Volume 17, Spring 2020

1

Epidemic Proportions

About

Johns Hopkins University’s premier undergraduate public health research journal is designed to highlight students’ research and fieldwork in the realm of public health, combine research and scholarship, and capture the breadth and depth of the undergraduate public health experience.

Photo by Maya Foster

2

Table of Contents

Photo by Mason Cole

LETTERS 8 9

Letter from the Editors Asim Dhungana, Soonmyung Hwang Featured Letter: Q&A Niccolo Dosto

RESEARCH 12

16

Developing Low-Cost Food for Malnourished Children in India Using Linear Optimization Amith Umesh, Varun Mahadevan, Rohan Mangal Pediatric Scald Burns: Parents’ Burn Knowledge, Recall of Circumstances, and Agreement with Medical Record Christine Lopez, Susan Ziegfeld, Eileen M. McDonald, Latanya Williams

POLICIES

22 Growing Need for Self-Sufficiency Measures for Refugees and Migrants during the Resettlement Process Soonmyung Hwang 26 Progression of Intersectional Reproductive Justice Reform within the U.S. House of Representatives Ananya Kalahasti 32

FEATURES

Tele-ROP in India: The KIDROP Experience Ahimsa Aradhya 36 Kamayan: A Community Feast Anna Leoncio 40

EDITORIALS

Shortcomings in Tanzanian Healthcare Stem from Underlying, Systemic Economic Instability Jay Asawla 42 More Than Meets The Eye: The Key Component Missing in Pre-medical Education Niccolo Dosto

A TYPEWRITER displayed in the window of an antique shop in Ireland. Photo by Mason Cole

LETTERS

LETTERS

From the Editors To our readers, The year 2020 marks the beginning of a new decade, and with it, novel expectations, hopes, and goals for the future, as well as renewed opportunities to reflect on the past. Without a doubt, the world has been witness to significant progress in the past decades in all areas, from healthcare to social reform. Through these collective efforts, people across the globe have accomplished public health feats that we could never have imagined possible even 10 years ago. At Epidemic Proportions, we believe that such monumental public health accomplishments were only achievable through the unified efforts of humanity, as nothing significant can be achieved without the help, support and guidance that we impart upon each other.

To encompass the role that our humanity has played in our public health achievements, our theme for the 17th volume of our journal is “The Human Connection.”

“The messages that each of these articles convey to the average reader are much needed in today’s world where deep-seated nationalistic agendas or personal views...tend to overshadow global collaboration.”

All articles in this volume highlight the importance of the collaborative human spirit in allowing us to reach one milestone after another. Notwithstanding this undeniable progress, significant work remains in ensuring and uplifting the public health and well-being of all peoples and all groups throughout our society. By sharing these articles, we hope to bring attention to the sustained efforts initiated by some members of our own community. The messages that each of these articles convey to the average reader are much needed in today’s world where deep-seated nationalistic agendas or personal views are increasingly overemphasized and tend to overshadow the value of global collaboration.

As you take the time to peruse this volume, we encourage you to use this opportunity to reflect on how meaningful interpersonal, intercultural, and international connections can change the face of public health for the better. What can we do together to fight the myriad health problems that continue to afflict our populations?

Indeed, we can only benefit from working with each other to tackle public health issues, unlocking our full potential to effect change that can leave a lasting impact for the years to come.

Asim Dhungana

8

Soonmyung Hwang

Photo by Mason Cole

Featured Letter

Q& A Niccolo Dosto with

A research coordinator at the Johns Hopkins Wilmer Eye Institute and Hopkins alumnus (class of ‘17), Dosto shares his career journey and lessons he learned on the way.

What are you doing now, and what are your plans for the future?

What advice do you have for current Hopkins students?

I am conducting a study on the adherence of glaucoma surgery

Don’t forget to exercise! The freshman 15 is real and you

patients to their post-operative eyedrops. I am applying to

don’t want it to turn into the senior 25.

medical school now and plan to become an ophthalmologist in the future.

Favorite Hopkins memory?

Taking naps on the beach on the weekends when the

How did your experience at Hopkins prepare you for your career?

weather was warm.

The academic and professional resources at Hopkins were invaluable to my pre-med experience. The proximity to the

What has your experience been with the Hopkins alumni net-

Johns Hopkins Hospital, as well as the abundance of research

work and professional connections after graduating?

and volunteer opportunities on and off campus, allowed me

I have not really used any alumni network connections,

to fully explore my interests as I prepared to become a future

but I do get constant emails and communications from

physician.

them so I am aware of the services I can use when I need them!

How have you been connecting your experiences in public health with being pre-med?

What was your favorite place to study on Homewood Campus?

After graduating from JHU, I completed a master’s degree at

A-level tables. I somehow cannot study in complete silence

the Bloomberg School of Public Health in Biochemistry and

so I need noise around me to concentrate.

Molecular Biology, which let me further my scientific education but with a public health twist. I also helped direct an initiative

What was your most influential experience in shaping your

called the Hero Lab for the nonprofit Medicine for the Greater

career path?

Good (MGG). The project paired undergraduates at Hopkins

The most influential experience for me was shadowing

with Baltimore City high school students in a mentorship

doctors at Wilmer when they saw patients in the clinic.

that culminated with a year-long project to benefit their local

Before I started doing research, I had no real interest in

neighborhoods.

ophthalmology as a specialty - I wanted to work with cancer patients when I was in high school. I became super into it the

How did extracirriculars shape your Hopkins experience?

more time I spent in clinic...I especially liked how satisfied

By joining the JHU Filipino Students’ Association, I was able

so many patients were only after a few visits, and how

to connect more fully with my culture and meet others from

many different subspecialties I could potentially get into,

the same ethnic background as me. My time with the Inter-Asian

like Retina and Glaucoma. I also had the chance to observe

Council (IAC) also made me aware of the various Asian-Amer-

a few eye surgeries as well as follow up with those same

ican issues and initiatives that were important to me. I also

patients at their post-op visits. Doing research at Wilmer

did an internship with Environment Maryland, a local envi-

has definitely influenced my career goals, and I am grateful to

ronmental group, that ignited my passion for green causes

be spending time at this institution among so many great

and climate change solutions.

faculty and mentors.

9

A PATRON browses the bookshelves at George Peabody Library. Photo by Amy Lu

RESEARCH

RESEARCH

Developing Low-Cost Food for Malnourished Children in India Using Linear Optimization Amith Umesh | Biophysics ‘21 Varun Mahadevan | Biophysics ‘21 Rohan Mangal | Public Health Studies ‘21 Linear Programming (LP) is seldom applied to formulating energy-dense foods for malnourished children in India—however even when used, these tools do not account for metabolite contents of ingredients. With this novel inclusion of an LP tool, this paper explores an effective method to develop cheaper and more nutritious foods for acutely malnourished Indian children.

S

Abstract olutions

to

acute

mal-

nutrition typically include provisions for lipid-dense foods (~ 50% lipids). Linear programming (LP) is seldom

applied to formulating energy-dense foods in India, causing unnecessarily high prices and inefficient ingredient use for current options on the market.

However, even when used, LP tools may not account for protein quality.

LP tools factoring protein digestibility corrected amino acid score (PDCAAS) and digestible indispensable amino acid score (DIAAS) have formulated cheaper and more nutritious energydense

foods

for

Sub-Saharan

Africa. With the inclusion of similar parameters in this study’s LP tool, the authors aim to develop cheaper and more nutritious energy-dense foods for malnourished children in India.

Malnutrition

12

objective functions, such as cost or

age), 20% are wasted (low weight-

total energy content, while maintaining

for-height), and 57% are Vitamin-A

minimum or maximum bounds on

deficient. Despite growing to the sixth

other fields, such as macronutrients,

largest economy by GDP in the latter

micronutrients, and water content.

half of the 20th century, India has

Specifically, the advent of computer-

also experienced growth in rates of

based LP has made it significantly easier

malnutrition, especially in its most

to execute large-scale optimization

impoverished states such as Jharkhand

problems

with

often

hundreds

and Madhya Pradesh.¹ Treating acute malnutrition often includes the provision of lipid-dense semi-solid foods, including readyto-use

therapeutic

foods

(RUTF),

ready-to-use supplementary foods (RUSF), and fortified food blends (FFB). Interventions using readyto-use foods (RUFs) are successful but costly, resulting from expensive ingredients, high shipping costs from foreign countries, and poor analysis of metabolites. Our team uses a linear programming tool (LP) to leverage local crop prices and their nutritional

Introduction emergency:

million are stunted (low height-for-

information is

rates

India’s of

acute

from

up-to-date

silent

databases and literature to maximize

mal-

the

amount

of

macronutrients,

nutrition among Indian children are

micronutrients,

five times more than those of Chinese

delivered to a child (ages 6 to 48

children and twice those of children in

months) per gram of product. LP is a

Sub-Saharan Africa. About 60 million

mathematical method used to solve

Indian children are underweight, 45

linear equations in order to optimize

and

metabolites

ACUTE MALNUTRITION is often treated by lipid-dense/semi-solid foods. Photo by Amith Umesh

of

parameters. Here, we aim to examine

on

the effect of using an LP tool in the

previously studied tool, developed

context of Indian malnutrition on cost

by a fellow collaborator, successfully

and overall composition of ready-to-

implemented LP for recipes specific

use therapeutic foods.

to Sub-Saharan Africa and Nigeria.5

Materials and Methods Database Searching for Local Ingredients: Market & Nutrient Values The AgriXchange™ tool developed by

the

Agriculture

and

Processed

Food Products Export Development Authority (APEDA), the Indian Food Composition Table, and the USDA Food Composition Database was used to extract information on market intelligence (availability and price), energy

content,

water

content,

macronutrient data, and micronutrient data on local crops, dairy, and meat. All nutritional parameters were included as per UNICEF requirements.2,3

Inclusion and Exclusion of Ingredients

other

given

parameters.

A

140.9

to maximize availability per 92 gram

Phosphorus

152.9

units of product. Nutrient parameters

Magnesium

40.6

Zinc

6.2

Copper

0.7

cost quotes from Vita Blend (a premix

Iodine

0.0478

production company) for a vitamin-

Selenium

0.0143

one to minimize cost and the other

in Table 1 were constrained based on UNICEF specifications. Since recipes’ micronutrient

content

generally

come from external supplements,

mineral premix are added to the final run with slightly varying constraints

5

Thiamine

0.2

Riboflavin

0.7

Vitamin B-6

0.2

three recipes outputted by this study’s

Vitamin B-12

0.0007

LP tool (Figure 1) meets all of the

Vitamin C

23.2

By minimizing cost and maximizing

Folic Acid

0.0932

Niacin

2.4

Biotin

0.0287

to yield various recipes.

Results The nutritional composition of the

requirements as per UNICEF (Table 1).

insects or meat (except fish), (2) have

each, in comparison to UNICEF’s 2281

a high moisture content, (3) may be

kJ (545 kcal) standard. Protein content

especially

contamination

is higher in formulated recipes by

by pathogens, and (4) are highly

8.3, 11, and 12 grams, respectively for

perishable. These criteria ensure recipes

recipes 1, 2, and 3. Fat content is greater

have a long shelf-life and are conducive

in these recipes by 15.8, 19.2, and

to

restrictions

20.2 grams. Nutriset S.A.S, a current

commonly found in India. We chose

industry leader with thirty years of

to include small indigenous fish due

experience in providing nutritional

to their density of protein (and fat),

aid in affected areas of Africa and Asia,

minerals and its commonality in many

has an approximate ingredient cost

Indian states. Results from a randomized

for an RUTF of 8.172 Indian rupees

controlled trial in Cambodia report

per 92 gram sachet.6 In comparison,

equal effectiveness of ready-to-use

the recipes formulated by this study’s

therapeutic foods (RUTF) recipes with

LP tool cost 4.01, 3.25, and 3.17 INR,

fish, as compared to traditional milk-

respectively. This RUTF, Plumpy Nut,

based formulas in spurring growth of

provides 12.8 g protein and 30.3 g fat at

malnourished children.⁴

500 kcal, in comparison to the values presented above.7 All three of the

Optimization

Iron

cost of ingredients. The program was

tool generates recipes that are 530 kcal

dietary

158000

Calcium

Two objective functions were used,

nutritional content per 92 grams, the

vegetarian

Lipid

6000

487.3

Unacceptable ingredients that were

to

Protein

Potassium

excluded include those that: (1) contain

prone

Required Amount (mg)

Nutrient

Pantothenic Acid

1.4

Retinol

0.3989

Vitamin D

0.0069

Vitamin K

0.0093

Vitamin E

8.8

Nutrient Moisture Content

Nutrient Energy

Required Amount (%) 2.50%

Required Amount (kJ) 2281

formulated recipes contain a higher

LP is an optimization tool used

fat and protein content than Plumpy

to maximize or minimize objective

Nut and are able to do so using cheaper

function(s) while placing constraints

ingredients.

TABLE 1 Nutritional Requirements for UNICEF Accepted RUTF6

13

Recipe Breakdown: Total kcal = 530 100 82

31.6

36

18

17

14.3

35

81

2.87 2.09 5.13 Protein (g)

Fat (g)

4.01 3.25 3.17

Fiber (g) Recipe 1

PDCAAS*

Recipe 2

Price (INR)

Recipe 3

*Measure of protein quality

FIGURE 1 Nutritional Breakdown for 3 Recipes.

Recipe 1: Milk Powder, Vegetable Oil, Peanuts, Sorghum, Sugar Recipe 2: Milk Powder, Vegetable Oil, Peanuts, Sorghum, Sugar, Sesame Flour Recipe 3: Milk Powder, Vegetable Oil, Peanuts, Sorghum (less), Sugar, Sesame Flour (higher)

Figure designed by Devan Patel

Discussion

a compounding impact on reducing the

We applied a previously validated LP tool to India in order to formulate energy-dense RUTFs,

for

foods,

specifically

malnourished

children.

Although LP is widely and historically used in African countries with high rates

of

child

malnutrition,

the

development of RUTFs for India using an LP tool has been limited. Without LP, manufacturers of RUF are purchasing costly

ingredients

from

foreign

producers—contributing to the overall burden of malnutrition in India.¹

burden of child malnutrition in India.

Further steps for scientific inquiry in future studies would include studying more specific nutritional metabolites such

as

purine,

isoflavonoids,

phosphatidylcholine, cholesterol, and ceramides, as these have a significant effect on growth in times of high metabolic

stress,

such

as

during

adolescence and childhood.

8,9

Acknowledgments We are grateful to Garyk Brixi, an undergraduate at Harvard College, for

By using ingredients local to India

providing his linear programming tool to

and applying LP, we aim to reduce the

assist the development of recipes for India.

overall cost of RUTF ingredients as

We are also grateful to Dr. Keith P. West for

compared to producers from foreign

his copious advice and recommendations

regions such as Europe. Although

on selecting ingredients and framing our

we

research question.

face

predicting

limitations costs

of

in

accurately

shipping

and

manufacturing, local production would

References

lower such costs with high certainty.

1. Helping India Combat Persistently High Rates of Malnutrition. World Bank. https://www. worldbank.org/en/news/feature/2013/05/13/ helping-india-combat-persistently-high-ratesof-malnutrition. Accessed October 1, 2019.

Furthermore, local production would empower the local population, further stimulate the local economy, and have

14

2. FoodData Central About Us. FoodData Central. https://fdc.nal.usda.gov/about-us.html.

Accessed October 1, 2019.

3. RUTF Product Specifications. UNICEF RUTF Product Specifications. https://www.unicef.org/supply/files/ Odile_Caron_RUTF_Product_Specifications.pdf.

Published September 12, 2013. Accessed October 1, 2019.

4. Borg B, Mihrshahi S, Laillou A, et al.

Development and testing of locally-produced ready-to-use therapeutic and supplementary foods (RUTFs and RUSFs) in Cambodia: lessons learned. BMC Public Health. 2019;19(1):1200. doi:10.1186/s12889-019-7445-2 5. Garyk Brixi, Developing Local Treatments for Acutely Malnourished Children in Sub-Saharan Africa: A Novel Optimization Approach Automatically Ensuring Protein Quality (FS14-06-19), Current Developments in Nutrition, Volume 3, Issue Supplement_1, June 2019, nzz038.FS14–06–19, 6. “Ready-to-Use Therapeutic Food (RUTF) Market Update.” UNICEF, UN, 28 Feb. 2019, www. unicef.org/supply/index_70579.html.

7. “Plumpy'Nut®.” Nutriset, 2018, www.nutriset. fr/products/en/plumpy-nut.

8. Hubert Vesper, Eva-Maria Schmelz, Mariana N. Nikolova-Karakashian, Dirck L. Dillehay, Daniel V. Lynch, Alfred H. Merrill, Sphingolipids in Food and the Emerging Importance of Sphingolipids to Nutrition, The Journal of Nutrition, Volume 129, Issue 7, July 1999, Pages 1239–1250 9. Kohlmann K, Callaghan-Gillespie M, Gauglitz JM, et al. Alternative ready-to-use therapeutic food yields less recovery than the standard for treating acute malnutrition in children from Ghana. Glob Health Sci Pract. 2019. doi:10.9745/GHSP-D-19-00004

Photo by Varun Mahadevan

Photo by Varun Mahadevan

RESEARCH

Pediatric Scald Burns: Parents’ Burn Knowledge, Recall of Circumstances, and Agreement with Medical Record Christine Lopez | Public Health Studies ‘20 Susan Ziegfeld | MSM, PN P-B.C. Eileen M. McDonald | M.S. Latanya Williams Pediatric scald burns most commonly occur in the child’s home under adult supervision. Yet, adults are not confident in their first aid ability and are unable to accurately describe their child’s burn severity.

Introduction

B

urns

are

have

injuries

significant

that and

long-term impacts on the people affected by them.

Nearly

every

minute,

someone in the United States suffers a burn injury serious enough to require treatment.¹ In the United States, the estimated cost burden resulting from child burn injuries is $3.5 billion a year.2 In the United States, burns and fires are the fifth most common cause of accidental deaths in children and adults.3 Burns impact practically every system of the body and require a multifaceted treatment plan that includes long-term follow-up and comprehensive support for proper healing.4 Scald burns are the most common type of burn in children under 5 years of age. Scald burns are a form of ther-

These children rely heavily on adults

jury and first aid treatment provided

to constantly supervise them and

by caregivers for scald burn injuries,

protect them from dangers, such as a

and to explore the level of agreement

hot liquid that can cause a scald burn.

about burn descriptors between par-

Additionally, younger children have

ents’ recall and the medical record.

thinner skin and can sustain a scald burn injury at lower temperatures than adults.

6

Furthermore, nearly 75% of

all scald burns in children are preventable. An estimated 376,950 scald burns were associated with consumer household appliances and products that were seen in US hospital emergency rooms between 2013 and 2017.7

Methods We used a convenience sample of caregivers attending an outpatient clinic with their child (age 9 mo. – 12 yrs.). Children must have obtained a scald burn injury from a hot liquid or food. The burn must not have been associated with suspected child abuse. One participant was excluded

Parental factors that influence scald

for reporting a bathtub scald burn.

burn injuries in children include lack

During routine follow care, one of the

of or inadequate supervision, lack of

authors (SZ) invited the eligible fam-

perceived danger by the caregiver, re-

ilies to learn more about the study.

sponsibility given to a child above their

Those who agreed were met by the

developmental ability, and abuse.7

study research assistant (RA) (CL) to learn more details of the study,

The aims of this study were to char-

and if interested, to obtain consent.

acterize the mechanisms of burn in-

Consented adults (participants) were

mal burn that results from hot liquid or steam. It is estimated that scald burns account for over 65% of the cases seen in children under five.5 At this age, children are at a higher risk for burn injuries due to their undeveloped motor and cognitive skills.

16

“The participants who contributed to this study visisted the follow up clinic from a wide range of locations. In fact, only 31% of the patients lived within a 10-mile radius of the burn clinic.

FIGURE 1 Characteristics of Study Participants and Patients (n = 54, unless noted otherwise) Figure designed by Trisha Parayil invited to complete a 39-item iP-

patient’s medical record by one of

up clinic from a wide range of loca-

ad-based survey, collected through a

the authors (LW) and a comparison

tions. In fact, only 31% of the patients

proprietary platform.

of these two reports was conducted.

lived within a 10-mile radius of the

Data was exported to an Excel spread-

burn clinic. The other 69% lived as far

The survey covered four categories:

sheet and descriptive statistics were

as 88 miles from the clinic.

mechanism of burn, characteristics

obtained using the formula func-

of burn, first aid knowledge, and par-

tion. Data on the zip code of partici-

As shown in Table 1 (see page 19),

ticipant and patient demographics.

pants was aggregated on a map using

most of the burn injuries occurred in the

Mechnism of the burn items included

EasyMapMaker and the straight dis-

home (80%), specifically in the kitchen

the location of the child and partici-

tance to the Johns Hopkins Hospital

(66%). The child was in the care of the

pant at the time of the burn, location

was calculated. Data were collected

participant for the majority of the re-

of the nearest person to the child at

over a 13-month period: May 2018-

ports (70%) and most participants did

the time of the burn, and the type of

May 2019. These procedures were

not see the injury occur (63%). In many

liquid implicated.

reviewed and approved by the Johns

cases, the child caused the hot liquid to

Hopkins Institutional Review Board.

spill onto him or herself (70%).

Data concerning the child’s burn characteristics: severity, Total Body

Results

As highlighted in Table 2 (see page

Surface Area (TBSA), location of

We obtained consent from 55 indi-

19), first aid was applied for most of

child’s body, and whether surgical

viduals who were attending the burn

the scald burn injuries. However, 50%

intervention was required, was also

follow-up clinic with a child, 100%

of them did not receive the proper first

collected from the participant. The

of whom successfully completed the

aid, which is applying cool running

survey

participant’s

survey and 76% of whom gave us per-

water to the injury. This happened

confidence in providing first aid,

assessed

the

mission to review their child’s medical

despite the fact that 70% of the par-

whether or not first aid was provided

record. One participant was excluded as

ticipants felt that they at least knew

at the time of injury and reasons be-

they did not meet the inclusion criteria.

enough to apply proper first aid to the

hind the decision, and participant’s

Figure 1 displays the characteristics of

child at the time of injury.

sources of first aid information. Par-

the study participants and the patient.

ticipant and patient age, gender, and

Most participants were the child’s

Table 3 (see page 18) demonstrates

zip code were also collected.

mother (75%). As is common with in-

the final medical record review. About

juries, boys (63%) were over-repre-

half of the parants did not recall the

Participants were asked permis-

sented among the patients. Most scald

Total Body Surface area of their child’s

sion to access their child’s medical

burn injuries reported in this study oc-

burn (48%). Most consented to a med-

record to corroborate burn character-

curred in children 5 and under (63%).

ical record review (78%). Approxi-

istics. When permission was granted, the

aforementioned

mately a quarter of the participants

characteristics

The participants who contributed to

of the burn were abstracted from the

this study visited the affiliated follow

did not know their child’s burn depth or severity (24%).

17

Discussion Scald burns continue to be a significant and preventable problem, as we found in the burn follow-up clinic. As seen in this population, most of these scald burns occurred in the home (specifically in the kitchen) and were caused by the child. Half of them received incorrect first aid and many of the caregivers did not know the severity of their child’s burn.

Our results suggest that there is a need for more prevention efforts related to scald burns. The majority of the participants in the study did not know the TBSA of their child’s burn and only a few correctly reported what was present in the medical record review. The instances described in this report are preventable and there are many potential areas for improvement in preventing these injuries in children. A few of the current scald burn prevention efforts include controlling the temperature of tap water in the household, travel mugs that have a lid and will not spill when knocked over, and efforts to practice kitchen safety by not holding a child while preparing foods. These are difficult to implement in various populations due to lack of access to resources or child care and there is a need for more extensive outreach to create a safer environment for the child.

if necessary. Half of the caregivers in

ber RE49CE 002466, funded by the

this study did not apply proper first aid

Centers for Disease Control and Pre-

which can have negative consequences

vention. Its contents are solely the

on the healing for the child.

responsibility of the authors and do not necessarily represent the official

This study was limited by the time

views of the Centers for Disease Con-

constraints of the project and the rela-

trol and Prevention or the Department

tively small sample size. Another lim-

of Health and Human Services.

itation of this study was the inability to compare some of the data to the medical

References

record review due to the lack of informa-

1. Scald Statistics and Data Resources. 2018. http:// ameriburn.org/wp-content/uploads/2018/12/ nbaw2019_statsdataresources_120618-1.pdf.

tion in the reports or the use of different injury terminology in the questions. The information provided in this report gives a thorough overview of some of the issues that the public health field faces when working to prevent pediatric scald burns.

With the results of this study in mind, our hope is that the number of these types of injuries can be reduced in the near future. Further research should look into the connection between parent initial first aid response and the outcomes of the injury.

In conclusion, the burden and prevalence of pediatric scald burns is an ongoing issue that must be addressed in public health. Injuries like these are preventable and applying first aid at the time of the injury is essential.

Acknowledgments Support was provided by the Woodrow

Wilson

Fellowship

Program

In the event that a burn injury does

through the Krieger School of Arts and

occur, caregivers should be equipped

Sciences at Johns Hopkins University,

with the knowledge that they should

which provided research funds to the

apply cool running water on the burn

author (CL). This study was support-

and seek more advanced medical care

ed by Cooperative Agreement num-

“Our results suggest that there is a need for more prevention efforts related to scald burns...

The instances described in this report are preventable and there are many potential areas for improvement.”

18

2. Mcloughlin E. The Causes, Cost, and Prevention of Childhood Burn Injuries. Archives of Pediatrics & Adolescent Medicine. 1990;144(6):677. doi:10.1001/archpedi.1990.02150300075020.

3. Department of Health and Human Services.

Injury Prevention - Burns. 2019. https://www.cdc. gov/masstrauma/factsheets/public/burns.pdf.

4. Krishnamoorthy V, Ramaiah R, Bhananker S. Pediatric burn injuries. International Journal of Critical Illness and Injury Science. 2012;2(3):128. doi:10.4103/2229-5151.100889.

5. Barrow RE, Spies M, Barrow LN, Herndon DN. Influence of demographics and inhalation injury on burn mortality in children.

Burns. 2004;30(1):72-77. doi:10.1016/j. burns.2003.07.003.

6. Klas KS, Vlahos PG, Mccully MJ, Piche DR, Wang SC. School-Based Prevention Program Associated With Increased Short- and Long-Term Retention of Safety Knowledge. Journal of Burn Care & Research. 2015;36(3):387-393. doi:10.1097/ bcr.0000000000000151.

7. Consumer Product Safety Commission. National Electronic Injury Surveillance System 1998-2017.

April 208AD. https://www.cpsc.gov/cgibin/ NEISSQuery/home.aspx. Accessed July 30, 2018.

TABLE 1 Mechanisms and Circumstances of Burn (n = 54, unless noted otherwise)

How did the hot liquid spill on the child?

Child pulled onto him/herself

39%

Child knocked over hot liquid

31%

Child was sitting alongside hot liquid

6%

Hot liquid was being held by a person and it spilled

6%

Another person knocked over hot liquid

4%

Other

15%

Child’s Home Relative’s Home Car Daycare

80% 13% 4% 2%

What were you or the caregiver doing at the time of injury?

Making hot drink or preparing food

22%

Attending to another family member

15%

Briefly left room where child was

15%

Working

7%

Using laptop/computer or watching TV

7%

Talking on phone

6%

Breast feed/bottle feeding

4%

Playing with child

2%

Answering the door

2%

Driving

2%

Other

17%

If at a home, in which room of the house did the injury occur? (n = 50) Kitchen Living Room Dining Room Bedroom Other

66% 14% 12% 4% 4%

Did you see the injury occur? (n = 39)

Was the child in your care when the injury occurred?

Yes No

Location where burn occurred:

Yes No

37% 63%

Did anyone else see the injury occur? (n = 24)

70% 30%

Yes No

43% 57%

TABLE 2 First Aid Knowledge (n = 54, unless noted otherwise)

Was first aid applied at the time of injury?

Yes No

70% 30%

At the time of the injury, how confident were you in your ability to apply first aid to the scald injury?

If applied, what was used? (n = 38) Cool running water

50%

Burn gel, cream, or ointment

18%

Cool compress or wet wrap

16%

I did not feel at all confident

30%

Ice

8%

I felt I knew enough to apply basic first aid

44%

Aloe Vera

5%

I felt very confident

26%

Butter

3%

TABLE 3 Characteristics of Burn and Medical Record Review (n = 54, unless noted otherwise)

If you recall it, please enter the amount of the Total Body Surface Area of your child’s burn.

Please pick the description that best matches your child’s burn depth/severity.

Range 1-50%

48%

Deep/Full thickness

11%

Unknown

52%

Partial/Deep

20%

Partial

17%

Superficial/Partial

19%

Superficial

9%

Don’t know

24%

Medical Record Review Consented to Medical Record Review

78%

Correct Report of TBSA

12%

19

SUNSET near the Ngorongoro Conservation Area.

POLICIES

U.S. NAVY BLUE ANGELS fly over Texas to show support for healthcare workers. Photo by Mason Cole

POLICIES

Growing Need for Self-Sufficiency Measures for Refugees and Migrants during the Resettlement Process Soonmyung Hwang | Neuroscience and Public Health Studies ‘21 In the midst of unsettling issues across the globe, many refugees and migrants are forced to assimilate into a new way of life that can be difficult to adjust to. The need to develop self-sufficiency among refugees and migrants in their new communities is evermore crucial to embrace their second chance at a new life.

Introduction

I

matic surges in refugee and migrant

imperative importance for refugees

numbers, with 25.9 million refugees

and migrants to receive the necessary

t is often easy to overlook the

and 3.5 million asylum seekers as of

services to maintain a stable level of

refugees and migrants who are

2019. Refugees leave their country

health and well-being. Yet, due to the

already settled in their new res-

of origin for varying reasons such as

numerous obstacles that face them,

ident countries with the polar-

persecution, armed conflict, and vi-

these vulnerable individuals often ex-

izing debates pertaining to ref-

olence, and do not have the capacity

perience difficulty receiving proper

ugee admissions in the United States.

to return to their countries of origin.

and timely services.

Simply providing these vulnerable in-

Alternatively, migrants leave for rea-

dividuals a new home without contin-

sons like seeking economic opportu-

As one of the nine resettlement

uous support proves to be ineffective

nities, family reunion, etc.2 Regardless

agencies in the United States, World

and potentially detrimental to ensur-

of their immigration status, refugees

Relief plays a crucial role in providing

ing a better lifestyle. Refugees and mi-

and migrants face numerous obstacles

the necessary support for refugees and

grants face a number of barriers as

ranging from poor health to language

migrants to assimilate into their local

they transition into a life that is com-

barriers during the resettlement pro-

communities. In Fiscal Year 2018, 724

pletely foreign to them, where most

cess.

refugees resettled in Illinois along

1

3,4

During this transition, it is of

have no prior exposure to the different

with 93 asylees.5 The organization

culture or way of life. Different fun-

provides the resources for refugees

damental components of a ‘normal’

and migrants to be self-sufficient in

lifestyle, such as language, financial

the Chicagoland area, through inten-

management, and education, can be

sive case management, employment

overwhelming and out of reach for

services, English education, and youth

most refugees and migrants. Many

services.

different complications may arise from such stressors that can affect the

Actions For Self-Sufficiency

lives of many refugees and migrants.

Self-Sufficiency Plans

Thus, it is ever more crucial to provide

As a Self-Sufficiency/Health & Well-

the necessary support and resources

ness Program intern at WRC, I worked

for these people in their transitions

to develop a personalized self-suffi-

and journeys to developing self-suf-

ciency plan for each of my refugee or

ficiency as they assimilate into their

asylee clients that would ultimately lay

new communities.

Background The United States and other places across the globe have seen dra-

22

the groundwork towards their assimilation into their new communities.

POSTER of Anti-Human Trafficking Workshop hosted at World Relief Chicago

Every individual possesses different needs and desires as they transition into a vastly new lifestyle in a foreign

Vulnerability addressed country. These include learning the English language, developing the capacity to navigate the U.S. healthcare system, and simply knowing how to get around their neighborhood.

Goals Within the first 3 months, learn to schedule transportation through Meridian for doctor appts.

Steps by World Relief

Actions for Client

1. Review with A.A. the steps needed to call.

2. Provide support/encouragement as needed.

cessful achievement of my clients’ individualized self-sufficiency goals within a year, through our intensive case management services. A year is often times too short of a period to accomplish everything that a client might seek to accomplish; however, by setting an accelerated deadline, it pushes the client and their case management team to achieve their goals and ensure an efficient tran-

None

2. Always ask for an interpreter.

One of my main responsibilities as an intern was to ensure the suc-

1. Call to schedule all appointments, go to WRC for help if needed.

Actions for Family

Withing the first 3 months, complete an intake assessment with a care coordinator through Meridian to assist with limited care management

Assist A.A. in calling Meridian and getting connected with care coordinator

Call Meridian and answer questions asked

None

Within the first 6 months, learn to troubleshoot problems that may arise with Meridian

1. Review with A.A. how to solve different problems that arise.

1. Review with R.L. the problems that arise.

None

2. Provide support on ongoing basis.

2. Call R.L. as problems arise after he has called

sition into their new lifestyles. Additionally, the self-sufficiency goals are developed to ensure that they can be feasibly achieved on the client’s

SELF-SUFFICIENCY PLANS like the one shown above, are used by the case-management team to help ensure that clients meet their individual goals.

part, making the seemingly daunting task of completing all of their goals within a year slightly more manageable.

did different chores around the apart-

and we were one step closer to achiev-

ment. For instance, I asked him how

ing a satisfactory level of assimilation.

he washed the dishes, with what kind of material, and how often he washed

A specific example of the work I have

them. After seeing that some of his

done at WRC involved one of my cli-

current practices were not at a satis-

ents named G.X. (initialized for client

factory level, I taught my client some

confidentiality). One of the self-suf-

means that would effectively keep his

ficiency goals that we set for G.X.

apartment sanitary, and in some cas-

was to learn and apply foundation-

es, I had him demonstrate some of my

al sanitation practices to ensure his

recommendations to ensure that he

apartment helped cultivate his health

truly understood. Yet, despite our ef-

and well-being. I was able to assess

forts, ensuring proper and maintained

his current living conditions and en-

sanitation of G.X’s apartment was only

gage in a meaningful conversation

one of his many self-sufficiency goals

with him on how he planned to keep

that needed to be tackled, and there

his apartment up-to-par in terms of

still remained a long way to go. How-

sanitation. I had him tell me how he

ever, progress insinuated over time,

Community Outreach In order to help a refugee/asylee successfully assimilate, it is imperative to expose the individual to the numerous resources offered and provided by their new community, ultimately helping them become accustomed to their new ways of life. Nonprofit resettlement agencies like World Relief work to bridge the gap between refugees/asylees and their new communities by placing heavy emphasis on community outreach.

It was part of my role to engage in community outreach for my refugee/ asylee clients by different means. Af-

“With refugee numbers continuing to increase across the globe, it is the international role of able countries to further engage in the humane process of allowing displaced individuals to f ind safety in a new resident country.”

ter discussing the specific needs of my clients, for instance, I would research into a number of services and providers that could potentially offer the services they needed. It is important to note that most, if not all, of WRC’s clients have limited financial means to invest in costly services, and as I

23

WORKSHOP presenters from STOP-IT talked with refugee and migrant families about steps to identify and prevent human trafficking in their local communities. Photo by Soonmyung Hwang and providers, one of the main criteria

ties, a Catholic-based nonprofit orga-

collaboration with the STOP-IT Ini-

in deciding which community partners

nization, offered an emergency cloth-

tiative of the Salvation Army where a

to refer my clients to was the cost of

ing assistance program, specifically

representative from STOP-IT came in

their services.

designed to offer donated clothing to

to present about signs of human traf-

people in need.

ficking and how to prevent it in our

For some of my clients, they only

local community. Human trafficking

possessed two or three items of cloth-

In addition, promoting educational

is a common yet overlooked issue that

ing that they wore nearly every day.

resources on various subjects relevant

affects vulnerable people all across the

They expressed their desire to receive

to refugee/migrant populations is also

globe who do not have the resourc-

clothing assistance for their whole

of great importance. There are many

es to clearly identify signs of human

family, but were concerned due to their

different organizations in our commu-

trafficking in their new communi-

extremely limited financial resourc-

nities that are relevant to individuals

ties. Trafficking can come in different

es that are spent on more imperative

like refugees and migrants. At WRC,

forms from sex trafficking to labor

needs such as food, water, and hygiene

for example, an Anti-Human Traffick-

trafficking, and refugees and migrants

products. Fortunately, Catholic Chari-

ing Workshop event was promoted in

are often susceptible to trafficking without proper awareness and ability

“For some, they may feel completely assimilated in about a year. For many, however, years can go by and the disparate barrier between them and their new communities may continue to exist.�

to report such illegal behaviors.

Discussion The government can only do so much in providing the necessary assistance to refugees and migrants in the

24

United States; thus, the role of non-

support, healthcare, and more during

sions, we must not overlook those al-

profit organizations like World Relief is

their times of transition, and the as-

ready residing in the U.S., and greater

evermore important during these crit-

similation process is not one that can

focus should be placed to develop the

ical times. With refugee numbers con-

be completed in a finite period of time.

self-sufficiency required of these indi-

tinuing to increase across the globe, it is

For some, they may feel completely

viduals to successfully assimilate into

the international role of able countries

assimilated in about a year. For many,

their new communities.

to further engage in the humane pro-

however, years can go by and the dis-

cess of allowing displaced individuals

parate barrier between them and their

to find safety in a new resident country.

new communities may continue to

However, in the case of the U.S., refugee

exist.

admissions are declining with changes in the political system, leading to less funding allocated to organizations that

Conclusions

directly assist refugees and migrants.

Based on the current state of glob-

With less funding, many of these orga-

al affairs, conflict, war and persecu-

nizations are forced to find other means

tion are all matters that will not reach

of financial support or shut down com-

a conclusion any time soon, making it

pletely, therefore restricting needed

imperative for governments to contin-

access to various services and resources

ue the intake of refugees and migrants

for refugee and migrant clients.

directly affected by such debilitating events. With approximately 70 mil-

All of these factors lead to the hin-

lion displaced individuals across the

drance of developing self-sufficiency

globe, there is a significant and urgent

among refugees and migrants who are

need for improvements in our system

simply trying to start a new life. De-

for finding new homes for these vul-

spite the decreases in refugee admis-

nerable individuals. When the refugee

sions in the U.S., we should not over-

numbers increase, the humane ap-

look the refugees and migrants who

proach would be to increase the num-

are already here residing in the U.S.

ber of annual refugee admissions, not

These are individuals who need great-

decrease them. However, even in the

er educational resources, financial

midst of decreased refugee admis-

Acknowledgments I’d like to acknowledge and thank my onsite supervisor, Rebecca Larsen, for serving as a supportive and ingenuous mentor during my time at World Relief Chicago, along with all the other individuals who I have graciously been able to meet at this nonprofit organization.

References 1. United Nations. Figures at a Glance. UNHCR. https:// www.unhcr.org/en-us/figures-at-a-glance.html.

Published June 19, 2019. Accessed August 28, 2019.

2. United Nations. Asylum and Migration. UNHCR. https://www.unhcr.org/en-us/asylum-and-migration.html. Accessed August 28, 2019.

3. Hameed S, Sadiq A, Din AU. The Increased Vulnerability of Refugee Population to Mental Health Disorders. Kansas Journal of Medicine.

2018;11(1):20-23. doi:10.17161/kjm.v11i1.8680.

4. Kotovicz F, Getzin A, Vo T. Challenges of Refugee Health Care: Perspectives of Medical Interpreters, Case Managers, and Pharmacists. Journal of Patient-Centered Research and Reviews. 2018;5(1):2835. doi:10.17294/2330-0698.1577.

5. Illinois Refugee Resettlement Program: FY18 Annual Report.

WORLD RELIEF in Chicago, Illinois is one of nine resettlement agencies in the U.S.. Photo courtesy of Soonmyung Hwang

2

POLICIES

Progression of Intersectional Reproductive Justice Reform within the U.S. House of Representatives Ananya Kalahasti | Public Health Studies and International Studies ‘21 Intersectional reproductive justice movement is a social movement at the heart of women’s reproductive health, one of the most pressing and politicized public health issues today. Fortunately there have been a number of discussions in the 116th Congress to take steps to address reproductive justice issues through structural, legislative and community building interventions.

Introduction

I

In recent years, the United States Congress has had an increasing influence on policies passed regarding health within the U.S. One such is-

sue that has been under significant political scrutiny has been abortion and reproductive health, which has been in the political mainstream since the 1970s. However, legislation continues to be passed that seeks to achieve equitable reproductive health goals. Throughout this article, we’ll first talk about the background of the reproductive health and justice movement, then, discuss upcoming solutions, including those that might be structural, legislative, or community oriented.

Background Reproductive health, and the right to access reproductive health resources, is the area of public health and medicine that targets women’s access to abortions, contraception, and proper healthcare for their reproductive needs. Reproductive health is specifically a public health issue because of the way society influences a women’s access to health, including through economic barriers, social taboos, and policy restrictions.

26

Reproductive health has long been

education regardless of their socio-

a highly politicized health issue, with

economic status, race, gender, loca-

past legislation instituting a ban on

tion, or immigration status. Policies

federal funding for abortions (the Gag

pertaining to many of these protect-

Rule) and allowing abortion legality

ed classes have inadvertently nega-

to be a reason to cut political aid to

tively impacted access to healthcare

other nations (the Hyde Amendment).

for many women across the country.

Within this presidential term itself,

Additionally, the reproductive justice

the current administration has been

movement is intersectional and rec-

particularly hostile towards wom-

ognizes the interconnectedness of all

en’s reproductive health issues, with

of these protected classes, especial-

repeated assertions that all funding

ly the way various protected classes

to Planned Parenthood should be cut

uniquely influence a woman’s access

off, and supporting state-level pol-

to reproductive healthcare.

icies that would ban abortions, and that would imprison doctors who

Today,

access

to

reproductive

don’t replant ectopic pregnancies in

healthcare is incredibly limited for

the uterus.

most and many women across the country. One particular example of this

It is from these policy developments

is regarding abortion access, as seen

that the reproductive justice move-

in Figure 1. This map shows the num-

ment is born. Reproductive justice is

ber of abortion clinics in each state in

a movement that operates at the in-

2018, with darker states having 50+

tersection of reproductive rights and

clinics and the 3 lightest colors having

social justice, with a core belief that

10 or fewer. From the map, we can see

people, particularly women, should

that over half of the states in the US

have access to reproductive care and

have fewer than 10 abortion clinics in

“The reproductive justice movement is intersectional and recognizes the interconnectedness of all protected classes, especially the various ways protected classes uniquely influence a woman’s access to reproductive healthcare.”

FIGURE 1 Map of number of abortion clinics in each state as of 2018. The darkest states have 50+ clinics, while the states colored with the three lightest shades have 10 or fewer clinics. Source: ANSIRH; Figure designed by Trisha Parayil their states. In many rural states, such

nal offices largely takes place through

of geographic location, and better un-

as North Dakota, South Dakota, Wy-

attending hearings, writing memos,

derstand stakeholders in reproductive

oming, Nebraska, and Kansas, most

listening to briefings, and conducting

justice policies. I also had the chance

women living in the state have to drive

analytical legislative research to pro-

to specifically connect this learning to

over 200 miles to access the nearest

vide recommendations. I was able to

the VA-03 District, which includes cit-

abortion clinics, which for many, is

attend a hearing early on in the sum-

ies like Hampton and Newport News,

across a state border, as many of these

mer in the Energy and Commerce

and use that contextual learning to

states only have 1-5 abortion clinics

Committee regarding Title X Funding,

apply what I learned to how these sit-

total, which are often located in the

which is related to Planned Parenthood

uations might manifest in places like

largest city, but aren’t necessarily ac-

funding. I was able to attend briefings

my hometown of Cleveland, OH, and

cessible to all residents of the state.

on Intersectionality and Reproductive

Baltimore, MD.

In contrast, most coastal states have

Justice, Sexual Risk Avoidance Edu-

abortion clinics within 25 miles of any

cation, Maternal Mortality, the Hyde

given location in the state, and thus

Amendment, and Harm Reduction on

these reproductive health services are

the Hill. Finally, I also had the chance

much more accessible.

to sit in on meetings with constitu-

Summer in the House of Representatives Objectives

Upcoming Solutions Past Progress and the Establishment of Taskforces

ents from the district regarding issues

The House has seen a large rise in

like adolescent pregnancy and planned

accomplishments so far in the 20th

parenthood expansion and access.

century and especially under the recent regain of the Democratic major-

The objective of this work thus was

ity in the House. In a structural sense,

I had the opportunity during the

to gain insight into the federal legis-

there are now many reproductive

summer of 2019 to work as a legislative

lative process, and how opinions & in-

health targeted or related caucuses in

intern in the House of Representatives,

fluence of various stakeholders come

the House, including the Black Mater-

in Rep. Bobby Scott’s office (VA-03)

to fruition with policy drafted and

nal Health Caucus, the End Sexual Vi-

and had the opportunity to help work

enacted. Secondly, I specifically had

olence Task Force, the Maternity Care

with a lot of the reproductive justice

the opportunity to explore legislative

Caucus, and the Health and Wellness

bills that came through the House

avenues to increasing access to repro-

Caucus. Additionally, there are many

this summer. Learning in Congressio-

ductive education and care, regardless

pieces of legislation that have already

27

been passed in the House, including the Consideration of the Reauthorization of the Violence Against Women Act (H.Res.281 regarding H.R. 1585), H.Res.106 regarding the prohibition of female genital mutilation in the US, and a number of other bills that protect immigrants, protect health care access and insurance for those with preexisting conditions, and policies that can help strengthen and fund community health centers.

Legislative Recommendations There are many specific legislative recommendations that can help advance reproductive justice initiatives in the US. The first is H.R. 1692, the EACH Woman Act (Equal Access to Abortion Coverage in Health Insurance), which repeals the Hyde Amendment. The Hyde Amendment prohibits the use of federal funding towards abortion and allows insurance com-

FIGURE 2 US Immigration and Customs Enforcement Memo delineating official ICE sensitive locations as an internal established practice in immigration raids and checks. Source: www.ice.gov

panies to not cover abortions. However, this legislation would require

officially labeled as abstinence-only

tals, schools, and police stations (in

all insurance providers, regardless of

education programs.

localities where ICE does not work with local law enforcement). H.R. 1011,

public or private, to cover any and all abortions obtained.

The third legislative area targeted

the Protecting Sensitive Locations

by the reproductive justice movement

Act, would officially declare these lo-

The next legislative area targeted

is community based reproductive jus-

cations as forbidden for immigration

by reproductive justice is education,

tice building. H.R. 2701 (the Youth

raids or officer visits. In the context

specifically with H.R. 2720, the Real

Access to Sexual Health Services Act

of reproductive health, this is partic-

Education for Healthy Youth Act.

of 2019) would provide community

ularly important as it allows undoc-

This bill mandates comprehensive

grants for reproductive education and

umented women and families to seek

and age-appropriate sex education

services in marginalized communi-

out medical care without fear of any

for schools around the country. One

ties. This especially is applicable for

legal repercussions based on their im-

specification of this bill is the differ-

those communities where proper ser-

migration status.

entiation between appropriate sex

vices and education programs are not

education and sexual risk avoidance

already funded or in place.

I had the opportunity to look at this

education. SRA is the newer form of

28

The fifth piece of legislation that

abstinence-only education that is

The fourth legislative area is that of

summer was H.R. 3296, the Afford-

being pushed nationwide, largely

immigration status. Many, especial-

ability is Access Bill, which provides

based off superstitious myths about

ly under the Trump administration,

over-the-counter contraceptive pill

virginity. However, throughout his-

have seen their ability to access health

coverage for all citizens in the United

tory, abstinence-only education has

resources notably deteriorated under

States. This bill specifically is target-

been proven to not work, and SRA

the targeted attacks on undocument-

ing those who may not have access to

functionally does not deviate from

ed communities. Previously, ICE laid

insurance to be able to cover prescrip-

this. This bill makes it more diffi-

out a number of ‘sensitive locations,’

tion birth control options or might not

cult in the future to implement SRA

where DHS officers can’t target indi-

be able to make visits to a physician

programs as with this bill, they are

viduals or families, including hospi-

to obtain a prescription. Research has

proven that the best way to prevent

outcomes from reproductive health

searched and documented here ended

maternal mortality risk is to limit

concerns; thus there is a strong need

up being passed, or even brought to a

those who are unintentionally getting

for better sexual education programs

vote, and all legislation (introduced in

pregnant, and increasing contracep-

across the US, especially those that are

both the House and the Senate) ended

tive access is the most cost-efficient

science-based, factually accurate, and

up being introduced and then having

way to do so.

integrate minority groups. As seen in

no meaningful action taken. However,

Figure 3, there are 19 states across the

as the legislative session concludes this

US where sex-ed is mandatory, that

upcoming December, time continues to

are required to teach about abstinence,

run out in terms of seeing meaningful

but not required to teach about contra-

progress on reproductive justice, espe-

ception. In addition to this, there are a

cially contingent on the results of the

number of school districts that mandate

2020 elections.

Community Building Many ways to improve access to reproductive health resources isn’t necessarily just in policy and legislation, but rather comes from community and coalition building recommendations as well. The first of these is to raise intersectional coalitions, and better represent ethnic groups and diversity in socioeconomic and immigration status, and gender and sexual identity.

Having these coalitions often makes it easier for local communities to pool

abstinence-only education and even more states and school districts that don’t require sex education at all. This specifically is a way to empower youth across the country to improve reproductive health outcomes in the future.

Conclusion

Acknowledgments A sincere thank you to the APAICS Summer Internship Program for the placement opportunity to work in the office of Rep. Bobby Scott, the staff of the DC office of Rep. Scott for their support in this project and the addition-

resources for common goals and al-

As demonstrated throughout this

al focus my work this summer gave to

lows for a better chance to fight back

paper, during the summer of 2019,

reproductive health and rights, and the

against policies that might inhibit ac-

there were a number of potential legis-

Johns Hopkins University Undergradu-

cess to resources.

lations that could continue to see better

ate Public Health Studies Department,

reproductive justice policies within the

for their support in this Applied Expe-

Additionally, educational access is

United States. Unfortunately, while this

rience project and opportunities to de-

directly linked to reduction of mater-

research was initially conducted nearly

velop my research and work through a

nal and infant mortality, and better

a year ago, none of the legislation re-

more structured and reflective process.

FIGURE 3 Map of states (in dark blue) required to teach about abstinence, if sex-ed is mandated at all, but not required to teach about contraception. Source: Guttmacher Institute; Figure designed by Trisha Parayil

29

SUNSET near the Ngorongoro Conservation Area.

FEATURES

SCHOOL CHILDREN sit in a classroom in West Bengal, India. Photo by Amith Umesh

FEATURES

Tele-ROP in India: The KIDROP Experience Ahimsa Aradhya | Molecular and Cellular Biology ‘21 Anand Vinekar | MD, FRCS, PhD Karnataka Internet Assisted Diagnosis for Retinopathy of Prematurity (KIDROP) allows for infants in rural areas and outreach centers lacking ROP specialists to be screened and treated efficiently.

Introduction

T

wenty-seven million babies are born annually in India, 3.5 million of whom

are

premature.

These individuals are at

risk for Retinopathy of Prematurity (ROP), a disease that occurs when abnormal blood vessels grow and spread throughout the retina, resulting in lifelong visual impairment and blindness. With fewer than 20,000 ophthalmologists, 2000 retina specialists and 200 ROP specialists in the country, the need outweighs the demand several fold.

The first and currently the largest tele-ROP service is the Karnataka Internet Assisted Diagnosis for Retinopathy of Prematurity (KIDROP), initiated in Bangalore, the capital city of Karnataka, in 2007. To date,

non-physician graders travel to re-

the team and was trained on the pro-

mote neonatal intensive care units,

tocol for screening and recording the

wherein 2000-2500 imaging sessions

patient’s diagnosis. For the next few

are performed each month.

weeks, I would be traveling with the team and assisting them in several

The process of allowing a non-ophthalmologist to screen for ROP using a wide-field camera was not initially accepted by neonatologists in India. Fur-

screenings in rural hospitals across the state of Karnataka.

Methods

thermore, these technicians were also

The ROP team must visit the neonatal

trained to make the ‘first’ diagnosis.

unit on a pre-fixed schedule, weekly. To

Even though this diagnosis was based

date, the KIDROP program covers 126

on a decision-based algorithm which

neonatal units in Karnataka in all dis-

was validated remotely by the ROP

tricts of the state and performs approx-

expert, there was considerable appre-

imately 2500 imaging sessions each

hension from neonatologists in “fear

month.

of missing the disease.” After validating the results and the outcomes of this

Once the camera arrives at the sched-

methodology, however, the advan-

uled center, it is transported to the NICU

tages were indisputable, and it rapidly

where the pre-identified infants are

became the preferred method of ROP

dilated and ready for imaging. Most re-

screening in rural areas and outreach

cently, a low-cost, portable camera was

centers lacking ROP specialists.

developed in India called the 3Nethra Neo (“Neo”), with clinical collabora-

this program has screened more than

tion of KIDROP. The Neo was designed

150,000 infants and has identified

In May 2019, I traveled to Ban-

more than 25,000 infants with Type

galore, India to volunteer with the

1 ROP1-5. The KIDROP model has ad-

KIDROP program and gain a bet-

dressed the problem of unscreened

ter understanding of the diagnosis

infants in rural areas by implement-

and treatment of ROP. Upon arrival,

ing a novel platform of telemedi-

I was greeted by Dr. Anand Vinekar,

cine and employing non-physician

the program director, and his team

Imaging is performed within the in-

graders for the first time. Teams of

of technicians. I was welcomed into

cubator, on the warmer, or in an ad-

specifically for ROP and infant retinal imaging. It provides a 120-degree field of view and is a contact camera with a single, monolithic, hand-held probe.

“The KIDROP model has addressed the problem of unscreened infants in rural areas by implementing a novel platform of telemedicine and employing non-physician graders for the first time.”

32

ROP SPECIALISTS remotely evaluate images/vidoes recorded by a medical team in neonatal units. Photo by Ahimsa Aradhya joining room under nurse supervision.

A special software program for this

lessen the crying. Once the necessary

Images are captured in the video mode

purpose has been created with a user

photos were taken with the Neo cam in

and the required still images are saved.

interface that is accessible on mobile

each eye, I would record the diagnosis

They are shown to the parents of the

devices or desktop systems.

in the booklet that would be given to

infant and the rating neonatologist where possible and documented on the ROP booklet given to the moth-

the infant’s mother.

Experience

As the hospitals we traveled to were

er, in the hospital records, the online

Each morning the team would meet

located in rural areas, many parents

database, and the image database. All

in Dr. Vinekar’s office within the main

did not understand the severity of ROP

images are backed up on to a secure

hospital, where we would gather the

and needed to be thoroughly briefed

online database and are available for

equipment and supplies for screen-

on the disease as well as the infant’s

the remote expert to evaluate. The

ings. We would the load the equipment

diagnosis. Being fluent in Kannada,

remote specialist views and reports

into the Neo Van and head to the as-

the native language of Karnataka, al-

these images on his or her smart

signed destinations for the particular

lowed me to communicate with the

phone.

The reporting time (by the

day. Once set up within the NICU of the

mothers, which was crucial in order

remote ROP specialist), on average

particular hospital, the technicians

to understand their concerns and re-

after upload, is four minutes. The

would begin by dilating the infant’s

assure them. Given that ROP causes

time taken to report all ‘severe cas-

pupil with drops and a stent to hold the

permanent blindness if not treated a

es’ of any session that need urgent

infant’s eye open. This was challeng-

few weeks after detection, we would

attention is less than 30 minutes.3

ing as the infant would squirm and cry

immediately schedule an appointment

Images are uploaded manually (Ret-

during the process. In order to make

with the mother to see Dr. Vinekar if

Cam) or automatically (Neo) for the

the process efficient for the infant, we

the disease was detected in the im-

ROP specialist to review and report.

would gently hold down the mouth to

ages. Another challenge for the par-

1,2

33

“In its twelth year, the impact of KIDROP in preventing infant blindness, assessed using the ‘blind person years’ formula, is over 154 million dollars.” ents was transportation, as many of them did not have vehicles to drive to the main hospital for an appointment with Dr. Vinekar. In these cases, we would coordinate with the parents and Dr. Vinekar would travel to their local hospital to perform the procedure.

Acknowledgments I would like to thank Dr. Anand Vinekar, MD, FRCS, PhD for making this experience possible and for helping put this article together. Furthermore, I would like to express my gratitude for the amount of time and effort he has dedicated to KIDROP, chang-

Through this experience I was able

ing the lives of infants across India. I

to understand the importance of effi-

would also like to thank the team of

ciency and proper protocol when deal-

technicians I worked with each day for

ing with a disease as severe as ROP.

training me and making me feel wel-

Furthermore, I was able to see the im-

come. Lastly, I would like to thank Dr.

pact that meaningful communication

Chaitra Jayadev, MBBS, PhD and the

has on the patient. Since ROP affects

individuals at Narayana Nethralaya

individuals very early on in life, it is

Hospital for helping guide my inter-

stressful on the mothers since they

ests in the field of ophthalmology.

have just recently given birth. Being able to support the mother through this difficult time and comfort her is important for the well-being of both the infant and the mother.

Impact In its twelfth year, the impact of KIDROP in preventing infant blindness, assessed using the ‘blind person years’ formula (i.e. number of infants x per capita income x lie expectancy), is over 154 million dollars. An impact assessment of scaling up the program in India showed that in the 10 highrisk ROP states, with a population of roughly 680 million, over 35,000 infants would be detected with ROP and over 1,200 require treatment annually.

References 1. Vinekar A, Gilbert C, Dogra M, Kurian M, Shainesh G, Shetty B, et al. The KIDROP model of combining strategies for providing retinopathy of prematurity screening in underserved areas in India using wide-field imaging, telemedicine, non-physician graders and smart phone reporting. Indian J Ophthalmol. 2014;62:41–9.

2. Vinekar A, Jayadev C, Mangalesh S, Shetty B, Vidyasagar D. Role of telemedicine in retinopathy of prematurity screening in rural outreach centers in India – A report of 20,214 imaging sessions in the KIDROP program. Semin Fetal Neonatal Med. 2015;20:335–45.

3. Vinekar A, Jayadev C, Bauer N. Need for telemedicine in retinopathy of prematurity in middle-income countries: EROP vs. KIDROP. JAMA Ophthalmol. 2015;133:360–1.

4. Vinekar A, Mangalesh S, Jayadev C, Gilbert C, Dogra M, Shetty B. Impact of expansion of telemedicine screening for retinopathy of prematurity in India. Indian J Ophthalmol. 2017 May;65(5):390395.

5. Vinekar A, Rao SV, Murthy A, Jayadev C, Dogra MR, Verma A, et al. A Novel, Low-Cost, WideField, Infant Retinal Camera,Neo: Technical and Safety Report for the Use on Premature Infants.

Transl Vis Sci Technol 2019.

The financial saving in ‘blind-person-years’ (BPY) is estimated at 108 million dollars annually.4 The KIDROP program is now being emulated in other states of India and other nations in the region.

34

MANY PARENTS did not understand the severity of ROP, so they had to be thoroughly briefed.

Photo by Amith Umesh

2

FEATURES

Kamayan: A Community Feast Anna Leoncio | Medicine, Science & Humanities ‘20 The Asian Pacific Islander Forward Movement highlights the need for more collaboration between community members and public health institutions to better understand the importance of culturally relevant initiatives.

L

os Angeles County is home

Pacific Islander Forward Movement

cific Islander into its respective ethnic

to many Asian Americans

(APIFM) to host a series of community

identities when imagining interven-

of different ethnic back-

workshops in Historic Filipinotown.

tions and initiatives focused around

grounds – with one of the most prominent being the

community health. Since then, the orForward

ganization has expanded and widened

Filipino-American community. Fil-

Movement began in 2007 as Asian and

their focus to tackle a wider range of

ipinos have a long history in Ameri-

Pacific Islander Obesity Prevention

community health and environmen-

ca and in California specifically. They

Alliance (APIOPA) with the purpose

tal justice issues that affect the API

were the first Asians to arrive on what

of bringing attention to the fact that

community of Los Angeles. Their Food

would become American soil when in

Asian Pacific Islander (API) communi-

Roots program focuses on bringing

1587, Filipino Luzonians aboard the

ties were often left out of public health

fresh produce from local Asian farm-

Spanish galleon Nuestra Señora de

efforts tackling the obesity epidemic.

ers to restaurants and farmers mar-

Buena Esperanza landed in Morro Bay

At that time, the organization under-

kets. Their Tobacco Prevention Team

in San Luis Obispo, California.

stood the importance of disaggregat-

is based in Diamond Bar and San Ma-

ing the category of Asian American Pa-

rino, CA where they are working with

1

Asian

Pacific

Islander

The Filipino-American presence in America has grown significantly since then. Now, Filipinos have become the fourth largest immigrant population in America. After the 1965 Immigration and Nationality Act, the number of Filipinos in America skyrocketed from around 200,000 in 1960 to roughly 2 million in the year 2000.2 Of these, 43% of the Filipino population of America lives in my home of Los Angeles County, making it have the highest concentration of ethnically Filipino people in the world, second only to Manila.3 Consequently, Filipino-Americans have a distinct and unique presence in Los Angeles. Despite all of this, Filipinos are often still overlooked and forgotten in conversations and research about Asian-Americans.4 I feel a lot of pride in my identity as a Filipino-American and have always wanted to work directly with members of my community. This past summer, I finally got my chance as I worked with the nonprofit Asian

36

APIFM interns present on the relationship between food and community.

Photo courtesy of APFIM

local residents to address smoking in

I focused on providing some basic and

history. Most of the attendees were

public areas with the goal of reducing

handy resources for how to view food.

first-generation

tobacco related health issues.

One major resource is MyPlate. MyPlate

women in their late 40’s to early 50’s.

was developed by the USDA in 2010 as a

They said that in the 1960’s, the Phil-

My role, though small, helped to ad-

new dietary guideline to replace previ-

ippines was one of the greatest pro-

dress the specific need to educate Fil-

ously used and popular food pyramids.6

ducers of rice in the world and repre-

ipino-Americans about the way their

Filipino-American

sentatives from other countries would

relationship with food may influ-

The guideline features five defined

come to learn about rice cultivation at

ence their health. I worked alongside

food groups of fruits, grains, vegeta-

the International Rice Research In-

APIFM’s Healthy Eating Active Living

bles, protein, and dairy, arranged in

stitute, an international research or-

(HEAL) team to develop and deliver a

portions across a plate. Many of our at-

ganization based in Los Baños, Lagu-

six-week community workshop about

tendees found MyPlate easier to visu-

na, Philippines.7 I had never heard of

nutrition that was culturally relevant

alize than previously used guidelines.

this, but it helped to contextualize the

for Filipinos. We used resources from

However, they also discussed with us

importance of rice in Filipino culture

the Los Angeles Department of Public

their concerns that perhaps myPlate

and cuisine.

Health’s guides for community work-

would be more difficult to utilize when

shops alongside our own experience

eating more traditional Filipino dish-

Through this experience, I learned

with Filipino culture and a previous

es. Filipino and Filipino-American

much about my own identity and cul-

APIFM curriculum to develop our own

meals often center around a singular

tural history through an avenue close

series. We also partnered with another

main dish served with unrestrained

to my heart: food. I also was able to

Los Angeles-based nonprofit, Search

amounts of white rice. Usually this

connect with people in my ethnic

to Involve Pilipino Americans (SIPA),

main dish involves mixing together

and Los Angeles community. I think

who connected us with the local com-

meat and vegetables in soups or stew,

that the work that organizations like

munity in Historic Filipinotown.

rather than cooking them individually

APIFM have done and continue to do is

into separate food groups. Thus, the

important and will continue to be im-

Throughout the whole process, we

visual arrangement of myPlate does

portant. As our attendees noted, there

wanted to respect the special place

not necessarily complement the typi-

is a need for more cultural relevant

that food has in Filipino culture. Filipi-

cal Filipino or Filipino-American style

resources for diverse communities.

no cuisine is a way to bring family to-

of eating.

Communities are asking for these re-

gether, a way of tying immigrants and

sources, and it’s important to listen so

diasporic communities to their home-

During this first lesson, my teaching

as to prevent the needs of these com-

land, and something that demon-

partner and I learned a valuable lesson

munities from being ignored or falling

strates the resilience and adaptability

that had been reiterated by our APIFM

through the cracks.

of Filipino people. (For example, Fil-

mentors and that we would learn again

ipino food has influences from Span-

and again during the duration of our

References

ish and American colonialism.) It also

series: the value of the knowledge in

tastes pretty great.

the community. It also helped to em-

1. Borah, Eloisa Gomez. “Chronology of Filipinos in America Pre-1989”. Anderson School of Management. University of California, Los Angeles.

phasize the importance of what we Our first workshop, we titled “En-

were doing by helping to create a cul-

joy Healthy Foods that Taste Great.” At

turally relevant nutrition series.

the beginning of this session and the

next two sessions, we had the attendees

Other important lessons we worked

complete the Food Behavior Checklist

on focused on other specifics of Fili-

in order to establish a baseline of their

pino cooking and ingredients. An en-

food-related behaviors before the be-

tire lesson was centered around rice.

ginning of the series. The Food Behavior

During this lesson, we explained the

Checklist was established at the Uni-

differences between white rice and

versity of California at Davis as a tool to

brown rice, and brought in samples of

evaluate eating behaviors before and af-

different grains for the attendees to

ter nutrition education lessons.5 During

look at and try to name. Rice holds an

this session, my teaching partner and

important part in Filipino culture and

2. Posadas, Barbara M. The Filipino Americans.

Westport: Greenwood Press, 1999.

3. Wu, Diana Ting Liu. Asian Pacific Americans in the Workplace. Alta Mira Press, 1997.

4. David, E. J. R., “Why Are Filipino Americans Still Forgotten and Invisible?” Psychology Today. Sussex Publishers, 2016.

5. Food Behavior Checklist. University of California Cooperative Extension.

6. myPlate. USDA. Retrieved November 10, 2019 from https://www.choosemyplate.gov.

7. International Rice Research Institute. Retrieved November 10, 2019, from International Rice Research Institute website: https://www.irri.org.

37

SUNSET near the Ngorongoro Conservation Area in Tanzania. Photo by Jay Asawla

EDITORIALS

EDITORIALS

Shortcomings in Tanzanian Healthcare Stem from Underlying, Systemic Economic Instability Jay Asawla | Neuroscience ‘23 A few words about my near-death experience in Tanzania and why it happened.

T

A Trip Gone Wrong he last time I visited Tanzania, I almost died.

Of course, this was not on the travel itinerary; I was primarily visiting

my extended family that lives in Dar es Salaam, the country’s capital city.

It was the summer of 2012, and at 10 years old, it was wonderful to experience the rich culture, exquisite food, and breathtaking safari of a foreign country. Unfortunately for me, this was not all that was in store. A few weeks into my vacation, I contracted a serious infection that required immediate medical attention. I had unsuspectingly drunk water of poor quality which caused severe inflammation of

clinic being in an old, dilapidated brick building. The walls were peeling, the AC was broken, the floor was carpeted with dust, and mosquitoes plagued the surrounding area. There were only two clinicians on duty at the time, and the last thing I remember before being sedated was the angry Swahili exchanged between my mother and one of the clinicians. The materials used for my operation were severely outdated. The amount of anesthetic used to sedate me was excessive, even by adult standards, not to mention that the needle I was injected with was expired. All of these shortcomings resulted in me falling dangerously ill, which is when my family packed their bags to rush home.

So What’s the Issue?

My experience in Tanzania opened my eyes to the poor state of medical infrastructure and practice in thirdworld countries. More often than not, patients in third-world countries have to spend exorbitant amounts of money to travel abroad to hospitals that can properly treat them. Only 54% of the Tanzanian population has access to clean drinking water, and just a quarter have access to improved sanitation facilities.1 I believe that my experience, in addition to the experiences of Tanzanian citizens, is evidence of several underlying issues with the most significant being the matter of Tanzania’s economy. In developing countries, wide-

my stomach. If left untreated, I would continue to experience severe abdom-

Once I returned to the United States,

spread poverty establishes a vacuum

inal pain while losing the ability to

I immediately noticed the stark con-

of quality education and healthcare.

properly digest food. Because my pe-

trast in the environment as compared

Tanzania is rampant with poverty: its

diatrician was over 8,000 miles away,

to the Tanzanian clinic. Instead of

GDP is ranked 201 among 229 coun-

it was necessary to have surgery in

the weathered-down building where

tries.2 The current slow growth of

a local clinic. Instead of recovering,

I was initially treated, this hospi-

economic development trickles down

however, my health took a turn for the

tal was pristine and equipped with a

to the healthcare expenditure per

worse.

small army of medical professionals,

capita. In the United States, the gov-

up-to-date equipment, sanitary con-

ernment spends an estimated $11,172

It was not the infection itself that

ditions, and most importantly, the

per person on healthcare.2 Meanwhile,

posed a major problem, but instead

fear for my safety was assuaged. I un-

in Tanzania, the average healthcare

the lack of tools and techniques need-

derwent a simple, 1-hour procedure

spending by the government totals

ed to treat me while I was in a weak-

in these updated conditions, and my

to just about $137 per person.3 Such a

ened state. I distinctly remember the

infection began to heal.

drastic disparity in healthcare spend-

“The walls were peeling, the AC was broken, the floor was carpted with dust, and mosquitoes plagued the surrounding area.”

40

integrates basic first-aid instructions would greatly benefit those living in poverty.

While

these

proposed

solutions

should be effective in theory, they also would be impossible without the significant contribution of financial aid from a foreign government. Tanzania currently receives an estimated $400 million USD annually in financial aid.7 This money is then spread to relief programs focused around combating AIDS, eliminating disparities in education, and promoting the growth of a free-market economy. I believe it would be in the best interest of the United States to continue and increase

FAMILY Asawla and his extended family in Dar es Salaam, the Tanzanian capital.

Photo courtesy of Jay Asawla

the amount of aid provided to developing nations such as Tanzania, as they would serve to be important allies

ing between the two countries leads to

wards farmers and other blue-collar

and continue to be important trade

a few inevitable truths: compared to

occupations would help alleviate any

partners.

the U.S., Tanzanian infants are 7 times

disparities within the working class

more likely to die, life expectancy is 13

and the poor.

years shorter, and both communicable and noncommunicable disease transmission are higher as evidenced by current malaria and HIV outbreaks.3,4

What Needs to Change

With the economy at the forefront of issues that play into Tanzania’s healthcare, another important aspect would be to ensure the education of Tanzanian citizens. In theory, all chil-

To improve the current state of

dren up to age 15 receive free primary

healthcare in Tanzania, we should

education. Unfortunately, poorer par-

propose policies that directly stimu-

ents cannot afford secondary costs as-

late the economy of the entire country

sociated with receiving a primary edu-

- not just the industrialized sector. As

cation, such as uniforms, examination

a developing nation, Tanzania’s econ-

fees, and class materials, and so their

omy is certainly growing, but with

children continue to be deprived.5 This

major setbacks. Systemic problems

results in a greater problem due to the

hinder progress; issues like abrupt tax

country’s lack of children’s educa-

increases, erratic regulatory changes,

tion - Tanzania has a severe absence

uneven policymaking, rising protec-

of physicians, numbering about 3 per

tionism, and lack of transparency all

100,000 people.6 It should be up to the

work together to foster government

government to remove the financial

corruption.

To rectify Tanzania’s

strain of a Tanzanian child wanting

economy, and by extension its health-

to pursue an education. Those fortu-

care system, policy must be passed

nate to attend school should receive

that ensures all citizens benefit from

an education catered towards voca-

the steady economy, not just those

tional work or to pursue higher edu-

working in the private sector or gov-

cation, i.e. a physician. Additionally,

ernment. Economic policy catered to-

a comprehensive education plan that

2

References 1. WHO | Mid-level health workers for delivery of essential health services. Who.int. November 2013. doi:/entity/workforcealliance/knowledge/ resources/mlp2013/en/index.html 2. Historical | CMS. Cms.gov. http://www.cms. gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.

Published 2018. Accessed February 1, 2020.

3. United Republic of Tanzania. World Health Organization. July 2019. doi:/countries/tza/en/index. html 4. Global Health | Tanzania | U.S. Agency for International Development. Usaid.gov. http://www. usaid.gov/tanzania/global-health. Published December 19, 2019.

5. Tanzania Education System. Scholaro.com. http://www.scholaro.com/pro/countries/tanzania/education-system. Published 2018. Accessed February 1, 2020.

6. Kwesigabo G, Mwangu MA, Kakoko DC, et al.

Tanzania’s health system and workforce crisis.

Journal of Public Health Policy. 2012;33(S1):S35-S44. doi:10.1057/jphp.2012.55 7. Ashley Quigley. How the US Benefits from Foreign Aid to Tanzania | The Borgen Project. The Borgen Project. https://borgenproject.org/howthe-us-benefits-from-foreign-aid-to-tanzania/. Published May 4, 2018. Accessed February 1, 2020.

41

EDITORIALS

More Than Meets the Eye: The Key Component Missing in Pre-medical Education

S

Niccolo Dosto | Biology and Spanish ‘17 To prepare to be a doctor, you have to see health services firsthand.

ir William Osler, one of the

some kind of clinical research before

city’s history of redlining, or hav-

four

professors

medical school as the experience gave

ing discriminatory housing practic-

of the Johns Hopkins Hos-

me the necessary skills to be a better

es, isolated neighborhoods from the

pital, once said: “The good

doctor in the future.

resources they needed to survive,

founding

physician treats the disease;

leading to food deserts and lack of ac-

the great physician treats the patient

In the summer of 2015, I joined the

cess to healthcare.² I had read about

who has the disease.”¹ Pre-medical

SToP (Screening to Prevent) Glaucoma

these issues in textbooks and school

students at any institution are flood-

team at the Wilmer Eye Institute. The

lectures but experiencing them up

ed with responsibilities – from doing

program consisted of trained under-

close gave me a more meaningful un-

research in labs to maintaining high

graduate students who traveled to dif-

derstanding of the city’s problems.

GPAs. Between diving into texts and

ferent churches, community centers,

In my three years of conducting eye

plating cells, it becomes easy for them

and apartments all over Baltimore City

screenings, I met people of different

to forget the true meaning of their ca-

to give free eye exams to seniors aged

backgrounds who I otherwise would

reer goals. When I began my under-

50 years and over. Using mobile retinal

never have had the chance to encoun-

graduate studies at JHU, I waded into

cameras, autorefractors, and various

ter. Most undergrads at JHU know

the same, high-pressure pre-med en-

field tests, we screened participants

vironment that had molded many fu-

for various eye diseases and gave free

ture doctors before me for over a hun-

follow-up appointments to Wilmer

dred years.

for those who qualified. We also gave away free reading glasses to people

My friends and I took and strug-

who had trouble reading up close. For

gled through the same basic science

some, our service was the only eye

courses, and we all graduated in the

exam they had received in many years.

end with some idea of what kind of

By the time the program ended in

physician we would like to be. Most

the summer of 2019, we had finished

of the people I knew did wet lab re-

screening over 8,000 individuals in

search and fulfilled their clinical pre-

Baltimore. We also developed valuable

med requirements by volunteering or

relationships with different organiza-

shadowing in between classes. In my

tions and advocacy groups all over the

sophomore year, however, I decided to

city to help us identify new places to

leave the traditional wet lab I worked

set up our mobile clinic.

at in Homewood to do public health

42

research at the Wilmer Eye Institute.

My experience with SToP brought

Although lab research was interesting,

me to all kinds of neighborhoods,

I felt like it did not provide me with the

from well-off suburbs to run-down

clinical practice and human connec-

housing projects. In Baltimore, it was

tion I desired in my pre-med journey.

common to see vast socioeconom-

My time at Wilmer convinced me that

ic differences in communities that

every prospective physician should do

were only a few city blocks apart. The

“My experience with the SToP (Screening to Prevent) Glaucoma team at the Wilmer Eye Institute brought me to all kinds of neighborhoods, from well-off suburbs to run-down housing projects. In Baltimore, it was common to see vast socioeconomic differences in communities that were only a few city blocks apart.” about the proverbial “Hopkins Bub-

course, but the most important lesson

from working three jobs. This critical

ble” – the idea that students never

I received was how to pay attention.

awareness served me well whenever I

leave the safety of Charles Village’s

Although we may not acknowledge

saw the more difficult patients in our

HopCop-patrolled borders. I was able

it, we often make self-centered judg-

program.

to “pop” this bubble with the SToP

ments about people around us every

program, and in doing so I discovered

day: the guy who cut me off on the

I used this ability to pay attention

the power and importance of making

freeway this morning must be a real

during an eye screening event at an

human connections. It is routine in

jerk, and the lady who screamed at

apartment complex in West Baltimore.

public health to collect data through

her kids at the grocery store must be a

I had examined a wheelchair-bound

surveys and cross-sectional studies.

bad parent. As I met more people who

woman who had been screaming every

There is no substitute, however, for

were different from me, however, I

kind of obscenity at me while I per-

spending time with someone and tru-

learned to be more charitable and less

formed the tests. She refused to lis-

ly understanding the context of their

arrogant in how I thought about oth-

ten to my instructions and questioned

situation.

ers. Perhaps the man on the freeway

every movement I made. During the

was late to an appointment, and the

exam, I noticed and focused on how

lady with the kids was sleep deprived

badly she needed to get a new eye-

My time in clinical research taught me to look beyond the numbers to understand a person’s entire story. I learned important clinical skills, of

SCREENING Dosto takes a fundus (retinal) photograph of a patient during an eye screening. Photo by SToP Glaucoma

2

setting. Other students may get such clinical proficiencies through volunteering, but practicing these skills in an academic or research setting helped me personally connect the idea that doctors are both scientifically-minded and compassionate people.

I now know to describe patients not just by their disease, but also by their social context, their personal beliefs, and their daily struggles. I would not have been able to receive all of these lessons if I had not joined the public

A ROW of screening equipment used in the mobile clinic where Dosto worked.

Photo by SToP Glaucoma glass prescription instead of letting

soning. Where better can he gain this

myself get easily frustrated. I kept up

fundamental training than in chemis-

a smile, gave her new glasses, and sent

try?”3 However, undergraduate scores

her on her way. As I sat down to take

in these subjects do not necessarily re-

a much-needed break, I felt a tap on

flect an individual’s ability to become a

my shoulder. The woman had wheeled

good physician. Psychologist Harrison

herself all the way back to the screening

Gough at the University of California,

area to thank me for helping her. She

Berkeley, found in 1978 that undergrad

explained that she had an intense anx-

STEM scores were inversely correlated

iety disorder, and that doctors had re-

with a student’s clinical competence

fused to see her time and time again be-

scores. Students with above average

cause of how uncooperative she was as

science grades were “narrower in in-

a patient. Through tears, she said that I

terests, less adaptable, less articulate,

was the first person to ever give her the

and less comfortable in interpersonal

time of day, and she was grateful that I

relationships than their lower scoring

never gave up on her. In that moment,

peers.”⁴ A study by PJ Tutton of med-

I knew that there was nothing else I

ical students in Australia suggests that

wanted to do in my entire life. No mat-

those with better pre-medical science

ter how difficult or frustrating, medi-

scores were more “shy” or “awkward

cine would be my future. I was grateful

and ill at ease socially,” becoming what

to have been able to look past her initial

he described as “the antithesis of what

behavior and paid attention to why she

most of us would want in a clinician.”5

came to our program for help.

Science education is essential for

44

Often, pre-med education stresses

pre-med students, and competen-

competency in science-related cours-

cy in STEM subjects helps one build

es like biology and physics. In 1917,

upon the education received in medical

Harvard anatomy professor Frederick

school. I felt, though, that my expe-

Hammett gave a speech to the Ameri-

rience in clinical research was as im-

can Chemistry Society emphasizing the

portant as my Organic Chemistry and

importance of such knowledge: “The

Biochemistry classes were in shaping

true physician must be a true diagnos-

me to become a better future physician.

tician. He can not [sic] be a diagnos-

I learned skills like cultural competen-

tician if he lacks power of observation

cy, patience, and empathy that one

and ability to carry on deductive rea-

cannot simply acquire in a classroom

health research team, and I implore pre-med students to consider doing clinical research along with their other activities. The patient experience is incredibly fulfilling, and such students might also learn something about themselves along the way. A person’s hopes and dreams matter as much to their health as their blood pressure and heart rate. The human connection is a powerful tool, and if Dr. Osler can be trusted, it can turn good physicians into great ones.

References 1. Centor RM. To be a great physician, you must understand the whole story. MedGenMed. 2007;9(1):59. Published 2007 Mar 26.

2. Badger, Emily. “The Long, Painful and Repetitive History of How Baltimore Became Baltimore.”

The Washington Post, 29 Apr. 2015, www.washingtonpost.com/news/wonk/wp/2015/04/29/ the-long-painful-and-repetitive-history-of-how-baltimore-became-baltimore/.

3. Hammett, Frederick S. “PRE-MEDICAL TRAINING IN CHEMISTRY.” Science, vol. 46, no.

1195, Nov. 1917, pp. 504 LP – 506, doi:10.1126/science.46.1195.504.

4. Gough, Harrison G. “Some predictive implications of premedical scientific competence and preferences.” Journal of medical education 53 4 (1978): 291-300 5. Tutton, Peter J. “Psychometric Test Results Associated with High Achievement in Basic Science Components of a Medical Curriculum.” Academic Medicine, vol. 71, no. 2, Lippincott Williams & Wilkins, 1996, pp. 181–86, doi:10.1097/00001888199602000-00027.

INNER HARBOR in downtown Baltimore. Photo by Mason Cole

SUNSET near the Ngorongoro Conservation Area.

Photo by Mason Cole

Submit We encourage students to submit articles about your experiences in local communities and abroad. Share your research projects, policy recommendations, stories, and opinions to contribute to the critical conversation on public health. Please contact us at epidemicproportions@gmail.com if you’d like us to feature your article or photography in a future issue.

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Acknowledgments The staff of Epidemic Proportions extend our sincere appreciation to: Ronald J. Daniels, President of Johns Hopkins University Beverly Wendland, Dean of the Krieger School of Arts and Sciences Ellen J. MacKenzie, Dean of the Bloomberg School of Public Health The members of the Public Health Studies Advisory Board: Colleen Barry, Andy Cherlin, Marie Diener-West, John Groopman, Laura Morlock, Joel Schildbach, Adam Sheingate, James Yager, and Scott Zeger The members of the Krieger School of Arts and Sciences Public Health Studies Program: Maria Bulzacchelli, Katherine Henry, Cara McNamara, Caroline Barry, Natalie Boyd, and Keri Frisch We would also like to thank our featured photographers: Mason Cole, Cole, Maya Foster, and Amy Lu

SUNSET near the Ngorongoro Conservation Area.

Photo by Mason Cole

Editorial Board Editors-in-Chief Asim Dhungana Soonmyung Hwang Research Lydia Lee (Editor) Ahimsa Aradhya Alyssa Lee Roshini Narayanan Policies Sanjana Murthy (Editor) Ananya Kalahasti Trisha Karani Emily Lee Lais Santoro Features Jesse Huang (Editor) Lisa Ha Joseph Kang MinJae Shin Han Zhang

Editorials Anagha Ashokan (Editor) Kriti Bomb Anna Fiedor Kathleen Li Kristine Nguyen Layout Trisha Parayil (Editor) Alyssa Lee Devan Patel Ying Zhang Publicity Sharon Chow (Director) Noor Al-Saloum Eumihn Chung Finance Joshua Woo (Director) Advisor Natalie Boyd

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