone was congenial and encouraging, he did not sugarcoat the workload we would be undertaking or the seriousness of the work we would be completing. We learned that we would meet on Zoom for a 90-minute meeting every Monday during which we would dissect the different aspects of a research paper and present the work we had done the previous week. In fact, Dr. Thorpe informed us that our first meeting together would be the last one he would run himself. For all weekly meetings thereafter, the two other undergraduates and I were 52

expected to take turns hosting the meeting by transitioning between agenda items. In addition, I was given the task of sending out recurring calendar invitations for the meetings. I was initially terrified of hitting the “end” button and emailing everyone at once, My assigned research topic was Racial Disparities in Healthcare Services Utilization (HSU) in gentrifying neighborhoods in the United States. HSU is a measure of the extent to which a person seeks out healthcare services, and we define it as attending officebased physician visits, attending office-based non-physician visits, or having a usual source of medical care. HSU is also an important indicator of accessibility of care, prevailing attitudes about health services, the efficacy of public health measures to improve health outcomes, and the role health plays in the lives of various groups of US residents. In my project, I studied the association between one’s race and whether or not they exhibited each of the listed measures of HSU. Though this association has been deemed to be significant in previous literature, no research team to date has studied the racial disparities in HSU in the context of gentrification specifically. Another JHSPH researcher, Dr. Darrell Gaskin, has done extensive work on racial disparities in HSU in segregated neighborhoods due to the important effect that place/neighborhood setting has on the local dynamic of healthcare consumption and how it varies by race. In analyzing the healthcare consumption data of those living in gentrifying neighborhoods specifically, we were able to gain insight into the potential implications of a different type of urban phenomena. To meet the standards of a research center at a graduate institution and work productively alongside distinguished scholars in the field Epidemic Proportions

of health disparities, he informed us that we needed to hold ourselves accountable for the tasks assigned to us. This was the first time in my academic career where my “teacher” was not necessarily someone I could fall back upon for deadline reminders or thoroughly structured assignments. For this reason, I found myself devoting a portion of my week towards carefully writing down thoughtful and unique questions to match the profound answers I could anticipate from them. During our first meeting and our first round of feedback on our project contributions, none of us left the Zoom meeting without extensive constructive criticism. They commanded a high level of specificity, precision, and depth to our writing that was never required in high school. I loved how they never let any instance of “BS,” vagueness, or improper formatting slide. For instance, we spent at least 75 minutes of our second meeting polishing our research questions. We struggled to correctly implement the PICO framework, which comprises components of any well-formed research question. The following four components now shape my understanding of any peer-reviewed paper I have read since the beginning of my research experience at JHSPH: P: Patients or populations Includes information on the population/ setting of interest I: Intervention/exposure Specifies the types of risk factors, exposures or intervention of interest C: Comparison group Specifies the comparison being made O: Outcome Specifies the outcome of interest Edition 19 Spring 2022

Before understanding of PICO Framework: Does exposure to gentrification cause changes in healthcare consumption among African Americans and other people of color as compared to whites? After understanding of PICO Framework: What is the association between race and healthcare service utilization (HSU) among Black and White adults living in US gentrifying neighborhoods? Dr. Thorpe and Dr. Smith gave me a profoundly more thorough understanding of the independent and dependent variables and their associated context as well as covariates during that meeting. The first draft of my research question was actually completely wrong in that I misunderstood what the independent variable was, which I initially felt embarrassed about. However, I realized that it made the most sense to appreciate learning from my mentors and gaining more refined knowledge regardless of how incorrect or undeveloped my initial question may have been. Searching for the right balance between self-efficacy and embracing help was deep-rooted in my research experience. Oftentimes, I learned the most in situations where I embraced the vulnerability of being wrong from the get-go. When self-sufficiency only went as far as knowing when to email my mentors to request guidance, I learned to still have pride in my accomplishments: my growth

But I now realize that there was power in taking on that kind of leadership, even though it was small, among a group of researchers I respected so much.” 53

from my starting point was far more important than how my goals were achieved. I am very thankful that my mentors spent so much time helping me to solidify my understanding of the relationship between variables because it helped me form more well-rounded takeaways when I went on to write the research paper.

Rather I understood my research mentors to be there primarily to give insight I could never hope to find on Google and complex answers specifically crafted from years of high-level study and scholarship.”

Though Dr. Thorpe was our primary mentor, I worked closely with Dr. Smith on my individual project specifically. About two weeks before receiving the data for statistical analysis, she gave me approximately 10-12 pertinent papers to read to have the necessary context for the work that would follow. It was in this period of time that I embraced close reading and annotation, especially since this was my first time trying to interpret literature on social science. I appreciated that Dr. Smith probed me with various questions about gentrification and the relevance of HSU to the study of public health disparities because it made me feel secure regarding the motivation for our work. In order to conduct the research and write our papers, we followed the inside-out method wherein we wrote the following sections of our research papers in an initially unintuitive order: methodology, results, introduction, discussion/conclusion, and abstract. This order ensured that we understood our data and research process first before attempting 54

to draw conclusions or synthesize those of prior literature. In writing the “Methods” section, I learned that the data we would use would be coming from the 2014 Medical Expenditure Panel Survey (to link a respondent’s healthcare utilization status to their race and census tract) and the 2006-2017 American Community Surveys (to determine whether a respondent’s census tract corresponded to a gentrifying neighborhood). The criteria for determining whether a neighborhood is indeed gentrifying is not widely agreed upon in the literature, but we used changes in median rent, median household income, and college-education rates within a census tract to simulate the entrance of middle- to upper-class migrants to a formerly disinvested neighborhood. After meeting with Dr. Smith over the course of two weeks to gain an understanding of the statistical analysis performed on the survey data, I learned the basic functionality of STATA, a prominent data analysis program in social science research, and the concept of Poisson regression, which we performed to determine the prevalence of HSU among White and Black residents of gentrifying neighborhoods. After adjusting for age, gender, education, income, employment, health insurance, marital status, region, and self-rated health, Black residents of gentrifying neighborhoods demonstrated a similar prevalence of having an office-based physician visit, a lower prevalence of having an office-based nonphysician visit (Prevalence Ratio [PR]: 0.74; 95% Confidence Interval [CI]: 0.60 - 0.91), and a lower prevalence of having a usual source of care (PR: 0.87; 95% CI: 0.77 - 0.98) as compared to their White counterparts. Writing the Introduction and Discussion sections was the most difficult and timeEpidemic Proportions

The thought of adding to the growing body of literature on health disparities is extremely fulfilling, especially because my work could one-day influence policy that may make healthcare access more equitable in gentrifying neighborhoods.” consuming part of the summer. I spent hours at a Panera booth across multiple days synthesizing and making connections between previous literature and evaluating the consistency of our results with those of researchers who also studied place-based racial disparities in HSU. I wanted so badly to be able to contribute possible causes of our findings and speculate on their implications in a similar way to authors I read at the beginning of the summer. These sections of my paper commanded the most thought and effort I had ever put into any of my previous academic work, including my college application essays. Because I didn’t have any classes or other responsibilities forcing me to divide my attention, I was able to put so much of myself into forming these speculations and conclusions. This is the value of summer research. Reflecting on my summer experience, I realize just how rare it is to be able to devote your thoughts and time toward one big endeavor. Despite the time-consuming and challenging nature of forming conclusions from both preexisting and new data, the thought of adding to the growing body of literature on health disparities is extremely fulfilling, especially because my work could one-day influence policy that may make healthcare access more equitable in gentrifying neighborhoods. By the end of the summer, I had produced a full working draft of a research paper, a 10-minute powerpoint presentation on my Edition 19 Spring 2022

work, and a poster for use at future symposia opportunities. Presenting at the NIH STEPUP Summer Research Symposium at the end of the summer was so gratifying. With my loved ones, peers, and research mentors in attendance, I got to step into the role of presenter and actually provide the answers rather than the questions in the Q&A session that followed. Now in the Fall semester, I continue to meet with Dr. Smith weekly as we edit and improve my manuscript. We hope to submit my paper for peer-review/publication in the Winter.

Amanda Ferber Computer Science & Public Health Studies Class of 2025

Photo Courtesy of Irfaan Karim 55

Photo Courtesy of Mason Cole 56

Epidemic Proportions

Research | Armaan Jamal

Vaccination Patterns, Disparities, and Policy Among Asian Americans and Asians Living in the US

This research article focuses on vaccination patterns in Asian Americans, as understanding vaccination coverage among disaggregated Asian American subgroups can inform policies aimed at increasing vaccine uptake. This summer, Armaan Jamal participated in the Stanford Center for Asian Research and Education (CARE) Scholars Program, an immersive research internship in Data Science and Vulnerable Populations with a focus on Asian Health. During the program, Jamal utilized various tools to conduct large database analysis, understand core concepts in health care research, and identify both problems and solutions in vulnerable populations. Most vaccine research aggregate Asian Americans as one population even though the Asian American population consists of several large subgroups and within-group heterogeneity in health-seeking behaviors. Throughout this article, Jamal further discusses how aggregating vaccine data on Asian Americans can mask several vaccine trends within each subgroup, which can lead to ineffective public health policies and reduced vaccination.


accine preventable diseases such as influenza, cervical cancer, and hepatitis B cause thousands of hospitalizations and deaths in the US each year.1-3 Racial and ethnic minorities have lower vaccination coverage rates than White

Edition 19 Spring 2022

Americans.4 Eliminating healthcare disparities in preventive health care is a major goal stated in Healthy People 2030.5 However, some vaccine-preventable diseases such hepatitis B and human papillomavirus continue to disproportionately impact Asian-Americans, 57

perhaps because vaccination coverage in the United States (US) among Asian-Americans and Asians is lower than among non-Hispanic Whites.6-9 To date, most of the research on vaccination rates in the US population aggregates data on Asian Americans despite there being differences in vaccination rates, health behaviors and outcomes between Asian American subgroups. Studies of influenza vaccination rates have shown large disparities among Asian American subgroups.10 However, disaggregated data on other vaccine preventable diseases among AsianAmericans is not available. Using the National Health Interview Survey from 2006-2018, we assessed vaccination coverage for seven vaccines (influenza, human papillomavirus, hepatitis B, tetanus (Td and Tdap), pneumococcal, and herpes zoster) among disaggregated Asian-American subgroups, and compared it to non-Hispanic whites. Understanding which groups are well-vaccinated and which groups have lower vaccination coverage can inform public health policies and clinical practices to reduce healthcare disparities in the US. Knowing which vaccines have the lowest uptake can help public health practitioners who work in communities with low vaccine coverage to focus resources on the most relevant interventions. Methods Data and Sampling Methods The National Health Interview Survey (NHIS) is a continuous, cross-sectional household interview survey that targets the civilian non-institutionalized US population. Data on socio-demographic information, access to healthcare, and health behaviors are 58

gathered through face-to-face or telephone interviews conducted by trained interviewers from the US Census Bureau. To ensure that the data is representative of the civilian noninstitutionalized US population, the NHIS uses a multistage area probability sampling design that incorporates stratification and clustering.11,12 Incorporating both stratification and clustering in the sampling method allows the objectives of NHIS to be achieved despite the fact that there are constraints in sample size. This study used the harmonized NHIS dataset from 2006 to 2018 provided by the Integrated Public Use Microdata Service (IPUMS).13 We included individuals 19 years or older who answered questions regarding the vaccines of interest. Vaccine coverage trends by race were analyzed using data from the entire study time frame (2006 - 2018). Racial disparities in vaccination coverage were analyzed using pooled data from 2015 to 2018 to provide the most recent results while maintaining sample size. We excluded participants with missing responses on race from the 2015-2018 NHIS data, which resulted in a study sample size of 262,721 observations. Vaccination Status Within NHIS, we identified seven CDC recommended vaccines in the NHIS dataset with sufficient data that are relevant from a clinical/public health perspective: human papillomavirus (HPV), hepatitis B, pneumococcus, influenza, tetanus (Td and Tdap), and shingles.14 Participants were asked whether they have ever received an HPV vaccine, a hepatitis B vaccine, and a pneumonia vaccine in separate questions. For the influenza vaccine, participants were asked “During the past 12 months, have you ever had a flu vaccination?” For the tetanus Epidemic Proportions

vaccine, participants were asked “Have you received a tetanus shot in the past 10 years?” For Tdap, participants were asked “Thinking back to your most recent tetanus shot, did the health care provider tell you or did the vaccine information sheet say the vaccine included the pertussis or whooping cough vaccine?” For shingles, participants were asked “Have you ever had the Zoster or Shingles vaccine, also called Zostavax®?” Prior to 2018, they were asked whether they had received the Zostavax vaccine. Vaccination status was determined by whether a participant answered “yes” or “no” to each question.

Understanding which groups are well-vaccinated and which groups have lower vaccination coverage can inform public health policies and clinical practices to reduce healthcare disparities in the US" Race/Ethnicity Race/ethnicity was measured based on participants’ self-identification and defined as: Non-Hispanic Black, Non-Hispanic White, Non-Hispanic Asian, Hispanics, and Other. The publicly available NHIS data disaggregated Chinese, Filipinos, and Asian Indians. Other Asian subgroups were aggregated “other Asians” to maintain anonymity. Native Americans and people who selected multiple races were grouped as “Other.” Covariates The demographic variables included in our study were age (19-26 years old, 27-49 years old, 50-64 years old, 65+ years old), sex Edition 19 Spring 2022

(female or male), marital status, and nativity (US born or foreign born). Socioeconomic variables included total family annual income (<=$34,999, $35,000-$74,999, $75,000), education level (less than high school, high school graduate/GED/some college, Bachelor’s degree or higher), any health insurance coverage, private health insurance coverage, Medicaid coverage, and Medicare coverage. Health covariates included selfreported health status (excellent/very good, good, fair/poor) and the number of visits to a physician’s office in the last 12 months (none, 1 visit, 2-3 visits, 4-7 visits, 8 visits or more). Statistical Analysis For each covariate of interest, we calculated the weighted percentages and 95% confidence intervals of participants who received each vaccine. Multiple logistic regression models were fitted for each vaccination outcome in a stepwise fashion. Predictive marginal means for each race/ethnicity were calculated as probability-weighted averages of the fitted probabilities of inoculation for the final model on a new, standardized population, where all the observations are respectively set to each race/ethnicity while holding other covariates at their respective probability-weighted means. Joinpoint version was used to analyze temporal changes in adult coverage for each vaccine from 2006 to 2018.15 All other statistical analyses were performed using R version 4.1.0. Survey weighting was performed using the survey package. In addition, we identified factors independently associated with the coverage of each included vaccine. Generally, being female, having higher family income, having a higher educational level, having health insurance, and engaging in health-seeking behaviors such as higher number of doctor visits are positively 59

TABLE 1 Proportion of vaccinated adults >= 19 years old by race in the Natinoal Health Interview Survey (NHIS) 2015-2018 cohort

Race (n=262,721; observations not missing race)

Have received Td Total Sample Size vaccine (n=69,394 (n=262,721; number out of 115,124 total; of observations with yes/no responses) no missing values in race) NHW (n=172,085) Chinese (n=3,165) Filipino (n=3,656) Asian Indian (n=3,525) Other Asian (n=5,819) Black (n=29,796) Hispanic (n=41,419) Other (n=3,256)

67.1 (66.4, 67.8) 45.7 (42.1, 49.4) 58.7 (55.2,62.2) 56.6 (53.2, 60.0) 53.8 (50.8, 56.9) 50.4 (49.2, 51.7) 53.2 (51.7, 54.7) 65.0 (62.0,67.9)

Have received Have received Have received Tdap Have received HPV Shingles vaccine pneumonia vaccine vaccine (n=19,672 vaccine (n=5,734 (n=15,255 out of (n=33,004 out of out of 26,823 total; out of 43,396 total; 60,882 total; yes/no 111,815 total; yes/no yes/no responses) yes/no responses) responses) responses) 73.5 (72.5,74.5) 83.4 (77.3, 89.6) 82.6 (78.0, 87.1) 74.6 (68.5, 80.6) 79.1 (74.6,83.7) 72.6 (70.2, 75.1) 71.0 (68.6, 73.3) 74.2 (68.2, 80.3)

37.6 (36.8, 38.3) 28.7 (22.2, 35.1) 30.5 (25.8, 35.2) 20.6 (13.8, 27.3) 31.8 (27.3, 36.3) 17.0 (15.6, 18.5) 19.8 (17.6, 22.0 29.5 (24.3, 34.8)

Weighted % (95% CI) 71.1 (70.4,71.9) 48.7 (40.9, 56.5) 62.8 (57.0, 68.6) 57.7 (48.2, 67.2) 48.4 (42.9, 53.8) 55.2 (52.9, 57.6) 49.5 (46.8,52.3) 63.4 (55.8, 71.0)

36.1 (34.8, 31.3) 37.9 (30.8, 45.0) 38.7 (29.4, 48.0) 12.9 (8.50, 17.3) 30.4 (24.5, 36.4) 29.6 (27.3, 31.9) 26.4 (24.5, 28.4) 33.2 (26.1, 40.2)

Have received Hepatitis B vaccine (n=32,055 out of 106,691 total; yes/no responses)

Have received flu vaccine in the past 12 months (n=53,068 out of 115,124 total; yes/no responses)

30.7 (30.1, 31.3) 38.5 (35.2, 41.8) 42.3 (38.9, 45.7) 41.2 (37.9, 44.5) 40.4 (37.8, 42.9) 29.5 (28.3, 30.7) 29.0 (28.0, 30.1) 36.0 (32.8, 39.3)

48.4 (47.9, 48.9) 43.1 (40.1, 46.1) 53.0 (50.0, 56.4) 47.1 (43.8, 50.4) 48.8 (46.1, 51.5) 37.1 (35.9, 38.2) 36.0 (34.9, 37.1) 44.8 (40.6, 48.9)

*Vaccination status stratified by demographic, socioeconimic, and health variables is not shown for simplicity of the table.

Table 1. Proportion of vaccinated adults >= 19 years old by race in the National Health Interview Survey (NHIS) 2015-2018 cohort. Vaccination status stratified by demographic, socioeconomic, and health variables is not shown for simplicity of the table. associated with vaccination. Being US-born is positively associated with having received all but Hepatitis B vaccines. Self-reported general health status has bi-directional associations. It is negatively associated with HPV, Shingles, Td, Tdap, Hepatitis B vaccination but positively associated with flu and pneumococcal vaccination. Results The weighted unadjusted vaccination coverage, weighted adjusted vaccination coverage, and results from Joinpoint regression analyses for each vaccine are summarized below. Joinpoint regressions for Chinese, Filipinos, Asian Indians, and non-Hispanic whites for each vaccine are presented in Figure 1. Influenza The estimated influenza vaccination coverage among adults aged 19 or older was 48.4% for non-Hispanic whites, 43.1% for Chinese, 53.0% for Filipinos, 47.1% for Asian Indians, 48.8% for other Asians, 37.1% for Blacks, 36.0% for Hispanics, and 44.8% for other races (Table 1). The adjusted Influenza vaccination coverage for Asian Americans, except Chinese, was higher than that for non-Hispanic whites. However, the adjusted influenza vaccine coverage for blacks was 60

lower than that for non-Hispanic whites (Table 2). The influenza vaccination coverage for all racial/ethnic groups increased from 2006 to 2018. However, the estimated APCs (annual percent changes) for most groups except Filipinos and other races, although still positive, decreased at some point during that time period. Asian Indian and Hispanic racial groups had statistically significant positive APCs of Influenza vaccination while other racial/ethnic groups did not have statistically significant APCs. HPV The estimated HPV vaccination coverage among adult females aged 19 or older when the HPV vaccine was first introduced in the US (2006) was 36.1% for non-Hispanic whites, 37.9% for Chinese, 38.7% for Filipinos, 12.9% for Asian Indians, 30.4% for other Asians, 29.6% for Blacks, 26.4% for Hispanics, and 33.2% for other races (Table 1). The adjusted HPV vaccination coverage for blacks and Hispanics are comparable to non-Hispanic whites, while the disparity between Asian Indians and non-Hispanic whites remains (Table 2). All racial/ethnic groups except other races have statistically significant positive APCs of HPV vaccination. Hepatitis B The estimated



vaccination Epidemic Proportions

coverage among adults aged 19 or older was 30.7% for non-Hispanic whites, 38.5% for Chinese, 42.3% for Filipinos, 41.2% for Asian Indians, 40.4% for other Asians, 29.5% for Blacks, 29.0% for Hispanics, and 36.0% for other races (Table 1). The adjusted Hepatitis B vaccination coverage for Chinese and Asian Indians are similar to non-Hispanic whites, while Filipinos and other Asians had higher coverage than non-Hispanic whites (Table 2). The estimated APCs of the Hepatitis B vaccination for most groups decreased in 2011 or 2012 but increased afterward. No racial/ethnic group had statistically significant APCs for the Hepatitis B vaccine.

shot was a Tdap shot, all minority groups had adjusted vaccine coverage comparable to that of non-Hispanic whites, with the exception of Filipinos and other Asians among whom Tdap coverage was higher than among nonHispanic whites (Table 2). Tdap coverage for non-Hispanic whites, Hispanics, and Blacks increased between 2008 and 2014 and then plateaued. Rates of Tdap vaccination were similar across all ethnic groups except for Asian Indians among whom there was increased coverage from 2008 to 2018. Additionally, no racial/ethnic group except Asian Indian, Black, and Hispanic had statistically significant APCs for the Tdap vaccine.

Td The estimated Td vaccination coverage among adults aged 19 or older was 67.1% for nonHispanic whites, 45.7% for Chinese, 58.7% for Filipinos, 56.6% for Asian Indians, 53.8% for other Asians, 50.4% for Blacks, 53.2% for Hispanics, and 65.0% for other races (Table 1). All minority groups, except Filipinos, had lower adjusted Td coverage than non-Hispanic whites (Table 2). Asian Indians, Chinese, and other races had relatively constant rates of Td vaccination from 2008 to 2018. The Td coverage for Filipinos, non-Hispnaic whites, and other Asians increased during that time period. However, the Td coverage for blacks decreased. Additionally, no racial/ethnic group had statistically significant APCs for the Td vaccine.

Shingles The estimated shingles vaccination coverage among adults aged 60 or older was 37.6% for non-Hispanic whites, 28.7% for Chinese,

Tdap The estimated Tdap vaccination coverage among adults aged 19 or older was 73.5% for non-Hispanic whites, 83.4% for Chinese, 82.6% for Filipinos, 74.6% for Asian Indians, 79.1% for other Asians, 72.6% for Blacks, 71.0% for Hispanics, and 74.2% for other races (Table 1). Among those whose received Td Edition 19 Spring 2022

Generally, being female, having higher family income, having a higher educational level, having health insurance, and engaging in health-seeking behaviors such as higher number of doctor visits are positively associated with vaccination." 30.5% for Filipinos, 20.6% for Asian Indians, 31.8% for other Asians, 17.0% for Blacks, 19.8% for Hispanics, and 29.5% for other races (Table 1). Asian Indians and Blacks have significantly lower adjusted shingles vaccination coverage than non-Hispanic whites, while all other racial/ ethnic groups have similar or higher adjusted coverages (Table 2). The shingles vaccination coverage for all racial/ethnic groups, except Chinese, show overall positive linear trends 61

Table 2. Adjusted vaccine coverage among NHWs, disaggregated Asian subgroups, Hispanics and Black in the Natinoal Health Interview Survey (NHIS), 2015-2018. Adjusted for all included covariates. from 2008 to 2018. However, the estimated APC for Blacks decreased by almost a half in 2012, and the estimated APC for non-Hispanic whites and Hispanics stopped increasing in 2014 and 2016, respectively. All ethnic/ racial groups except Chinese had statistically significant positive APCs for the shingles vaccine. Pneumococcal The estimated pneumococcal vaccination coverage among adults aged 65 or older was 71.1% for non-Hispanic whites, 48.7% for Chinese, 62.8% for Filipinos, 57.7% for Asian Indians, 48.4% for other Asians, 55.2% for Blacks, 49.5% for Hispanics, and 63.4% for other races (Table 1). There are not statistically significant differences in adjusted pneumococcal vaccination rates among Chinese, Filipinos, and Asian Indians compared to non-Hispanic whites. Other Asians, Blacks, and Hispanics have lower adjusted vaccination rates than non-Hispanic whites (Table 2). Pneumococcal vaccination rates increased for Blacks, Filipinos, Hispanics, and non-Hispanic whites from 2006 to 2018. However, for Chinese, Asian Indians, other Asians, and other races, it remained constant. Additionally, Black, Filipino and Hispanic racial/ ethnic groups had statistically significant 62

positive APCs for the pneumococcal vaccine. Discussion Racial/ethnic disparities persist in recent adult coverages of the seven CDC-routinely recommended vaccines in this study. Our study confirmed results from previous studies that adult vaccination coverages in blacks and Hispanics are generally lower than non-Hispanic whites.16,17 One possible explanation is that they are less aware of the recommended vaccines due to lack of effective patient-provider education and provider recommendation of the HPV vaccine.18 Moreover, compared to non-Hispanic whites, blacks and Hispanics are less likely to receive recommendations for vaccines from doctor visits.18 All existing literature treated Asian Americans as one homogeneous group. However, our study recognized the great homogeneity within the Asian population and identified disparities that were never examined before. Previous literature concluded that Asians as a whole have lower adult vaccination coverage than non-Hispanic whites. We found that, for all included vaccines, some Asian subgroups have comparable or higher coverages than non-Hispanic whites while the others don’t, Epidemic Proportions

suggesting that disparities exist within the Asian American population. We separated the illness corresponding to each vaccine into three categories: sex-related (HPV), chronic (Hepatitis B), and acute (Flu, Shingles, Pneumococcal, Td, Tdap), and organized the discussion accordingly. We found that Asian Indian women are less likely to receive the HPV vaccine compared to non-Hispanic whites, while Chinese, Filipino, and other Asian women are not. The low HPV vaccination coverage among Asian Indian women may relate to family influence, as Asian Indian mothers are less likely to consider getting the HPV vaccine for their daughters due to stigma related to issues of sexual activity despite the protective benefits it provides. Moreover, acculturation and generation status can also influence the acceptability of the HPV vaccine since first-generation immigrants are less likely to accept the HPV vaccine compared to second-generation immigrants.19 This is a particularly relevant explanation since there is a large foreign-born population within the Asian Indian population.20 For the Hepatitis B vaccine, Filipinos and other Asians have higher adjusted coverage than non-Hispanic whites, while Chinese and Asian Indians do not. Studies have shown that Asian Americans have a higher prevalence of Hepatitis B compared to other racial/ethnic groups in the US.21,22 Moreover, Chinese Americans males are six times more likely to report Hepatitis-B related liver cancer compared to non-Hispanic whites.23 Chinese Americans are also ten times more likely to get diagnosed hepatocellular carcinoma (HCC),

the majority proportion of which are associated with Hepatitis B infection, compared with non-Hispanic whites.24 However, their Hepatitis B vaccine uptake does not match up with their higher prevalence of Hepatitis-B related diseases. A potential explanation is that Hepatitis B is stigmatized in the Asian American community.25 For the five vaccines that prevent acute diseases, Filipinos have higher or similar adjusted vaccination coverages compared to non-Hispanic whites. However, Asian Indians have lower adjusted coverages in the tetanus and shingles vaccine compared to nonHispanic whites, and Chinese also have lower adjusted coverage in the shingles vaccine. To our knowledge, these are novel findings as no existing literature investigated tetanus and shingles vaccination in Chinese and Asian Indians. The Joinpoint regression analysis shows that coverages in all selected vaccines for all racial/ethnic groups are overall increasing, with few exceptions. However, under closer examination, disparities exist in vaccination coverage trends. First, the estimated average annual percent changes (AAPCs) of vaccination coverage for each racial/ethnic group differ. In general, we observed higher AAPCs in minority groups than non-Hispanic whites for most of the selected vaccines, which could be partially explained by relatively low coverage in the earlier years as well as some successful campaigns and community engagements that specifically target racial/ ethnic minority groups.26 Moreover, the estimated APC in several vaccines for some

Racial/ethnic disparities persist in recent adult coverages of the seven CDC-routinely recommended vaccines in this study." Edition 19 Spring 2022


Overall, the disparities in adult vaccination coverage and its trends suggest that diversified implementations are needed for improvement."

racial/ethnic groups plateaued, or even decreased, at some point between the time period examined. We propose two explanations for the differences in vaccination trends across racial/ethnic groups. First, the occurrences of vaccine shortages may have differential impacts on racial/ethnic groups. For instance, the decreases in the estimated APC of Hepatitis B vaccination coverage across all racial/ethnic groups around 2010-2012 might be related to an adult Hepatitis B vaccine shortage that began in 2009 and lasted for a few years, where a major pharmaceutical company experienced disruptions in Hepatitis B vaccine production.27 The APC of Hepatitis B vaccination for non-Hispanic whites, however, has a lower estimated decrease than all other groups, which is consistent with previous studies on racial disparities under vaccine shortages.28,29 Second, some adverse events occurred during the examined time period could also have differential impacts on racial/ ethnic groups. For example, the decreasing trend in Hepatitis B vaccination in the Chinese population from 2012 to 2018 may relate to the death of 17 children after Hepatitis B vaccine inoculation in China in 2013.30 Studies have shown that, although the relation between the inoculation and death of children was refuted after investigation, such an adverse event produced long-lasting distrust and skepticism against the vaccine.31 64

Overall, the disparities in adult vaccination coverage and its trends suggest that diversified implementations are needed for improvement. Consistent with previous studies, we found that higher health-seeking behaviors and possession of health insurance both contribute to higher vaccination intake.32–35 From the government’s perspective, healthcare reforms such as the Patient Protection and Affordable Care Act show promise to increase the overall health insurance coverage and access to care.36 Also, further actions should be taken to mitigate the vaccination shortages. From healthcare facilities’ perspective, adoption of reminder/recall systems and universal electronic health records would help improve the overall adult vaccination coverage. From providers’ perspective, education on the awareness of racial/ethnic disparities in vaccination coverage, assessment of patients’ vaccination status during visits, and scientific explanations followed by recommendations of vaccines would be helpful as well. To address the racial/ethnic disparities, public health interventions targeting contributors of low vaccination coverage specific for each racial/ethnic group are needed. For example, based on our findings, Hepatitis B screening in the Asian American community should be endorsed. Awareness campaigns aiming to dispel misinformation about the Hepatitis B vaccine in the Chinese American community may ameliorate the decreasing trend in Hepatitis B vaccination. Analogously, similar programs targeting the Asian Indian immigrants on the importance of the HPV vaccine are necessary. Other disparities suffered by the Asian American community we found, such as the low shingles vaccination coverage in Asian Indians and low tetanus vaccination coverage in Chinese and Asian Indians, are not studied. Therefore, future research should be directed Epidemic Proportions

Figure 1. Vaccination trends in Asian Indian, Chinese, Filipino, and NHW, NHIS 2006-2018. Weighted vaccination rates for each survey year are connected by dotted lines. Fitted Joinpoint regressions are represented in solid lines of different colors that correspond to each race presented. To avoid clutter, only four racial/ethnicity groups are included in the above figure. Edition 19 Spring 2022


To address the racial/ ethnic disparities, public health interventions targeting contributors of low vaccination coverage specific for each racial/ ethnic group are needed."

accordingly to better inform more effective interventions for these subgroups. References:

1. Products - Data Briefs - Number 361 - March 2020. Published June 26, 2020. Accessed June 30, 2021. https://www.cdc.gov/nchs/products/databriefs/db361.htm

ajph.91.11.1865 9. Lee-Lin F, Menon U. Breast and cervical cancer screening practices and inventions among Chinese, Japanese, and Vietnamese Americans. Oncol Nurs Forum. 2005;32(5):995-1003. doi:10.1188/05.onf.995-1003 10. Srivastav A, O’Halloran A, Lu PJ, Williams WW. Influenza Vaccination Coverage Among English-Speaking Asian Americans. Am J Prev Med. 2018;55(5):e123-e137. doi:10.1016/j.amepre.2018.06.018 11. NHIS - About the National Health Interview Survey. Published September 16, 2020. Accessed November 3, 2021. https://www.cdc.gov/nchs/nhis/about_nhis.htm 12. srvydesc.pdf. Accessed November 3, 2021. https:// ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_ Documentation/NHIS/2018/srvydesc.pdf 13. IPUMS NHIS. Accessed November 3, 2021. https:// nhis.ipums.org/nhis/

2. Cervical Cancer Statistics | Key Facts About Cervical Cancer. Accessed June 30, 2021. https://www.cancer.org/ cancer/cervical-cancer/about/key-statistics.html

14. Recommended Vaccines by Age | CDC. Published January 12, 2021. Accessed November 25, 2021. https:// www.cdc.gov/vaccines/vpd/vaccines-age.html

3. CDC. Burden of Influenza. Centers for Disease Control and Prevention. Published October 4, 2021. Accessed November 26, 2021. https://www.cdc.gov/flu/about/ burden/index.html

15. Joinpoint Regression Program. Accessed November 3, 2021. https://surveillance.cancer.gov/joinpoint/

4. Lu P jun, O’Halloran A, Williams WW, Lindley MC, Farrall S, Bridges CB. Racial and ethnic disparities in vaccination coverage among adult populations. Am J Prev Med. 2015;49(6 Suppl 4):S412-S425. doi:10.1016/j. amepre.2015.03.005 5. Vaccination - Healthy People 2030 | health.gov. Accessed November 3, 2021. https://health.gov/ healthypeople/objectives-and-data/browse-objectives/ vaccination 6. Schabath MB, Villa LL, Lin HY, et al. Racial Differences in the Incidence and Clearance of Human Papilloma Virus (HPV): The HPV in Men (HIM) Study. Cancer Epidemiol Biomarkers Prev. 2013;22(10):1762-1770. doi:10.1158/1055-9965.EPI-13-0303 7. Products - Data Briefs - Number 361 - March 2020. Published June 26, 2020. Accessed June 30, 2021. https://www.cdc.gov/nchs/products/databriefs/db361.htm 8. Yu SM, Alexander GR, Schwalberg R, Kogan MD. Prenatal care use among selected Asian American groups. Am J Public Health. 2001;91(11):1865-1868. doi:10.2105/ 66

16. CDC. Racial and Ethnic Minority Groups. Centers for Disease Control and Prevention. Published May 21, 2021. Accessed June 30, 2021. https://www.cdc.gov/flu/ highrisk/disparities-racial-ethnic-minority-groups.html 17. Singleton J. Influenza and Pneumococcal Vaccination of Adults Aged ≥65: Racial/Ethnic Differences. American journal of preventive medicine. 18. Ojeaga A, Alema-Mensah E, Rivers D, Azonobi I, Rivers B. Racial Disparities in HPV-related Knowledge, Attitudes, and Beliefs among African American and White Women in the U.S. J Cancer Educ. 2019;34(1):66-72. doi:10.1007/ s13187-017-1268-6 19. Katz IT, Bogart LM, Fu CM, et al. Barriers to HPV immunization among blacks and latinos: a qualitative analysis of caregivers, adolescents, and providers. BMC Public Health. 2016;16(1):874. doi:10.1186/s12889-0163529-4 20. Bhuiyan AR, Kabir N, Mitra AK, Ogungbe O, Payton M. Disparities in Hepatitis B Vaccine Coverage by Race/ Ethnicity: The National Health and Nutrition Examination Survey (NHANES) 2015–2016. Diseases. 2020;8(2):10. doi:10.3390/diseases8020010 Epidemic Proportions

21. Daniels NA, Gildengorin G, Nguyen TT, Liao Y, Luong TN, McPhee SJ. Influenza and Pneumococcal Vaccination Rates among Vietnamese, Asian, and Non-Hispanic White Americans. J Immigr Minor Health. 2010;12(3):370-376. doi:10.1007/s10903-008-9195-6

30. Phillips-Caesar E, Coady MH, Blaney S, et al. Predictors of Influenza Vaccination in an Urban Community during a National Shortage. Journal of Health Care for the Poor and Underserved. 2008;19(2):611-624. doi:10.1353/ hpu.0.0006

22. Ethnic differences in human papillomavirus awareness and vaccine acceptability | Journal of Epidemiology & Community Health. Accessed November 3, 2021. https:// jech.bmj.com/content/63/12/1010

31. Meina L, Xiaodong L, Lulu Z. Hepatitis B vaccine adverse events in China: Risk control and regulation. Hum Vaccin Immunother. 2014;10(10):2992-2993. doi:10.4161/ 21645515.2014.971643

23. Budiman A, Ruiz NG. Key facts about Asian origin groups in the U.S. Pew Research Center. Accessed November 3, 2021. https://www.pewresearch.org/facttank/2021/04/29/key-facts-about-asian-origin-groupsin-the-u-s/

32. Yu W, Liu D, Zheng J, et al. Loss of confidence in vaccines following media reports of infant deaths after hepatitis B vaccination in China. International Journal of Epidemiology. 2016;45(2):441-449. doi:10.1093/ije/ dyv349

24. Upadhyaya N, Chang R, Davis C, Conti MC, SalinasGarcia D, Tang H. Chronic Hepatitis B: Perceptions in Asian American Communities and Diagnosis and Management Practices among Primary Care Physicians. Postgraduate Medicine. 2010;122(5):165-175. doi:10.3810/ pgm.2010.09.2213

33. Lu P jun, Nuorti JP. Pneumococcal polysaccharide vaccination among adults aged 65 years and older, U.S., 1989-2008. Am J Prev Med. 2010;39(4):287-295. doi:10.1016/j.amepre.2010.06.004

25. Ma GX, Lee S, Wang M, et al. The Role of Sociocultural Factors in Hepatitis B Screening Among Asian Americans. South Med J. 2011;104(7):466-472. doi:10.1097/ SMJ.0b013e31821f8ab0 26. Chen Jr MS, Dang J. Hepatitis B among Asian Americans: Prevalence, progress, and prospects for control. World J Gastroenterol. 2015;21(42):11924-11930. doi:10.3748/wjg.v21.i42.11924 27. Yoo GJ, Fang T, Zola J, Dariotis WM. Destigmatizing Hepatitis B in the Asian American Community: Lessons Learned from the San Francisco Hep B Free Campaign. J Canc Educ. 2012;27(1):138-144. doi:10.1007/s13187-0110252-9

34. Lu PJ, Nuorti JP. Uptake of pneumococcal polysaccharide vaccination among working-age adults with underlying medical conditions, United States, 2009. Am J Epidemiol. 2012;175(8):827-837. doi:10.1093/aje/ kwr376 35. Lu PJ. Surveillance of Vaccination Coverage Among Adult Populations — United States, 2018. MMWR Surveill Summ. 2021;70. doi:10.15585/mmwr.ss7003a1 36. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010;363(14):12961299. doi:10.1056/NEJMp1008560

24. Protection of Racial/Ethnic Minority Populations During an Influenza Pandemic | AJPH | Vol. 99 Issue S2. Accessed November 3, 2021. https://ajph-aphapublicationsorg.laneproxy.stanford.edu/doi/full/10.2105/ AJPH.2009.161505 28. No end in sight for adult hepatitis B vaccine shortage | CMAJ. Accessed November 3, 2021. https://www.cmaj. ca/content/182/12/E580.short 29. Yoo BK, Kasajima M, Phelps CE, Fiscella K, Bennett NM, Szilagyi PG. Influenza Vaccine Supply and Racial/ Ethnic Disparities in Vaccination Among the Elderly. American Journal of Preventive Medicine. 2011;40(1):1-10. doi:10.1016/j.amepre.2010.09.028 Edition 19 Spring 2022

Armaan Jamal Molecular and Cellular Biology Class of 2023 67

Photo Courtesy of Irfaan Karim 68

Epidemic Proportions

Features | Gabriella Ewachiw, Kathleen Li, and Yasheel Pandya

Day at the Market: A Health Outreach Initiative

In this collection, Ewachiw, Li, and Pandya share photos and perspectives of the people behind “Day at the Market,” a biweekly fair held at the Northeast Market in Baltimore focused around spreading awareness of the various opportunities available to members of their community. The programs they support range from health insurance to job search assistance to energy programs, and the authors hope to illuminate the individuals behind the movement here. Barbara Bates-Hopkins, “The Brain of Day at the Market” Ms. Barbara Bates-Hopkins (or “Ms. Barbara,” as everyone calls her) is the “Brain of Day at the Market.” Every other Wednesday, she helps community groups and Johns Hopkins volunteers set up outreach tables at the Northeast Market. The people behind these tables are here to inform Baltimore community members about programs to help protect their health, save energy, and whatever else they might need. And community members teach at these tables too. Community members tell volunteers, students, and professors what they actually need. This “bidirectional learning” comes from Ms. Barbara’s hard work over the last 14 years—since 2007, she has built tight connections between the people on both sides of the table. Ms. Barbara started Day at the Market in 2007 with the support of her colleagues at Johns Hopkins. She was inspired by her community Edition 19 Spring 2022

outreach work with the Historic East Baltimore Community Action Coalition (HEBCAC) and wanted to raise awareness of community organizations and their resources. Additionally, Ms. Barbara knew that people may not be comfortable asking questions or seeking help in formal settings. This made Northeast Market a perfect location to create a new program. With these goals in mind, Ms. Barbara helped create Day at the Market, a space for community organizations and Johns

She was inspired by her community outreach work with the Historic East Baltimore Community Action Coalition (HEBCAC) and wanted to raise awareness of community organizations and their resources.” 69

Hopkins doctors, professors, and students to “meet people where they are.” The key to the program’s success, Ms. Barbara says, is collaboration. She knows everyone’s face and story, and everyone knows her as Ms. Barbara. She points out some people who have helped Day at the Market grow: Glenn Ross, Community Consultant and Urban Environmentalist, drops by for a chat. He is active in a variety of local groups and provides Johns Hopkins SOURCE with important updates and news from the surrounding communities. Meanwhile, Rosie from Rose’s Bakery leads communication for the Northeast Market Merchants’ Association. Her genuine and consistent support “is the glue that makes our collaboration happen.” This collaboration model has worked so well at the Northeast Market that Ms. Barbara started another program at Lexington Market. Community organizations and volunteers are set to be at Lexington Market every 3rd Wednesday, and Baltimore Public Market Management has encouraged expansion to even more of the Markets. Meanwhile, Day at the Market keeps growing at Northeast Market.

Ms. Barbara Bates-Hopkins, Community Relations Coordinator in the Johns Hopkins Center for Urban Environmental Health. She would like to acknowledge the work of Dr. John Groopman, Dr. Michael Trush, Ms. Pat Tracey, and Dr. Norma Kanarek in the direction of the Center.

acknowledge some people have been too scared to even enter various parts of Baltimore, community-building events like Day at the Market “bridge and erase that disconnect.” Ms. Barbara hopes that regular engagement helps everyone learn from and trust each other.

Over the last 14 years, Day at the Market’s missions have stayed the same. First, the people of Baltimore can teach students and professors how to best work in the community. Most importantly, Day at the Market isreuniting Baltimore’s communities. Though we

The event also gives Hopkins a place to address the needs of the community and share their research findings.” 70

Lindsay Diedrich, Dr. Panagis Galiatsatos, Dr. Joann Bodurtha, and Ms. Barbara Bates-Hopkins Epidemic Proportions

Turnaround Tuesday Featured: Jermietra Carroll (JC) and Raekwoa Brandon Turnaround Tuesday is a “jobs movement” organization that helps people re-enter the workforce and creates jobs in Baltimore. They hold sessions on Tuesday mornings in the church because it is a place to show “dignity and respect,” and are a people-driven organization.

Raekwoa Brandon and the Turnaround Tuesday Day Market tablecloth Turnaround Tuesday is a “movement” because they get to know the people they help and stay with employees for 2 years even after connecting people to jobs. Over the past 5 years, they have helped connect over a thousand people with employers.

Turnaround Tuesday business cards and mint bowl

Turnaround Tuesday has played an instrumental role particularly in the wake of the COVID-19 pandemic. They continue to connect people to jobs, combating the ongoing challenge of pandemic-driven unemployment.

Jermietra Carroll (JC) and Raekwoa Brandon at the Turnaround Tuesday table Edition 19 Spring 2022


Jamie Stewart, Shirl Parnell, and Kim Thomas at the VALUE Baltimore table VALUE Baltimore Featured: Shirl Parnell, Jamie Stewart, and Kim Thomas VALUE Baltimore works with the Baltimore City Health Department to encourage people to get the COVID vaccine. They particularly want to increase vaccination rates in elderly homes and other communities facing disparities. That’s why Shirl Parnell and other COVID vaccine ambassadors came in to help educate people about the vaccine. Parnell has worked to debunk a lot of vaccine misinformation during her time as a vaccine ambassador. Many false rumors about the vaccine scare people into not getting it. However, she has found her work meaningful because Parnell sees people come back to 72

the table and register for their vaccines. Parnell and her fellow VALUE ambassadors want to tell everyone this: “If you want to get over this pandemic and get back to normal, get vaxxed.”

VALUE Baltimore COVID vaccination pamphlets and giveaway materials Epidemic Proportions

Aetna Better Health Featured: Patricia Wright, Community Development Coordinator Aetna Better Health of Maryland is a Medicaid health insurance plan offered in the state of Maryland. They directly reach out to the local East Baltimore community to educate residents about how they can qualify for Medicaid, enroll in Medicaid, and navigate their insurance coverage. With the COVID-19 pandemic driving unemployment, many community members have lost health insurance, limiting their affordability and accessibility to health care. Aetna Better Health’s community outreach holds utmost importance especially during these circumstances. Wright especially enjoys interacting with uninsured community residents since it allows her to offer helpful resources on how to obtain health insurance.

Aetna educational pamphlets and giveaway materials Wright finds meaning in the diversity of her experiences at the Health Fair. With unique interactions at each fair, she can deeply understand and assist address the issues faced by the local community.

Patricia Wright, Aetna Community Development Coordinator at the Aetna Day at the Market table Edition 19 Spring 2022


Living Legacy Featured: Morgan Phillips, Latrice Price The Living Legacy Foundation of Maryland is at Day at the Market to educate people about organ donation. Morgan Phillips and Latrice Price have had to combat misinformation about organ donation (like the myth of organ stealing), and also walk people through what organ donation might look like. They encourage potential organ donors to be transparent and “tell your family your decision about being an organ donor.”

Morgan Phillips and Latrice Price during an interview

Living Legacy educational pamphlets and giveaway materials

Morgan Phillips and Latrice Price educating a Market customer about Living Legacy 74

Epidemic Proportions

Bloomberg School of Public Health Featured: Candace Cooper The Bloomberg School of Public Health (BSPH) plays an important role in providing education to the Baltimore community. During November, which is Diabetes Awareness Month, they have been providing dietary education, answering diet-related questions, and suggesting healthy alternative food choices for day-to-day life. “It is really important for practitioners to look at root causes of the condition and barriers to care, not just what is surface-level” Cooper enjoys the diversity offered by the Health Fair. This provides an opportunity to connect with people of different backgrounds and better understand barriers to care in the Baltimore community.

Candace Cooper with an educational pamphlet about diabetes

BSPH health fair tablecloth Edition 19 Spring 2022

BSPH educational pamphlets and giveaway wheel 75

Family Health History Table Featured: Yasheel Pandya, Silvia Lin, Dr. Joann Bodurtha The Family Health History table raises awareness of family history and empowers community members to act on their own family histories. The volunteers give community members a chance to discuss their family health concerns and direct people to resources about disease screening, testing, and other health resources that align with their needs. They also give people the opportunity to create a “family tree” of their family health history that community members can share with their physicians. Dr. Bodurtha and the Family Health History volunteers hope to build trust with the community to combat the historical distrust of medical institutions in Baltimore. In addition to challenges in building trust, the table sometimes has trouble piquing the interest of local residents who may be overwhelmed by

Family health history educational poster and flyers other priorities. Despite these challenges, volunteers love the vast perspectives of the people they interact with. By sharing stories of struggles with medications, family illnesses, and even health system issues, community members and volunteers participate in a collaborative exchange that strengthens one another’s understanding of family history.

Yasheel Pandya and Silvia Lin with family health surveys and educational pamphlets 76

Epidemic Proportions

The Johns Hopkins Institute for Clinical & Translational Research/HOPE Featured: Dr. Cheryl Himmelfarb, Cyd Lacanienta, Donald Young The Johns Hopkins Institute for Clinical & Translational Research (ICTR) has helped sponsor Day at the Market since 2011, and the two share the same goal –to promote bidirectional learning. But in contrast to Day at the Market’s focus on health and social services, the ICTR’s focus is on making sure scientists understand how to work with the community. According to Dr. Cheryl Himmelfarb, Deputy Director for the ICTR, “Research informed and guided by the community is more meaningful and impactful [in driving health]... improvements in the community.” That makes the Day at the Market an ideal area for outreach. Northeast Market is one of the six Baltimore Public Markets, which are one of the longest-running public market systems in the United States.1 It’s a part of Baltimore’s history. However, the lunch rush can testify that the Market is also a part of daily life. In contrast to how researchers usually interact with the community, Dr. Himmelfarb notes that tabling during Day at the Market helps physicians and researchers become a constant in the community and build trust. These strong relationships have been especially helpful during the COVID-19 pandemic. Through the market, Dr. Himmelfarb says that doctors and scientists have been able to share important information on vaccines, testing, and prevention. At the same time, they’re listening to community concerns. In Northeast Market and other city markets, the HOPE research project is surveying unvaccinated Baltimoreans on why they aren’t vaccinated. The results may help scientists Edition 19 Spring 2022

Cyd Lacanienta at the HOPE survey table

Donald Young at the HOPE survey table

Northeast Market from the outside 77

understand barriers to covid testing and vaccination, and learn how to better protect the public from COVID-19. There have been some challenges in starting conversations between researchers and the public. Himmelfarb states that researchers often just want to recruit research participants and get guidance on how to study the community’s issues without actually bringing their results back. That’s where ICTR comes in. They train researchers on how to best communicate their results to the community. “Scientists use a lot of acronyms,” Himmelfarb states. “[ICTR helps] researchers clarify and simplify messages.” At the HOPE fair table, between interviewing unvaccinated Baltimoreans, Cyd Lacanienta supported the same mission. To both Lacanienta and Himmelfarb, research isn’t just a question of what researchers can learn about a community. Research is an opportunity to learn from them and meaningfully give back—to create a “true exchange.”1 That starts by building relationships with community members, like in Day at the Market. Conclusion Come to the Northeast Market during Wednesday’s lunch rush, and you have half a chance of seeing Day at the Market in action. From the corner of East Monument and North Duncan, you’ll see Ms. Barbara and her team right of the entrance. On the left, there are tents over the table outside, where people might be taking blood pressures or giving out surveys. Further inside the market, there are groups who can help you with anything from donating organs to re-entering the workforce.

to health. But what about the job movement table? Social factors like employment can also impact your well-being because they can change what you eat, how you exercise, and how much stress you feel. Your health is affected not only by medical treatments, but also how you live your life. That’s the beauty of Day at the Market. The tables are hosted by community organizations and people from Hopkins on a wide variety of topics, from preventative measures to help getting treatment. This initiative means that people at the tables have to listen and learn, as well as educate. Market-goers have a lot to share about their personal story, what they think are problems, and how these problems should be fixed. There’s power in these conversations, which are only made possible by building relationships and being present—in this case, being at the Northeast Market every other Wednesday. For more information or to get involved with Day at the Market, please contact Ms. Barbara Bates-Hopkins at 443-750-2009 or bhopkin1@jhu.edu. References

1. Baltimore Public Markets Corporation. About Us. Baltimore Public Markets. https://baltimoremarkets. org/about/. Published 2022. Accessed January 17, 2022.

Some of the tables are more obviously connected to health than others. Access to vaccines, for example, is indisputably related 78

Epidemic Proportions

Gabriella Ewachiw Molecular and Cellular Biology Class of 2023

Kathleen Li Biology & Public Health Studies Class of 2022

Yasheel Pandya Molecular and Cellular Biology & Public Health Studies Class of 2022 Edition 19 Spring 2022

Photo Courtesy of Mason Cole 79

Photo Courtesy of Eirnin Mahoney 80

Epidemic Proportions

Policy | Evelyn Shiang

Incorporating Unintentional Childhood Injury Prevention in Federally Funded Home Visiting Programs

In this article, Shiang proposes federally funded home visiting programs to provide low-income, new mothers with services to improve a range of maternal and child health outcomes. While the scope and impact of these programs have been considerable, they provide limited interventions for preventing unintentional childhood injury—the leading cause of death among young children in the United States. This policy brief covers the background of unintentional childhood injuries, introduces federally funded home visiting programs as one solution, and discusses the potential for incorporating unintentional childhood injury in these home visiting programs.


ederally funded home visiting programs provide low-income, new mothers with services to improve a range of maternal and child health outcomes. With consistent bipartisan support and billions of dollars in funding over the past decade, these programs have had considerable scope and impact. However, home visiting programs currently provide limited interventions for preventing unintentional childhood injury—the leading cause of death among young children in the U.S. In this policy brief, I will cover the background of unintentional childhood injuries, introduce federally funded home

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visiting programs, and discuss the potential for incorporating evidence-based unintentional childhood injury prevention in these programs.

The burden of unintentional childhood injuries is disproportionately carried by young children in lowincome families, with the rate of home injuries resulting in medical care being greater for low-income than for higher income families.3 " Unintentional Childhood Injury In the U.S., unintentional injuries are the leading cause of death for children under the age of 4 and result in an estimated 2 million emergency department (ED) visits for the age group each year.1,2 Nonfatal injuries among young children mostly occur in or around the home and include falls and being struck by or against an object.2–4 Most fatal accidents among young children, such as suffocation and drowning, also commonly occur in the home.2,5 The total cost of unintentional childhood injuries is high, at approximately $300 billion each year.6 Among children under the age of 4, unintentional injury related deaths cost about $3 billion, hospitalizations cost about $7 billion, and ED visits cost about $15 billion anually.6 For injuries caused by falls and being struck by or against an object to young children, annual hospitalization costs are respectively about $3 billion and about $700 million, and ED visit costs are respectively about $7 billion and $2 billion.6 82

The burden of unintentional childhood injuries is disproportionately carried by young children in low-income families, with the rate of home injuries resulting in medical care being greater for low-income than for higher income families.3 Studies have shown that for a variety of socio-environmental reasons, low-income families are less likely to have safety devices such as smoke alarms installed in their homes and practice safe behaviors such as providing a safe sleep environment for infants.7,8 Home Visiting as a Solution One approach to addressing unintentional childhood injuries, especially among lowincome families, is through voluntary pediatric home visiting programs. Pediatric home visiting began in the U.S. in the 1800s when female volunteers at private charities visited new mothers of poor urban communities.9 The idea was that companionship from the wealthy would correct character flaws perceived as contributing to poverty. During the Great Depression, most private charities were forced to close, and the federal government adopted home visiting as a new initiative to address causes of unemployment.10 The 1960s War on Poverty catalyzed the development of numerous diverse home visiting programs by both public and private non-profit agencies.9 Today, home visiting programs prioritize lowincome, new mothers and families with the services and skills necessary to raise physically, socially, and emotionally healthy children.11 The goals of home visiting programs vary widely, with some designed to assess risk factors in living conditions and parental mental health, while others employ interventions based on different theories of child development. Home visitors often include social workers, nurses, mental health counselors, or paraprofessionals and differ according to each program’s aims. Epidemic Proportions

In 2010, President Barack Obama signed the Affordable Care Act into law. This established the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, providing $1.5 billion to the Department of Health and Human Services (DHHS) to distribute over 5 years to states implementing evidence-based home visiting programs.11 President Donald Trump signed a bill in 2018 to reauthorize the MIECHV program, providing $2 billion in funding for another 5 years. More recently, the DHHS awarded $40 million in emergency home visiting funds as part of President Joe Biden’s American Rescue Plan to support families affected by COVID-19.12 The reach of MIECHV funding has been incredible: in fiscal year 2020, the initiative served 140,000 families, with most earning incomes at or below the Federal Poverty guideline.11 While support for many federally funded public health initiatives has historically varied with changes in the White House, the MIECHV program has achieved approval from both sides of the aisle. Steadfast support for the MIECHV initiative can in part be attributed to the rigor with which home visiting programs accepted for its funding are evaluated. The DHHS identifies evidence-based home visiting models through the Home Visiting Evidence of Effectiveness (HomVEE) review, an annual assessment of the research literature to ensure all programs receiving MIECHV funding improve outcomes in at least one of eight domains: (1) child health, (2) child development and school readiness, (3) family economic self-sufficiency, (4) linkages and referrals, (5) maternal health, (6) positive parenting practices, (7) reductions in child maltreatment, and (8) reductions in juvenile delinquency.13 As of 2021, the HomVEE review has identified 19 home visiting models that meet the DHHS criteria for an evidence-based home visiting model, meaning states are only Edition 19 Spring 2022

authorized to subsidize home visiting programs following these models with MIECHV funds.13 Incorporating Injury Prevention The potential for evidence-based home visiting programs to prevent unintentional childhood injury among vulnerable families is clear. First, they are generously and publicly funded with longstanding bipartisan support in Congress and the White House. Second, existing home visiting programs have established relationships with high-risk families and the ability to access their homes—two elements that organizations interested in delivering injury prevention services, such as fire departments and academic centers, frequently lack. Still, only 2 of the 19 home visiting models eligible for MIECHV funding have been evidenced to improve outcomes in unintentional childhood injuries, and 3 others have been shown to have no effect at all. This low number is in part because unintentional childhood injury is not included as a DHHS benchmark for MIECHV funding. However, certain regional home visiting programs have been successful in addressing unintentional childhood injury. One example is the Nurse-Family Partnership (NFP) developed by Olds, which is one of the few evidence-based home visiting models that has been tested in multiple randomized controlled trials and demonstrated to reduce unintentional childhood injuries.14 The model consists of a home-based education program designed to improve mothers’ attentiveness and parenting behaviors. In a trial on NFP conducted in New York, the babies of nursevisited women presented to the emergency room with fewer injuries than those of controls in their second year of life.15 However, a review of home safety interventions 83

by Kendrick et al. found that interventions which provided free, low cost, or discounted safety equipment were more effective than those which only provided education.16 The New York City Health Department’s “Children Can’t Fly” program included a nurse home visiting component which provided accident prevention counseling in addition to registering families for window guards that were being distributed by the city. The program was successful in reducing falls by 50% in 2 years in the borough where the campaign was most concentrated and led to the landmark decision by New York City officials mandating apartment owners to provide window guards where young children reside.17 Similarly, the Johns Hopkins Center for Injury Research and Policy (CIRP) previously facilitated a partnership between a Phoenix chapter of NFP and their fire department counterpart to supplement fire prevention education with smoke alarm and carbon monoxide (CO) detector installation services. Prior to the intervention, there was no working smoke alarm in 55% of homes and no CO detector in 92% of homes.18 At the conclusion, the CIRP found that all homes were equipped with at least one working smoke alarm and a CO detector if there was a source of CO in the home prior to the visit. Multicomponent interventions involving the provision of safety equipment to comprehensively address a range of different unintentional injury types have also seen favorable outcomes.19 The HOME Injury Study was a randomized controlled trial providing safety devices addressing unintentional childhood falls, cuts/pierces, strikes, poisons, and burns. Children in the intervention group lived with significantly fewer injury hazards and had a 70% reduction in the rate of preventable 84

injuries compared with controls after 2 years.19 Future Directions Unintentional injury remains the biggest threat to the health of young children, especially those in low-income families. Evidence-based home visiting programs have the potential to prevent unintentional injuries among this population, but advocacy is needed to standardize these measures nationally. Although the next reauthorization of MIECHV funding will occur after 2023, it is not too early for the public health community to call for greater emphasis on unintentional injury prevention in the DHHS criteria for evidenced-based home visiting. Eliminating unintentional injury in the U.S. requires prevention efforts through as many venues as possible. Prevention through evidence-based home visiting programs should be prioritized as one part of this strategy. Acknowledgements I would like to thank Dr. Wendy Shields at the Johns Hopkins CIRP for guiding me through this review of the literature and providing me ongoing support for research on injury prevention policy. References

1. 10 leading causes of death by age group, United States 2015. Centers for Disease Control and Prevention. https://www.cdc.gov/injury/images/lc-charts/leading_ causes_of_death_age_group_2015_1050w740h.gif. Accessed November 6, 2021. 2. Borse NN, Gilchrist J, Dellinger AM, Rudd RA, Ballesteros MF, Sleet DA. Patterns of unintentional injuries among 0-19 year olds in the United States, 2000-2006. https://stacks.cdc.gov/view/cdc/5155. Published December 2008. Accessed November 6, 2021. 3. Adams PF, Kirzinger WK, Martinez ME. Summary health statistics for the U.S. population: National Health Interview Survey, 2012. https://www.cdc.gov/nchs/ data/series/sr_10/sr10_259.pdf. Published December Epidemic Proportions

2013. Accessed November 6, 2021.

2021. Accessed November 6, 2021.

4. Phelan KJ, Khoury J, Kalkwarf H, Lanphear B. Residential injuries in U.S. children and adolescents. Public Health Rep. 2005;120(1):63-70. doi: 10.1177/003335490512000111.

13. Reviewing evidence of effectiveness. Home Visiting Evidence of Effectiveness. https://homvee.acf.hhs.gov/ sites/default/files/2021-10/HomVEE-Summary-BriefSept2021.pdf. Published September 2021. Accessed November 6, 2021.

5. Runyan CW, Casteel C, Perkis D, Black C, Marshall SW, Johnson RM, Coyne-Beasley T, Waller AE, Viswanathan S. Unintentional injuries in the home in the United States: Part I: Mortality. Am J Prev Med. doi: 10.1016/j.amepre.2004.09.010 6. Data & statistics (WISQARS™): Cost of injury reports. Centers for Disease Control and Prevention. https:// wisqars.cdc.gov/cost. Updated September 18, 2018. Accessed November 6, 2021. 7. Liu Y, Holland AE, Mack K, Diekman S. Disparities in the prevalence of smoke alarms in U.S. households: Conclusions drawn from published case studies. J Safety Res. 2011;42(5):409-413. doi: 10.1016/j. jsr.2011.10.001 8. Kendal-Tackett K, Cong Z, Hale TW. Mother-infant sleep locations and nighttime feeding behavior. https:// connect.springerpub.com/content/scl%3A%3A%3A 1%3A%3A%3A1%3A%3A%3A27.full.pdf. Published 2010. Accessed November 6, 2021. 9. Weiss HB. Home visits: Necessary but not sufficient. Future Child. 1993;3(3):113-128. doi: 10.2307/1602545 10. Roibal HS. A look back into the history of home visiting. https://www.cdd.unm.edu/ecln/HVT/common/ pdfs/2016_7_History%20of%20Homevisiting_Roibal. pdf. Published July 2016. Accessed November 6, 2021. 11. The Maternal, Infant, and Early Childhood Home Visiting program. Health Services and Resources Administration.https://mchb.hrsa.gov/sites/default/files/ mchb/MaternalChildHealthInitiatives/HomeVisiting/ pdf/programbrief.pdf. Published July 2021. Accessed November 6, 2021. 12. U.S. Department of Health & Human Services. HHS awards $40 million in American Rescue Plan funding to support emergency home visiting assistance for families affected by the COVID-19 pandemic. https:// www.hhs.gov/about/news/2021/05/11/hhs-awards40-million-american-rescue-plan-funding-supportemergency-home-visiting-assistance-familiesaffected-covid-19-pandemic.html. Published May 11, Edition 19 Spring 2022

14. Olds DL. Prenatal and infancy home visiting by nurses: from randomized trials to community replication. Prev Sci. 2002;3(3):153-72. doi: 10.1023/a:1019990432161 15. Olds DL, Henderson CR, Chamberlin R, Tatelbaum R. Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics. 1986;78(1):6578. doi: 16. Kendrick D, Young B, Mason-Jones AJ, Ilyas N, Achana FA, Cooper NJ, Hubbard SJ, Sutton AJ, Smith S, Wynn P, Mulvaney C, Watson MC, Coupland C. Home safety education and provision of safety equipment for injury prevention (Review). Evid Based Child Health. 2013;8(3):761-939. doi: 10.1002/ebch.191 17. Spiegel CN, Lindaman FC. Children Can't Fly: A program to prevent childhood morbidity and mortality from window falls. Am J Public Health. 1977;67(12):11437. doi: 10.2105/ajph.67.12.1143 18. Omaki EC, Frattaroli S, Shields WC, McDonald EM, Rizzutti N, Appy M, Voiles D, Jamison S, Gielen AC. Pilot study of a novel partnership for installing smoke alarms. Matern Child Health J. 2018;22:1025-1032. doi: 10.1007/s10995-018-2482-5 19. Phelan KJ, Khoury J, Xu Y, Lindy S, Hornung R, Lanphear BP. A randomized controlled trial of home injury hazard reduction: The HOME injury study. Arch Pediatr Adolesc Med. 2011;165(4):339345. doi:10.1001/ archpediatrics.2011.29

Evelyn Shiang Psychology & Public Health Studies Class of 2023 85


Epidemic Proportions

Editorials | Meghana Dantuluri

What We Can Learn from the Thailand Department of Public Health

In this article, Dantuluri describes her study abroad internship experience in Thailand during the summer of 2019, during which she had the privilege of working at one of Bangkok’s numerous government public health centers. During this program, Dantuluri witnessed the range of free services provided by this clinic to the surrounding lowincome communities in Bangkok. This article highlights some of the most noteworthy initiatives the clinic was implementing, along with Dantuluri's takeaways about the importance of having such prevention measures in place for vulnerable populations throughout the world.


ccess to healthcare is one important determinants Without proper care, of their genes or environment,

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of the most of health. regardless people are 87

FIGURE 1 Number of households prevented from medical impoverishment.

Number of Households (in 1,000)

Before UCS

If without UCS

After UCS

Figure 1. Number of households prevented from medical impoverishment. doi: http://doi.org/10.1371/journal.pmed.1001726.g001

inevitably more vulnerable to disease. In more developed areas where healthcare is easily accessible, small medical interventions such as vaccinations, dressing wounds, or even medicine for common colds tend to be taken for granted. However, in less developed countries such as Thailand, these services are not always as easily accessible. In the past, Thailand’s healthcare system was based on four different health insurance programs, separated into formal and informal employment. However, this system created many issues, leading to almost 30% of the population being uninsured by 2001. This affected Thai people inequitably because the majority of uninsured people were from lower income communities.1 These issues included mistargeting due to difficulties with accessing income from informal employment as well as 88

adverse selection, resulting in a rise in illness.2 In 2002, however, Thailand was able to insure their entire population with the implementation of the Universal Coverage Scheme (UCS).2 It covers 75% of the population, with the rest of the population (the wealthier) covered by private insurance plans. UCS is also known as the 30-baht scheme, since it requires only a 30 baht copay ($0.90 USD) for all outpatient and inpatient services, with exemptions for certain groups such as the poor, elderly, and children under 12.2 Overall, UCS is funded mainly by progressive tax revenue, and it provides a comprehensive benefits package including curative and rehabilitation services.2 Since the implementation of UCS, people from low-income communities gained greater access to care facilities, which ultimately improved their health.2 The number of Epidemic Proportions

households that were prevented from medical impoverishment significantly decreased over time (Figure 1).3 Moreover, the incidence of catastrophic health spending decreased after UCS (Figure 2).4 As a result, the Bangkok Metropolitan Administration (BMA) established a health provision that includes the department of medical service (tertiary care, 7 hospitals) and the department of health (primary and secondary care, 68 health centers).1 Each health center is assigned to one district in Bangkok, and each consists of smaller subcenters in the surrounding communities. Under the UCS plan, the health centers are responsible for treating all Thai citizens for free.2 After working at one of these health centers myself, I realized not only the value in such a program but also the gaps in the U.S. healthcare system that prevent vulnerable populations from receiving adequate care. Public Health Center 21, where I worked, is one of the largest health centers in the city and is responsible for the Wattana district, which encompasses 14 sub-centers in the communities and 34 schools in the area for

which they provide care. This center treats almost 85,000 patients living in this district and provides a wide range of services. There is an outpatient clinic that treats primary care and urgent care issues. There are also numerous specialty clinics that provide care in specific areas like Dental health, sexually-transmitted disease (STD) testing, Tuberculosis care, Psychiatry, and Drug Rehabilitation. Lastly, there is a social work department to connect patients with resources and a community health team that provides direct care services to patients in neighboring schools and lowincome communities. Observations - Direct Health Care In order to protect the health of the surrounding communities, Public Health Center 21 utilizes two main strategies. The first strategy implements secondary and tertiary prevention measures to address health issues as they arise and prevent them from worsening. Secondary prevention entails catching diseases at early stages, and tertiary prevention involves preventing death and exacerbation of existing disease. The main

Figure 2. Incidence of catastrophic health spending by wealth quintiles, > 10% household consumption, 1996-2009 Edition 19 Spring 2022


outpatient clinic treats a variety of issues that patients face, and it allows them to address their health problems early without having to visit a private hospital. Whether it be free routine immunizations, treatments for injuries and wounds, medicines for common colds/ flu, or even routine care for chronic issues like diabetes or hypertension, this clinic serves all the basic healthcare needs of the surrounding communities. Community health workers also travel to the surrounding communities to provide these same services. For example, they would give routine immunizations at local schools (Image 1), or provide routine care for bedridden patients such as wound dressing and medication delivery. Additionally, the specialty clinics have incorporated unique strategies to ensure their patients maintain their treatment regimens. For example, at the Tuberculosis clinic, they use a directly observed treatment program, which requires patients to take their medication inperson at the clinic under the observation of a nurse or physician. In the early stages of treatment, a patient may have to come into the health center every day to ensure that they are adhering to the treatment protocol.

Community nurse speaking to children at a local school after they have received routine immunizations. 90

Furthermore, if a patient misses a day in attendance, the staff will track the patient and provide them with counseling so that they adhere to the treatment regimen. This type of treatment program was novel to me, but evidently, it is very effective at treating tuberculosis. Moreover, given that the center is strategically placed in an easily accessible location, transportation does not pose an issue for a majority of the patients. Another example of effective health maintenance I witnessed was in the STD clinics, which provided routine testing and counseling services for sex workers from the nearby areas in Bangkok. This clinic provided free testing once a month for HIV and other sexually transmitted diseases, as well as free counseling and education about safe sex practices and use of contraceptives. Moreover, these workers were always provided with condoms and other contraceptive resources. I was most impressed by how the clinics were able to abate the stigma associated with this profession by treating these individuals as any other patient and encouraging them to take initiative in protecting their own health. Secondly, the clinic was able to promote the secondary prevention measure of routine screening to detect these diseases at their early stages and provide patients with proper care in a timely manner. Since the HIV epidemic is widespread in Thailand and especially among sex workers in Bangkok, the capability of the clinic to provide such services at no cost removes all possible barriers in accessing its healthcare services. Another notable service provided by the psychiatry clinic was visiting neighboring schools in the community to conduct neuropsychological exams on at-risk children. These children were identified by their families Epidemic Proportions

or their school teachers based on performance on exams or their behaviors. The psychiatrists would then conduct necessary exams to screen children who are in the early stages of possible neurological or mental disorders. Such secondary prevention measures allow psychiatrists to provide appropriate therapies or treatments to the children. Once again, all

A community worker teaching an exercise routine to elderly members of the community. these services are provided at no cost to these children and their families. The last example of a unique service provided by this clinic was their drug rehabilitation program. This clinic especially struck me given that drug rehabilitation is difficult for many individuals in the United States to afford. This center provides methadone replacement treatment for anyone in the community (regardless of if they are Thai citizens) at no cost. This treatment was similar to that from the TB clinic where the patients had to be physically present in the clinic in order to take their methadone treatment. In this case, the measure is to ensure that the patients do not abuse methadone by trying to re-sell it for real heroin. Moreover, this process is Edition 19 Spring 2022

helpful to ensure that they are following the correct dosages to slowly wean them off of methadone into taking a placebo. This clinic was especially interesting given the use of harm reduction programs, which we studied deeply in public health courses. The clinic provides these users with a safe space to take this replacement drug, and includes a catered treatment plan to help them slowly recover from their substance abuse. Furthermore, the clinic supplements this treatment with educational and counseling sessions, which together have been very effective for people in the surrounding communities. Observations - Preventive Health Care Aside from direct health care with these specialty clinics, the other strategy utilized by Public Health Center 21 included education interventions to promote health behaviors and lifestyles in the surrounding communities. Of note, there was a team of community health workers that would attend local elderly centers and teach them exercise routines to incorporate into their daily lives (Image 3). This was aimed to help control and prevent chronic diseases such as diabetes, hypertension, and other forms of heart disease. Moreover, the Center provides weekly crafts and other activities to make sure patients are continuing to build their fine motor skills and mental abilities and prevent cognitive decline. This experience was eye-opening because the center was not only providing direct health care but also aiming to prevent the onset of diseases in the surrounding communities. Conclusion Ultimately, I witnessed innovative and effective initiatives provided by this public health center. I was able to see first-hand how their recent transition to a universal health scheme allowed the center to provide numerous free services 91

to surrounding communities and eliminate the biggest barrier in accessing care: financial distress. Moreover, the public health center was able to address the barrier of transportation access by placing clinics in hotspots all over the city. This experience allowed me to understand the importance of addressing such barriers to help promote the health of low-income and vulnerable populations. In light of the COVID-19 pandemic, I witnessed how such populations in the U.S. are disproportionately affected by emergencies and chronic diseases. Thus, it is essential to have extra measures in place to prevent disease outbreaks, screen them at early stages, and provide accessible care. I am grateful for my experience abroad in allowing me to learn about a healthcare system in a different country and understand gaps that exist in the U.S. healthcare system. Specifically, these gaps include the lack of focus on preventative medicine. There is increasing financial support for the maintenance of chronic diseases in the U.S., but there needs to be equal importance placed on the prevention of these diseases, especially in low-income populations that are more vulnerable. Additionally, the number of uninsured citizens in our country is alarming and causes many health issues to go unaddressed and untreated. Although economic reform is required before such a universal healthcare system can be feasible, this experience showed me its potential effectiveness once implemented. In the meantime, it is essential that we continue interacting with vulnerable communities, learning about the different health disparities that plague their lives, and working to provide effective safety nets that protect their health.



1. Organization of BMA. Bangkok Metropolitan Administration. Http://www.Bangkok.go.th/main/page. php?&328&1=en. Published 2007. 2. Paek SC, Meemon N, Wan TT. Thailand’s universal coverage scheme and its impact on health-seeking behavior. Springerplus. 2016;5(1):1952. Published 2016 Nov 10. doi:10.1186/s40064-016-3665-4 3. Tangcharoensathien V, Limwattananon S, Patcharanarumol W, Thammatacharee J. Monitoring and evaluating progress towards Universal Health Coverage in Thailand. PLoS Medicine. 2014;11(9). doi:10.1371/journal.pmed.1001726 4. Tangcharoensathien V, Pitayarangsarit S, Patcharanarumol W, et al. Promoting universal financial protection: How the Thai Universal Coverage Scheme was designed to ensure equity. Health Research Policy and Systems. 2013;11(1). doi:10.1186/1478-4505-1125

Meghana Dantuluri Public Health Studies Class of 2020

Epidemic Proportions

Photo Courtesy of Mason Cole Edition 19 Spring 2022


Research | Sophia Park

An Illusion of Explanatory Depth in the Public’s Understanding of COVID-19

Our understanding of COVID-19 seems to be constantly changing with new updates being continuously released on the internet. With the repository of information available on the Internet, we tend to conflate our own internal knowledge with the information easily accessible to us online. This project conducted by Sophia Park aims to explore the role of the “illusion of explanatory depth” in the public’s understanding of COVID-19. Park explores two studies released on Johns Hopkins University’s SONA Psychology Research Portal, which asked subjects to rate their level of confidence in explaining COVID-19 related concepts to a peer. The data analyzed thus far shows that subjects with access to the internet resources average a higher self confidence rating than those without. In this article, Park further explores how the Internet can instill a false sense of confidence in people’s own assessment of their understanding of COVID-19.


Epidemic Proportions

Photo Courtesy of Mason Cole

Since the discovery of COVID-19 in December 2020, scientific knowledge regarding the virus has only been expanded upon. In the advent of the digital age where we have accessibility to the internet at virtually any given location and time, we are constantly being updated with new information regarding the pandemic. However, how much of this information do we actually understand? Recent studies reveal that people often confuse external resources such as the internet with their own internal knowledge. Therefore, people tend to inflate their self-assessed comprehension, as they are unable to discern the outsourced knowledge of internet searching, with their own understanding of the researched subjects.1 Furthermore, another study published in Cognitive Science 2002 explains the mechanisms behind the “illusion of explanatory depth” where people feel that they have a much more in-depth understanding of the world and its complex phenomena, than the fairly limited understanding they actually do have.2 Although past research does reveal that the ability to search for information on the internet inflates an individual’s perceived Edition 19 Spring 2022

level of understanding, there is a gap in how this applies within the context of the ongoing coronavirus pandemic. Building on these findings, our project will explore the role of the “illusion of explanatory depth” in the setting of the COVID-19 pandemic. We aim to elucidate the public’s depth of understanding regarding COVID-19, in contrast to their perceived depth of understanding. Do people actually have a sense of how well they understand the science behind COVID-19? How does internet accessibility play a role in inflating perceived knowledge? In addition, what are the implications of inflated perceived knowledge on people’s health behaviors (eg. hand washing, mask wearing, vaccine adherence)? Through a series of brief online survey questionnaires asking subjects to rate

People tend to inflate their self-assessed comprehension, as they are unable to discern the outsourced knowledge of internet searching, with their own understanding of the researched subjects.1 " 95

their ability to explain aspects of COVID-19 to a family member or friend, we expect to see that internet accessibility plays a key role in instilling a sense of false confidence in people’s understanding of the COVID-19 pandemic. Methods Our project involves a series of survey questionnaires that randomly assign subjects one out of three conditions: Internet Search, Internet Directed, and No Internet. In all three conditions, the subject is first asked to rate their ability to explain four COVID-19 related concepts to a friend or family member on a scale of 1 (very poorly) to 7 (very well). In all three conditions, before accessing any external information, the subject is given time to read the first subset of questions. Prior to answering these questions in the Internet Search condition, the subject is asked to search on four different websites (World Health Organization, Centers for Disease Control and Prevention, Harvard Health, and Johns Hopkins Medicine) before providing their answers. In the Internet Directed condition, the subject is given direct links to those four websites with articles that have information that is relevant to the questions being asked. In the No Internet condition, the subject is provided

with articles from those four websites but not given any additional internet access. After the first and second subsets of questions, each participant was asked which source was the most helpful to them. To ensure the integrity of the experiment, all subjects were given two debriefing questions after the third subset of questions which asked whether they used any additional internet resources. We have released two studies thus far: Study A and Study B. Both studies were released through the SONA Psychology Research Portal, which allowed us to recruit and survey students from Johns Hopkins University. Undergraduate students in courses within the Psychological and Brain Sciences Department were provided extra credit for completing our studies. Each study was capped at 300 participants in order to allow for around 75100 subjects per condition. Although both studies that were released asked the same first subset of questions, the second and third subsets of questions differed. Both studies directed subjects to answer the first subset of questions, followed by a second and third subset of questions. Study participants were not given access to any additional resources before answering. In Study A, the second subset of questions

Figure 1. The first subset of questions asked in both studies that were released. These questions asked subjects to rate their ability to explain different COVID-19 related concepts to a friend or family member. 96

Epidemic Proportions

Figure 2. Comparison of the confidence levels in rating ability to explain COVID-19 related concepts amongst all three conditions in Study A. "1" and "2" refer to the first and second subsets of questions. included four additional COVID-19 related concepts. The participant was asked to rate their ability to explain to a friend or family member on the same scale as the last. The third subset of questions would then be focused on the subject’s optimism relative to the pandemic. These were four questions that asked subjects to rate the degree of agreement with different statements regarding the future of COVID-19. This study was released in late 2020 before the announcement of a vaccine available, and thus included statements such as, “I am confident that a COVID-19 vaccine will be widely available next year.” The scale used in this subset was from 1 (highly disagree) to 7 (highly agree). Study B asked a new subset of questions that investigated a participant’s level of confidence in assessing adequate health behaviors in Edition 19 Spring 2022

different situations. For example, one being: “Over the next two months you may find yourself in situations where it is beneficial to your health and the health of those around you to wear a mask. How confident are you in your own ability to determine when to wear a mask?” The subjects were asked to rank their ability to assess their behavior on a scale of 1 (not confident at all) to 7 (very confident). Once completing these questions, the subjects were directed to a third subset of questions that asked for their likeliness to seek out further information from a scale of 1 (very unlikely) to 7 (very likely). These statements were also associated with health behaviors as they asked how likely the subject would be to seek additional information when determining necessary health behaviors (eg. length of time to quarantine, when to wear a mask). 97

Results We are currently in the process of analyzing the results from Study A. This study had 293 student participants with 101 subjects having the Internet Search condition, 94 subjects having the Internet Directed condition, and 98 subjects having the No Internet condition. We found that the subjects with the Internet Search condition averaged the highest rates of confidence in answering all subsets of questions with averages of 5.6825, 5.385, and 3.7875, respectively. Additionally, the subjects with the Internet Directed condition averaged the second highest rates of confidence with averages of 5.62, 5.1475, and 3.4775, respectively. Lastly, subjects within the No Internet condition had the lowest rates of confidence with averages of 5.4025, 4.8125, and 3.285. In addition, all conditions revealed that the average rate of confidence decreases with the second subset of questions and further with the third subset of optimismrelated questions. Although we are still in the process of analyzing these results, we have constructed a graph comparing the results of these three conditions within all three subsets of questions. In terms of other results, we expect to see confidence rates influence choices in health behaviors, as well. Discussion From the analyzed results of Study A, we see a clear trend that people tend to rate their confidence in ability to explain COVID-19 related concepts higher when they have access to internet sources. With the first subset of questions, the Internet Search subjects that were able to search the suggested websites averaged a confidence rating of 5.6825 out of 7. This is in contrast to the No Internet subjects that averaged a confidence rating of 5.4025 out of 7. Furthermore, we also found that when participants were unable to access 98

The internet instills a false sense of confidence in people’s own assessment of their comprehension "

any resources prior to answering the second subset of questions, the average confidence ratings dropped in all conditions. These results suggest that people rely heavily on accessing external resources, specifically the internet, in their confidence in explaining COVID-19 related concepts. These results align with our initial hypothesis that the internet instills a false sense of confidence in people’s own assessment of their comprehension. Although subjects in the Internet Directed and No Internet conditions had access to the same information, subjects in the Internet Directed condition had higher average rates of confidence. Past studies reveal that the act of searching online for answers tends to be associated with an individual’s own perceived knowledge. People view the internet as a “transactive memory partner” and are unable to discern that this information is stored externally rather than internally, which leads to an inflated selfperception of understanding.1 In addition, past studies have also revealed that people are generally unable to discern strong explanations from weak explanations, specifically within a scientific context. A 2008 study published in the Journal of Cognitive Neuroscience detailed that subjects found illogical explanations with neuroscience information to be more satisfying than those without.4 Another study also supports the public’s general inability to discern truthful information, as it revealed that people are inattentive to accuracy when sharing Epidemic Proportions

information about COVID-19 on social media platforms.2 Although subjects in the Internet Search condition had to find relevant information on their own with only names of suggested websites provided, they had the highest average ratings of confidence. People tend to overestimate their ability to identify relevant information which also contributes to an inflated self-perception of understanding.

(Class of 2023)) at The Visual Thinking Lab under the guidance of Dr. Jonathan Flombaum.

Our analyzed results and the future findings of this project will provide insight into how the internet can influence people’s perception of their understanding of COVID-19, and how this can affect behavioral decisions. Much of the current information regarding COVID-19 is being spread through internet platforms such as social media by the general public. With social media platforms being echo chambers where algorithms can easily sway public opinion, there is great opportunity for the proliferation of misinformation. A 2020 Nature Human Behavior article by Dr. Cornelia Betsch emphasized the significance of behavioral science data in identifying how people perceive their own risk, with a key focus on misinformation and use of the language addressing this crisis.5 As the COVID-19 pandemic continues, behavioral studies that focus on public perception in response to the communication of health policy are essential to mitigating individual actions. The results of our studies may provide insight into how government agencies and media outlets can choose to disseminate information that will better allow people to calibrate their own sense of understanding of COVID-19.

2. Pennycook, G., McPhetres, J., Zhang, Y., Lu, J. G., & Rand, D. G. (2020, July 1). Fighting COVID-19 Misinformation on Social Media: Experimental Evidence for a Scalable Accuracy-Nudge Intervention. Psychological Science, 31(7), 770-780. doi:10.1177/0956797620939054

Acknowledgements: This research was conducted by a team of undergraduate students (Isabella Rubin (Class of 2021), Shanelle Quinn (Class of 2023), Pamela Li (Class of 2023), and Sophia Park Edition 19 Spring 2022

References 1. Fisher, M., Goddu, M. K., & Keil, F. C. (2015). Searching for explanations: How the Internet inflates estimates of internal knowledge. Journal of Experimental Psychology: General, 144(3), 674-687. doi:10.1037/xge0000070

3. Rozenblit, L., & Keil, F. (2010). The misunderstood limits of folk science: An illusion of explanatory depth. Cognitive Science, 26(5), 521-562. doi:10.1207/s15516709cog2605_1 4. Weisberg, D. S., Keil, F. C., Goodstein, J., Rawson, E., & Gray, J. R. (2008). The seductive allure of neuroscience explanations. Journal of cognitive neuroscience, 20(3), 470–477. doi: 10.1162/jocn.2008.20040 5. Betsch, C. How behavioural science data helps mitigate the COVID-19 crisis. Nature Human Behavior 4, 438 (2020). https://doi. org/10.1038/s41562020-0866-1

Sophia Park Behavioral Biology Class of 2023 99

Photo Courtesy of Eirnin Mahoney 100

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Policy | Neha Skandan

The Hidden Epidemic: A Call to Reform Secondary School Education on the Opioid Crisis

In her review, Skandan considers the ongoing epidemic of opioid misuse befalling the U.S. She identifies a need for targeted interventions to the issue starting at an early age – particularly a strengthening of adolescent health education focused on recognition of its signs in others and knowing how to avoid becoming a victim oneself. She hopes that these reforms will be able to curtail some of the opioid epidemic’s spread, alter how it’s perceived, and empower younger generations to make a lasting difference in their own lives.


hen Emily was seventeen, her high school principal approached her with concern after noticing blisters on her arms. She brushed off the situation as she was scared to reveal the truth: she was suffering from opioid use disorder. She

Edition 19 Spring 2022


developed opioid dependence after being prescribed pain medications for a surgical procedure, and her condition only worsened over time. She hated her lifestyle, and in that moment, she struggled to control the events in her life. Her friends witnessed her struggle and wanted to prevent her from excessive drug use but did not know how to help or even approach her. Only after Emily witnessed an older woman succumbing to a fatal drug overdose did she enter recovery. Emily is now a Certified Recovery Specialist in Pennsylvania, an organizer of a community outreach program for substance use disorders, and the mother of a charismatic six-year-old child. Looking back, Emily wishes she had been more open about expressing her feelings at the time so that her friends could have been better informed about how they could intervene. She felt that there was not enough conversation on how to navigate such situations and that bystanders often fail to intervene when they witness a loved one battle opioid use. Unfortunately, Emily’s experience represents that of over 11.5 million individuals who struggle with opioid misuse.1 The state of Maryland is especially impacted by the crisis, with overdose rates more than 1.5 times higher than the national average. In 2017, Baltimore County had the highest overdose fatality rate of any city in the United States.2 The COVID-19 pandemic exacerbated this hidden epidemic with nationwide drug overdose deaths reaching a record high of over 100,000 this past year.3 An innumerable number of factors from the lockdown have contributed to a spike in opioid overdose cases, from mental health concerns to individual impacts of an unstable economy. However, the pandemic did not cause the opioid epidemic to surge; it exploited 102

She [Emily] felt that there was not enough conversation on how to navigate such situations and that bystanders often fail to intervene when they witness a loved one battle opioid use." existing gaps in society that allowed the opioid epidemic to plague the nation for decades. Young adults, in particular, have suffered from the opioid crisis, as long-term substance misuse cases usually originate in adolescent years. Opioid-related mortality among young adults has skyrocketed nationwide with devastating patterns in states more severely impacted by the opioid epidemic. For example, data from the Pennsylvania Task Force and Advisory Committee Report show that opioid-related mortality among adolescents and young adults aged 13 to 25 years in Pennsylvania increased nearly threefold (268.2 percent) from 1999 to 2016, and the trend has since risen tremendously.4 Furthermore, not only did 1.9 million young adults misuse opioids in 2018, but a majority also reported strikingly low perceived risk of harm.5 The consequences of opioid misuse stretch well into adulthood, requiring targeted interventions on prevention at an early age. In Dr. Joshua Sharfstein and Dr. Yngvild Olsen’s book The Opioid Epidemic: What Everyone Needs to Know, addiction is described as “an interaction between the substance, an individual, and the environment.” Given this definition, Dr. Sharfstein and Dr. Olsen discuss that preventing addiction entails reducing exposure, assisting individuals exposed to the substance early-on, and promoting an environment that encourages healthy Epidemic Proportions

behavior.6 All of these primary interventions are designed to prevent the onset of opioid and other substance misuse, but doing so requires the population to have a heightened awareness of these preventative measures. Thus, to specifically address the youth opioid epidemic, prevention entails stronger adolescent health education that emphasizes how to protect oneself and aid others who may be struggling. National initiatives have been launched to tackle various angles of the opioid epidemic. For example, the National Institutes of Health has offered university research grants through the funding initiative Helping to End Addiction Long-Term (HEAL), where ten universities have received grants to address the crisis from different angles.7 One such research group is the play2PREVENT Lab at the Yale Center for Health & Learning Games, where I was a research assistant during my senior year of high school.8 Directed by Yale School of Medicine Professor Dr. Lynn Fiellin, the play2PREVENT Lab developed a digital intervention titled ‘playSMART’ to raise awareness of opioid use and mental health for adolescents. Through decision-making features embedded in the game, playSMART empowers teenagers to address their own mental health and prevent

Educational games indeed have the potential to effectively deliver messages on opioid prevention to adolescents since the design of the digital interventions are relatable and realistic with situations that can mirror youth’s own lives.9 " Edition 19 Spring 2022

opioid misuse. The six storylines in the game emphasize distinct situations related to opioid misuse, from the mismanagement of medical prescriptions to adolescent social situations that may involve substance misuse. Given the high prevalence of concurrent substance use and mental health issues, playSMART highlights common symptoms of mental distress that may lead to opioid misuse. The storylines also demonstrate how to lend support to family members or close friends who may be struggling with opioid use disorder and/or mental illness. The goal is to implement playSMART in school-based health centers nationwide. “There are major gaps in teens’ understanding about the risks associated with opioids— particularly prescription opioids—that need to be fixed,” Dr. Fiellin said. “The long-term benefits of playSMART are to hopefully have adolescents build a solid understanding of the risks, harms, and benefits associated with their choices. If adolescents can experience these aspects ‘safely’ in a game, it will help them to manage decisions in the healthiest way possible in real life.” A study published in the Journal of the American Pharmacists Association showed that educational games indeed have the potential to effectively deliver messages on opioid prevention to adolescents since the design of the digital interventions are relatable and realistic with situations that can mirror youth’s own lives.9 This study also concluded that the incorporation of presentations and other forms of media can help to relate the topic of opioid misuse and prescription safety to a diverse group of adolescents with different learning styles. Thus, the combination of a variety of informational measures can work to engage adolescents on opioid safety 103

education. Through my work with the play2PREVENT Lab, I have realized that there is a demand nationwide for preventative education in the fields of drug misuse and mental health. A common theme of such initiatives is that awareness serves as a driving force to prevent substance misuse in adolescents. The Opioid Crisis Toolkit for Teenagers that I designed with the assistance of Dr. Natalie McGuier, a biological sciences professor at Carnegie Mellon University, compiles information on the opioid crisis into a comprehensive workshop for secondary schools and an accompanying hands-on guide for teenagers.10 From detailing symptoms of opioid dependence to guidance on identifying an overdose, the toolkit includes interactive items to practice with during hands-on classroom activities and apply in a real-life setting. The Opioid Crisis Toolkit of Teenagers has been implemented in regional Pennsylvania high schools and made available in community support centers. Supplementing creative avenues, such as educational games, with more traditional workshop presentations and handouts can help provide crucial information in the classroom setting. More importantly, interventions in the school setting will perhaps work to normalize these issues and empower the younger generation to erase the stigma of opioid use. Currently, societal stigma around substance misuse still stands as a barrier for individuals who are affected by the condition to receive medical care. In a study conducted by the National Institute on Drug Abuse, due to the stigma, only 36% of individuals with substance use disorders reported as seeking recovery.11 Addressing the stigma of opioid use disorder entails understanding that opioid dependence is a medical condition rather than a moral 104

weakness. Changing society’s perceptions of substance use disorders is key in encouraging individuals to seek preventative measures and treatment more openly. Unfortunately, the stigma is deeply-rooted in society, especially among older populations. However, the collective perspective of society in the future can be transformed if the rising generations are better informed about opioid dependence. In addition to creative learning measures as detailed above, it is imperative that secondary schools supplement county drug and alcohol programs by providing teenagers with the tools to not only protect themselves from substance misuse, but also serve as supportive resources for others. We should equip young adults early-on with knowledge on how to prioritize their health and wellbeing. However, fully targeting the adolescent population requires a multidimensional approach. At a wider level, we must begin with a willingness to speak more openly about substance misuse in society without stigma. As a targeted intervention, classrooms provide an ideal setting for adolescents to gain crucial education on opioid safety and access resources that highlight prevention education. In the long-term, having clear discussions during secondary school on substance misuse will better equip rising generations to reform society’s current perceptions of opioid misuse. The opioid crisis calls for heightened awareness, as we are at a point where almost everyone knows of an individual affected by these issues. However, we also have the knowledge to reduce the burden of these issues, and it is time for action to save lives. The power lies in teenagers – through collective education, awareness, and peer support, the younger generation has the potential to strike Epidemic Proportions

a crucial dent in the opioid epidemic. References

1. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on MedicationAssisted Treatment for Opioid Use Disorder; Mancher M, Leshner AI, editors. Medications for Opioid Use Disorder Save Lives. Washington (DC): National Academies Press (US); 2019 Mar 30. 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK541397/ 2. Baltimore City's Response to the Opioid Epidemic. Baltimore City Health Department. https://health. baltimorecity.gov/opioid-overdose/baltimore-cityoverdose-prevention-and-response-information. Published October 21, 2020. Accessed November 8, 2021. 3. Vital Statistics Rapid Release - Provisional Drug Overdose Death Counts. National Center for Healthn Statistics. https://www.cdc.gov/nchs/nvss/vsrr/drugoverdose-data.htm. Published November 4, 2021. Accessed November 8, 2021.

November 8, 2021. 8. play2PREVENT Lab. Yale Center for Health & Learning Games. https://medicine.yale.edu/intmed/ genmed/games/. Published October 12, 2021. Accessed November 8, 2021. 9. Abraham O, Szela L, Brasel K, Hoernke M. Engaging youth in the design of prescription opioid safety education for Schools. Journal of the American Pharmacists Association. October 2021. doi:10.1016/j. japh.2021.10.016. 10. Skandan N. How to Help a Loved One Struggling with an Opioid Use Disorder. Opioid crisis Toolkit for Teenagers. https://toolkitforteens.wixsite.com/ opioidcrisis. Published 2020. Accessed November 8, 2021. 11. Kulesza M, Larimer ME, Rao D. Substance use related stigma: What we know and the way forward. Journal of addictive behaviors, therapy & rehabilitation. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4228689/#R5. Published May 27, 2013. Accessed November 17, 2021.

4. Warm Hand-Offs in Pennsylvania: A Task Force and Advisory Committee Report. Joint State Government Commission: General Assembly of the Commonwealth of Pennsylvania. http:// www.jsg.legis.state.pa.us/resources/documents/ ftp/publications/2020-12-29%20(2019HR216) WARM%20HAND-OFFS%20REPORT%2012.28.20. pdf. Published December 2020. Accessed November 17, 2021. 5. Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration.https:// www.samhsa.gov/data/sites/default/files/cbhsqrepor ts/NSDUHNationalFindingsRepor t2018/ NSDUHNationalFindingsReport2018.pdf. Published 2018. Accessed November 8, 2021. 6. Olsen Y, Sharfstein JM. The Opioid Epidemic: What Everyone Needs to Know. Oxford, NY: Oxford University Press; 2019.

Neha Skandan Molecular and Cellular Biology & Public Health Studies Class of 2025

7. Helping to End Addiction Long-term. National Institutes of Health. https://heal.nih.gov/. Accessed Edition 19 Spring 2022


Features | Aanya Shahani

Learning from a Pandemic: Mass Vaccination and COVID-19

In her retrospective, Shahani details her experiences beginning her college career amidst the Covid outbreak. The widespread vaccine scarcity she witnessed motivated her to volunteer at the M&T Bank Stadium Mass Vaccination Site, later described as the most successful such vaccination site in US history. Here, she shares the insights she gained and describes the challenges our communities continue to face in their pursuit of COVID immunity. 106

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“US surpasses 20 million COVID-19 cases, while experts foresee tough times in January” “UK Prime Minister imposes harsh lockdown as new COVID-19 variant spreads” “5-person limit on all undergraduate gatherings, Stay-at-home orders lifted, Mandatory 3x/Week COVID testing.” These were the headlines during my first few weeks at college in person, in Spring 2021. My birthday was just around the corner, and there had been a cluster of cases on campus as a result of a frat party, and suddenly, two of my four friends were in isolation, and my roommate and I were concerned that we may have caught it too. I remember wondering if the pandemic was Edition 19 Spring 2022

ever going to end. I remember being anxious about the prospect of potential vaccines – not because I didn’t trust the science but because I didn’t know better – I didn’t think you could vaccinate against a virus. February progressed into March, and suddenly, it was here – the vaccine, the saving grace, the ‘hack’ to end the pandemic through herd immunity. It seems easy enough, right? Just stick a needle into 80% of the population’s arms, and we’ve achieved it! If only. I laugh at my naivety now. I recall my parents urging me to get vaccinated and me explaining to them that I would have to wait since I was class 3C: the last to get my shot because I was low-risk and perfectly healthy. Shots were ‘out-of-stock’ like wildfire, and people that were in the eligible classes were 107

also struggling to get their shots. It was around that time when I learned of the Facebook group: Maryland Vaccine Hunters. Eagerly, I joined the group and kept up-to-date with vaccinations in Maryland – who was eligible, where you could get a shot, which places had the longest wait time, which locations usually had extra shots that went to waste. And then came the email. In early March, Johns Hopkins University began recruiting volunteers for shifts at the M&T Bank Stadium Mass Vaccination Site in non-clinical roles. I was so excited, and I knew that spots would fill up before I could process the news that I called home, forgetting about the 9.5 hour time difference, waking my parents up to get their seal of approval – after all, in their eyes, I was abroad, alone, unvaccinated and wanting to interact with other, unknown unvaccinated individuals. I started at the M&T Bank Stadium on March 9, 2021. We saw about 200 patients and administered the J&J Vaccine. It was so crowded but still efficient, and I thought that 200 in a whole day didn’t seem like enough

M&T Bank Stadium served as a two-floor mass vaccination site in Baltimore, Maryland, that administered 248,698 vaccinations between February and July 2021. 108

to be considered mass. I feared for cities like my Mumbai, which has 22 million people. I continued to work at the stadium, and we continued increasing our capacity to about 6500 people in a day or about 1100 per hour. The physician in charge of the stadium mass vaccination site described it as the ‘most successful mass vaccination site in US History,’ and we had the pleasure of welcoming Vice President Kamala Harris, Dr. Anthony Fauci, Governor Larry Hogan, and several eminent members of the CDC, as well as prominent religious leaders, in several of our efforts to promote vaccination. I couldn’t get enough. I kept going back to learn more and help and become a part of the Baltimore and greater Maryland community – to make Baltimore feel a little more like home. I lived vicariously through the stories of my newfound friends at the sites, be it the travel nurses from all over the United States, the National Guard, or the pharmacy techs. Eager as I was to learn, I did every task offered to me: navigating patients through the sites, observing patients for potential side effects, keeping patients in the queue for those with disabilities company and escorting them, translating for few patients that spoke Hindi, checking for appointments and announcing the ‘vaccine of the day,’ taking patient histories and completing screening forms and even setting up the pop-up vaccination sites, all while making friends in the patients themselves, as well as the amazing nurses, police officers, national guardsmen and women, and support staff along the way. It took a village to create a successful mass vaccination site from a football stadium, and we were lucky to have that village. I kept up with the Maryland Vaccine Hunters Facebook group and watched as patients echoed our efforts with words of praise, commandment and gratitude – a stark change Epidemic Proportions

Student leaders of the Vaccine Volunteer Project along with Dr. Misti McKeehen discussed their experiences with President Daniels and his wife over brunch. from the initial grumpiness at long wait times and teething inefficiencies. Yet, at some point in the middle of May, the demand for vaccination died despite all our best efforts. We’d stand around for hours waiting for patients to get their shots and there’d be close to no one. And so, I moved on to simultaneously assisting at the Morgan State University Community Vaccination Site. It was much smaller but we saw more patients come in, often from minority groups in the city of Baltimore. And then came the pop-up clinics at community centers – the Village Learning Place library and at the CentroSol Fair at Patterson Park, where we had fewer and fewer people come in. However, it was at these places that our time helping with vaccinations came in handy – we tasked ourselves with convincing the unconvinced to take the step beyond the wall of uncertainty and get their shot. By mid-June, it didn’t matter where I was— whether I was Edition 19 Spring 2022

at the grocery store, in a Lyft, on the bus, I’d be asking people around me if they had their shots and if not, I’d be convincing them to get it. Each of the three kinds of sites taught me so much about their approach to vaccinations and how they met the need at that moment. Mass vaccination sites, like M&T, were the first to open, when people clamored for their shots. They were all about efficiency with a splash of meaningful, personal connection – reassuring those that came that they were doing the right thing by taking their shot and at the right place, their care was in the best of hands. It was a unidirectional flow – patients entered from one end and followed the arrows to three different stations – registration, vaccination and observation – before exiting a door at the other end, thus reducing face109

to-face interactions as well as increasing efficiency. The more efficient we became, the less people waited, the happier they left. Some people came in happy – one came in her wedding dress, because her wedding was canceled due to the pandemic, and this was a momentous occasion in her life, while another brought in Ferrero Rochers for the staff. Some even remembered me from their first shots – which humbled and amazed me since their interactions with me were often limited to less than half a minute. Community Vaccination Sites, like the clinic at Morgan State University, opened next, trying

in those that weren’t clamoring, that weren’t convinced, that were ‘iffy’ at best about their shot. Pop-up clinics were the last to open, and they were the literal definition of enticing people to get them to take the vaccine – patients were given ice cream after their shots, entered into raffles for fancy prizes. The pop-up clinics were everywhere they could be – I even saw one at the state fair and at a farmer’s market! It seemed like we were rewarding stubbornness so that we could reach that barrier of herd immunity.

Staff photo day at the mass vaccination site to reach those that may not have got the opportunity at mass vaccination sites, or for those who considered these sites far or maybe even didn’t trust these big sites. This was the first time that I truly understood what it meant to ‘take the vaccine to the people.’ Unlike the stadium, where people came from across Maryland, and sometimes, across the East Coast, the patients at MSU were typically from the surrounding neighborhoods and often current students and alumni of the university along with their families and friends. It was the next best step, because it was time to bring 110

As someone who’d never worked in a ‘job’ setting prior to the mass vaccination site, I was unsure of what to expect. But the M&T Bank Stadium Mass Vaccination Site was the epitome of harmony between different entities – the leadership team, the national guard, the stadium authorities, the nurses, the pharmacy personnel, the support staff, the police department. Good leadership existed at every level – personnel were rarely lost or confused with no one to go to for help. Leadership took feedback seriously, and implemented it as best they could – creating efficiency through small, Epidemic Proportions

sometimes seemingly unnoticeable changes in the flow of the site, allowing us to increase how many shots we administered, how many patients we saw, how long they waited in line, and how we could maximize efficiency even when the systems failed us. And last but not the least, they led by example – they always stepped up when required – it didn’t matter how menial the task was. Very early into the vaccination scheme, on March 30th, we had an unexpected slowdown, where we were fully equipped to vaccinate but had no one to vaccinate. As a result, more than half the staff was given the day off by way of lottery, simply because there was just no point in having so many people sit around doing nothing when there were only 10 appointments an hour for the next four hours. We closed down the bottom floor of the twofloor site, reduced it from 6 queues to just the queue for people with disabilities and had around 15 vaccination stations instead of 79. There were 45 minutes left in my shift, and suddenly the queue for people with disabilities – the only open queue – began to back up. I was stumped, and confused, and I watched as the leadership team, who had picked up their stuff, ready to leave, dropped their bags, looked me in the eye, and said, “One queue is about to become four, can you handle it?” There was no time or option to say no. Four queues, my short self waving a purple Baltimore Ravens flag to alert people as to where the voice telling them what to do was coming from, and 400 registrations and shots later, it was done. Everyone assumed a role that may not necessarily have been theirs from the start and 36 arduous minutes later, we had administered the vaccine to everyone present and the sudden chaos dissipated into the dull humdrum of everyday show. Edition 19 Spring 2022

So, then I suppose that the question of the pandemic is: what makes people so hesitant – so afraid – to take the vaccine? It takes me back to a conversation I had with a Lyft driver on my way to the med campus from my last ever shift in June at the mass vaccination site. I openly asked him if he had been vaccinated, and when he responded with a resounding no, I promptly asked him why. His response is what drove me to try to understand the problem of vaccine hesitancy but I do think that he summed it up best. He said, “First, they didn’t want to give it to us minorities. They made it so impossible to get an appointment that I thought, maybe it’s better that I don’t get it. Maybe there’s something in there that isn’t going to suit my body – I’ve been hearing these vaccines have side effects that can harm your heart. I don’t trust them – they created this vaccine so quickly that I just don’t trust the science. I’m just going to wait and see what happens to my friends who’ve taken it. If they’re alive next year, I’ll take it as well.” I rapidly debated him, countering all his points and urged him to get his shot, which he could do almost instantaneously at the stadium. I’d like to think I convinced him, but his arguments drove me to create a brief mental list of why people are hesitant to take vaccines: misinformation, lack of information and what I refer to as ‘once bitten twice shy syndrome.’ We all know about misinformation as a reason for vaccine hesitancy – that old tale about the MMR vaccine resulting in autism (completely unproven), which reduces the number of children in the US that get that vaccine to date. With the emergence of social media as the prominent source of information for most in our generation and our parents’ generation, it can feel as if there’s no escaping the gospel truth that one random aunty put up in your family WhatsApp group – after all, countries 111

A Hopkins volunteer working in the observation section at M&T Stadium are wasting billions of dollars on vaccination because they want to introduce a GPS microchip into your body to track you, and all you need is a simple herbal supplement to cure COVID-19. While social media platforms have now started an attempt to curb misinformation, we can only hope and pray that it’s enough before the next pandemic strikes. But one such way to combat both misinformation, and the lack of information is to give people access to more information – show them the data because cold, hard numbers don’t lie. Educate people through talks and understanding how the vaccine was created, why it was created and how the benefits significantly outweigh the risks. But I suppose what is missing the most, from this war against vaccine hesitancy, is the touch of a human being. According to research by the WHO, one of the most effective vaccination strategies is to simply offer testimonies of real112

life people, ordinary citizens, like you or me. In fact, this is one of the advertising industries’ favorite ways to market products to us, so it comes as no surprise that it’s an ideal way to promote vaccines to hesitant individuals either. It can also be an effective use of social media – posts like these do go viral. So many individuals also contest vaccinations due to their religious beliefs – and this time, at least in Baltimore – we brought in religious leaders, and we tried to encourage people that it wasn’t anti-religious to get their vaccines. But this brings me to my favorite, and so a far rather ominous point of ‘once bitten twice shy’ syndrome. Minority populations like people of color and economically disadvantaged people have a troubled history with vaccinations and government. These populations have constantly been at a disadvantage – either vaccinations have been denied to them, or they’ve not received appropriate care, or some Epidemic Proportions

other reason that has caused widespread mistrust in both vaccinations and the government that administers them – hence the name, once bitten, twice shy. For example, in the Tuskegee Syphilis study, not only were Black men denied treatment via penicillin for over 40 years, which was widely available at the time, but they were also misinformed of their diagnosis and prescribed ‘placebo-like’ treatments. This is by far not the only study wherein minorities and their rights have been abused in the healthcare sector by people in power, and the impacts on hesitancy to trust new medicine and new research are multiplicative. The most effective ways to combat this, according to recent research,

I suppose that the question of the pandemic is: what makes people so hesitant – so afraid – to take the vaccine?" seems to be a combination of emotion and legislation – empathizing with these communities and making special efforts to reach out to them, like at the community and pop-up vaccination sites, and also legislating against vaccine exemptions. In California, legislation against vaccination exemptions due to non-medical reasons increased vaccination rates among preschoolers by 4%. It's here that I will humbly remind readers that vaccine hesitancy is a privilege of individuals who have access to these vaccines. There are several regions that struggle to give their populations access to vaccines – take the continent of Africa and the COVID-19 vaccine, for example – but I will also point out that even in countries where the vaccine is not as abundant, for example in my home country Edition 19 Spring 2022

of India, there is hesitancy, and there’s still a long way to go before we can combat it in developing and developed nations. Hesitancy seems to have the same root cause – distrust in the government. Often viewed as a political stunt to garner more votes, several Indians, especially those that are the urban uneducated, are hesitant to take the vaccines and become the scapegoats of the next government propaganda agenda. However, all hope is not lost. Tucked away in the mountains trying to escape the latest omicron wave of COVID-19 during my winter break, I surveyed vaccinations in the surrounding villages. In the Mahabaleshwar Zilla Parishad, Satara District, where the Red Cross Society has adopted 96 villages and two primary health centers in a government-private partnership, there is above 98% vaccination, and given that booster shots for those above the age of 60 as well as vaccinations for children aged 15-18 were approved just weeks ago, there is almost 36% booster dose vaccination and 96% firstdose vaccination amongst children. It takes a certain ingenuity to reach these people in remote villages, shielded from a lot of the city’s WhatsApp University and public outreach. Not only are these people unaware of the importance of vaccination, but they also have no means to get to big government hospitals where the vaccine is administered for free, and without the knowledge of the importance of vaccination, and largely feeling like they have a really bad case of the seasonal flu, they don’t have the motivation to seek out the vaccine. There are also those villages that claim their religion prohibits vaccination, or that their doctors advised against vaccination, or that they were simply scared and didn’t believe in the vaccine. Reaching these remote villages with sufficient 113

vaccines maintained at the correct temperature was a feat. The Red Cross Society, whose motto is ‘to reach the unreachable,’ utilized an existing ‘boat ambulance’ and repurposed it to assist in vaccine distribution for the 56 villages by the banks of the backwaters and obtained through a donation by the Tata Group, a specially modified vaccine van, with a fridge and a hospital bed, to administer vaccines to 40 mountainous remote villages in the district. But the innovation didn’t end there. The one key advantage that this district had, is the government-private partnership. They had a certain faith in the Red Cross Society because these were the people that had trained their village girls to be auxiliary nurse midwives and allowed for the safe delivery of babies in villages since 2008, and these were the people that came in for general health checks and diagnosed cases of malaria through simple blood tests, leading to faster treatments, and allowing the sick to be well and back to earning their bread and butter in the fields quicker. The Red Cross Society too, used this faith to their advantage, but with honesty and integrity. They reached out to those doctors that advised their patients against the vaccine and counselled them. They approached the religious leaders, much like in the United States and convinced them to persuade their religious groups to vaccinate – with nearly full success! The same way the United States publicized vaccination of political leaders, they vaccinated the villagedesignated political leaders first, and under the spheres of influence of these individuals, as well as multiple outreach campaigns prior to the vaccination drives through the very same WhatsApp University that created a lot of their doubts, the doubts of the rural villagers in this district were quelled. The persistence of the Red Cross Society in the district paid off, and the district officials ranked their primary health 114

centers as #1 and #2 (of 72) in the district. On Saturday, January 15, 2022, I went alongside one of the general health drives to one of the most remote villages in the district called Aarav using the boat ambulance. Aarav is so remote that in the case of a landslide, which is exceedingly common in the monsoon, the village becomes isolated by road, and in the summer, the village becomes isolated by water. Neither are viable modes of transport in case of emergency, because the nearest basic health center is 45 minutes by boat ambulance, which is much faster than a village boat, and two hours by road. In a village of not more than 48 people, mostly elderly, as the healthcare worker spoke about nutrition and wellbeing for the elderly bringing about a whole host of different issues, I asked how many of them were doubly vaccinated against COVID-19, and saw the entire village

Equipped with basic first aid, a stretcher, medications, and cold chain storage for vaccines, this boat ambulance was purchased by Bel-Air Hospital, Pannchgani for the Tapola Primary Health Center after amassing donations worth INR 1,500,000 (USD 20,165). It is the first of its kind in Maharashtra. Epidemic Proportions

raise their hands. Most wore masks, but it was apparent that they didn’t much suffer the medical wrath of COVID-19, since there weren’t any hosts to bring it to them as a result of the national lockdowns. They simply took the vaccine because someone they trusted was administering it and it was free. The healthcare worker emphasized that she would bring booster doses the following week and that they all had to take them, starting with the

Vaccine freezers are housed in the Primary Health Center. ‘village elder,’ and a resounding ‘ho’ (meaning yes) echoed in the village. However, the same hesitancy prevalent in Mahabaleshwar district, is omnipresent in the villages of India, including the neighboring district of Panchgani, which is exclusively under government control. There, the vaccination rates are low, and villagers continue in their mistrust, resulting in what seems to be an abysmal difference from their neighbors. Simply educational material is not enough, since that alone cannot quell their questions. In the US, hesitancy seems to arise from a different kind of mistrust, one wherein the underrepresented minorities feel as though vaccination is a hidden way by which the government can marginalize them further. Edition 19 Spring 2022

In both nations, there’s a long road ahead to combat vaccine hesitancy and I opine that it starts with both acknowledgment of the past, and transparency about the vaccines. As the need for vaccination volunteers reduced in Baltimore, my shifts slowed down, but the lesson learned from this pandemic was invaluable. Not only have we learned the importance of mass vaccination, masking, and keeping a safe distance from one another, but also we’ve learned how to vaccinate in mass, how to take vaccines to the people in smaller communities, and we’re still learning how to convince those hesitant to get their shot. We’ve learned that there are vaccines for RNA diseases, and we’ve proved once again that vaccines do work. We’ve also re-learned the importance of being there for one another, even when physically impossible – we’ve learned the importance of having a support system when in isolation and when a crisis hits – whether it’s dropping off a casserole for a neighbor in isolation or keeping a friend company through Zoom. It’s a lesson we should cling onto with both hands, because for all we know, as much as I’d never, ever wish for it, the next pandemic could be right around the corner. Despite the tragedy that has been and continues to be COVID-19, there’s so much we’re learning, and as someone who might be in healthcare the next time a pandemic rolls around, I’m going to grasp onto every scrap of knowledge I can. Acknowledgements: Baltimore: None of my experiences would have been possible without the opportunity provided by Johns Hopkins University. A special shoutout to Misti McKeehan, Director of the Center for Social Concern. And of course, the experience wouldn’t be as amazing 115

The fully vaccinated residents of Aarav listening in rapt attention as the healthcare worker explains the importance of eating a balanced, nutritious diet and exercising without everyone involved: nurses, national guard, police officers, support staff, stadium officials, administrative staff, pharmacy techs., and of course, the patients. Mahabaleshwar: I owe all my experiences here to Dr. Prem Sheth, who organized these experiences, and the Indian Red Cross staff that showed us around: Coordinator Sandip, Nurse Aarti Murshe, Nurse Snehal Jadhav, MHW Amrut, Vishal, all the nurses and healthcare staff at Tapola and Talegaon primary health centers and of course, the lovely residents of Wagahvale and Aarav villages, who welcomed us into their hearts and homes and shared the little they had with us. Last but not the least, my parents, who accompany me and support all my Aanya Shahani crazy ideas. Neuroscience & Molecular and Cellular Biology Class of 2024


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Photo Courtesy of Mason Cole 118

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Editorials | Jasmine Wu

An Ethical Analysis of Vaccine Prioritization Scarcity of resources during the pandemic has highlighted the important ethical issue of prioritization. Who do we protect first, and why is it ethically permissible to prioritize their lives over other demographics? In this article, Wu explores the vulnerability of home health aides throughout the pandemic as well as the role they play in preventing at-risk patients from becoming seriously ill and in reducing strain on our healthcare system. Wu reports that these home health aides repeatedly report feeling undervalued and often face difficult circumstances. This article further discusses how protecting home health aides can maximize economic and social utility, save lives, and have long-term effects on the United States healthcare system.


f safe COVID-19 vaccines are in short supply, the decision of who to vaccinate first becomes pressing. Although utilitarian point of view argues that frontline physicians should be vaccinated first, a deeper analysis of the backgrounds of home health aides (HHAs) shows otherwise. Home health aids should be prioritized because such priority adheres to utilitarianism and maximizes total benefits. Home health aides (HHAs) are healthcare workers who go to their patients’ homes and help them complete basic tasks, such as grooming, chores, and grocery. They often care for the elderly,

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disabled, chronically ill, and the cognitively disabled. HHAs assist people who cannot find employment or take care of themselves, so these people depend greatly on home health aides to survive. These patients are also atrisk for COVID-19, defined here as being more likely to develop serious side effects such as chronically difficult breathing and organ damage. I also define benefits as not just the number of lives saved, but also the maximization of social good as Persad et al. argue in their paper Allocation of Scarce Medical Resources.1 Not only can individuals become seriously ill and die, but quarantine, business closures, and virtual schools also affect those who are healthy. Indeed, Johns Hopkins’ interim framework for COVID-19 vaccine distribution includes societal benefits as part of the common good.2 Health inequities and reparations for systemic discrimination have gained additional awareness and are distinctly illustrated by higher mortality rates and distrust of medical professionals among people of color. Instead of defining the priority group based on demographic factors like race or class, Persad et al. argue that there are other more nuanced methods of addressing inequalities. This method of prioritizing HHAs preserves future value by taking into consideration the social and economic effects of the pandemic. Vaccinating HHAs first can help save the most lives and protect a professional group that is already extremely vulnerable during the pandemic. Individuals over 65 years old make up over 70% of home health aide patients and are one of the most at-risk groups for COVID-19, compromising a majority of the mortalities.3 Further, the elderly and those with debilitating chronic illnesses that require home 120

health aides are unlikely to work and leave the house, so the HHA is one of their major connections with the outside world. Therefore, vaccinating HHAs and preventing them from getting sick subsequently protects at-risk populations from infection, reducing potential deaths through multiplicity. Additionally, 90% of HHAs are women, 67% are minorities, and 33% are immigrants. They make near minimum wage, and a higher proportion have preexisting chronic disorders compared to other health professionals.4 They get no overtime or sick pay and 20% are uninsured, placing them at a greater economic disadvantage.

The economically and socially disadvantaged HHAs and their patients are more likely to be negatively impacted by COVID-19.”

A greater benefit to society through minimizing negative consequences is created by protecting HHAs from COVID-19 and indirectly promoting social equity, as Persad et al. recommend. Many argue that doctors should be the first to receive the vaccine because doctors (in addition to many other healthcare professionals) put their own health at greater risk by directly interacting with COVID-infected patients, especially in the ICU. Additionally, doctors implement medical treatments for many patients, saving the lives of more patients than HHAs do. Some frontline doctors, such as pulmonologists and trauma surgeons, are the last “line of defense” for patients before COVID-caused death—they are directly responsible for saving lives and preventing the Epidemic Proportions

grief and expenses that follow after a person dies. In comparison, the domestic work and basic medical care provided by HHAs does not seem as vital toward saving a life. Socially, doctors are bound by the Hippocratic Oath to do no harm and prioritize the care of their patients over themselves. This oath is an ethical obligation that requires doctors to take reasonable precautions in order to keep their patients safe, which includes vaccines when they do not pose significant risk to the body. Patients should also have confidence in their doctor’s ability to keep patients safe - a confidence that could potentially be undermined if doctors cannot get vaccinated. Vaccines can help maintain trust and respect in a patient-physician relationship, and safeguard the quality of healthcare for the future.

Vaccines can help maintain trust and respect in a patientphysician relationship, and safeguard the quality of healthcare for the future.”

Although the principle of maximized utility is justified here, this argument is practically flawed due to our failure to protect and value home health aides, leaving them especially vulnerable to tragedy. For example, imagine an Olympic swimmer and someone covered in fish blood who cannot swim have fallen off their boat into the ocean. You can only throw one person a life jacket that magically repels sharks. Even without the life jacket, the Olympic swimmer may safely reach shore. However, the other person would surely die if they did not have the life jacket, either from being ravaged by the sharks or drowning. By giving Edition 19 Spring 2022

doctors the vaccine first, we have failed HHAs, an already socioeconomically disadvantaged group, and left them to “die”. I will further elaborate on the specifics behind why giving HHAs the vaccine results in maximized utility throughout the rest of this paper. This argument assumes that the two people are not equally likely to be eaten by sharks. Translated into real life, this would mean that the HHAs are more likely to become ill from COVID-19, and if they received the vaccine (or the magic life jacket that repels sharks), they would be much safer from infection. Although it may seem counterintuitive that HHAs are more likely to get infected compared to frontline and ICU doctors, studies have found that healthcare workers in the ICU consist of a much smaller proportion of COVID-19 cases among health care workers because they have better access to personal protective equipment (PPE). Indeed, family care physicians had the greatest mortality rate because of their less effective PPE (e.g. they did not have access to surgical masks).5 Data was not collected on home health aides, but they have struggled even more to obtain even the most basic PPE during the pandemic.4 Many received little to no training on how to use PPE from their employers, therefore lacking the knowledge to keep themselves safe. Most of the PPE equipment during the shortages was restricted to hospital employees, leaving HHAs and their many patients defenseless against COVID-19. The lack of PPE directly increases transmission risks for the HHAs, patients, families, and visitors. Many HHAs are also without private transportation, which increases their transmission risk every time they take the bus or subway to work. Additionally, patients admitted to hospitals are required to wear masks and take a COVID-19 test. Physicians 121

are alerted if the patients test positive, allowing them to take better precautions. HHAs do not have access to such warning systems, and patients are not required to wear masks inside their own homes. Indeed, a study found that infection rates among HHAs were triple that of the most infectious areas of New York City.6 I believe HHAs have the right to work in safe conditions and their patients have a right to safe care. Through neglecting to properly protect HHAs with PPE and training, employers and the government have perhaps unintentionally breached these rights with real consequences to the health of everyone involved. Additionally, HHAs do not have the same technologies as hospitals, including technology designed to keep everyone inside the hospital safe, and not just frontline doctors. The homes of patients do not have stringent disinfecting and sanitary technology, so nothing is sterile. Additionally, they are in a confined space without hospital-grade ventilation or negative pressure rooms to reduce disease spread. As stated before, HHAs are not provided with the high-quality masks, such as KN95s, which are given for free to hospital employees (these masks are extremely difficult to purchase if you are not a hospital representative working directly with manufacturers). Additionally, healthcare workers with a knowledge of natural histories of disease frequently use Betadine (a gentle disinfectant safe for any body part, found in all hospital supply closets) or Nozin to swab the insides of their noses, killing all viruses inside that could multiply and later cause a full-blown infection. These are both materials that HHAs cannot access, but healthcare workers inside hospitals can use these sanitizers freely. PPE quality and availability determine infection likelihood, but some HHAs do not have access to any PPE, so they are forced by their 122

employers to make their own out of popsicle sticks and paper towels.4 Circling back to the swimming analogy, even if there are more sharks in the water near the Olympic swimmer, he has the ability and the support to possibly outpace them and reach the shore safely. However, the other person has no means to defend themselves without the shark-repellant life raft. Vaccinating frontline doctors who contract the disease at much lower rates and already have extensive personal protection equipment fails to maximize utility in the same way pouring water into a glass that is already full spills the extra water onto the ground, where it is wasted. Vaccination would provide much-needed protection for not only HHAs, but also their patients and families, resulting in a much larger reduction in COVID-19 cases. Secondly, this analogy assumes that doctors and HHAs are not equal in their ability to “swim,” and this argument is undeniably true. Translated to reality, this means that HHAs are less likely to “stay afloat,” whether that is emotionally, socially, financially, etc. and are often in more desperate circumstances that could be mitigated by receiving the vaccine. Because many HHAs never received a college education, they possess much less knowledge of disease etiology and prevention, and thus are more vulnerable to disease even when both physicians and HHAs do not have access to masks. Doctors know intimately the differences in mask filters, and many were able to engineer their own masks during mask shortages. HHAs also report being undervalued and unrecognized, in stark contrast to the financial bonuses, free lunches, and parades held to honor frontline healthcare workers. They must not remain undervalued, as the demand Epidemic Proportions

and workload for HHAs will likely increase as more people are left debilitated by COVID-19 and return home for long-term care. Patients recovering from severe COVID-19 can continue to shed the virus for over a month after their recovery, putting HHAs at greater risk as the pandemic progresses.7 Additionally, more elderly people are forced to stay indoors, and their families may hire HHAs to help them live comfortable lives and keep them company. Vaccinating HHAs first will reduce the number of severe COVID cases among at-risk patients, thus reducing the workload and health risks for HHAs in the future. This effectively mitigates a positive, escalating feedback loop, and the resulting preservation of future value adheres to the principle of maximum utility.

HHAs face the most hazards, yet receive none of these benefits because they are not in the position to ask for them.” Lastly, HHAs have much less freedom and negotiating power when it comes to finances. 20% of doctors wanted to quit their jobs during the pandemic and simply retire early because they are paid much higher wages than HHAs who make a median of just over thirteen dollars an hour.8, 9 Many HHAs do not have the freedom of quitting their jobs or stop working if they get sick, as many of them are low-income and uninsured. Their ability to work is tied to their ability to support their families. HHAs are also treated like gig workers and are not in a position to negotiate better wages or working conditions, while nurses in Detroit Medical Center managed to negotiate raises as hazard pay. If their employers will not protect them, Edition 19 Spring 2022

the vaccine could significantly improve their mental health and financial stability through confidence that they will not get sick. Doctors and other relatively privileged healthcare workers with bargaining power do not necessarily face these challenges, so giving them the vaccine first would not be a maximization of economic and social benefits. Vaccinated HHAs also reduce overall healthcare costs to society by protecting at-risk patients so that they do not become infected. Doctors, on the other hand, treat those who are in the hospital after they become seriously ill and utilize expensive machinery (ventilators, for example). Patients are billed a much higher fee, costly and scarce medications are used up, and the patient’s health necessarily has deteriorated in order to go to the hospital in the first place. The economic and emotional costs of treating severe COVID infections are much greater than preventing at-risk patients from becoming ill in the first place. Therefore, vaccinating HHAs will maximize utility economically as well. Home health aides play an upstream role in COVID-19 treatment by preventing at-risk individuals from contracting the virus by being able to stay at home. Indeed, 7 million people directly depend on HHAs, and research has shown that their working conditions may explain why COVID-19 transmission rates have been so high.6 Vaccinating HHAs first would indeed result in widespread impacts throughout the healthcare system with an increased focus on disease prevention. Less COVID-19 patients and overflowing ICUs would mean we would not feel the need to also vaccinate doctors with such urgency, and our healthcare system would be under less strain. It is as if we removed some of the “sharks” in the “ocean”. Doctors would experience 123

less stress, PTSD, and burnout, a historically disadvantaged medical profession would be properly valued and protected, and the future of healthcare may be changed to prioritize harm reduction through prevention rather than costly, invasive medical treatments. References

1. Steinbock B, London AJ, Arras JD, Persad G, Wertheimer A, Emanuel E. Principles for Allocation of Scarce Medical Resources. In: Ethical Issues in Modern Medicine: Contemporary Readings in Bioethics. 8th ed. New York: McGraw-Hill; 2013. 2. Toner, E., Barnill, A., Krubiner, C., Bernstein, J., PrivorDumm, L., Watson, M., Martin, E., Potter, C., Hosangadi, D., Connell, N., Watson, C., Schoch-Spana, M., Veenema, T., Meyer, D., Lee Daugherty Biddison, E., Regenberg, A., Inglesby, T., & Cicero, A. (2020, August). Interim Framework for COVID-19 Vaccine Allocation and Distribution in the United States. Center for Health Security. Retrieved November 15, 2021, from https://www.centerforhealthsecurity.org/ our-work/pubs_archive/pubs-pdfs/2020/200819vaccine-allocation.pdf. 3. Mitzner, T. L., Beer, J. M., McBride, S. E., Rogers, W. A., & Fisk, A. D. (2009, October). Older adults' needs for home health care and the potential for human factors interventions. Proceedings of the Human Factors and Ergonomics Society ... Annual Meeting. Human Factors and Ergonomics Society. Annual Meeting. Retrieved November 15, 2021, from https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4270052/.

6. Theresa A. Allison, M. D. (2020, November 1). Extreme vulnerability of home care workers during the COVID-19 pandemic. JAMA Internal Medicine. Retrieved November 15, 2021, from https:// jamanetwork.com/journals/jamainternalmedicine/ fullarticle/2769095. 7. What is the duration of viral shedding in persons with coronavirus disease 2019 (covid-19)? Latest Medical News, Clinical Trials, Guidelines - Today on Medscape. (2021, June 25). Retrieved November 15, 2021, from https://www.medscape.com/ answers/2500114-197467/what-is-the-durationof-viral-shedding-in-persons-with-coronavirusdisease-2019-covid-19. 8. Gilchrist, K. (2021, June 2). Covid has made it harder to be a health-care worker. now, many are thinking of quitting. CNBC. Retrieved November 15, 2021, from https://www.cnbc.com/2021/05/31/covid-is-drivingan-exodus-among-health-care-workers.html. 9. U.S. Bureau of Labor Statistics. (2021, September 8). Home Health and Personal Care Aides : Occupational outlook handbook. U.S. Bureau of Labor Statistics. Retrieved November 15, 2021, from https:// www.bls.gov/ooh/healthcare/home-health-aidesand-personal-care-aides.htm#:~:text=Some%20 aides%20work%20with%20only,purpose%2C%20 such%20as%20hospice%20care.

4. Cahan, E. (2020, October 20). Most home health aides 'can't afford not to work' - even when lacking PPE. Kaiser Health News. Retrieved November 15, 2021, from https://khn.org/news/mostly-poorminority-home-health-aides-lacking-ppe-shareplight-of-vulnerable-covid-patients/. 5. Among healthcare workers, family and primary care doctors may have been most at risk of dying from covid-19. Penn Medicine. (n.d.). Retrieved November 15, 2021, from https://www.pennmedicine.org/ news/news-releases/2020/july/among-healthcareworkers-family-primary-care-doctors-most-at-riskof-dying-from-covid19. 124

Jasmine Wu Molecular and Cellular Biology & Public Health Studies Class of 2025 Epidemic Proportions

Photo Courtesy of Mason Cole Edition 19 Spring 2022


Baltimore Service Organizations Looking for more ways to get involved with and learn more about public health work in Baltimore & beyond? Check out some of the amazing organizations highlighted within this edition of Epidemic Proportions & get involved in your community today! Shepherd’s Clinic & The Joy Wellness Center Shepherd’s Clinic provides healthcare services to uninsured adults in Baltimore. The clinic offers medical care, behavioral health programming, and wellness services to over 800 patients annually. The types of case management and community relationships which the clinic has pioneered for the uninsured are models of cost-efficient and effective care. This holistic and integrative approach proves to be effective in best meeting a variety of needs for patients. Contact: info@shepherdsclinic.org Day at the Market This partnership collaborates to bring health, nutrition, and exercise resources to Baltimore through common goals of creating healthier communities by being the bridge to dismantle barriers that keep our neighborhoods from being healthy. In support of the public markets’ mission statement to strengthen connections to communities, this partnership addresses food and nutrition issues and raises awareness to national health observances of the month, the prevention of heart disease, obesity, cancer, unemployment, and substance abuse to empower and build healthy communities in both East and West Baltimore. Contact: bhopkin1@jhu.edu Turnaround Tuesday Turnaround Tuesday trains its participants to act on issues as leaders in their communities and in their workplaces. Through strategic partnerships with employers throughout the Baltimore region, Turnaround Tuesday has put over 600 (and counting!) Baltimore citizens to work in living wage jobs. Every Tuesday, participants, guests, and leaders gather at two training sites. We share our stories, listen to each other, and become leaders as we take part in this second chance jobs movement. Contact: (410) 528-0305 Helping Other People through Empowerment (HOPE) HOPE is a peer led wellness & recovery resource center. Their mission is to empower Baltimore City adults by increasing awareness of available resources through the assistance and encouragement of peer support in a comfortable and welcoming environment. HOPE referral services, resources, 126

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groups, and activities are free of charge, and do not require insurance from clients. Contact: info@hopebaltimore.com Project PLASE Project PLASE addresses homelessness in Baltimore by providing temporary housing, permanent housing, and supportive services to homeless adults and families. They serve the most vulnerable and underserved populations, including persons with mental illness, HIV/AIDS, addiction, developmental disabilities, and ex-offenders, etc. Project PLASE aims to treat, restore and rehabilitate the whole person, as well as empower each individual to function at the highest level possible. Contact: volunteer@projectplase.org St. Francis Neighborhood Center By utilizing education, art, mentoring and tutoring, the St. Francis Neighborhood Center works to provide people with the tools they need to advance their lives financially and socially, while fostering positive interpersonal and community connections. This in turn gives people a sense of self-empowerment, which is the principal driving force in creating extraordinary change within individuals and the community. These programs build self-esteem as well as academic, emotional, interpersonal, social, and community development that works to address complex challenges in an effort to break the cycles of urban poverty. Contact: (410) 669-2612 International Rescue Committee The International Rescue Committee provides opportunities for refugees, asylees, victims of human trafficking, survivors of torture and other immigrants to thrive in Baltimore and around Maryland. The IRC works with government bodies, civil society actors and local volunteers to help refugees and immigrants integrate and contribute to our communities. Contact: volunteerbaltimore@rescue.org THREAD: The New Social Fabric Thread weaves a new social fabric by connecting students, university and community-based volunteers, and collaborators. Thread makes a ten-year commitment to the young people at the heart of the Baltimore community, beginning in 9th grade. By radically and permanently reconfiguring the social support structure of all involved, Thread breaks the cycle of crime, poor educational and economic outcomes and replaces it with a new cycle of educational attainment, service and social well-being. Contact: info@thread.org Tutorial Project at JHU The Johns Hopkins Tutorial Project is an after-school tutoring program that provides academic support for elementary school students (grades 1-5). Children are paired with Johns Hopkins University students and receive one-on-one tutoring in reading and math. Contact: tutorial@jhu.edu Edition 19 Spring 2022


2021 - 2022 Staff Editors-in-Chief

Kriti Bomb & Jesse Huang Class of 2022

Editor: Swati Kumar Class of 2024 Cate Jackson Class of 2023

Treasurer Joshua Woo Class of 2022

Editor: Kristine Nguyen Class of 2022 Neha Skandan Class of 2025

Research Staff

Editor: Roshini Narayanan Class of 2022 Hannah Bruckheim Class of 2022

Diane Kang Class of 2023

Shivni Patel Class of 2023

Features Staff

Layout Staff

Editor: Joseph Kang Class of 2023

Jasmine Wu Class of 2025

Editor: Devan Patel Class of 2023

Christiana Liu Class of 2023

Ian Chiu Class of 2023

Anna An Class of 2023

Han Zhang Class of 2023

Tanisha Luthria Class of 2024

Lola Godoy Class of 2025


Samhi Boppana Class of 2025

Hyun Woo Kim Class of 2024

Editorials Staff Kathleen Li Class of 2022

Policy Staff

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