Volume 22, Spring 2025

Table of Contents 4

Letter from the Editors-in-Chief

5

Letter on the Founding of Epidemic Proportions

6

Opening Letter

7

A Note on the Cover

Neha Skandan, Wassim Bouhsane

J.D. Goodyear, PhD, Former Associate Director of the Public Health Studies Program Adam Seth Levine, PhD, SNF Agora Professor of Health Policy and Management, Johns Hopkins University Carlos Haring, Niki Zouzoulas

Features 10

Reproductive Justice in Baltimore Through the Artistic Lens

13

Medicine as a Universal Language

15

From Edamame to Anaphylaxis: One Student’s Allergy Battle

17

A Divided Golden City: Highlighting SROs in San Francisco

20

Poverty, Racial Divides, and French Fries: Addressing Fast-Food Culture

24

Public Health Implications of High Dementia Prevalence in Baltimore

Joanie Ryu

Sumin Han

Gaayathri S. Nadarajah Connie Huang

Jeffrey Mathew

Ishanika Damani

Editorials 30

Safe Menstruation: A Human Right

32

Breaking Barriers: Advancing Women’s Representation in Healthcare

35

Losing the Democracy We Never Had

37

A Community-Based Approach to Restoring Trust in Public Health

41

The Politics of a Petri Dish

46

Public Health Pulse: Thoughts from the Next Generation of Leaders

Ahla Bommareddy Anannya Sharma Carlos Haring

Booseong Eric Seo Isabelle Jouve

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47

Why is Community Important in Public Health?

Policy 50

Evaluating and Improving Translation Services for LEP Patients in Healthcare

53

Waging the War Against Medical Misinformation

56

Private Equity’s Growing Role in Healthcare: Impacts and Policy Solutions

59

Reproductive Healthcare Access: Voter Trends in the 2024 Election

62

Baltimore Therapeutic Treatment Center & Inmate Mental Health

Indu Bodala

Pranav Kotamraju, Conner Feng Shreya Kesarwani Abriti Chatterjee Anahat Goraya

Research 68

Potential Options for Managing Long COVID: A Literature Review

71

After Hours, Out of Options: Overcoming Barriers to Accessible Childcare

77

OSRX Atropine+ to Treat Myopia: A Literature Review

80

The Impact of Urbanization on Hyderabad’s Lakes and Water Pathways

85

COVID-19’s Impact on Pediatric Dry Eye Syndrome Incidence

88

Policy Memo: Increasing Funding Toward Sexual Health Screenings

90

Public Health Research Highlights

91

Community Organizations in Baltimore, Maryland

92

Epidemic Proportions Staff 2024-2025

94

Closing Letter

95

Acknowledgements

Wanli Tan

Annabelle Huang Arjit Singh

Surya Panyam Arjit Singh

Tim Huang

Ellen J. MacKenzie, PhD, ScM, Dean of the Johns Hopkins Bloomberg School of Public Health and Bloomberg Distinguished Professor

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Letter from the Editors-in-Chief To Our Readers, As we reflect on our time as Public Health Studies students at Hopkins, we are reminded of a question that was initially posed in Introduction to Public Health our freshman year: “What is public health?”. At first glance, this question may seem simple to answer, yet over the past few years, we have come to realize the deeper complexities in aiming to define public health. In many respects, Epidemic Proportions was established twenty-two years ago in an effort to shed light on this question. Since then, the journal has provided a platform for undergraduate students to share their experiences engaging in public health fieldwork and research, as well as to voice their perspectives on public health matters that resonate with them.

As the articles in this volume illustrate, the challenge in answering, “What is public health?” stems from the diverse and interdisciplinary nature of the field. Public health spans disciplines ranging from law and medicine to engineering and environmental science. It is both visible and invisible, working on the frontlines to minimize morbidity and mortality during times of crisis while working behind-the-scenes to keep our daily food and water supply safe. It is practiced in the largest of cities and in the smallest of villages, constantly striving to provide all the opportunity to lead longer, happier, and healthier lives.

In the ever-evolving and vast landscape of public health, a major challenge lies in connecting the diverse communities that constitute the field. How can the research community effectively inform the policy community, ensuring that evidence is translated into initiatives and interventions that benefit all levels of society? How does community engagement shape public health practice and vice versa? Public health thrives on recognizing the significance of and subsequently fostering collaboration between diverse communities of individuals, from healthcare providers and researchers to policymakers and their constituents. The need for greater collaboration between such communities has inspired the theme of the twenty-second volume of Epidemic Proportions: “Connecting Communities, Committing to Change.”

Shared in this volume are a multitude of experiences and viewpoints surrounding matters of great public health importance, all of which add depth and nuance to our understanding of the public health challenges we face. As you peruse our journal, you will be whisked from Baltimore to San Francisco to Laos, landing in cafeterias, clinics, and correctional facilities, among a number of other places. Amid the unprecedented uncertainty that the field is currently facing, we encourage you to reflect critically on the role of communities in advancing public health research, policy, and practice while doing so. We find ourselves in a critical time that necessitates increasing our engagement and collaboration with communities. By doing so, we can forge a path forward while simultaneously uncovering more insights to the question, “What is public health?” in the years to come.

On behalf of the entire Epidemic Proportions team, we thank you for taking the time to read our journal at such a pivotal moment in the field of public health. We hope that you enjoy “Connecting Communities, Committing to Change” as much as we enjoyed producing it.

Sincerely,

Neha Skandan

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Wassim Bouhsane

Letter on the Founding of Epidemic Proportions J.D. Goodyear, PhD, Former Associate Director of the Public Health Studies Program Last year marked the fiftieth anniversary of undergraduate public health education at Johns Hopkins University. Coincidentally, and depending on how you count, it was also the twenty-fifth anniversary of the Public Health Studies (PHS) Program. Being point person in the establishment of the program, a new iteration in public health education, was enormously fulfilling.

Dr. Gert Brieger, the first director of the PHS Program, and I often found ourselves with gratified smiles as we watched the program unfold. It was always the students who inspired us. From my years in the Office of Academic Advising, I knew Johns Hopkins’ undergraduates to be academically enthusiastic and intellectually curious. Yet being around PHS majors all day was especially gratifying, and their enthusiasm was infectious.

So it happened that one afternoon, I was chatting with Zirui Song, a sophomore pre-med with a passion for economics as well. I’m not even sure he was a declared PHS major at the time, but I knew that he had a lively mind and enjoyed discussing ideas. It occurred to me to pitch an idea that I had been mulling over for some time about the PHS major starting a journal. His enthusiasm for the idea was overwhelming. When I pitched the idea to another sophomore, Claire Edington, not a pre-med but focused on the humanities, she, too, was clearly excited by the prospect. A third PHS major, Eric Ding, a junior, was so supportive of the idea that he wondered why I hadn’t come up with it sooner.

It was clear that this initiative had to be run fully by students. They would be in charge of all aspects of editing and publishing the journal. We began with eight students, I believe, sitting around the seminar table on the first floor of 3505 N. Charles St., the home of the PHS Program. Over several meetings, they hashed out ideas about what the journal should entail, what it might look like, and what to call it. When Eric proposed the name, “Epidemic Proportions”, we all knew that we were on our way.

This origin narrative reflects a simpler time. The PHS Program was small and lean, a startup if you will, and not the behemoth that it is today. I was the only advisor, Gert was on-site part time, and there was no administrative assistant assigned to the program. We could pretty much do as we pleased. Epidemic Proportions emerged in this environment. Students provided all of the energy and labor, while I offered encouragement, with the seed money coming from the PHS Program’s budget. In my view, Epidemic Proportions would play an important role in shaping the future of the program.

Zirui had the foresight to ensure that copies of the first issue would be distributed to the deans of the Homewood schools and the Dean of the School of Hygiene and Public Health (now the Bloomberg School of Public Health). Eventually, a copy found its way to Dean Al Sommer. I know this because he “invited” me to lunch at his office to learn more about me and the PHS Program initiative that was partially under the umbrella of the School of Public Health. There on his desk was a copy of that first issue of Epidemic Proportions. He lifted it, clearly impressed as he nodded with approval. It was a proud moment for me to tell him that it was a fully student-run operation. I believe that meeting was somewhat of a watershed moment for the PHS Program, and Epidemic Proportions was instrumental in raising the profile of the major. Further supporting this belief is that when Dean Sommer retired and there was a search for his replacement, the PHS Program was asked to supply enough copies of the journal such that all of the job’s candidates could read it over and gain an appreciation for the job’s undergraduate component.

I retired ten years ago, and so much has changed in the world of public health since then. I’m so pleased that the tradition of Epidemic Proportions endures. The journal has made remarkable strides since its founding. In these tumultuous times, I urge the journal’s authors, editors, and readers, as well as the PHS Program, to be resilient in the face of the headwinds that the university and the nation are facing. I implore you to stand fast and keep up the good work. Your efforts are essential.

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Opening Letter Adam Seth Levine, PhD, SNF Agora Professor of Health Policy and Management, Johns Hopkins University To the Readers of Epidemic Proportions, I am honored to be writing this letter to you!

At one level, collaboration in communities is one of those topics that is “obviously” critical for public health.

For instance, to prevent homicides, communities across the U.S. are creating violence reduction councils in which diverse stakeholders share data and devise recommendations together. And during the COVID pandemic, public health workers in cities across the country responded to novel health, economic, and educational challenges by initiating new collaborative relationships with data and front-line service delivery experts.

These examples are just the tip of the iceberg. Yet while we know that collaboration is important for public health, as a topic of inquiry, it generally plays a supporting role rather than being the main attraction.

That is what makes this issue of Epidemic Proportions so exciting! It puts the process and goals of collaboration—why it is important, when it arises, how to proceed, what makes it challenging, and what impact it has— front and center.

As you read the articles in this issue, several insights from the science of collaboration will be reflected. First, at its most fundamental level, collaboration entails people with diverse forms of expertise and experience engaging directly with one another on issues of mutual concern. Violence reduction councils, for example, entail connecting law enforcement data on homicides that have already occurred with data from front-line practitioners (schools, community-based organizations, and others) to think about how to prevent them from happening in the future.

Second, new collaborative relationships often don’t arise on their own, even when decision-makers would value them. Instead, there can be unmet desire. The creation of new violence reduction councils, for example, is so noteworthy in part because it represents a new way of working for many communities that has not always been the case.

Third, collaboration can have a range of goals. At one end is informal collaboration: knowledge exchange between decision-makers who may otherwise remain autonomous. One legacy of the pandemic is that, in many cities across the country, public health workers now have new connections across the community that they can reach out to, even just for advice on how to tackle challenges. At the other end is formal collaboration: new projects or initiatives that entail shared ownership and decision-making authority, as well as mutual accountability. They often entail sharing resources as well. The documents that violence reduction councils produce would be one example.

The pages that follow feature great examples of collaboration to advance public health in a wide variety of communities, often in response to quite difficult circumstances. I trust that they will inspire you to think anew about the collaboration that is needed in your work going forward!

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A Note on the Cover The cover of the journal, designed by Niki Zouzoulas, Rose Chen, and Pearl Shah, is a whirlwind of color and texture that invites the viewer to explore it more deeply. Inspired by the theme, “Connecting Communities, Committing to Change”, the cover design team sought to represent various elements of public health in a vivid and mesmerizing manner. The two faces on each side of the cover represent the human aspect in the field of public health, while the central “tree” symbolizes our connection to nature and the environment—natural or man-made—around us.

We can first discuss the inspiration behind the right and left faces. The icons within them are either specific to medicine (right face) or to holistic aspects of health (left face). The right face, designed by Rose Chen, emphasizes the medical field and includes icons like DNA, medical gloves, a heart, and a coronavirus particle. The left face, designed by Niki Zouzoulas, focuses more on community health and showcases international foods, the diversity of the human experience, and mental health activities like meditation. Together, both faces seek to represent the vast field of public health by highlighting its many dimensions—from clinical and physical health to mental, social, and cultural well-being.

The central element of the tree illustrates both abstract concepts and natural scenes, guiding the viewer through a visual journey from the built environment to the organic world. It begins with structured patterns representing man-made elements—the bricks of buildings, the side of a busy apartment complex, underground sewers, and the gears of innovation—before seamlessly blending into imagery of nature, including lush foliage, falling rain, blooming flowers, and vast constellations. Moreover, its slight asymmetry mimics the organic growth of a tree, a symbol of both transformation and connection. Designed by Pearl Shah, its intricate details include a busy meadow, flowing water, and various small, vibrant scenes, inviting the viewer to take a moment to absorb the depth and complexity within it.

Through the collaborative efforts of three different artists and the valuable guidance of Layout Team Lead Carlos Haring, the concept of community and connection was brought to life in this cover. We hope you appreciate the artistic story as much as we do!

Shannon Xiao

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Features

Shannon Xiao

Features

Reproductive Justice in Baltimore Through the Artistic Lens Joanie Ryu An underappreciated niche of Baltimore’s public health scene, reproductive justice is a movement addressing reproductive rights and family planning. Reproductive justice encompasses the social, economic, physical, and mental well-being of the community that is indispensable in achieving these goals. In short, reproductive justice and public health are arguably one and the same.

As I explored Baltimore and the art it had to offer, I uncovered a photo journey of reproductive justice in Baltimore. I specifically chose visual art as the medium for its ability to express and deliver implicit human experiences and emotions.

By addressing reproductive justice in Baltimore in tandem with the city’s visual art scene, we place the voice of each artist behind these connections to social questions. We thus reach a more humanized understanding of Reproductive Justice, and public health in general.

This mural is full of ambiguities: is the subject wading into the water or exiting it? Is the sun rising or setting behind her? Having no artist’s statement that I could find, these questions are left to interpretation.

There are some details that are more concrete. For one, the mural’s location; to take this photo, I stood directly across from a Planned Parenthood building. This location, like many others, is known to often host angry pro-life Baltimoreans on its steps. Could the artist have painted the child as a guilt-tripping figure, reminding those entering the establishment of what they are there to do?

With that, I thought it essential to note that the child here is Black.

With this is introduced a potential aspect of mourning. From the optimist’s eye, the sun rises, symbolizing the dawn of life. Yet the artwork can just as easily be reinterpreted— perhaps the sun is setting. In 2021, infant mortality rates were higher for Black babies than any other race in Baltimore.1 The baby in this mural is inextricable from her vulnerability; though she lives only in paint on this wall, iterations of her live and die all too quickly every day in this city and beyond. There is a very real dual take on this piece, reflective of the coexisting grief and joy of Black birth in Baltimore.

Mural of a young child, located in downtown Baltimore

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Hannah Atallah’s sweeping artwork provides a colorful backdrop to this community playground in the Abell neighborhood. In the art-

ist’s statement on her website, Atallah describes herself as “operating at the nexus of art [and] community engagement… crafting… murals tailored to their environmental settings”.2 So she does, brightening up this joyful and nostalgic space so quietly instrumental to local youths’ health.

A mural beside Waverly Commons, an outdoor event venue

Standing beside this space, looking on at a toddler scooting around in a toy car, I was hit with a wave of nostalgia. In that moment, Baltimore felt a bit less foreign, somewhat more intimate.

Play, despite its frivolous manner, is in fact fundamental to a child’s physical, mental, and social development. Outdoor play time particularly stimulates creativity, self-direction, and spontaneity.3 The promotion of enjoyable physical activity is also an essential aspect of this playplace and its associated beautification. One in every three school-aged children in Baltimore suffers from obesity and the correlated health effects.4 When spaces like these are constructed in such an appealing manner, families in Baltimore are more incentivized

Features to bring their children here, and therefore, to reap the benefits of outdoor play.

Raising healthy children is a basic tenet of Reproductive Justice, and beautiful spaces for our little ones work towards this public health need quite effectively.

Directly beside this mural is the parking lot in which the weekly farmer’s market takes place, providing me as well as other Hopkins students an easily accessible opportunity to engage with Baltimore in a fun and positive way. I’ve noticed that regular attendees of the farmer’s market often have less disparaging things to say about the city as a whole, whereas those who mainly stay on-campus seem to have an inflated sense of the city’s perils.

The beautiful primary colors of this mural serve as an encouraging supplement to the bustle and energy of the farmer’s market, the Waverly Book Festival, and music festivals.

Much like Abell’s playground, the beautified commons area attracts locals to gather much more effectively than a barren equivalent ever could. It is in community spaces such as this that local action flourishes. With the increased support of local organization comes the enhancement of local power.

Though lack of faith in local power is prevalent, it can be strongly argued that local action is often if not always the catalyst for national movement. In All Health Politics is Local: Community Battles for Medical Care and Environmental Health, Merlin Chowkwanyun, Professor of Sociomedical Sciences at Columbia’s Mailman School of Public Health, argues that “it is the local level that ultimately shapes the execution and the fate of ambitious national social welfare initiatives”.5 Chowkwanyun points to

four different case studies in cities around America that exemplify the power of grassroots organization in motivating larger-scale change.

Public health can only thrive in connection to one another. As we, together, take in the vibrancy of this enhanced place, there comes a sense of hope and a return of brightness.

This collage by an anonymous female inmate brings the outsider a vision of innumerable conflicting feelings—the Grim Reaper looms in the bottom center, to the right of the question ‘How did it start?’. A cut-out calls for justice for George Floyd, as Black and Brown women look on.

Collage art by an anonymous female inmate, displayed in Red Emma’s

Inflated incarceration rates are a pressing public health problem in Baltimore particularly, with Baltimoreans making up 40% of Maryland’s incarcerated population but only 9% of Maryland’s population overall.6 With the overturning of Roe v.

Wade, it has become impossible for the incarcerated to safely access abortion care, alongside other reproductive healthcare pertaining to menstruation, ovarian and uterine health, etc.7 It is more than understandable the doubts and fears the artist was facing as she crafted this piece.

Surprisingly enough, this Male/ Female statue was actually wildly unpopular when it was first erected

Niki Zouzoulas

Male/Female statue located outside of Penn Station

in front of Baltimore’s Penn Station.

Says John McIntyre in an old video from the Sun, “the city chose… to represent Baltimore’s quirkiness”.8 The location of the statue–directly outside of Penn Station, placing it directly in view of newcomers to the city–fueled a significant part of this contention. Baltimoreans complained that it would be an odd first impression for visitors, that it would send a message about Baltimore that they disliked. This objection has weight in that Male/ Female does, in fact, play a symbolic role for the city simply by merit of its location.

At this point, I’ve visited Penn Station and, correspondingly, Male/Female several times. The statue does begin to take on a sense of familiarity, a deeper association with Baltimore’s identity, over time and visits.

Male/Female is a statement by Jonathan Borofsky on how differing energies mesh to create a stronger whole. Borofsky is also the artist behind several other gigantic installations, the most famous being the iterations of Hammering Man, a motile statue crafted as tribute to the workers of the world.

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Features With this knowledge, the statue took on a new dimension regarding Reproductive Justice in Baltimore. I believe every work by an artist inherently carries the values expressed in their other works, and I began to feel a sense of pride towards the status of this figure as a symbol of the city. These works persist as part of Borofsky’s legacy, and by extension, those of the cities which contain them.

Male/Female represents the sameness of all people within, regardless of gender and other constructed factors; it was constructed by an artist who believes in the vitality of workers to society; it’s not a far reach to tie these principles back to those of reproductive justice, especially concerning communal health regardless of gender, birthing and socioeconomic status.

Mural located in Charles North neighborhood of Baltimore

Admittedly, I had a strongly negative impression of Charles North, where I found this mural. Every single time I’ve been there, seeking to enjoy a night out at the local KBBQ place with friends, we’ve been catcalled by adult men we pass on the streets. The discomfort, fear, and anger brought on by this experience synthesized a general distrust of this neighborhood and its residents.

I was walking almost too fast, avoiding the risk of interacting with more catcallers, to register this message; yet once I did, I was forced to stop in my tracks. I recognized the phrase from my Reproductive Justice in Baltimore class—I am because you are.

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I thought this motto the perfect picture to wrap up my exploration of reproductive justice in Baltimore through visual art. Of course each individual’s wellbeing is unquestionably linked to the wellbeing of all others; this idea is the foundation that movements like Reproductive Justice are built on. This idea is what drives us to study and to care about public health at all.

Coming across this message specifically in this area jarred me once and for all from the negative mindset with which I was approaching Baltimore neighborhood culture.

Before my own eyes was evidence that people here cared about community-centered welfare.

In Charles North specifically, the median income is $35,154 and the rates of assault and robbery are more than five and ten times that of the national average, respectively .10 With these indicators, it’s reasonable to assume that most neighborhood residents often don’t have the safety and stability to work for social change and large-scale movements. In this context, I thought it especially significant that I found this mural here, serving both as a presence of care and hope to the people of Charles North and a countermeasure to false judgment calls that newcomers such as myself might make.

As I concluded my photo journey in this moment, I could observe the shifts I’d experienced in my perception of Baltimore. It has become a city that is no longer unfamiliar, threatening, and closed-off, but a place where people relate to one another and to the world in ways so similar to how I do. People here also want safety and stability for themselves and their families, the right to healthcare, and community connection, among other things.

Through the visual art of Baltimore, the concept of reproductive justice becomes much more clear.

References

1. Maryland Vital Statistics Infant Mortality, 2021. Maryland Department of Health; 2023. https://health.maryland.gov/vsa/ Documents/Reports%20and%20Data/Infant%20Mortality/InfantMortalityAnnualReport_2021_Final.pdf 2. Atallah H. Artist Statement. Hannah Atallah. Published 2024. www.hannahatallah.com/about 3. Schipperijn J, Cathrine Damsbo Madsen, Mette Toftager, et al. The role of playgrounds in promoting children’s health – a scoping review. The international journal of behavioural nutrition and physical activity.

2024;21(1). doi:https://doi.org/10.1186/ s12966-024-01618-2 4. RethinkYourDrink.

Baltimore City Health Department. Published December 2, 2015. https://health.baltimorecity.gov/ sugar-sweetened-beverages 5. Chowkwanyun M. All Health Politics Is Local. UNC Press Books; 2022.

6. 6.Initiative PP. Maryland profile. www. prisonpolicy.org. https://www.prisonpolicy.org/profiles/MD.html 7. Lewis N, Canning C. Abortion Is Just One Part of a Larger Story About Pregnancy Behind Bars. The Marshall Project. Published June 30, 2023. https://www.themarshallproject.org/2023/06/30/post-roe-abortion-prison-jail-reproductive-justice 8. John McIntyre: Jonathan Borofsky’s “Male/Female” By The Baltimore Sun. Facebook.com. Published 2022.

Accessed December 1, 2024. https:// www.facebook.com/baltimoresun/videos/10155697820999712/ 9. Niche. Niche. Published 2024. Accessed December 1, 2024. https://www.niche. com/places-to-live/n/charles-north-baltimore-md/

Author’s Biography Joanie (Eunji) Ryu is a first-year at Hopkins planning to major in public health with a minor in Medicine, Science, and the Humanities. She has been an avid writer since elementary school and loves observing the ways creativity and public health connect. Her goal is to continue to find ways to apply this passion in different aspects of life and education.

Features

Medicine as a Universal Language Sumin Han As the early sun rose over the misty hills of Vang Vieng, a small town in Laos known for its serene landscapes, I stepped off the bus with our medical service camp team as part of the Bluecross Organization. I was filled with nervousness and uncertainty about what to expect. However, those feelings quickly faded as we were greeted by children running with the brightest, purest smiles, their warm embraces welcoming us into their home.

For the children and elders who approached us with hope in their eyes, we offered more than just medical care—we shared empathy, compassion, and a genuine connection that transcended language barriers.

What I hadn’t anticipated was how profoundly this experience would transform me, leaving an impact just as deep as the one we hoped to make in their lives.

Yulia Gadalina/Pixabay

Upon arriving in Vang Vieng, I was immediately struck by the stark contrast between the rural environment and the bustling cities I was accustomed to in Korea. Instead of hospitals and pharmacies on every corner, the streets were lined with

vendors selling cloth. Our temporary clinic, quickly became a focal point for the community. From the moment we opened our doors, people began to line up at dawn, clutching their registration slips, their faces filled with curiosity and gratitude.

The clinical task at hand transformed into something far more meaningful—a shared connection that transcended language, culture, and medical procedure.

As I prepared to carry out the glucometer reading, I gently took the hand of an elderly patient, carefully following the steps I had practiced countless times. Her frail hands trembled slightly when I pricked her finger to collect a drop of blood, but despite the discomfort, she looked up at me and offered a smile that radiated the warmth and familiarity of my grandmother’s face. Through a local translator, she whispered softly, “I’ve lived many years, but this is the first time I feel like someone truly cares about my health.” Her words, simple yet profound, struck a deep chord within me. In that moment, the clinical task at hand transformed into something far more meaningful—a shared connection that transcend-

ed language, culture, and medical procedure. It was a moment of trust, fragile yet strong, blossoming between two strangers from vastly different worlds.

While providing medical services was essential, our mission extended beyond diagnostics and treatment. We wanted to leave the community with knowledge that would be passed along long after we were gone. With the help of local translators, I led educational sessions on dental hygiene and proper handwashing techniques—topics that seem simple yet are powerful in preventing the spread of infectious diseases.

I will never forget the group of children who gathered around, their wide, curious eyes following every movement as I demonstrated the proper way to brush teeth using a model. For many of them, brushing three times a day was not a habit they were accustomed to. Limited access to clean water and toothpaste had made oral hygiene a secondary priority, something not easily prioritized in their daily struggles. Yet, as we distributed toothbrushes and toothpaste, the children’s faces lit up with excitement. They eagerly mimicked the brushing techniques we demonstrated, their laughter

Anita/Pixabay

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Features filling the air as they sang along to the catchy song we created to help them remember the steps.

Later that day, I witnessed one of the children from the session teaching his younger sibling how to wash their hands properly. It was a small yet significant victory, showing that our message had resonated. These moments where education sparked behavioral change were among the most fulfilling aspects of the camp.

The experience was not without its challenges, of course. Language barriers, cultural differences, and the lack of medical equipment were significant hurdles. However, these challenges became opportunities for growth. We had to improvise, relying on basic tools and using our instincts when modern diagnostic equipment was unavailable. This reminded me that healthcare extends beyond technology; it is about human touch and the genuine desire to help.

I recall a particularly challenging moment when a mother hesitated to let us examine her young child, fearing that our modern medical tests might harm him. Despite our efforts to reassure her, it was the gentle words of an elderly Lao woman, who seemed to know the mother well, that made the difference. She approached and said, “We may not understand all their tools, but their hearts are here to help us.

Trust them as you would trust me.”

The mother’s anxiety eased, and she allowed us to proceed.

In that moment, I felt a deep sense of humility. The mother’s hesitation was a reflection of the uncertainty that often accompanies unfamiliarity with modern medical practices, especially in a community where traditional methods have been passed down through generations. I could sense her protective

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igormattio/Pixabay

instincts as a mother, unwilling to let anyone risk harm to her child.

But it was the words of the elderly Lao woman, grounded in trust and shared experience, that bridged the gap between fear and understanding. Her reassurance reminded me that what we were doing wasn’t just about offering medical care—it was about listening, respecting, and gaining trust through human connection.

As the camp came to a close, we had one final opportunity to offer a hug to the children and hold the hands of the villagers. Each villagers’ embrace was warm, full of gratitude and silent understanding, as if it spoke for both of us. In that instant, I realized how deeply these connections had touched us all.

The bonds we formed, so simple yet powerful, spoke volumes about the universal language of care —a language that goes beyond all barriers, even the distance between us.

I still find myself reflecting on the faces of the people we had met—the children with their bright smiles, the elders with their stories etched in wrinkles, and the families who embraced us as one of their own. In just a few short days, we had become a part of their lives, and they had become a part of mine.

In a world that often feels divided, experiences like these remind us of our shared humanity. The smiles, the stories, and the simple gestures of kindness in Vang Vieng taught me that while we may come from different backgrounds and speak different languages, the desire for health and happiness is universal.

The connections I made—with the villagers, with local volunteers, and with my own team—were as impactful as the medical services we provided. While I continue my journey in public health, I carry with me the lessons from Laos—the importance of empathy, the power of education, and the joy of forming meaningful connections. It is these moments that shape not only our careers but also our very understanding of what it means to be human.

Author’s Biography My name is Sumin Han, a sophomore majoring in Public Health Studies with a deep interest in Parkinson’s disease research and its implications for improving patient care. Aspiring to become a physician, I’m dedicated to bridging research and clinical practice. Beyond academics, I find joy and inspiration in music and creative expression.

Features

From Edamame to Anaphylaxis: One Student’s Allergy Battle Gaayathri S. Nadarajah It all started with Moo Shu Pork.

It was a dish she had eaten frequently enough but this day was different. Instead of simply delighting in the tangy dish, Grace Gerber was faced with something she had encountered many a time before–an allergic reaction. Gerber was no stranger to allergies. By that point she knew extensively of her allergies to mango, kiwi, pineapple, cantaloupe, honeydew, corn, cabbage, latex and even sodium lauryl sulfate. But this reaction was something unexpected. Uncharted territory.

Grace Gerber had never before experienced an allergic reaction to Moo Shu Pork, but in the months following this fateful day, that was sure to change.

Grace Gerber had never had issues with soy-based foods before. If anything, she frequently indulged in them. Gerber initially brushed off her allergic reaction to Moo Shu Pork until a few weeks later when she was faced with yet another unexpected reaction–this time to edamame. After an allergy test, it seemed as though the mystery was solved–she was allergic to foods with high soy content like soy sauce, tofu, and–of course–edamame. Yet despite taking the necessary precautions, more than a year later, Gerber found herself puzzled yet again: sushi, protein bars, and even chocolate seemed to be causing her allergic reactions. It seemed that her allergy had evolved. Her allergy was now not limited to simply high-soy content foods but also soy

ing something with high soy content in their room. Gerber assumed this would be perfectly safe, given that she herself wasn’t ingesting it.

Yet she recounts, “Almost immediately my face swelled and my eyes swelled up, which were key signs of anaphylaxis. I got hives on my skin and in my mouth.”

Charles Echer/Pixabay

Soy beans in a field

derivatives–something that is rare but not unheard of for individuals with severe soy allergies.

Now entering her freshman year of college–and with another year of experience living with a soy allergy under her belt–Grace Gerber felt like she finally knew the extent of her allergy. But her allergic reactions and their frequency only got worse.

“The first week I had one. The second week I had three. And then it kept going up from there to the point where I was having an allergic reaction, like almost every day,” Gerber explained. “With allergies… once you’ve developed an allergy, the more you’re exposed, the worse your allergy gets.”

Gerber’s relationship with her soy allergy developed further after one fateful evening in her dorm room. Gerber’s roommate was eat-

Gerber immediately left the room. While Gerber’s reaction stopped progressing, it took “several hours to get back to normal.” The experience left her with the conclusion that her soy-allergy was now airborne–something she had never experienced with any of her other allergies before.

“I have to think of my dorm as like a home base, because I can’t eat anywhere else.”

As Gerber persevered to find ways to coexist with her newly airborne allergy, she was disheartened by the school’s inability to help her. “I met with the school’s dietitian…but there’s an extent as to how much she can help…” She explained. There were numerous issues in regulating JHU dining halls to ensure a safe, allergen-friendly environment for her. After a long back and forth, and multiple allergic reactions even in dining areas Volume 22

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Features she was promised would be safe, Gerber was eventually faced with the reality that JHU could not guarantee that “any of [their] facilities are completely safe.”

Gerber attributes the most frustrating part of her airborne soy-allergy to its limitations. Even the way she thinks has been modified since her allergy has gone airborne.

“I have to think of my dorm as like a home base, because I can’t eat anywhere else,” she recounts.

Furthermore, Gerber’s attempts to avoid having an allergic reaction requires constant vigilance which is often exhausting. “It’s like constant [tracking]. This is eaten in that room, so I can’t go in that room.”

Despite Gerber’s conscientiousness, she has still experienced allergic reactions in some of the most unexpected of places. “The other night there was something that was eaten in the hall [outside my dorm room] that had a lot of soy, like Chinese food,” she shared. “When I went into the hall, I immediately had an allergic reaction.” Such instances serve as a reminder that even in places where one expects to be safe from allergens, there is always risk of an allergic reaction.

While Gerber has found ways to reduce the frequency of her allergic reactions, this doesn’t discount the severity of these reactions. Gerber explains that when she gets a reaction it throws off her entire routine. “The symptoms don’t last for just the day, they go on. They stop developing but they don’t go away.”

Gerber experiences a number of uncomfortable symptoms as a result of her reactions including hives on her skin, as well as in her mouth and throat. These often blister over and bleed in the days following exposure to an allergen.

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When asked if there was anything in particular Gerber hoped the larger community could understand about her life with allergies, the following stood out to her.

“I think in general, people could be more aware that people have allergies…just being aware that people do have those limitations.”

Bin Gu/Pixabay

When asked what she would change in the way Hopkins and the general community handles food allergies, Gerber wanted to highlight two key flaws–unclear/ incorrect labeling and cross-contamination. Gerber further explained that while nut allergies are more commonly known throughout society and thus are more definitely labeled on products, the same cannot be said for soy. “It’s really hard not knowing if something’s safe or not. It’s really hard when things are unclear…some companies only label it [as soy] if it’s made with soy beans and they won’t label it if it’s soybean oil.” She continues, “At restaurants and dining halls…a big reason why I can’t go to them is because of cross-contamination and that people don’t necessarily take proper precautions. Like they don’t wash things off or don’t wear gloves or don’t change their gloves.”

These simple interventions during food preparation could prevent life-threatening anaphylaxis events for those with allergies. By standardizing these procedures, the result could be mutually beneficial

for both those with and those without life threatening allergies.

My conversations with Grace Gerber have served as a reminder of just how much our daily routines can shift in response to something as seemingly straightforward as food. For Gerber, the challenges of managing an airborne soy allergy has reshaped not just her college experience but also how she interacts with the world around her.

Listening to Grace Gerber’s experiences have made me realize the true complexities of living with an allergy–nuances that those without allergies may not fully recognize.

It’s not just about avoiding food– it’s about anticipating hidden dangers whether it’s Chinese food in a hallway or the unlabeled soybean oil in a product. Her story serves as a powerful reminder of the need for greater allergy awareness and support from both the Hopkins community and beyond.

Author’s Biography Gaayathri S. Nadarajah is a freshman at Johns Hopkins University, majoring in Public Health Studies.

Passionate about storytelling, she seeks to explore the intersection between the humanities and community health. In addition to her academic pursuits, Gaayathri enjoys artistic endeavors of all kinds and sparking thought-provoking conversations

Features

A Divided Golden City: Highlighting SROs in San Francisco Connie Huang San Francisco: a city known for its history, cultural enclaves, and tech boom. But behind all these charming features and wealth, thousands of families and individuals are hidden in single-room occupancy (SRO) hotels. SRO housing is often a single eight-by-ten-foot room where occupants share bathrooms and kitchens with the rest of the floor.1,2 Currently, there are around 19,000 residential SRO rooms.1 SRO hotels have been a significant part of San Francisco’s housing landscape for over a century, shaping the divided quality of life and health among the city’s residents today.

History of SROs Initially, SROs were designed as low-cost housing for transient workers and the working class during the late 19th and early 20th centuries, a time of rapid industrialization in the city.1,2 These buildings were located in areas like the Tenderloin, South of Market (SoMa), and Mission District.2 In the early 20th century, SROs provided affordable accommodations as waves of immigrants and laborers came to San Francisco.2 They were particularly popular among migrant workers, sailors, and those unable to afford larger apartments.

The rise of large, multi-story SRO hotels was prominent from the 1910s through the 1940s. However, after World War II, as economic conditions improved and housing policies evolved, the number of SROs started to decline. By

the 1960s and 1970s, many of these hotels began to deteriorate due to neglect, disinvestment, and urban renewal policies that started to transform neighborhoods like the Tenderloin. In the late 20th century, however, SROs became one of the city’s only affordable housing options due to their low operating costs and federal funding.1 The city adopted policies to preserve and regulate these buildings, as they had become homes for a growing population of low-income residents, families, and people with health or social issues.2

Many growing families also reside in a single room that fails to meet the needs of a family.

Quality of Life in SROs Compared to traditional hotels, SRO hotels have lower-quality living spaces that affect the daily lifestyles of their occupants. Historically, many SROs were poorly maintained, with overcrowded conditions, aging infrastructure, and minimal amenities.3 The rooms themselves are typically small—often just enough space for a bed and a small dresser—while residents share common facilities like bathrooms, kitchens, and laundry rooms.3,4

Over the years, as the city’s population grew and housing prices soared, the conditions in many SROs deteriorated, leading to widespread concerns about their livability.5 Many residents are low-income individuals, including elderly people, disabled individuals, veterans, and those dealing with mental health issues or substance abuse.3,4,5 This has led to challenges in terms of social support, health services, and overall living conditions.3,5 Many growing families also reside in a single room that fails to meet the needs of a family. In an interview with The San Francisco Standard, Miyu Yu explains the struggle of raising her family of 6 in one SRO room: “Sometimes, the boys need to use the bathroom in the morning before school. When other seniors are using the bathroom, the boys cannot use it. So the boys have to relieve themselves in the room”.6 SRO hotels are simply not a sustainable housing solution for families.

However, with the increasing need for affordable housing, many SROs in San Francisco have been re-envisioned as critical lifelines for those who cannot afford market-rate rent.1 Even though these are viable short-term options, Section 8 Housing is the only way to receive appropriate housing for many residents, which takes years for approval. Over time, the city has made efforts to improve the conditions of these buildings, especially through health and safety codes and city investments in maintenance and rehabilitation.1,5 Volume 22

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Features Health in SROs Health issues have long been a concern in SROs, particularly because these buildings often lack adequate sanitation and are densely populated.3 Shared bathrooms and kitchens can contribute to the spread of disease, with poor air quality–especially in older buildings–exacerbating respiratory problems.3,5,6 During the COVID-19 pandemic, families and individuals struggled to isolate themselves after infection. Mental health challenges are also common among residents, with a significant number suffering from conditions like depression, PTSD, and substance use disorders.

To address these issues, San Francisco has developed public health programs specifically tailored to SRO residents. These initiatives aim to improve mental and physical health by offering on-site medical services, providing social services, and funding community-based organizations that help residents access health care, nutrition, and social support.1,5

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Current Policies In recent years, SROs in San Francisco have been at the center of debates about affordable housing and homelessness. Various policies have been implemented to ensure the preservation of these buildings and their residents’ well-being.

Preservation and Rehabilitation: The city has passed legislation to preserve existing SROs, many of which are located in neighborhoods experiencing rapid gentrification.

This has included efforts to stabilize rents and protect tenants from displacement due to rising market prices.1,5 Additionally, rehabilitation projects have aimed to restore these buildings, improving plumbing and electrical systems.5 Supportive Housing: As part of the city’s efforts to combat homelessness, some SROs have been designated as “supportive housing,” providing services and resources such as case management, addiction recovery, and mental health support.1,5 These programs aim to

improve the quality of life for residents while also addressing broader social issues like homelessness.

Tenant Protections: San Francisco has some of the strongest tenant protection laws in the country. These laws are particularly important for SRO tenants, who often face eviction threats or displacement. For example, the city has rent control ordinances that apply to many SROs, preventing landlords from raising rents beyond a certain limit and making it difficult to evict tenants without just cause.1 Health and Safety Standards: The city continues to enforce strict health and safety standards for SROs, including regular inspections, fire safety regulations, and requirements for building maintenance.5 There are also initiatives to reduce overcrowding, such as collaborations between the Department of Building Inspection (DBI) and nonprofit community organizations on housing referrals, and ensure that SROs meet basic stan-

Rob Sarmiento/Unsplash

Features dards for living conditions. Still, residents of many SROs continue to face challenges in maintaining a healthy living environment.5 Funding for Supportive Services: The city funds a range of services designed to improve the lives of SRO residents, including mental health services, addiction treatment programs, and outreach to people experiencing homelessness.5 San Francisco is also exploring new ways to integrate SRO residents into the broader social safety net, addressing issues like food insecurity and access to healthcare.5 Yet, these initiatives aren’t sufficient to fully resolve the issue. Tenants and workers in SRO hotels have noticed persistent pest, drug, crime, health, violence, and homelessness problems among residents, with San Francisco leaders neglecting the hotels and related nonprofits.5 From 2020 to 2021, 14% of

overdose deaths in San Francisco occurred inside SRO hotels. Residents have also threatened hotel workers and other tenants with violence, such as a resident slashing another resident with a knife. Many residents in underfunded and understaffed SRO hotels are left to endure their health conditions and even die, emphasizing the need for focused efforts on many SRO hotels and residents.

Conclusion SROs in San Francisco have played a crucial role in providing affordable housing, especially for low-income and vulnerable populations, for over a century. While the living conditions in these buildings have been challenging, San Francisco is actively introducing policies focused on preservation, health, tenant protections, and supportive services. However, there is a need for continued effort from all stakeholders in the communi-

ty, including public health officials and local organizations. Ultimately, SRO rooms pose a health burden to their occupants. From the dependency of SROs for housing to the unhealthy living spaces, SRO hotels prove the many disparities that plague the “Golden Gate City”, including poverty, housing instability, and poor health status.

References

1. San Francisco’s Community Stabilization | Single Room Occupancy Hotel Protections. San Francisco Planning. Published 2017. https://projects.sfplanning.org/community-stabilization/sro-hotel-protections. htm 2. History of S.R.O. residential hotels in San Francisco – Central City SRO 2. Collaborative. Central City SRO Collaborative. Accessed November 27, 2024. https://ccsroc. net/s-r-o-hotels-in-san-francisco/ 3. Ellinger M. Sixth Street - FoundSF. www.foundsf.org. https://www.foundsf. org/index.php?title=Sixth_Street 4. The Bold Italic. Life Inside SF’s Vanishing Single Resident Occupancies. Medium. Published July 10, 2014. https:// thebolditalic.com/life-inside-sf-s-vanishing-single-resident-occupancies-the -bolditalic-san-francisco-20bf7aa0b3c8 5. Palomino J, Thadani T. S.F. has spent millions to shelter the homeless in rundown hotels. These are the disastrous results. The San Francisco Chronicle. Published April 26, 2022. Accessed November 27, 2024. https://www.sfchronicle.com/ projects/2022/san-francisco-sros/ 6. Bearman S. Chinatown’s Hidden Poverty: How a Family of Six Survives Living in a Tiny Room. Youtube; February 15, 2023.

Accessed November 27, 2024. https://youtu.be/ZH44TRTz24k?si=Vd305ZGjbAboohmr

Author’s Biography Connie Huang is a sophomore studying Public Health and Biology. She is interested in child health, Asian-American health, and the social determinants of health surrounding these two populations.

Outside of her work on health, she enjoys cooking and exploring new restaurants.

Jared Erondu/Unplash

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Features

Poverty, Racial Divides, and French Fries: Addressing Fast-Food Culture Jeffrey Mathew I went to high school in the heart of urban Rockford, Illinois. After being a booming screw manufacturing city in the 1800-1900s, the town was slowly demolished from its former glory by overseas shipping and urban sprawl during the 20th century. As the Great Migration of the 1940s increased the Black worker population, White residents fled to the developing suburbs in the periphery. Since then, Rockford has been known to be a dangerous city, that consistently ranks among one of the most dangerous small cities in the nation.1 In addition to becoming the most dangerous area in the US, Rockford’s supermarkets changed locations to the suburbs as the city became a food desert because of racial demographic changes. My high school, Auburn High School, was ¾ minority students with a 41.4% Black population.2 I remember watching long lines outside the window on the school bus in the mornings at fast food chains just a few minutes away from school including McDonald’s, KFC, Popeyes, and Burger King. Although these food chains were not considered ‘healthy’, they were popular places for lunch or after-school meals. Additionally, many of my fellow students worked at these locations over the summers because of these fast food chains’ appeal to adolescent palate, affordability, and proximity.

On the other hand, the number of supermarkets or healthier alternatives was limited compared to other suburban areas I visited.

As a teenager, this seemed to be

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the mundane reality of my city, but I’ve come to realize that food deserts and the overwhelming presence of fast food are a problem in several other Black and low-income urban communities such as Baltimore, Chicago, Philadelphia, and Detroit. Geographical locations of fast food tend to correlate with the fact that predominantly Black neighborhoods (80% Black or more) have one additional fast-food restaurant per square mile compared to predominantly white neighborhoods (around 80% white).3 Some authors, including historian Dr. Naa Oyo A. Kwate from Rutgers University, indicate that race is an overwhelmingly more important factor in geographical settings of fast food compared to income, as areas of higher income Black neighborhoods had statistically insignificant differences in fast food exposure.4 The importance of this issue in terms of public health is centered around the several negative effects of higher levels of access to fast food versus healthy alternatives on the health of Black populations. Specifically, because fast food tends to provide food that is high calorie and trans-fat dense, these populations often succumb to obesity which leads to several other long-term effects including diabetes, osteoporosis, cardiovascular disease, and some forms of cancer.

Additionally, studies have shown that obesity also increases the years of life lost (YLL) ranging from 4-12 years based on the severity of the disease.5 Access to fast food has a significant correlation with obesity rates

as Black adults have the highest rates of obesity by race 49.6% compared to 42.2% in whites and 44.8% in Hispanics.6 There is growing concern that having greater access to affordable, fast food in Black communities may increase unhealthy consumption, leading to higher levels of obesity and its negative effects on the population.

How can we find a way to solve this problem? The issue has more under the surface than one might assume. There are many suggestions of how we can fix these issues, but it seems that modern public health experts point to community-based initiatives, and specifically, competitive community-based initiatives as being the best solution.

There are psychological reasons that community-based initiatives might be a more effective method to decrease obesity. This includes the fact that it allows community members to get first-hand experience of seeing the positive health outcomes of these changes. Erin Guerricabeitia, the founder of Boise Urban Garden Schools, a non-profit that helps develop child-based community gardens throughout the city, stated that “Today, kids have lost the connection between where their food comes from and how to properly nourish their bodies… and there are major health consequences from this disconnect”.7 Erin goes on to say that community gardens can be a way to mentally bridge the gap that is present for many low-income families. It is a recent movement in my local neighborhood

Features where hospitals and non-profits are creating garden beds throughout the city, even in elementary schools, that hope to put the keys to reducing obesity into the hands of the community itself.

However, many researchers may argue that such small community-based efforts may be weak because it does not outweigh the benefits that fast food portrays.

The historical connections between Black communities and fast food are important to dissect to show that there are significant barriers to the efficacy of such initiatives. Marcia Chatelin a professor of African Studies at the University of Pennsylvania, in her book Franchise: The Golden Arches in Black America, documents the long and deeply intertwined nature of Black communities to the McDonald’s corporation.8 There are four major tenets of historical arguments present that can be used to challenge community-based initiatives: 1. Racial Targeting Fast food operatives such as White Castle, McDonald’s, Kentucky Fried Chicken (KFC), and Wendy’s desiring to serve humble

quick meals quickly transformed into franchise-based, multi-million dollar corporations that defined America’s consumer revolution. The major audience of this movement at its release was white suburbia as franchisee owners, customers, and locations were centered on this population. However, during the Civil Rights Movement, McDonald’s and such corporations eventually tapped into the possibility of shifting their brand focus from White to Black urban populations Increasing the focus on targeting this population through advertising, employment, and the portrayal of the Black family ideal. Fast food has become a cornerstone for these communities from children to families as they support families with wages and affordable, nutritious food. It will be difficult to bring community-based initiatives to dislocate this decades-long shadow of fast food in these communities due to racial targeting.

2. Black Franchising Around the same time as the Civil Rights movement and the increase in Black consumption of fast food, many white owners closed or

left their operations in these urban centers. The need for new owners and the increased trust of the Black population led McDonald’s administrators to attempt to find Black franchise owners who could serve as the bridge between the Black population and corporate McDonald’s which was the beginning of ‘Black capitalism’. McDonald’s in areas of high Black populations have gained high popularity and trust in the community and greater revenue compared to white areas.

Community members and franchisee owners may not be able to gain the same financial incentives from community-based interventions, often voluntary, making it a less lucrative opponent to deeply entrenched capitalist systems.

3. Governmental Backing A critical component of Black communities’ connection to corporate fast food was government backing. Several pro-civil rights political leaders and later, free market presidents such as Richard Nixon found similarities in supporting the growth of Black Capitalism as a means to increase equality and revenue within the private sector.

Although there were attempts for

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Features policy-initiated community-based activism by Michelle Obama to reverse these decisions through her child obesity initiative “Let’s Move!”, it has not been successful in overturning decades-old policies that tied the knot between fast food and black communities.9 4. Stereotypes As the Black community has been attuned to fast food and has decreasing access to healthier alternatives, there is a significant community belief that healthier foods are expensive and belong to the white population, and if their diets change it will take away their culture.10 Therefore, there are psychological cultural barriers that seed distrust of healthier foods as a foreign entity in the population. Community-based initiatives, although addressing several of the economic issues, may not be easy to integrate into Black communities.

The deep ties of Black communities to fast food is a result of both capitalism and governmental policies. Ideally, if policymakers and activists want to completely solve the issue of access to healthy food in these communities which is largely a systemic issue, they must aim to dismantle what historical avoidance and systemic profit-maximization have done within Black communities.

For example, the government can attempt to push for healthier alternatives on fast food menus which it has done before. Yet, such alternatives are not feasible, as they require dismantling the profit-pumping bureaucracy that capitalism has created, which many policymakers would look on unfavorably. Regulating advertising is one example of this uphill battle, which has been seen as a violation of free speech such as in the Virginia State Board of Pharmacy

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(1976) case that extended the First Amendment to commercial products.11 Governmental support and lobbyists often believe that capitalism will work for the best interests of the people and the freedom to act as it so chooses, and this deep-seated sentiment will make it harder for such policies to be passed.

The deep ties of Black communities to fast food is a result of both capitalism and governmental policies.

Therefore, community-based initiatives must tackle the largest issues of their implementation which are a lack of financial incentives and a polarized political climate. Increased public health efforts in racial communities have focused on competitive community-based approaches as a way to indirectly oppose capitalistic efforts.

These approaches aim to target trusted voices in the community to learn, educate, and provide services to their community for a healthier lifestyle with financial incentives. Starting such initiatives may be inexpensive yet address several of the issues that are raised by Dr. Chatelin’s book. These strategies, although more challenging to jumpstart in a variety of communities at the same time and are currently scarce, may be a more effective and trusted way to provide healthier alternatives to fast food and thereby limit the consumption of fast food.

In the realm of fast food alternatives, there are a few organizations

that have started to initiate community-based approaches to tackling Black obesity with relative success.

As a branch of United Community Centers, a social justice center for the Black population of Eastern New York, East New York Farms (ENYF) stands as a way to promote food justice through competitive community-led initiatives. ENYF provides resources to local Black farmers to grow fruits and vegetables in their homes or in community gardens that are facilitated by the group.12 Once grown, produce is sold at farmers’ markets at affordable costs to the community and waste is composted. ENYF also provides educational workshops to schools and communities about healthy diets and hires local high schoolers to work to cook, grow, or educate peers about healthy alternatives. In 2023, The group was able to run 3 farmers’ markets with 40 community gardens and 20 backyard gardens. In just one of their many partnerships they were able to distribute 2125.16 lbs of grown produce to over 200 residents. Gardeners on the other hand were able to raise income with 18 local gardeners gaining $6,728 of profit and $200,000 going to donated funds. The large success of this program has been due to the fact that it is run by the community.

The ENYF program may be a possible means to fight back against fast food dependence not only in Eastern New York but other urban Black communities.

Many public health researchers and non-profit groups are starting similar competitive initiatives across the country. These can come in the form of community-based grocery Co-ops that directly involve the community in the decision-making and workforce of selling fruits and vegetables to the community, such as found in

Features the ghettos of Detriot.13 The financial incentives that it provides may make effective community-based initiatives more lucrative to these communities in integrating healthier food into daily diet over fast food.

From the success of these examples there are a few important factors that competitive community-based initiatives should take into account while promoting healthier alternatives: 1. Financial Sustainability Such programs should be able to run based on profits from sold produce alone. Although ENYF was not able to do this, they were able to generate revenue for those involved. Being able to maintain an autonomous entity requires strict management of resource allocation.

2. Keeping Produce at an Affordable Price One of the major stereotypes associated with healthier foods in Black communities is their high price, however, making these prices comparable to those of a fast food chain are effective means to reduce resistance to buying such goods.

3. Employing Youth As a future-based approach, ENYF should focus on providing paid internships and opportunities to benefit and be directly involved in this system. Educating young individuals and allowing them to see the possibility of healthier alternatives may be beneficial for their community values in the future as they can teach their families and peers the importance of a healthier diet.

4. Partnering with Trusted Organizations and Community Groups Historically, Black communities have not had a good relationship with large corporations, government, and stereotypical advantag-

es of white communities including increased access to produce. Taking advantage of organizations that Black communities trust such as churches, may be beneficial in effectively increasing trust and reliability in healthy alternatives.

These four principles can be implemented to a community’s needs and bring potentially life-saving public health changes.

In my senior year of high school, I witnessed the last standing supermarket in the community disappear, removing the last fern from the already sparse nutritional landscape of my community. Yet, I have hope. Public health researchers and community partners are attempting to find ways to better serve people’s health needs over benefits.

Although community-based initiatives may not lead to systemic change, it is a feasible spark that may ignite a societal movement. I believe that by participating in capitalism through competitive community-based alternatives, we may be able to see a revolution of healthier alternatives that provide health equity for the black population in my town and throughout the United States.

References

1. Bobby G. Illinois is Home to One of the Most Dangerous Cities in America - and It’s NOT Chicago. My 1053 WJLT. Published May 6, 2024. Accessed January 21, 2025. https://my1053wjlt.com/rockford-il-dangerous-city-analysis/ 2. Auburn High School. Usnews.com. Published 2024. Accessed December 2, 2024. https://www.usnews.com/education/ best-high-schools/illinois/districts/rockford-sc hool-district-205/auburn-highschool-6987 3. E234: White Burgers, Black Cash – a history of fast food discrimination - World Food Policy Center. World Food Policy Center. Published April 8, 2024. https://wfpc. sanford.duke.edu/podcasts/white-burgersBlack-cash-a-history-of-fas 4. Block JP, Scribner RA, DeSalvo KB. Fast food, race/ethnicity, and income:

a geographic analysis. Am J Prev Med. 2004;27(3):211-217. doi:10.1016/j.amepre.2004.06.007t-food-discrimination/ 5. ontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003;289(2):187193. doi:https://doi.org/10.1001/jama.289.2.187 6. TEDx Talks. How a garden can help grow healthy kids and reduce obesity | Erin Guerricabeitia | TEDxBoise. YouTube.

Published April 29, 2016. Accessed January21, 2025. https://www.youtube.com/ watch?v=xT8UwfwkCaY 7. National Institute of Diabetes and Digestive and Kidney Diseases. Overweight & Obesity Statistics. National Institute of Diabetes and Digestive and Kidney Diseases. Published December 13, 2019. https:// www.niddk.nih.gov/health-information/ health-statistics/overweight-obesity 8. Marcia Chatelain. FRANCHISE : The Golden Arches in Black America. Liveright Publishing Corp; 2021.

9. Facebook, Twitter, options S more sharing, et al. Michelle Obama’s nutrition campaign comes with political pitfalls. Los Angeles Times. Published July 21, 2013. https://www.latimes.com/nation/la-namichelle-food-20130712-story.html 10.Belle G. Can the African-American Diet be Made Healthier Without Giving up Culture — York College / CUNY. www. york.cuny.edu. Published 2009. https:// www.york.cuny.edu/english/writing-program/the-york-scholar-1/volume-5.2 -spring-2009/can-the-african-americandiet-be-made-healthier-without-giving-up culture 11. Barnhill A, Ramírez AS, Ashe M, et al.

The Racialized Marketing of Unhealthy Foods and Beverages: Perspectives and Potential Remedies. J Law Med Ethics.

2022;50(1):52-59. doi:10.1017/jme.2022.8 12. Trevino M. United Community Centers. October 1, 2024. Accessed December 1, 2024. https://ucceny.org/the-grounded-community-east-new-york-farms/. 13.

Wilbourn M. Bringing Grocery Stores to Low-Income Urban Food Deserts COVER SECTION. https://resources.uwcc.wisc. edu/Grocery/grocery_low-income_urban_food_deser ts.pdf

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Public Health Implications of High Dementia Prevalence in Baltimore Ishanika Damani As a full-time summer volunteer at the Insight Memory Care Center (IMCC), a nonprofit organization in Fairfax, Virginia that provides care, support, and education for those with early-stage dementia, I spent 5-6 hours each weekday over a period of two months assisting with the organization’s programs and facilitating brain-stimulating activities.

My daily responsibilities included researching activities and developing exercises known to help dementia patients with memory retention and physical fitness, helping prepare for lunch, and assisting the coordinators with their regular tasks and duties. Throughout each day, I spent a lot of time talking to and interacting with the dementia patients, and through this experience, I was able to witness first-hand some of the struggles that they experienced each day as victims of such a devastating disease. This inspired me to learn more about dementia, its incidence in the country as a whole and in Baltimore, Mary-

land specifically, and its implications in the field of public health.

Dementia is a general term for a group of neurological conditions that cause a decline in mental ability and interfere with daily life. It is characterized by the impairment of at least two major brain functions.

As a volunteer at IMCC, I noticed that most, if not all, of the patients that I interacted with suffered from memory loss to some extent. I remember having a conversation with a patient one morning in which they talked about an experience that they had gone through in their childhood. Later that same day, the patient told me the exact same story for a second time, not realizing that they had already recounted this story to me once before. This is known as same story syndrome, and it is commonly seen in dementia patients. In addition to memory loss, victims of dementia typically experience difficulty in thinking, trouble with language, and chang-

Gerd Altmann/Pixabay

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es in behavior, along with a variety of other symptoms such as confusion, disorientation, depression, anxiety, and hallucinations.1 Some behaviors associated with dementia that I observed on a daily basis were patients misplacing items such as their glasses or wallets, having trouble with articulating their thoughts, being unable to recall recent conversations, and forgetting the names of people that they interacted with almost everyday.

Over 55 million people in the world are estimated to have had dementia in 2020.

During my time as a volunteer at IMCC, one of my main responsibilities was to research, develop, and facilitate exercises to help slow the decline in cognitive functions.

The most common types of activities that the patients participated in were trivia games, brain teasers, and various memory games. I usually oversaw the trivia games, which were about topics that ranged from popular celebrities in the 1960s and ‘70s to world capitals. While facilitating these activities, I saw that some patients had a lot of difficulty recalling the answers to questions that they had likely known the answer to at some point in their lives.

However, other patients seemed to

Features have little to no trouble answering the same questions, showing how dementia does not present itself in the same way in all patients.

Dementia is a progressive disease, meaning that it worsens over time, and it has no cure, though there are various treatments available to help alleviate and slow down the progression of symptoms.1 Patients diagnosed with dementia often have shortened life expectancies, not only due to the disease itself but also because of the complications that it is commonly associated with, such as brain damage, infections like pneumonia, cardiovascular problems, and cancer.2 Many of the dementia patients that I worked with had been diagnosed with at least one other underlying disease, even though they were all still in the early stages of dementia. The most common one that I saw was diabetes. Dementia is most common in adults over the age of 65, and over 55 million people in the world are estimated to have had dementia in 2020. This number is only expected to grow in coming years, with its world prevalence expected to almost double every 20 years and reach 78 million people by 2030.3 As such, dementia is one of the most significant public health challenges of the 21st century.

Alzheimer’s disease is a type of dementia that causes the gradual loss of memory and thinking skills, which eventually leads to the inability to perform simple tasks.2 As the country’s population ages, the prevalence of Alzheimer’s is increasing, and this has profound social, economic, and healthcare implications.

Across the United States, the prevalence of Alzheimer’s disease is a major public health concern, as the progressive nature of the disease causes patients to lose their ability to perform everyday activities as they age, requiring increasing levels

Nils Huenerfuerst/Unsplash

of care and support. While I was a volunteer at IMCC, I was struck by the impact of dementia not only on the patients themselves but also on their friends and families. Almost all of the dementia patients had to have a relative or close friend drop them off and pick them up each day from the dementia center, as the patients themselves were unable to drive themselves due to the loss of cognitive function that dementia causes, even at its early stages. By interacting with the patients’ families each day, I could see the emotional exhaustion and stress that they went through everyday by having to care for their patient while watching the disease progress and knowing that they could not do anything to stop it. Additionally, I was amazed at the level of patience that the patients’ loved ones and the caregivers at IMCC possessed. Dementia leads to increasing amounts of repetitive behaviors, confusion, disorientation, and communication issues, making it very difficult for the patients to understand what is happening around them. This often causes them to become frustrated and agitated, which can cause them to lash out at the people around them. While I was a volunteer, I frequently witnessed a patient becoming upset due to not being able to answer a trivia question or forgetting something that they thought they should have known and then taking that anger out on other patients or on the IMCC staff. Each

time this happened, the staff were able to stay calm and defuse the situation, and I was astounded by how patient they were. The emotional, physical, and financial toll that Alzheimer’s and other forms of dementia take on patients, caregivers, and the broader community is immense, meaning that public health initiatives are critical in addressing the growing challenge posed by the disease.

In the United States, approximately 1 in every 9 people aged 65 or older has Alzheimer’s disease, and the risk of developing Alzheimer’s doubles approximately every five years after the age of 65.4 Alzheimer’s and other forms of dementia cost the US economy more than $350 billion annually due to the high costs of medical care, longterm care, and lost wages.5 These costs are projected to increase even more significantly in the coming years as the population ages.

Baltimore, Maryland is one of the cities in the country with the highest incidence of Alzheimer’s, with approximately 16.6% of its population above 65 years old being diagnosed with the disease6 compared to only 4% in the country as a whole.4 One reason for this may be Baltimore’s high population, with it being the most populous city in the state of Maryland.7 A high overall population indicates that there is also a higher aging population, Volume 22

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Features and since Alzheimer’s is a disease that affects older populations, this is likely one of the causes for this.

Additionally, Baltimore has a female to male ratio of 107.2 women per 100 men, which is higher than the national average of 102 women per 100 men8. Almost two-thirds of Alzheimer’s patients are women4, which could be another reason why Baltimore’s Alzheimer’s incidence is so much higher than that of the country as a whole.

One of the main reasons that Alzheimer’s prevalence is a major health crisis in Baltimore lies in the fact that it is one of the most racially and ethnically diverse cities in the country. Nearly 60% of Baltimore’s population is composed of African Americans, and the remaining population including growing numbers of Hispanics and Asians.9 Previous studies have shown that African Americans are almost twice as likely as Caucasians to develop dementia10, which would explain the high prevalence of dementia in Baltimore. This conclusion is based only on a comparison of the number of African Americans and Caucasians diagnosed with the disease, but additional studies have shown that African Americans and people of color are almost 35% less likely to be diagnosed with dementia as compared to their Caucasian counterparts10, meaning that African Americans may be even more likely to develop Alzheimer’s as compared to Caucasians than the study reported. In addition to providing an explanation for why Baltimore’s dementia incidence is so high compared to that of the US as a whole, this highlights a significant public health issue that exists in Baltimore and throughout the US with relation to Alzheimer’s: there is a significant racial disparity in the diagnosis and treatment of dementia.

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Racial and ethnic disparities in healthcare are not a new concept in the United States, but the lower rates of Alzheimer’s diagnosis in African Americans despite a higher incidence of the disease in this population indicates that these disparities are not primarily biological

African Americans are almost twice as likely as Caucasians to develop dementia. in nature - they are largely due to systemic barriers to healthcare access, such as race, culture, and socioeconomic status. As a volunteer at IMCC, I noticed that the majority of the patients that I worked with were Caucasians. IMCC is a dementia center, meaning that it specializes in taking care of those who have already been diagnosed with dementia. It does not play any part in actually diagnosing dementia or prescribing medical treatments. As such, the prevalence of Caucasians among patients under the care of IMCC does not in any way reflect on the diversity of memory care center itself; rather, it suggests that those from minority racial groups are less likely to be diagnosed with dementia and therefore less likely to be put under the care of dementia centers like IMCC. This can then lead to them having poorer health outcomes compared to their Caucasian counterparts. In diverse cities such as Baltimore, the effects of these social disparities of healthcare are particularly pronounced, and the consequences that lack of equal access to healthcare can have on individuals living with serious medical conditions such as Alzheimer’s can be devastating.

One of the most significant barriers to addressing Alzheimer’s in minority populations is access to healthcare. African Americans and Hispanics are more likely to be uninsured or underinsured than Caucasians,11 which can delay diagnosis and limit access to healthcare services needed to effectively manage the disease and slow its progression. Many members of minority populations are diagnosed later in the progression of the disease, by which time symptoms have become more advanced and medical intervention is less effective. In addition to systemic barriers, cultural barriers also contribute to the delayed diagnosis of Alzheimer’s in minority populations, as members of these populations may be afraid of seeking medical treatment due to the racial stigmas that exist in their communities. Even when they do access healthcare services, members of minority populations may face biases from medical professionals that can impact the quality of their treatments.

Socioeconomic status also plays a major role in determining access to high-quality Alzheimer’s care.

As in many US cities, there are significant disparities in income, education, and employment between racial and ethnic groups in Baltimore12. Due to systemic barriers that limit African American and Hispanic access to high-paying jobs and high-quality education, these minority groups often belong to lower-income socioeconomic groups, which limits access to healthcare and impacts the ability of members of these groups to afford the very costly Alzheimer’s disease care.

The racial disparities with regards to access to healthcare that are seen throughout the US are particularly concerning in Baltimore, as this city has a high percentage of

Features African American residents. These residents often have limited access to healthcare services and economic opportunities, which can exacerbate the impact of Alzheimer’s on the community, contributing to later diagnoses, poorer health outcomes, and greater caregiver burden. Additionally, the African American community faces higher rates of chronic conditions that increase the risk of Alzheimer’s, such as hypertension, diabetes, and cardiovascular disease13, and due to barriers to healthcare access, these conditions often go undetected or are poorly managed in those belonging to minority populations.

This causes an increase in the risk of developing dementia later in life.

Addressing these barriers to healthcare access in minority groups is crucial to diagnosing and effectively treating underlying health conditions that cause Alzheimer’s as well as the disease itself.

In response to the growing dementia crisis in Baltimore, Maryland and in the United States as a whole, public health officials must develop strategies to address the disease’s devastating impact on its victims and on the community. These strategies should focus on promoting early detection, reducing barriers to healthcare access, and funding dementia research. Early diagnosis of Alzheimer’s disease is crucial for improving outcomes of patients, and as such, public health campaigns should focus on educating the public about the seriousness of Alzheimer’s, its signs and symptoms, and ways to receive diagnosis and treatment by medical professionals. As the demand for Alzheimer’s treatment and care grows, barriers to access to healthcare must be broken so that those suffering from the disease can receive prompt and effective treatment. In particular, public health officials should focus on reducing health in-

equities based on race in order to reduce the disproportionate burden of Alzheimer’s on minority populations, particularly in diverse cities such as Baltimore. Additionally, public health initiatives should focus on funding research centered on dementia prevention, diagnosis, and treatment in order to reduce the incidence of Alzheimer’s disease locally, nationally, and even globally. Through a combination of various public health initiatives, the prevalence of Alzheimer’s disease in Baltimore, Maryland and in the United States can be reduced, decreasing the impact of the impending dementia crisis.

Gert Stockmans/Unsplash

References

1. What is Dementia? Alzheimer’s Disease and Dementia. https://www.alz.org/alzheimers-dementia/what-is-dementia.

2. The later stage of dementia. Alzheimer’s Society. https://www.alzheimers.org.uk/ about-dementia/symptoms-and-diagnosis/how-dementia-progresses/later-stages-dementia.

3. World Health Organization: WHO, World Health Organization: WHO. Dementia. https://www.who.int/news-room/ fact-sheets/detail/dementia#:~:text=Currently%20more%20than%2055%20million,injuries%20that%20affect%20the%20 brain. Published March 15, 2023.

4. Alzheimer’s Disease facts and figures. Alzheimer’s Disease and Dementia. https://www.alz.org/alzheimers-dementia/facts-figures.

5. PharmD WW. Economic burden of Alzheimer disease and managed care considerations. The American Journal of Managed Care. 2020;26(Suppl 8):S177-S183. doi:10.37765/ ajmc.2020.88482 6. Staff CB. Baltimore City among areas with highest Alzheimer’s prevalence in U.S. CBS News. https://www.cbsnews. com/baltimore/news/baltimore-city-highest-alzheimers-disease-rate-prevalence/.

Published July 17, 2023.

7. Maryland cities by population (2024). https://worldpopulationreview.com/ us-cities/maryland.

8. Baltimore city, Maryland Gender Ratios.

Copyright (C) 2024 States101.com. https:// www.states101.com/gender-ratios/maryland/baltimore-city.

9. Weininger B. Celebrating diversity.

Visit Baltimore. https://baltimore.org/ meetings/celebrating-diversity/#:~:text=Diverse%20City,-Baltimore%20is%20 proud&text=Remnants%20of%20the%20 immigration%20patterns,of%20Hispanic%20and%20Asian%20residents.

Published October 28, 2024.

10.Data shows racial disparities in Alzheimer’s disease diagnosis between Black and white research study participants. National Institute on Aging. https://www. nia.nih.gov/news/data-shows-racial-disparities-alzheimers-disease-diagnosis-between-black-and-white-research.

Published December 16, 2021.

11. Hill L, Artiga S, Damico A. Health Coverage by Race and Ethnicity, 2010-2022 | KFF. KFF. https://www.kff.org/racial-equity-and-health-policy/issue-brief/ health-coverage-by-race-and-ethnicity/.

Published January 11, 2024.

12. Racial inequality in the United States.

U.S. Department of The Treasury. https:// home.treasury.gov/news/featured-stories/ racial-inequality-in-the-united-states. Published November 19, 2024.

13. Barnes LL, Bennett DA. Alzheimer’s disease in African Americans: risk factors and challenges for the future. Health Affairs. 2014;33(4):580-586. doi:10.1377/ hlthaff.2013.1353

Author’s Biography Ishanika Damani is a freshman majoring in Molecular & Cellular Biology and Applied Mathematics & Statistics. She is interested in exploring the applications of data science and machine learning methods to epidemiology and clinical research. Her prior work includes developing a deep learning model for more efficient diagnosis of cancer.

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Editorials

Shannon Xiao

Editorials

Safe Menstruation: A Human Right Ahla Bommareddy An estimated 500 million individuals suffer from menstrual poverty at present.1 A pandemic affecting both economically developed and developing nations, period poverty refers to the inaccessibility of menstrual products, proper sanitation facilities, and education needed to safely manage menstruation. Societal attitudes toward menstruation serve as the foundation upon which these systemic inequalities persist. Providing affordable access to hygiene products and facilities, along with destigmatizing menstruation, are crucial in combating period poverty worldwide.

With high prices and a pink tax— the phenomenon of female-marketed products having inflated prices compared to male-marketed products—sanitary products are unaffordable to many marginalized groups. Low-income girls and women are the most disenfranchised; nearly 61 percent of the United States population lives paycheck-to-paycheck, meaning a significant proportion of the population lacks guaranteed access to hygiene products.2 Populations such as the incarcerated, homeless, refugees, and migrants particularly suffer from inadequate sanitary products and washing facilities, leaving them more susceptible to urogenital infections and mental illnesses such as anxiety and depression.1 Moreover, menstrual poverty afflicts developing nations to an even greater extent. For example, in certain regions of India, there is a lack of proper sanitary products, adequate female bathrooms, and reproductive health education; young

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girls living in poverty cannot afford proper products, nor can they manage their cycles at school in the absence of clean female bathrooms.

Consequently, approximately 23 million girls drop out of school annually, as they cannot bear the burden of menstruating in a place where safe management of menstruation is inaccessible.2 Menstrual poverty is a detriment to mental health, physical health, personal finances, and education.

By pushing for legislation that makes these products and facilities affordable, this public health crisis can be mitigated. The American Medical Association has called for menstrual products to be tax-exempt on the basis that they are classified as necessities.3 In the United States, only certain states provide free sanitary products in middle schools and high schools; the Menstrual Equality Act for All 2023 should be lobbied for by activist groups to ensure that all schools provide free sanitary products.2 Providing students with these necessities prevents them from missing or dropping out of school because of their cycle. Furthermore, current government programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children and the Supplement Nutrition Assistance Program, should be expanded to cover the cost of menstrual hygiene products, as these products ensure the health and well-being of women.2 Additionally, federal governments can collaborate with NGOs (non-governmental organizations) to provide free menstrual products in public spaces, ensuring public health in regards to periods is not comprised; the Bunga Pads initiative, founded by the

Malaysian NGO MyCorps Alumni, accomplishes this and gives young girls the opportunity to learn without fearing the consequences of their periods.3

Menstruation is viewed as a disgusting taboo—to be spoken of in hushed voices and never in the presence of men.

However, we must also attack the problem at its source by deconstructing ingrained biases toward menstruation. Menstruation is viewed as a disgusting taboo—to be spoken of in hushed voices and never in the presence of men. In some cultures, prevailing stigmas force girls and women to sleep separately, not touch the food, and not attend places of religious worship.3 These stigmas create a sense of isolation for women, negatively impacting their mental health. Individuals use dirty rags in lieu of pads because of financial strains and ongoing fears of speaking about the taboo, causing a plethora of health issues. The financial burdens and stigmas have severe ramifications, such as girls dropping out of school, that force women to miss higher education and career opportunities that can bring them financial freedom, thus continuing the cycle of menstrual poverty. Therefore, education programs led by public health experts that relay accurate informa-

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Percentage of teenagers in the United States who struggled to afford feminine hygiene products as of 2023

60 50 40 30 20 10 0

Struggled to afford period products

Worn period products longer than recommended

Rarely or never find free period products in public bathrooms

A 2023 survey, published by John Elflein on May 14th, 2024, revealed the percentage of teenagers in the United States who struggled to afford feminine hygiene products.4

tion about menstruation to both males and females must be implemented to combat period poverty.

Dispelling myths allows individuals to seek the resources and help they need without fear of judgment.

tion is a natural biological process in the human body; therefore, it is imperative that we view affordable and accessible hygiene products as a human right—not a privilege.

Additionally, the accessibility of products can be eco-friendly and promote female financial independence. Studies have found that banana-fiber pads are the most cost-effective and sustainable menstrual product, and they are easily manufactured with natural resources in certain developing countries.5 Therefore, women in these countries can use these products while also earning a living by producing them, thus empowering themselves.

1. Miller, Trisha A., et al. Understanding Period Poverty and Stigma: Highlighting the Need for Improved Public Health Initiatives and Provider Awareness. Journal of the American Pharmacists Association, vol. 64, no. 1. October 19, 2023. Accessed December 1, 2024. www.sciencedirect.com/science/ article/abs/pii/S1544319123003229?dgcid=rss_sd_all#:~:text=Period%20poverty%20is%20the%20lack, https://doi. org/10.1016/j.japh.2023.10.015.

2. Mann S, Byrne SK. Period poverty from a public health and legislative perspective. MDPI. November 28, 2023. Accessed December 1, 2024. https://www.mdpi. com/1660-4601/20/23/7118.

3. Jaafar H, Ismail SY, Azzeri A. Period poverty: A neglected public health issue. Korean Journal of Family Medicine. July 2023.

Accessed December 1, 2024. https://pmc. ncbi.nlm.nih.gov/articles/PMC10372806/.

4. Elflein J. Percentage of teenagers in the United States who struggled to afford feminine hygiene products as of 2023. Statista. May 14, 2024. Accessed December 1, 2024. https://www.statista.com/statis-

Period stigma isolates and shames individuals, upholding gender inequity. The accessibility of these products is crucial in promoting female health, education, and financial independence, lessening gender inequity. Menstrua-

References

tics/1242985/us-period-poverty-teenage-students/.

5. Aridi R, Alissar Yehya. Sustainability assessment of sanitary pad solutions to reduce period poverty. Environment, Development and Sustainability. December 26, 2023. Accessed December 1, 2024. doi:https://doi. org/10.1007/s10668-023-04338-y.

Author’s Biography Ahla Bommareddy is a freshman studying Public Health and Writing Seminars. She is interested in medical journalism and strives to raise awareness around public health and healthcare inequities. In her free time, she is an avid reader and writer. Picture this: a hospital room where every decision, every word, and every choice tilts the odds of survival in your favor— now imagine those odds rising simply because a woman stands at the helm. The evidence is clear: the future of healthcare is female, and it’s time we embraced it.

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Editorials

Breaking Barriers: Advancing Women’s Representation in Healthcare Anannya Sharma

TopSphere Media/Unsplash

Researchers have found that patients of female physicians fare much better than those of male physicians when measured by patient outcomes.1 These include lower patient mortality, patient readmission rates, and post-operative complications such as infections, bleeding, shock, and nerve damage. Another study revealed that hospitals with at least 35% female anesthesiologists and surgeons in their operating teams showed a 3% reduction in the risk of major postoperative complications within 90 days, such as infections, organ dysfunction, or significant bleeding.2 The question does arise, however, that if training during medical school is given equally to future male and female physicians, then

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why does this disparity emerge in patient outcomes? To address this, we must look at the inherent differences in how the two groups of physicians tackle patient care.

The pillars of quality patient care are ideals such as compassion and care and practices such as active listening and communication.

Unsurprisingly, female physicians display all these traits to a greater extent than their male counterparts. While being more empathetic and open listeners, they are also better at consistently adhering to medical guidelines and working with members of their surgical team. In addition to these skills, female physicians often advocate for patient well-being beyond immediate medical concerns, addressing broader aspects such as mental health and social determinants of health.

By adopting a more holistic perspective, they build stronger doctor-patient relationships, resulting in better treatment adherence and improved outcomes. Perhaps this is also why women physicians also face fewer malpractice claims.

Another potential reason for these patient outcomes could be the tendency of male physicians to often under-diagnose patients, particularly female patients, as indicated by previous studies.3 This is, for the most part, because medical training is based on male physiology and fails to take into account the nuances of the female body.

Clinical research has historically failed to give an equal representation of the female population which has led to less knowledge within the medical community about how conditions potentially represent them-

Editorials selves differently in females. With this limited knowledge imparted to them during their training, it is more difficult for physicians to diagnose female patients accurately. However, while male physicians often underestimate the severity of symptoms reported by female patients or dismiss and attribute them to emotional or psychological causes, female physicians are likely more empathetic in this regard, leading them to better diagnose these patients, according to Dr. Megan Ranney, dean of the Yale School of Public Health.

With all this evidence suggesting better patient care from female physicians, it is evident that a higher priority must be given to investing in female representation within medicine. A target area for this is closing the gender-based wage gap that persists, one that often discourages women from pursuing a career as a practicing physician after they complete their training. Current data indicates that across a 40-year career, male physicians earned an average adjusted gross income of $8,307,327, while female physicians earned an average of $6,263,446.4 This represents a large relative difference of 24.6% between the wages received by the two groups. The results suggest that, throughout their careers, female physicians in the United States are projected to earn, on average, over $2 million less than their male counterparts. If healthcare systems have the opportunity to reduce patient deaths and readmission rates, they must try their very best to do so, and perhaps addressing this wage gap is the first step toward that end goal.

Civilizations of the past across the world understood this very advantage of having women leading the process of healing as versions of female physicians can be found in

different cultures. In Egypt, priestesses of the god of medicine Isis were greatly respected healers, considered at a physician’s status, for they were believed to have been bestowed with the gift of healing from Isis herself. Female physicians in Rome were known as “medicare” and were considered equal in skill as their male counterparts, managing busy clinics. At the school of medicine in Salerno, Italy, the “magistra medicine” were well known for their intellectual achievements within medicine, and one of them, Trotula, even wrote a book on obstetrics and gynecology that went on to be used for 400 years.5

Bringing more women into leadership roles in healthcare isn’t just about achieving gender equity—it’s about systemic improvement.

It was only with European colonization that the idea of female healers became seen as ‘evil’ and ‘satanic’. Female healers, who often had previously held positions of respect and influence within their communities, threatened male-dominated power structures, leading to their demonization. Now labeled as devil worshippers, female healers who were once lauded for their skills in using herbs and tonics to cure the masses were now hunted, beheaded, and burnt. Between the 13th and 18th centuries, during the era of witch hunts, women were largely excluded from the medical profession and denied access to formal medical education.

In England and France, the introduction of licensure laws and the establishment of guilds in the 13th century further restricted women’s participation in medicine. By the 17th century, even midwifery, once dominated by women, had become male-controlled. Although women were barred from practicing medicine professionally, they continued to work in limited numbers in domestic roles as nurses and midwives, positions considered subordinate to male physicians, an idea that has trickled its way into the mindsets of today. This issue of limited female representation in healthcare doesn’t just limit itself to physicians. In today’s day and age, we need more women leading in every sphere of the healthcare industry - from those who make the health policies that define the lives of so many patients to those who approve trials that have the power to revolutionize healthcare.

We also have data that supports this decision. Researchers studying the health outcomes in matrilineal societies looked at the particular case of the Mosuo people, a tribe in China, and compared various biomarkers of individuals from this tribe to those belonging to patrilineal societies.6 What they found is that biomarkers for inflammation, blood pressure, and hypertension were lower for those belonging to the matrilineal society compared to those from the patrilineal society.

Interestingly, the women from the matrilineal group also fared better than the men in the same group.

Many reasons have been hypothesized for this difference in health status, with the most probable of these being that in a predominantly matriarchal society, there is a greater emphasis on autonomy and better social support and division of resources in such societies. Patriarchal societies, on the contrary, have been found to exacerbate health inVolume 22

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Editorials the gender imbalance within the industry, those in power can not only improve patient care but also build more resilient, effective, and equitable healthcare systems for the future. It’s time to prioritize female representation—not as an afterthought, but as a cornerstone of rebuilding and reimagining global healthcare.

References 1. Atsushi Miyawaki, Jena, A. B., Roten-

Accuray/Unsplash

equalities due to the reduced autonomy and resource control these societies forced on their populations, and this impacts women living in these societies the most.

In today’s time, when healthcare systems across nations are struggling to bounce back from the impact of the pandemic and the demands of increasingly sick populations are struggling to be met, those in power must recognize the increased quality of patient care they can bring about by bringing more female representation at each level of the healthcare industry.

Women bring unique perspectives, often rooted in collaborative and empathetic leadership styles, that are crucial for navigating the complexities of today’s healthcare crises. From frontline workers to policymakers, increasing female representation can address critical gaps in care delivery and decision-making. Research indicates that countries with female leaders, such as New Zealand under Jacinda Ardern, Germany under Angela Merkel, and Taiwan under Tsai Ing-wen demonstrated quicker and more decisive action, including earlier lockdowns.7 This approach resulted in significantly fewer deaths and cases compared to their maleled counterparts. These women garnered international praise for their

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science-based and compassionate responses to the pandemic, and such examples underscore how the inclusion of women at the forefront can lead to improved outcomes not just in public health crises but in everyday healthcare systems.

Similarly, if hospitals and clinics were to be led by administrations with females at the helm, they would prioritize patient-centered care, improve communication among teams, and focus on preventative health measures—all of which are crucial as healthcare systems strain to meet rising demands.

Bringing more women into leadership roles in healthcare isn’t just about achieving gender equity—it’s about systemic improvement. Female leaders often champion policies that benefit entire populations, such as increased access to preventative care, better mental health services, and initiatives to reduce healthcare disparities. Their unique ability to balance technical expertise with emotional intelligence creates a more holistic and inclusive approach to healthcare management.

Healthcare systems are at a crossroads. While the challenges they face are immense, so too are the opportunities for transformation. By recognizing and addressing

stein, L. S., & Tsugawa, Y. (2024). Comparison of hospital mortality and readmission rates by physician and patient sex. Annals of Internal Medicine. https://doi. org/10.7326/m23-3163 2. Hallet, J., Sutradhar, R., Flexman, A., McIsaac, D. I., Carrier, F. M., Turgeon, A. F., McCartney, C., Chan, W. C., Coburn, N., Eskander, A., Jerath, A., Perez d’Empaire, Pablo, & Lorello, G. (2024). Association between anaesthesia–surgery team sex diversity and major morbidity. British Journal of Surgery, 111(5). https://doi.org/10.1093/ bjs/znae097 3. Lau, E. S., Hayes, S. N., Volgman, A. S., Lindley, K., Pepine, C. J., & Wood, M. J. (2021). Does Patient-Physician Gender Concordance Influence Patient Perceptions or Outcomes? Journal of the American College of Cardiology, 77(8), 1135–1138. https://doi.org/10.1016/j.jacc.2020.12.031 4. Whaley, C. M., Koo, T., Arora, V. M., Ganguli, I., Gross, N., & Jena, A. B. (2021).

Female Physicians Earn An Estimated $2 Million Less Than Male Physicians Over A Simulated 40-Year Career. Health Affairs, 40(12), 1856–1864. https://doi. org/10.1377/hlthaff.2021.00461 5. Wynn, R. (2000). Saints and sinners: Women and the practice of medicine throughout the ages. JAMA, 283(5), 668. https://doi.org/10.1001/jama.283.5.668-jms0202-4-1 6. Reynolds, A. Z., Wander, K., Sum, C.-Y., Su, M., Thompson, M. E., Hooper, P. L., Li, H., Shenk, M. K., Starkweather, K. E., Blumenfield, T., & Mattison, S. M. (2020). Matriliny reverses gender disparities in inflammation and hypertension among the mosuo of china. Proceedings of the National Academy of Sciences, 117(48), 30324–30327. https://doi.org/10.1073/ pnas.2014403117 7. Garikipati, S., & Kambhampati, U. (2020, June 3). Leading the fight against the pandemic: Does gender “really” matter?Papers.ssrn.com. https://papers.ssrn.com/ sol3/papers.cfm?abstract_id=3617953

Losing the Democracy We Never Had

Editorials

Carlos Haring For a large part of 2024, the American people have been bombarded with political messages from the campaign of President Biden, Vice President Kamala Harris, and former president Donald Trump. Out of all the political messages that Trump, Biden, and Kamala echoed during their campaigns, there was one that all three got resoundingly wrong.

The potential loss of democracy was a message perpetuated by both sides. Kamala and Joe Biden warned of the threat of project 2025, a policy agenda created by a conservative think tank that lays out a path for the next conservative president to consolidate power.1 Trump warned of election meddling until he was winning on election night.2 However, one cannot lose something that one has never truly had. Institutionalized disenfranchisement of voters, especially amongst minorities, is not only still commonplace but is being built upon in the present day. Furthermore, this disenfranchisement has likely had and will continue to have ramifications social determinants of health due to policies that are implimened in goverment.

The concept of every vote mattering never seemed as salient as it did during the Bush vs Al Gore presidential campaign. In the final count of the votes, Florida’s secretary of state declared that Bush had won Florida by only 537 votes.3 A case was brought against the supreme court that called into question the constitutionality of Bush’s election win. Al Gore argued that a technical difficulty in ballot count-

ing in Florida, known as the “hanging chad”, caused votes for him to go uncounted. Ironically there was far less discourse over hundreds of thousands of potentially lost votes due to Florida’s felony disenfranchisement laws. According to the sentencing project, 5.9% of Florida’s population was ineligible to vote while 31.2% of the black population, one out of every three black adults, were ineligible to vote.2

Institutionalized disenfranchisement of voters, especially amongst minorities, is not only still commonplace but is being built upon in the present day.

Social determinants of health were very much on the ballot that election cycle. During his campaign, Bush pushed for private school vouchers instead of funding public schooling, a move that would disproportionately benefit white students over marginalized groups with 12% of white students being in private school compared to only 6% of African-American and 4% of Hispanic according to the National Center of Education Statistics.4,6 This would only perpetuate the existing racial inequalities in the education system. Education has a

large impact on social mobility and socio-economic status. Social mobility and socio-economic status have an impact on health outcomes.

As a result, inequalities in education could trickle down to perpetuate existing health outcomes.

Public health decisions were also decided on in a more direct manner. Bush also campaigned that he would stifle the creation of a more expansive healthcare system, according to the Washington Post.5 During his eight years of presidency, the population of uninsured individuals slightly increased.7 Lastly, Bush would go on to appoint two Supreme Court justices, John Roberts and Samuel A. Alito Jr, who would have a major role in several public health-related rulings. Both justices would be part of the majority opinion of Burwell v. Hobby Lobby which would allow companies to not have to cover certain type of healthcare due to religious reasons.8 The main effect of this was the loss of birth control as a covered medical cost. With it being more expensive to purchase birth control, it is reasonable to assume those who are less financially able would not have access to medication that could prevent pregnancies. It is impossible to extrapolate what could have happened if the election had gone a different way or to what extent public health disparities may not have been amplified or reduced. What can be said is that the voices of millions of Americans were silenced in that decision-making process.4 Many formally silenced voices were able to speak freely during the 2024 election as felony disenVolume 22

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Editorials franchisement laws are on the decline. According to the sentencing project, felony disenfranchisement has decreased by 24% from 2016 to 2022.9 However, another policy trend that has the potential to have large impacts on disentrancement is on the rise. Voter identification laws has become popular with an increase in the perceived threat of voter fraud. At face value, it would appear requiring all individuals to present a driver’s license, birth certificate, or social security card at voting sites or through mail in ballots would ensure voting security. People that were not citizens could not tamper with the democratic process. These laws, however, have the potential to restrict 11% of American citizens from voting in elections a percentage far greater than that of the 1990s.10, 4 In a more topical situation, the presidential election of 2024 was determined by far less than 11% of those who voted.11 These laws will disproportionately impact the elderly, disabled, and racial minorities; they are less likely to have the documents required for voter ID.10 Action has been taken on the federal level to combat the impact of disfranchisement. In 2021, Joe Biden passed an executive order to promote voter participation like facilitating voter participation in prisons and voter registration.

Unfortunately, these policy decisions can only tiptoe around the anti-democratic laws implemented by states.12 Without authorization from an existing law passed by congress, Biden could not do anything to restrict voter ID laws. This is a battle that must currently be fought at the state level. The upshot is that the same means that have allowed voter ID and felony disenfranchisement laws to be passed can be utilized to reverse the damage of these laws and prevent their implementation in the first place. For exam-

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ple, just this year, Nebraska passed a law that granted those who have completed their sentence, their full right to vote.13 Fewer policy measures have been taken against voter ID, but making your voice heard by voting and joining advocacy groups are ways to make headway on this issue.

Public health issues like reproductive rights, healthcare, drug pricing, and gun violence were already on the ballot in November.14 Since the president appoints individuals to lead regulatory agencies, the president has great influence in steering the way in which laws passed by congress are interpreted. With the appointment of Robert F. Kennedy Jr. as the US Secretary of Health and Human Services, fluoride, vaccine regulation, and food additive policy are also subject to change.15 Although the impacts on existing voter ID laws this election cycle is yet to be seen, it is imperative to stop the disentrancement of the American people, especially when it impacts those who are already marginalized. If we are to truly claim that we have a stake in democracy, we need to act like a democracy.

References

1. Wendling, M. Project 2025: The rightwing wish list for another Trump presidency. BBC. Published September 11, 2024.

Accessed January 20, 2024.

2. Swenson, A. Trump reverted to familiar playbook. Sowing doubts about the voting until the results showed him winning.

Updated November 6, 2024. Accessed January 20, 2024.

3. NCC Staff. On this day, *Bush v. Gore* settles the 2000 presidential race. Constitution Center. Published December 12, 2023. Accessed December 2, 2024. https://constitutioncenter.org/blog/onthis-day-bush-v-gore-anniversary 4. The Sentencing Project. III. Current impact of disenfranchisement laws. Human Rights Watch. Accessed December 2, 2024. https://www.hrw.org/legacy/reports98/ vote/usvot98o-01.htm 5. Balz D, Allen M. Bush and Gore clash sharply on health care and education. The Washington Post. Published October 17,

2000. Accessed October 19, 2024. https:// www.washingtonpost.com/archive/politics/2000/10/18/bush-and-gore-clashsharply-on-health-care-and-education/ ac040e56-2191-401d-a9a7-fde69c3d6a58/ 6. National Center for Education Statistics (NCES). Private school enrollment. NCES. Published 2020. Accessed October 19, 2024. https://nces.ed.gov/programs/coe/ pdf/coe_cgc.pdf 7. ASPE. National uninsured rate remains largely unchanged at 7.7 percent in the third quarter of 2023. Health and Human Services. February 2024. Accessed December 2, 2024. https://aspe.hhs.gov/ sites/default/files/documents/e497c623e5a0216b31291cd3763df1d/NHIS-Q3-2023Data-Point-FINAL.pdf 8. Oyez. Burwell v. Hobby Lobby Stores.

Accessed December 2, 2024. https://www. oyez.org/cases/2013/13-354 9. Uggen C, Larson R, Shannon S. Locked Out 2022: Estimates of People Denied Voting Rights. The Sentencing Project. Published October 25, 2022. Accessed December 2, 2024. https://www. sentencingproject.org/reports/lockedout-2022-estimates-of-people-denied-voting-rights/ 10.Brennan Center for Justice. Voter ID. Accessed December 2, 2024. https://www. brennancenter.org/issues/ensure-every-american-can-vote/vote-suppression/ voter-id 11. Leip D. 2024 presidential general election results. Atlas of U.S. Presidential Elections. Published 2024. Accessed December 2, 2024. https://uselectionatlas.org/RESULTS/ 12. Biden JR. Executive order on promoting access to voting. The White House. Published March 12, 2021. Accessed December 2, 2024. https://www. whitehouse.gov/briefing-room/presidential-actions/2021/03/07/executive-order-on-promoting-access-to-voting/ 13. Wayne J. Legislative Bill 20. State Net. Published April 17, 2024. Accessed December 2, 2024. https://custom.statenet.com/public/resources. cgi?id=ID%3Abill%3ANE2023000L20&ciq=ncsl5 14. Johns Hopkins Bloomberg School of Public Health. What’s at stake for public health in the 2024 U.S. election? Published October 9, 2024. Accessed December 2, 2024. https://publichealth.jhu.edu/2024/ election-2024-whats-at-stake-for-publichealth 15. Cooper J. What to know about Robert F. Kennedy Jr., Trump’s pick for health secretary.

Associated Press.

Updated November 14, 2024.

Accessed December 2, 2024. https:// apnews.com/article/robert-f-kennedy-jrrfk-things-to-know-explained-who-is-hhs5288a4a7277d1a0b4a7ede8f57a971ce

Editorials

A Community-Based Approach to Restoring Trust in Public Health Booseong Eric Seo On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. At its peak, 44.2 million new cases emerged each week.1 Today, thanks to vaccines, public health interventions, and global cooperation, weekly cases have dropped below 100,000, showing significant progress in containing COVID-19.1 As we recover, however, a new threat looms: a “pandemic of mistrust.” During COVID-19, misinformation and disinformation on social media, political polarization, and inadequate early responses from governmental agencies eroded trust in public health. This cynicism towards public health remains today and has weakened fundamental public health infrastructures, contributing to declining vaccination rates, and increasing rejection of

public health resources.2 Trust in public health remains vital, as it influences how the public will respond to health emergencies.

A lack of trust can significantly compromise the health of the individual and their communities, as they are less likely to adhere to health recommendations.3-6 This article will explore the critical role of fostering community partnerships and building strong relationships between local health departments and community based organizations (CBOs) to strengthen the public health system.

Introduction In June 2022, The Commonwealth Fund Commission on a National Public Health System, reported that “The public health enterprise is facing a crisis in trust.”7

But what does trust entail? Trust reflects the confidence people have in the ability and reliability of healthcare providers and institutions. In the face of a public health crisis, public trust in health systems significantly influences how communities respond to health emergencies like COVID-19; without trust, people are less likely to adopt health recommendations, such as getting vaccinated, leading to worse health outcomes.3-6 Additionally, mistrust may also undermine coordinated public health efforts to combat outbreaks and pandemics.8-9 For example, mistrust in government and health infrastructure during COVID-19 helped fuel the virus’s spread by weakening adherence to guidelines such as vaccination and social-distancing mandates.10

Public Health Departments Major Reasons for Trust

CDC

State

Local

Followed scientifically valid research

94%

87%

85%

Have the experts

92%

75%

67%

Made vaccines and testing widely available

83%

86%

88%

Have given clear recommendations for people to protect themselves

79%

81%

87%

Information matched other sources I trust

71%

80%

82%

Provided detailed information

70%

64%

63%

Provided information frequently

68%

67%

68%

Staff worked hard under difficult circumstances

65%

73%

79%

Seemed to care about people

64%

69%

73%

Steered clear of private-sector influence

56%

54%

51%

Steer clear of a lot of politcs

56%

50%

54%

Provided good care at public health clinics

49%

58%

71%

Have done a good job at controlling COVID-19 spread

49%

53%

55%

I trust the government generally

24%

34%

29%

Source: Data analysis from February 2022 nationally representative online and telephone survey of 4,208 U.S. adults. Questions: "What are the reasons you trust [entity] a great deal to provide accurate information about the COVID-19 outbreak? Are each of the following a major reason, a minor reason, or not a reason at all that you trust them a great deal for accurate information?" Results above show adults who reported trusting each agency "a great deal" in response to survey questions.

Figure 1a - Major reasons for trust in CDC, state and local public health departments12

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Editorials Public Health Departments Major Reasons for Lacking Trust

CDC

State

Local

Political influence on recommendations and policies

74%

72%

70%

Have given too many conflicting recommendations

73%

61%

58%

Private-sector influence on recommendations and policies

60%

53%

48%

Inconsistency in followng scientifically valid research

51%

48%

43%

Restrictive recommendations go too far

44%

38%

42%

I don't trust the government generally

39%

39%

42%

Lack of action to stop the spread of COVID-19

35%

34%

31%

Not respectied religious beliefs

28%

25%

23%

Lack of fair treatment for rural communities

21%

21%

22%

Lack of fair treatment for racial and ethnic minority communities

19%

25%

20%

Source: Data analysis from February 2022 nationally representative online and telephone survey of 4,208 U.S. adults. Questions: "Why don’t you trust [entity] to provide accurate information about the coronavirus outbreak? Are each of the following a major reason, a minor reason, or not a reason at all that you personally don't trust them a great deal for accurate information?" Results above show adults who reported lower trust ("somewhat," "not very much," or "not at all") in response to survey questions.

Figure 1b - Major reasons for lacking trust in CDC, state and local health departments12

Over recent decades, trust in the U.S. government, and in turn the public health system has steadily declined.11 With this “pandemic of mistrust” looming, this article examines the reasons for mistrust in US public health agencies, and highlights the importance of community focused public health responses.

Conversely, mistrust in federal, state, and local agencies stemmed from the belief that there was a political influence on health policies/ recommendations (>70%), that the private-sector influenced policies/ recommendations (48-60%), and finally, people believed that each public health agencies provided conflicting information (58-60%).12

Understanding the Causes of Mistrust A nationally representative study by Harvard, the CDC and colleagues conducted a first-of-its-kind survey to understand why people trusted or distrusted public health agencies during the COVID-19 pandemic. The study found that trust in federal health agencies was driven by: following scientifically valid research (94%), valuing expertise (92%), ensuring vaccine/test availability (83%), and providing clear recommendations (79%).12 The reasons were similar for state and local public health agencies.12 The study showed that trust is not a factor of how well organizations are able to contain the virus, but by their ability to make scientifically backed policies, provide protective resources like vaccines and tests, and offer clear/transparent recommendations.12

Community Approach to Restore Trust Now that we understand the issue, what are some steps that can be taken to restore trust in public health?

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The Commonwealth Fund on a National Public Health System emphasized that effective public health systems strengthen the “social ties among public health agencies, healthcare providers, and community residents.”13 While building trust requires diverse efforts, the key to strengthening the public health system is through fostering community relationships and partnerships.

Research has shown that skepticism of political and private-sector influence leads to mistrust in health systems.12 As a major source of mistrust involves political and private sector influence on policies/recom-

mendations, engaging community stakeholders in this process may allow for greater transparency and trust. As a result, efforts that aim to include communities in the process of making policies and recommendations are vital.

Efforts to engage stakeholders could include establishing an advisory board composed of communi ty based organizations (CBOs) and community members to help identify public health problems that are relevant and specific to their community. Involving communities enhances transparency of information and reduces the likelihood of conflicting information. Additionally, when communities actively participate in crafting policies that impact them, there are positive impacts on health outcomes and health behaviors, as more targeted interventions addressing the specific and unique needs communities face can be created.14-15 Since trust in public health depends on clear/transparent communication and accessible protective resources like vaccines, collaborations with community-based organizations (CBOs) can amplify trust-building efforts.12 During the COVID-19 pandemic, community-based organizations (CBOs)

Editorials in California collaborated with local public health departments to assist in COVID-19 response efforts.16 CBOs helped distribute resources like COVID-19 tests, food, and housing and assisted with contact tracing.16 Additionally, CBOs partnered with governments and other organizations to form coalitions focused on providing information regarding COVID-19, vaccination, and testing.16 For example, the Asian Pacific Islander Forward Movement (APIFM) worked with local pastors and youth leaders to help share information about COVID-19.16 As mentioned, community involvement in discussions is vital to building trust. CBOs in California helped empower civilians to share their stories with policymakers.

By providing toolkits, and advocacy training, CBOs allowed passionate civilians to advocate for their needs and have a voice in the process of crafting policies/recommendations.16 CBOs were crucial for supplementing the gaps in the government’s response. As they were best able to provide a voice for communities, CBOs effectively served as bridges between the government

and the community. These efforts ultimately provided greater transparency of information, allowed for meaningful community participation in government, and provided vital resources to many different communities, ultimately assisting in building trust with the government.16 Another important example highlighting the effectiveness of community-based partnerships is the Community Navigators Program by Public Health - Seattle and King County, the public health department in King County, Washington. Launched during the peak of the COVID-19 pandemic, this program recruits trusted and established members of the most impacted communities to “educate, equip, and serve” as representatives and advocates, providing critical health information.17,19 The program’s navigators represent over 45 of the most affected communities by racial inequities and COVID-19.17 Acting as bridges between the community and government resources, navigators help communities “navigate” the often intimidating and complex world of

health information.19 Lina Rauf Bayat, a Community Navigator with the Public Health Afghan Health Initiative, highlights the importance of building trust within communities: “People can not trust the system directly, so a community navigator is someone they can trust first.”18 She explains how she helped address health concerns, housing challenges, and food insecurity by developing trust both at a personal and cultural level.18 Navigators also have helped address vaccine hesitancy, misinformation, and other social determinants of health that prevent their communities from accessing essential care.20 Beyond serving as messengers of important health information, navigators also serve as advocates for their communities. For example, when Stephanie Ung, a community navigator representing the Khmer community, noticed that mass vaccination clinics were ineffective for her community, she helped develop smaller vaccination clinics that were not only closer to the community, but also equipped with trans-

Vonecia Carswell/Unsplash

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Editorials lators.20 Ung emphasized that the program gave them a “platform to vocalize what our priorities were.”20 In essence, the Community Navigator Program uses community leaders to build trust, making healthcare more accessible for underserved populations. Originally designed to address the concerns of the COVID-19 pandemic, the Community Navigators Program aims to expand its focus on the social determinants of health, including education, housing and food security.20 A Step Forward While community relationships and partnerships are powerful for trust building, truth itself is volatile.

It must not be taken for granted and requires continuous nurturing. As a result, fostering long-term partnerships and community relationships is vital and requires extensive time and dedicated resources.

A prioritization of community-focused relationships and partnerships will build greater trust and more resilient public health systems, which is essential to improving health for all.21 References

1. Weekly confirmed COVID-19 cases. Our World in Data. Published 2020. https://ourworldindata.org/grapher/ weekly-covid-cases?tab=chart&country=GBR~USA~CAN~BRA~ZAF~KOR~ITA~MEX~OWID_WRL 2. Barbieri V, Wiedermann CJ, Lombardo S, Piccoliori G, Gärtner T, Engl A. Vaccine Hesitancy and Public Mistrust during Pandemic Decline: Findings from 2021 and 2023 Cross-Sectional Surveys in Northern Italy. Vaccines. 2024;12(2):176. doi:https:// doi.org/10.3390/vaccines12020176 3. LaVeist TA, Isaac LA, Williams KP. Mistrust of Health Care Organizations Is Associated with Underutilization of Health Services. Health Services Research.

2009;44(6):2093-2105. doi:https://doi. org/10.1111/j.1475-6773.2009.01017.x 4. Armstrong K, Rose A, Peters N, Long JA, McMurphy S, Shea JA. Distrust of the health care system and self-reported health in the United States. Journal of General Internal Medicine. 2006;21(4):292-297. doi:https://

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doi.org/10.1111/j.1525-1497.2006.00396.x 5. Siegrist M, Zingg A. The Role of Public Trust During Pandemics. European Psychologist. 2014;19(1):23-32. doi:https:// doi.org/10.1027/1016-9040/a000169 6. Moucheraud C, Guo H, Macinko J. Trust In Governments And Health Workers Low Globally, Influencing Attitudes Toward Health Information, Vaccines. Health Affairs. 2021;40(8):1215-1224. doi:https:// doi.org/10.1377/hlthaff.2020.02006 7. The Commonwealth Fund. Meeting America’s Public Health Challenge. www. commonwealthfund.org. Published June 21, 2022. https://www.commonwealthfund.org/publications/fund-reports/2022/ jun/meeting-americas-public-health-challenge 8. Woskie LR, Fallah MP. Overcoming distrust to deliver universal health coverage: lessons from Ebola. BMJ. Published online September 23, 2019:l5482. doi:https://doi. org/10.1136/bmj.l5482 9. Blair RA, Morse BS, Tsai LL. Public health and public trust: Survey evidence from the Ebola Virus Disease epidemic in Liberia. Social Science & Medicine. 2017;172:89-97. doi:https://doi. org/10.1016/j.socscimed.2016.11.016 10.Bollyky TJ, Hulland EN, Barber RM, et al. Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021. The Lancet.

2022;0(0). doi:https://doi.org/10.1016/ S0140-6736(22)00172-6 11. Blendon RJ, Benson JM. Trust in Medicine, the Health System & Public Health.

Daedalus. 2022;151(4):67-82. doi:https:// doi.org/10.1162/daed_a_01944 12. SteelFisher GK, Findling MG, Caporello HL, et al. Trust In US Federal, State, And Local Public Health Agencies During COVID-19: Responses And Policy Implications. Health Affairs. 2023;42(3):328337. doi:https://doi.org/10.1377/ hlthaff.2022.01204 13. Restoring Trust in Public Health. www. commonwealthfund.org. Published February 14, 2023. https://www.commonwealthfund.org/publications/2023/feb/ restoring-trust-public-health 14. O’Mara-Eves A, Brunton G, McDaid D, et al. Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis.

Public Health Research. 2013;1(4):1-526. doi:https://doi.org/10.3310/phr01040 15. Community Trust And Relationships: The Key For Strengthening Public Health Systems | Health Affairs Forefront.

Health Affairs Forefront. Published 2024. https://www.healthaffairs.org/content/ forefront/community-trust-and-relationships-key-strengthening-public-health-systems

16. How California’s Community-Based Organizations Filled the Gaps for Underserved Communities Meeting the Needs of Racially & Ethnically Diverse Communities during the Pandemic 2 HOW CALIFORNIA’S CBOs FILLED the GAPS for UNDERSERVED COMMUNITIES. Accessed December 4, 2024. https://www. changelabsolutions.org/sites/default/ files/2021-09/CA_CBOs_Covid_Report_ FINAL_20190908_0.pdf 17. What we do - King County, Washington.

Kingcounty.gov. Published 2025. https:// kingcounty.gov/en/dept/dph/about-kingcounty/about-public-health/equity-community-partnerships/areas 18. Meet our Community Navigators. www.youtube.com. Published October 26, 2022. https://www.youtube.com/ watch?v=mPnSnmRYV4o 19. Action I. Building Trust In Action by Working With Community Partners: Seattle & King County. YouTube. Published July 22, 2024. https://youtu.be/QyeJkF29RQQ?si=T7NoqZEdgQApFClh 20.

“Community navigators” bridge the healthcare gap for BIPOC groups. Cascade PBS. Published 2023. https://www. cascadepbs.org/investigations/2023/02/ community-navigators-bridge-healthcare-gap-bipoc-groups 21. Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation during Public Health Emergencies.; 2024. https://centerforhealthsecurity.org/sites/default/ files/2024-07/2024-07-12-checklist.pdf

Author’s Biography Booseong Eric Seo is a freshman studying Molecular & Cellular Biology, Public Health and Anthropology. Outside of Epidemic Proportions, he is a part of the Global Medical Missions Alliance and HERO. In his free time, Eric likes to read and rock climb.

The Politics of a Petri Dish

Editorials

Isabelle Jouve Introduction In September 2023, JHU biologists published the most detailed analysis to date of embryos undergoing in-vitro fertilization (IVF) and resulting genetic errors in early development.1 The next month, JHU chemical engineers successfully developed nanotechnology to deliver drugs to fight aggressive breast cancer tumors while conserving healthy cells–a landmark improvement on standard therapies.2 In November 2024, researchers in the Whiting School’s Department of Chemical and Biomolecular Engineering created gel strips that shift shape based on instructions written in their DNA code.3 These historic advancements—along with countless others at JHU—were funded in part or entirely by the $3.181 billion in research grants the institution receives from its largest source of such funding, the federal government.4 JHU also relies on federal funding for other beneficial areas for students, such as graduate medical education. Consider this—at JHU, nearly 70 percent of incoming firstyear students pursue pre-health tracks to attend medical school. In 2023, JHU generated more medical school applicants than any other private university, with 494 students applying. This new generation of physicians-in-training will navigate the residency matching process, which collects 86 percent of its funding from the federal government.5

erate with different rhetoric and values. This communication gap can create barriers to applying scientific knowledge in policymaking and employing governmental funding mechanisms to progress cutting-edge milestones. While the partisan politics and theatrics of D.C. may seem far removed from breakthroughs like shape-shifting DNA gel strips, they are, in reality, deeply connected, often determining whether such achievements are even possible.6 This raises two central questions—what exactly is the federal government’s role in funding scientific and medical advancements?

How can Hopkins students bridge the gap between science and policy by increasing their involvement and influence in the democratic process through university programs and resources?

By understanding the intersection of government and science, students entering STEM fields gain awareness of the factors affecting their post-graduate career opportunities. Through civic and political engagement in this nation’s democracy, students can mold the very issues that will shape their futures.

Federal Government’s Role in Scientific and Medical Advancement Research and Development (R&D) Funding The federal government is a significant source of research and development (R&D) funding at JHU and other institutions in the United States.4 In the 2022 fiscal year, the total federal R&D budget reached $190.4 billion, an increase of nearly 47 percent since 2000.7 Corporate spending, which provides approximately $693 billion annually, is the only contributor to R&D surpassing federal funding levels.8,9 Federal R&D funds are distributed across a wide range of STEM fields. For instance, 42 percent of basic research funding supports areas like agricultural sciences, biological and biomedical sciences,

Despite the federal government’s overwhelming influence on research at institutions like JHU, two distinct communities—scientists and policymakers—often opVolume 22

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Editorials health sciences, natural resources and conservation, and other life sciences. The federal government provides the largest contribution to its funding for many of these fields, such as psychology.10 Grants for medical and scientific research depend heavily on a network of federal government agencies, including the Department of Health and Human Services, the Department of Agriculture, and the Department of Energy. These executive institutions, along with their sub agencies—such as the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Agency for Healthcare Research and Quality (AHRQ)—are responsible for distributing R&D awards. Within each, specialized divisions, such as the NIH’s Offices of Research Services (ORS) and Extramural Research (OER), are dedicated to managing staff and resources that support scientific achievement.9,10 Residency Placements The federal government is the primary financier of graduate medical education (GME) in the United States, allocating approximately $20 billion annually to support residency programs. Much of this funding is administered through the Department of Health and Human Services, primarily by Medicare. Medicare’s contributions cover the cost of training medical residents, including their salaries, benefits, and additional expenses incurred by teaching hospitals from specialized training equipment and increased staff for supervision.

Other federal entities, such as the Department of Veterans Affairs and the Department of Defense, subsidize GME funding through similar programs.11 The Balanced Budget Act of 1997 capped the number of residen-

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cy positions funded by the federal government.12 Since then, federal support for residency placements has increased only once, with the Consolidated Appropriations Act of 2021, which added 1,000 new Medicare-funded residency positions. However, given the growing demand for medical professionals, debate continues regarding whether this limit should be further expanded.13

Each year, Congress dictates how much funding federal agencies and their programs will receive.

Federal Funding Disbursement by Congress Who determines how funding for research, residency positions, and other programs critical to scientific and medical progress is allocated within the federal government?

And who decides how much money goes to institutions like Johns Hopkins University or the companies that may eventually employ its students? The answer lies in Article 1, Section 9 of the U.S. Constitution, which grants control over federal spending to Congress through a process known as “appropriations.”

Each year, Congress dictates how much funding federal agencies and their programs will receive.14 The rationale behind this arrangement is to give taxpayers a direct voice in government spending.

Constituents elect members of Congress who can advocate for fund-

ing priorities based on the needs of their districts and adjust program funding levels every year after considering factors like emerging threats or inflation.

Trends in legislative action reveal the stances elected officials, particularly those who control the appropriations process, take on a range of issues, including scientific and medical research advancement funding. For instance, in September 2023, Rep. Kay Granger (R-TX-12), then-chair of the House Committee on Appropriations, suggested eliminating 2,000 federal research grants for diseases like cancer, Alzheimer’s, and heart disease.15 Then, Rep. Kathy McMorris Rodgers (R-WA-05) released a report in June 2024 as Chair of the House Committee on Energy and Commerce, which outlined a plan to reduce the number of National Institutes of Health (NIH) centers from 27 to 15 and revoke NIH’s authority to allocate funds without explicit congressional approval–thus limiting the ability of researchers to respond quickly to public health emergencies.16 However, in March 2024, Senator Jeanne Shaheen (D-NH), as Chair of the Senate Committee on Appropriations, Subcommittee on Commerce, Justice, and Science, proposed increased federal research funding for the National Aeronautics and Space Administration’s (NASA) James Webb Space Telescope and initiatives to discover asteroids and comets potentially on a collision course with Earth.17 That same month, Rep. Brian Fitzpatrick (R-PA-01) introduced the LOANS for Biomedical Research Act, which guarantees bonds to support loans for clinical trials of drugs and medical devices.18

Editorials Your Role as a JHU Student Engagement with Elected Legislators Differences in legislators’ actions—regardless of Democratic and Republican party affiliation—highlight the importance of everyone, including students at JHU, understanding the stances of their elected officials. This knowledge should inform voters in future elections by encouraging a thorough examination of candidates’ past statements, work, and voting records, especially for incumbents or those with prior legislative experience.

Moreover, this awareness can drive engagement in other ways; even if you cannot vote, there are numerous ways to express your views and influence your candidates’ or elected officials’ positions on certain issues. For instance, calling your elected representatives to express your opinions can

be particularly timely ahead of scheduled votes on issues such as funding for scientific and medical advancements. By contacting the representative who serves your area—regardless of whether or not you can vote or do vote for them— you are conveying your position as a resident in their district and the community they represent.

Additionally, you can engage with elected officials by attending community events hosted by their offices to discuss important issues with them or their staff. Even further, you can email or mail a letter to your representative expressing your opinion and urging them to take specific actions. Amplifying officials’ posts on social media also helps reach more stakeholders.

Institutional Resources for Democratic Involvement JHU has dedicated significant

Vlad Gorshkov/Unsplash

resources and programming to solidify its commitment to engaging students in political processes and civic responsibilities, especially over the last decade. Most notably, in October 2023, JHU opened the Hopkins Bloomberg Center (HBC), a state-of-the-art facility between the U.S. Capitol Complex and the White House, with faculty from the university’s nine academic divisions.19 HBC has quickly become a hub for events and speakers on topics often involving policy and scientific innovation. Recent forums included a talk by the U.S. Health and Human Services Secretary Xavier Becerra on regulatory solutions to reduce the healthcare industry’s carbon footprint and an overview of global quantum strategies from key private and public sector players.20, 21 Alongside the opening of HBC, JHU launched its inaugural cohort of the Hopkins Semester DC (HSDC), a residential program in Washington, D.C., focused on cultivating students’ public service and policy interests.22 Through this program, HSDC students have applied their JHU training across disciplines, including public health and engineering, to influence policy through internships at the U.S. Senate, the Department of Homeland Security, and the National Alliance on Mental Illness (NAMI), as well as research on topics such as policy solutions to promote reproductive health and wellbeing during substance use disorder treatment. JHU is building upon the success of HSDC by forming a new School of Government and Policy in Fall 2026.23 On the Homewood campus, Hopkins Votes has led efforts to promote student engagement in civic life. For instance, voter participation at JHU increased from 7.5 percent in 2014 to 29.4 percent in 2018 due to Hopkins Votes iniVolume 22

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Editorials tiatives like hosting information sessions on voter registration, providing students with voter toolkits, and recruiting student ambassadors to organize office hours and events raising awareness about the importance of voting.24 Conclusion Your participation in democracy directly impacts funding for programs that influence research, residency placements, and post-graduate opportunities for you, other JHU students, and people nationwide. At JHU, initiatives like HSDC and Hopkins Votes incentivize and expand student involvement in political and civic activities. However, these efforts to bridge the gap between science and policy can be further strengthened through strategies recommended in a 2022 report from the JHU Stavros Niarchos Foundation Agora Institute (SNF Agora Institute).

Institutional solutions suggested include integrating democracy-related content into coursework and encouraging student involvement in legislative advocacy.24 JHU students, your voice matters more than ever—now is the time to engage with politics and embrace your democratic responsibility. You have invested in your education and must advocate for your future careers and the issues defining them.

References

1. Johns Hopkins University. IVF study sheds new light on early stages of embryo development. The Hub. Published October 2, 2023. https://hub.jhu.edu/2023/10/02/ ivf-embryo-fate/ 2. Johns Hopkins University. New nanotech weapon takes aim at hard-totreat breast cancer. The Hub. Published September 15, 2023. https://hub.jhu. edu/2023/09/15/new-nanotech-weapontakes-aim-at-breast-cancer/ 3. Johns Hopkins University. Molecular Morphers: DNA-powered gels shapeshift on command. The Hub. Published November 22, 2024. https://hub.jhu.

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edu/2024/11/22/dna-powered-gels-shapeshift-on-command/ 4. Johns Hopkins University. Johns Hopkins leads nation in research spending for 44th consecutive year. The Hub. Published January 5, 2024. https://hub.jhu. edu/2024/01/05/nsf-higher-education-research-spending-2022/ 5. AdmissionSight. How to Succeed in Johns Hopkins Premed Track. AdmissionSight. Published September 5, 2024. https://admissionsight.com/johns-hopkins-premed/ 6. Li N, Luczak-Roesch M, Donadelli F. A computational approach to study the gap and barriers between science and policy.

Science and Public Policy. 2022;50(1):1529. doi:https://doi.org/10.1093/scipol/ scac048 7. Pece CV. Federal R&D Obligations Increased 0.4% in FY 2022; Estimated to Decline in FY 2023 | NSF - National Science Foundation. Nsf.gov. Published 2022. Accessed January 21, 2025. http://ncses.nsf. gov/pubs/nsf24322 8. National Science Board. National Science Board. Published 2025. Accessed January 21, 2025. http://www.nsf.gov/nsb/ news/news_summ.jsp?cntn_id=309719 9. National Patterns of R&D Resources 2021-2022 | NSF - National Science Foundation. Nsf.gov. Published 2021. https:// ncses.nsf.gov/data-collections/national-patterns/2021-2022#tableCtr10478 10.Pece CV. Analysis of Federal Funding for Research and Development in 2022: Basic Research | NSF - National Science Foundation. Nsf.gov. Published 2022. https:// ncses.nsf.gov/pubs/nsf24332 11. Wagner MJ, Frazier HA, Berger JS. Navigating the Rapids: How Government Funds Flow to Graduate Medical Education. Journal of Graduate Medical Education. 2024;16(3):339-340. doi:https://doi. org/10.4300/jgme-d-24-00378.1 12. “H.R.2015 - 105th Congress (19971998): Balanced Budget Act of 1997.”

Congress.gov, 2015, www.congress.gov/ bill/105th-congress/house-bill/2015.

13. D-TX-28 H. H.R.133 - 116th Congress (2019-2020): Consolidated Appropriations Act, 2021. Congress.gov. Published 2019.

Accessed January 21, 2025. http://www. congress.gov/bill/116th-congress/housebill/133/ 14. National Constitution Center. The United States Constitution. National Constitution Center. Published September 17, 1787. https://constitutioncenter.org/the-constitution/full-text 15. FACT SHEET: Republicans’ Extreme Continuing Resolution. House Committee on Appropriations. Published September 18, 2023. https://democrats-appropriations. house.gov/news/fact-sheets/fact-sheet-republicans-extreme-continuing-resolution 16. Reforming the National Institutes of

Health Framework for Discussion: NIH Mission and Leadership Must Be Accountable, Integrated, and Agile; June 2024. https://d1dth6e84htgma.cloudfront.net/ NIH_Reform_Report_f6bbdca821.pdf 17. “BILL SUMMARY: Commerce, Justice, Science, and Related Agencies Fiscal Year 2024 Appropriations Bill | United States Senate Committee on Appropriations.”

Www.appropriations.senate.gov, www.appropriations.senate.gov/news/ majority/bill-summary-commerce-justice-science-andrelated-agencies-fiscal-year-2024-appropriationsbill.

18. R-PA-1 BK. H.R.7539 - 118th Congress (2023-2024): LOANS for Biomedical Research Act. Congress.gov. Published 2023. https://www.congress.gov/bill/118th-congress/house-bill/7539 19. Hopkins Bloomberg Center | Johns Hopkins in Washington, D.C. Johns Hopkins in Washington, D.C. Published December 23, 2024. https://washingtondc.jhu. edu/bloomberg-center/ 20.

Addressing Health Care’s Carbon Footprint with Secretary Xavier Becerra | Johns Hopkins Bloomberg School of Public Health. Johns Hopkins Bloomberg School of Public Health. Published January 15, 2025. https://publichealth.jhu.edu/ events/2024/addressing-health-cares-carbon-footprint-with-secretary-xavier-becerra 21. Global Quantum Strategies Overview 2024. The Hub. Published 2024. https:// hub.jhu.edu/events/2024/09/08/global-quantum-strategies-overview-2024/ 22.

19.Johns Hopkins University. New program gives Hopkins students a gateway to D.C. The Hub. Published March 19, 2024. https://hub.jhu.edu/2024/03/19/ new-hopkins-semester-in-dc/ 23.

20.Johns Hopkins University. Johns Hopkins to launch new School of Government and Policy in Washington, D.C. The Hub. Published October 6, 2023. https://hub.jhu.edu/2023/10/06/johnshopkins-school-of-government-and-policy/ 24.

Warren S, Agora S, Fellow V. Democratic Engagement a Review at Johns Hopkins University.; 2022. Accessed January 21, 2025. https://snfagora.jhu.edu/ wp-content/uploads/2022/04/DemocraticEngagement_SNFAgoraReport.pdf

Author’s Biography Isabelle Jouve is a junior Public Health Studies major pursuing a career in health policy and public service. She enjoys traveling and spending weekends with friends!

Editorials

Grace Dadson/Unsplash

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Public Health Pulse: Thoughts from the Next Generation of Leaders might or should the field of pubQ How lic health change in the future?

A A A

With public health services shrinking, we must protect vulnerable communities from harmful policies and safeguard their health.

Public health could incorporate more of an individualistic approach to support more people worldwide.

Climate issues will become important in public health as our world continues to face climate change.

might integrating mental health Q How services into primary care settings

improve outcomes for patients in underserved communities?

mental health into primaA Integrating ry care improves access and early in-

A A

countries do you feel are doing Q Which a good job of upholding public health and the values it encompasses?

currently has a very inA Germany depth health system that is complete-

A

ly free for everyone and encompasses all types of care.

Canada’s healthcare system focuses on preventative care and early detection for chronic diseases.

Q How do we address access to resources regionally based on mandated governmental support or individual action?

and local communities A Governments must work together to allocate resources fairly, ensuring health equity and access to basic needs like food and water.

46

tervention, benefiting underserved communities.

This would help underserved patients who don’t feel represented or don’t have access to resources.

Doing so could improve mental health screening in underserved communities with limited access, leading to earlier diagnosis and better treatment outcomes.

is a suggestion you would want Q What to make to your health department to improve public health?

Medicaid and Medicare A Expanding coverage to include dental care!

food deserts by increasing A Fighting access to affordable and fresh food,

supporting local farmers, and increasing nutrition education in schools.

opportunities for locals to A Increasing express concerns in convenient ways

A

(e.g., text, call, workplace).

Establishing anonymous online forums for sensitive health topics to reduce stigma and provide resources.

Why is Community Important in Public Health?

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Policy

Shannon Xiao

Policy

Evaluating and Improving Translation Services for LEP Patients in Healthcare Indu Bodala

Background Growing service gaps routinely challenge the American medical infrastructure. An area where this is especially evident is the lack of translation services for Limited English Proficiency (LEP) patients.

Translation services ensure that all patients, regardless of their background or condition, can communicate and comprehend their health accurately, which is imperative to guarantee quality medical treatment and care. However, medical settings ranging from large-scale hospital systems, satellite centers, and regional private clinics struggle to supply essential interpreter services to a community’s most vulnerable. A perturbing discovery found that only 56% of all American-based hospitals provide essential translation services for newly immigrated LEP patients despite the LEP community growing exponentially, showing an 80% increase in the population from the early 2000s to the present day.1-2 These population shifts are caused by rises in immigration initiatives, global conflicts, and displacements from

50

natural disasters, thus heightening the need for efficient support systems to aid individuals navigating a foreign and vastly different society. Translator shortages are placing patients from predominantly marginalized communities at more significant harm, thus highlighting hidden but prominent systemic inequities in healthcare.

Impact on Quality of Health Healthcare is a fast-changing field with evolving technology, innovative practices, and expansive policies, yet inequities brought forth by language barriers still persist. With over 66 million non-English language speakers, the American medical system fails to provide the efficient resources needed to provide quality care to English language learner patients.

It is expected for all medical institutions to provide medical interpreter services as mandated by the Civil Rights Act of 1964, Title VI, however as per the Wall Street Journal approximately 17,000 medical translators are actively employed within US hospitals. Currently, LEP

cottonbro studio/Pexels

patients endure a slew of medical shortcomings, ranging from translator shortages to cultural biases and even medical apathy. A study

by Lindholm et al3 found that L.E.P patients received diminished quality of care, faced higher readmission rates, and had longer hospital stays than their English-proficient counterparts. As per the study, the L.E.P patient demographic averaged a minimum of five-day hospital stays, more than double the average hospital stays for non-L.E.Ps (two days) due to miscommunication and medical errors brought forth by language barriers. The ramifications of mass translator shortages are extensive and dangerously diminish the medical efficacy of the American healthcare system.4 The most common causes for translator shortages are large LEP population influx and budgetary constraints.5 Rapid growth in LEP patient populations is accelerating the need for quality translators, resulting in a higher demand than available supply.

Furthermore, limited financial resources and government budget cuts for social welfare programs force medical institutions to limit their translation services.1 The inability to provide qualified translators poses intense ramifications on the quality of medical care addressed to L.E.P. patients. The extent of the impact can be observed in a case study conducted on the California healthcare system’s ability to effectively treat their Na-

Policy tive Hawaiian and Pacific Islander (NHPI) patients during the peaks of the COVID-19 pandemic. The study found that the immense lack of translators for these communities led to increased virus-related deaths in the NHPI demographic with the crude mortality rate being the highest in the State.6 The increase in virus-related deaths can be attributed to the NHPI demographic facing language barriers thus being unable to comprehend the health and hygiene practices needed to avoid infection effectively and the medical providers failing to provide vaccine information in a digestible and timely manner. Likewise, a 2014 study conducted by the Society of Healthcare Epidemiology in America credits language barriers, miscommunication, and translator shortages as some of the biggest causes for Hispanic and Asian patient demographics having a higher probability of developing clinical infections, where the rate of contracting at least one healthcare-associated infection is 3.3% and 3.8% respectively in contrast to the 1.1% rate for non-hispanic white patients.7 Infectious diseases are not the only public health problems that is disproportionately impacting minority patients facing language barriers. A 2012 study found that mammography scan results and physician follow-ups take concerningly longer in L.E.P. demographics than in English-proficient patients.8 The delay in providing the critical information is concerning as Breast cancer is an aggressive, tenacious, and fast-moving disease; if not immediately identified and treated, the disease can lead to clinical metastasis and eventual death.

A clear and distinct trend emerges when holistically analyzing the extent of damages inflicted

upon the quality of care for LEP patients as shown in a 2016 medical safety study where over 30% of all reported malpractice cases are attributed to miscommunication between LEP patients and their care team, with the damages and retribution payments (compensation to patient or their family) amounting to 1.7 billion dollars.9 The lack of expendable and accessible translators within the healthcare system is placing the health and safety of minority patients at increased risk.

per the Maryland Office of Minority Health and Health Disparities 2023 Annual Report, immigrant communities are found to have the largest amount of Years of Potential Life Lost along with the highest reports of deaths caused by chronic illnesses (cancer, diabetes, heart disease, etc). Maternal mortality rates are also disproportionately higher in Baltimore City LEP communities.12 Furthermore, a report released by the Public Justice Center finds that within Maryland and Baltimore City many mental health providers are denying essential translation services to LEP adolescents seeking mental health support and care.13 The lack of essential resources, namely translation services, in Maryland reflects health inequities on the National scale, resulting in poor health outcomes among vulnerable communities.

By promoting equity, inclusivity, and patient-centered care practices, the healthcare system can strive Policy Initiatives towards eliminating Current While the implications of translator shortages in clinical settings disparities and ensurare rampant and affecting the lives ing that all individuals of many Baltimore City residents, officials and policy advoreceive the care and elected cates have also begun to develop support they deserve. and implement policy interventions

Impact in Baltimore The effects of a national shortage of medical translators is especially felt in the incredibly diverse ethnic and cultural demographic of Baltimore City, where over 10% of the city population is comprised of immigrants and 1 in 4 children have at least one immigrant parent.10 The largest concentration of LEP individuals is mostly found in the southeast region of Baltimore City, specifically along the Pulaski Highway and around the Johns Hopkins Bayview Hospital, with the proportion of LEPs nearing 20.7%.11 As

and programs to address the discrepancies faced by LEP communities. In the Fall of 2022, Baltimore City Mayor Brandon M. Scott alongside his Director of Immigrant Affairs announced the formation of the Baltimore New American Access Coalition which seeks to “minimize the economic and social disparities faced by immigrant and refugee families.” This initiative promises a strong monetary investment ($4 million) into LEP communities to improve accessibility to health and social resources along with addressing language barriers by investing in translation services within clinical and governmental settings.

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Policy The Mayor’s efforts have been praised by numerous community stakeholders and advocates ranging from the International Rescue Committee to the Maryland Chapter of CASA (an advocacy organization working to address healthcare, economic, and social disparities faced by minority and immigrant communities through various programs).14 This program has already helped over 700 Baltimore City families and a second phase of the program is expected to expand this number, additionally $4 million of funding has been allocated to advance efforts to bridge disparities brought forth by language barriers (including healthcare and social welfare services).15 Suggested Policy Initiatives Progress has certainly been made to address language barriers and medical inequities within LEP communities, however there is still substantial work to be done to address the gaps in medical services and care. Implementing evidence-based solutions and policy recommendations is essential to bridge gaps in healthcare accessibility and quality of care for L.E.P patients.

Such efforts that recently emerged in clinical settings across the country include the utilization of video and telephonic interpretation services. These services have been praised by public health researchers for its accessibility, convenience, and unique ability to serve various linguistic backgrounds.

However, a major drawback for this initiative is the cost of services associated with video/telephone interpreters with the estimated cost amounting to $132 per hour.16 Regardless, numerous States have begun to embrace clinical telephone interpretation services in tandem with training clinical providers to be knowledgeable of such services and how to effectively utilize them

52

for their LEP patients. It is time for Maryland to also fully embrace such initiatives and ensure all healthcare providers are actively utilizing video/telephone interpreters. Such actions are essential to bring forth a paradigm shift in healthcare delivery that prioritizes cultural diversity, linguistic inclusivity, and empathetic care for all patients.

References

1. Language Diversity and English Proficiency in the United States | Immigration Research Library. www.immigrationresearch.org. Published November 2016. https://www.immigrationresearch.org/ report/migration-policy-institute/language-diversity-and-english-proficiency-united-states 2. Mulrooney Eldred S. With Scarce Access To Interpreters, Immigrants Struggle To Understand Doctors’ Orders. Npr.org. Published 2019. https://www.npr.org/sections/ health-shots/2018/08/15/638913165/ with-scarce-access-to-medical-interpreters-immigrant-patients-struggle-to-unders 3. Lindholm M, Hargraves JL, Ferguson WJ, Reed G. Professional Language Interpretation and Inpatient Length of Stay and Readmission Rates. Journal of General Internal Medicine. 2012;27(10):1294-1299. doi:https://doi.org/10.1007/s11606-0122041-5 4. Newman B. Doctors’ Orders Can Get Lost In Translation for Immigrants. Wall Street Journal. Published January 9, 2009. Accessed January 6, 2025. https://www.wsj. com/articles/SB1043387263668459264 5. Dahima R, Luo M, Dhongade V. Medical Interpretation in the U.S. Is Inadequate and Harming Patients. The Hastings Center. Published May 22, 2023. https://www. thehastingscenter.org/medical-interpretation-in-the-u-s-is-inadequate-and-harming-patients/ 6. Haley J, Zuckerman S, Rao N, Karpman M, Stern A.; 2022. https://www.urban. org/sites/default/files/2022-12/Many%20 AANHPI%20Adults%20May%20Face%20 Health%20Care%20Access%20Challenges%20Related%20to%20Limited%20English%20Proficiency.pdf 7. Bakullari A, Metersky ML, Wang Y, et al. Racial and Ethnic Disparities in Healthcare-Associated Infections in the United States, 2009–2011. Infection Control & Hospital Epidemiology. 2014;35(S3):S10-S16. doi:https://doi.org/10.1086/677827 8. Karliner LS, Auerbach A, Nápoles A, Schillinger D, Nickleach D, Pérez-Stable EJ. Language Barriers and Understanding of Hospital Discharge Instructions. Medical Care. 2012;50(4):283-289. doi:https://doi.

org/10.1097/mlr.0b013e318249c949 9. CRICO. Press Release: Failures in Communication Contribute to Medical Malpractice. Harvard.edu. Published January 31, 2016. https://www.rmf.harvard.edu/News-and-Blog/Press-Releases-Home/Press-Releases/2016/February/ Failures-in-Communication-Contribute-to-Medical-Malpractice 10.Profile of the Foreign-Born Population In. https://vera-institute.files.svdcdn.com/ production/downloads/publications/profile-of-foreign-born-population-baltimore. pdf 11. Office of Minority Health and Health Disparities Annual Report FY 2023.; 2024. https://health.maryland.gov/mhhd/Documents/MHHD%20FY2023%20Annual%20Report.Final%20%281%29.pdf 12. monicasol. New report: Maryland mental health providers’ failure to provide interpretation and translation services denies care to children and adolescents with limited English proficiency. Centro SOL. Published December 7, 2022. https://jhcentrosol.org/health-policy/report-speaking-the-language/ 13. Mayor Brandon M. Scott Announces $4 Million ARPA Initiative to Support Immigrant and Refugee Communities in Baltimore City. Mayor Brandon M. Scott. Published October 12, 2022. https://mayor.baltimorecity.gov/ news/press-releases/2022-10-12-mayorbrandon-m-scott-announces-4-million-arpa-initiative-support 14. The Baltimore New American Access Coalition (BNAAC). Mayor’s Office of Immigrant Affairs. Published April 12, 2023. https://mima.baltimorecity.gov/advancing-resources-baltimore-new-american-access-coalition-bnaac 15. Masland MC, Lou C, Snowden L. Use of Communication Technologies to Cost-Effectively Increase the Availability of Interpretation Services in Healthcare Settings. Telemedicine and e-Health.

2010;16(6):739-745. doi:https://doi. org/10.1089/tmj.2009.0186

Policy

Waging the War Against Medical Misinformation Pranav Kotamraju, Conner Feng In the context of health care and medicine, the spread of misinformation—false or inaccurate information—is harmful and potentially deadly because it can discourage people from following evidence-based recommendations to protect their health and well-being.1 Psychologists believe that the effectiveness of misinformation can be explained by individual, group, and societal factors. At the individual level, people often lack the ability or motivation to identify false information because of problems such as inadequate media literacy and a tendency to seek out information consistent with their preexisting views. At the group level, social networks often consist of people who share more or less the same beliefs about society, leading to “echo chambers” that skew their understanding of reality. Finally, at the societal level, agents including politicians and popular personalities are motivated to spread misinformation to sway public opinion to benefit their own agendas.2 Following the Scientific Revolution, scientific literacy was low with most people remaining uneducated and fearful of things they did not understand. An early example of the effectiveness of medical misinformation in hindering the goals of public health is the negative backlash against the early prototype of the smallpox vaccine introduced by English physician Edward Jenner in 1796. Jenner’s use of cowpox to inoculate patients against the deadlier and more dangerous smallpox was initially met with widespread skepticism and derision, from both the scientific community and the

public, especially since the mechanism by which vaccines worked was not yet understood. Clergymen spoke out against the “unholy” animal origins of the vaccine, feeding into uncertainty about its safety. A popular cartoon from the time illustrated some peoples’ belief that the use of cowpox scabs could cause miniature cows to sprout from one’s arms.3 As scientific understanding of vaccination improved with the introduction of the germ theory by Louis Pasteur and Robert Koch, vast leaps were made in medicine, resulting in a period of massive success for the field of public health as the causative agents of many previously mysterious and deadly diseases were discovered.4 The significant decline in smallpox infection rates was particularly notable and Jonas Salk’s development of the inactivated polio vaccine in 1955 was thus widely welcomed and celebrated by the public. In the 1960s and 70s, however, vaccine-related accidents and investigations greatly decreased public confidence in the safety of vaccinations. In the Cutter Incident of 1955, a vaccine manufacturer released polio vaccines contaminated with live virus, leading to 10 deaths, 200 cases of paralysis and more than 40,000 children contracting mild cases of polio. While the incident was found to be an isolated instance of human error, the government and pharmaceutical industry’s failure to protect the public fostered fear and mistrust and created a demand for alternative explanations.5 In 1974, a retrospective study on the use of diphtheria, tetanus, and pertussis (DTP) vaccine, which had been introduced two de-

cades prior, reported 36 children with severe neurological complications after receiving the vaccine.

While a government investigation determined that such side effects were extremely rare, the study was heavily reported on and dramatized in the media. In 1982, NBC released the television program DPT: Vaccine Roulette which distorted vaccine research and exaggerated claims of long-term side effects such as brain damage from the DPT vaccine.6 Amidst this controversy, vaccination uptake rates in the UK dropped from 81% to 31% between 1974 and 1980.7 The public health campaign to eliminate preventable illnesses such as measles through vaccination received perhaps its largest setback yet in 1998, when respected British medical journal The Lancet decided to publish an article by physician Andrew Wakefield that concluded there was a causative link between receiving the MMR vaccine and autism in young children.8 The ensuing public controversy galvanized the vaccine-skeptic movement and resulted in a sharp rise in confirmed cases of measles in England and Wales from 56 in 1998 to 971 in 2007.9 Wakefield’s article was later retracted. All subsequent cohort studies using much larger sample sizes have failed to replicate his findings, and a subsequent journalistic investigation accused Wakefield of having a conflict of interest by standing to profit from the introduction of a rival vaccine, but Wakefield has stood by his claims and continues to defend his paper.10 Additional support for Wakefield’s findings came from public Volume 22

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Policy figures. For example, one op-ed, “Deadly Immunity” was published in Rolling Stone and Salon focused on connections between autism and thimerosal, a mercury compound historically used as a preservative in vaccines that at the time was only found in few versions of the flu and hepatitis vaccine.11 In the modern Internet age, televised or printed mass media has been traded for social media as a primary source of information. As the 21st century ushered in this new vehicle for people to receive information about the world around them, a new term– “infodemic” was coined by political analyst and journalist David Rothkopf to describe the overabundance or flooding of a system with so much information on a particular issue it becomes difficult to distinguish fact from fiction. Combining the words “information” and “epidemic,” Rothkopf first used it in the context of the 2003 severe acute respiratory syndrome (SARS) outbreak to criticize what he saw as the irrational, panicked public response to SARS which devastated regional economies.12 The characteristic features of infodemics include volume and velocity of information. Volume refers to the amount of information present, which is almost unlimited in a social media ecosystem where any person can create or amplify any claim. Additionally, with social media information can appear from any source anywhere in the world, making it highly decentralized and almost impossible to pinpoint its exact origin. Velocity refers to the speed at which information is transmitted. On social media platforms information can be posted in a matter of seconds, which means that it can take mere hours for a popular post with a lot of exposure to “go viral” and reach an audience of hundreds of thousands or millions.13 The unvetted spread of information

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means oftentimes false or distorted information is offered that contradicts the most up to date and scientifically accurate. The average user has neither the ability nor motivation to sort through the information and determine facts from fiction.

Instead, they can pick and choose which ones to expose themselves to, and which ones to ignore or reject.13 As a result, the typical public health mission of ensuring uniform adoption of evidence-based preventative measures or treatments becomes more difficult than it already is.

The COVID-19 global pandemic was perhaps the most significant test of the global health infrastructure’s ability to respond to public health misinformation in modern times. In the United States in particular, government recommendations, which changed frequently as the pandemic progressed, were met with fierce resistance in some quarters. Resistance to public health measures was certainly motivated by a variety of factors, but it is safe to say that a significant contributor was misinformation about the nature of the pandemic and the public health measures implemented in good faith by public health authorities.14 At the individual level, contributing factors to the widespread public acceptance of misinformation include the intense polarization that characterizes the modern political climate. In a polarized environment, users often use confirmation bias or selective exposures to find information or narratives that align with their existing political opinions or ideology.15 At the societal level, public figures with their own agendas or goals often offered their own advice on how individuals could best protect themselves from the pandemic. Activists skeptical of the safety and efficacy of vaccines found a new target with the introduction of mRNA-based COVID vaccines.15 They proposed that the

public could not trust the safety of such a vaccination due to the expedited timeline in which it was developed. Within the context of the infodemic, these voices offered an alternative to the official scientific consensus for individuals who are traditionally more skeptical of government authority or the medical establishment, including those with a conservative political ideology, with a high school education or lower, people who live in rural areas, and African-Americans.16 The solution to much of this misinformation doesn’t seem to lie in empowering adults who are already in the spaces where the misinformation persists. In fact, a study from the University of Washington found the phrase “do your own research” usually means the exact opposite: it is associated with COVID-19 “misperceptions and scientific mistrust.”17 Dis- and misinformation are not new problems in public health. It can even be argued that in the past, it was more difficult to arrive at the truth with health-related scenarios due to a lack of the internet. One of the earlier disinformation stories was planted by the Soviet Union during the Cold War, claiming that US secret service experiments gone-wrong had unleashed HIV and AIDS on the world.18 A story like that required meticulous effort and planning then, but today, the same thing that allows us to combat disinformation, the internet, also allows it to spread incredibly quickly and easily. Public health and medical misinformation can take much more reading than usual to debunk due to their highly scientific nature. Hence, the fight to combat these lies should start even before being exposed to those lies. It should begin in schools and classrooms, in colleges with media literacy courses. A study from Stanford found that students from middle school through college were

Policy unable to discern factual information in a significant way.19a Further, they found that college students were “duped” by websites that had “high production values.”19b Students today will be bombarded with more and more misinformation, and if there is no intervention, the next generation of lies will continue to be spread, rather than the next generation of debunking. This in-classroom, bottom-up method to approach disinformation is not new, it has been proposed in multiple states as official bills. In New Jersey, bill S588 mandates teaching media literacy from grade school.20 One highly touted method is called “lateral-reading”, which involves deeply fact-checking sources and using the same methods that fact-checkers do. This strategy was actually implemented in a real, urban school district. The plan involved teaching the teachers first, on how to implement media literacy and lateral reading into their curriculums. Next, in 6 total units, the teachers taught the students and found that they were much better at discerning fake and real information, compared to a control group and using pre and post-surveys.21 Even more exciting, a study in a college setting was also conducted in an introductory biology course.

At the beginning of the class, many students did not fully trust scientific institutions nor did many of them fully trust COVID vaccines.

So, the professor included sections in some classes where specific scientific questions were addressed and explored, especially regarding the vaccines. By the end of the course, attitudes towards vaccines and other scientific institutions became significantly more positive.21 The journey to fight disinformation has to start slowly, and going through classrooms and education is undoubtedly one of the slowest ways to approach this. However,

building a generation of fact checkers will make it so that scientific institutions can slowly rebuild their credibility. Many Americans no longer have as much faith in government, policy, and public health as they once did. With this policy solution, starting from the top with government bills mandating instruction, all the way to colleges and schools having real instruction on these topics, we can begin the true war against misinformation.

References

1. American Psychological Association.

Misinformation and disinformation. American Psychological Association. Published 2024.https://www.apa.org/topics/journalism-facts/misinformation-disinformation 2. Scheufele DA, Krause NM. Science audiences, misinformation, and fake news.

Proceedings of the National Academy of Sciences. 2019;116(16):7662-7669. doi:https:// doi.org/10.1073/pnas.1805871115 3. Jin SL, Kolis J, Parker J, et al. Social histories of public health misinformation and infodemics: case studies of four pandemics.

Lancet Infectious diseases/The Lancet Infectious diseases. 2024;24(10). doi:https:// doi.org/10.1016/s1473-3099(24)00105-1 4. Saleh A, Qamar S, Tekin A, Singh R, Kashyap R. Vaccine Development Throughout History. Cureus. 2021;13(7):e16635. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8386248/ 5. Fitzpatrick M. The Cutter Incident: How America’s First Polio Vaccine Led to a Growing Vaccine Crisis. J R Soc Med. 2006;99(3):156.

6. Nuwarda RF, Ramzan I, Weekes L, Kayser V. Vaccine Hesitancy: Contemporary Issues and Historical Background. Vaccines. 2022;10(10):1595. doi:https://doi. org/10.3390/vaccines10101595 7. Gangarosa E, Galazka A, Wolfe C, et al.

Impact of anti-vaccine movements on pertussis control: the untold story. The Lancet.

1998;351(9099):356-361. doi:https://doi. org/10.1016/s0140-6736(97)04334-1 8. Wakefield A. RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. The Lancet.

1998;351(9103):637-641. doi:https://doi. org/10.1016/s0140-6736(97)11096-0 9. McIntyre P, Leask J. Improving uptake of MMR vaccine. BMJ. 2008;336(7647):729730.doi:https://doi.org/10.1136/ bmj.39503.508484.80 10. British Researcher Wakefield Defends Link Between Vaccine and Autism. ABC News. Published January 5, 2011. https:// abcnews.go.com/Health/Autism/autism-

vaccine-link-research-dr-andrew-wakefield-fraud/story?id=12630566 11. Mnookin,STAT S. How Robert F. Kennedy, Jr., Distorted Vaccine Science. Scientific American. Published January 11, 2017. https://www.scientificamerican.com/article/how-robert-f-kennedy-jr-distorted-vaccine-science1/ 12. Simon FM, Camargo CQ. Autopsy of a metaphor: The origins, use and blind spots of the “infodemic.” New Media & Society.

2021;25(8):146144482110319. doi:https:// doi.org/10.1177/14614448211031908 13. Zielinski C. Infodemics and infodemiology: a short history, a long future. Revista Panamericana de Salud Pública. 2021;45:1. doi:https://doi.org/10.26633/rpsp.2021.40 14. Nelson T, Kagan N, Critchlow C, Hillard A, Hsu A. The Danger of Misinformation in the COVID-19 Crisis. Missouri Medicine.

2020;117(6):510. https://pmc.ncbi.nlm.nih. gov/articles/PMC7721433/ 15. Bolsen T, Palm R. Politicization and COVID-19 vaccine resistance in the U.S. Progress in Molecular Biology and Translational Science. 2021;188(1):81100.doi:https://doi.org/10.1016/ bs.pmbts.2021.10.002 16. AlShurman BA, Khan AF, Mac C, Majeed M, Butt ZA. What Demographic, Social, and Contextual Factors Influence the Intention to Use COVID-19 Vaccines: A Scoping Review. International Journal of Environmental Research and Public Health. 2021;18(17):9342. doi:https://doi. org/10.3390/ijerph18179342 17. Chinn S, Hasell A. Support for “doing your own research” is associated with COVID-19 misperceptions and scientific mistrust. Harvard Kennedy School Misinformation Review. Published online June 12, 2023. doi:https://doi.org/10.37016/mr2020-117 18. Kramer M. The MIT Press Reader. The MIT Press Reader. Published May 26, 2020.

Accessed December 1, 2024. https://thereader.mitpress.mit.edu/operation-denver-kgb-aids-disinformation-campaign/ 19. Donald B. Stanford researchers find students have trouble judging the credibility of information online. Stanford Graduate School of Education. Published November 22, 2016. https://ed.stanford. edu/news/stanford-researchers-find-students-have-trouble-judging-credibility-information-online 20.

New Jersey S588 | 2022-2023 | Regular Session. LegiScan. Published 2022.

Accessed December 2, 2024. http://legiscan.com/NJ/text/S588/id/2610908 21. Wineburg S, Breakstone J, McGrew S, Smith M, Ortega T. Lateral Reading on the Open Internet. papers.ssrn.com. Published November 15, 2021. https://papers.ssrn. com/sol3/papers.cfm?abstract_id=3936112

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Policy

Private Equity’s Growing Role in Healthcare: Impacts and Policy Solutions Shreya Kesarwani ency means private equity firms are not regulated to the same extent as public firms.5

Introduction In recent decades, the United States healthcare system has experienced a significant rise in private equity (PE) investment, increasing from $5 billion to $100 billion in the past 20 years—a staggering 2,000 percent growth.1 Private equity refers to ownership of a firm that is not publicly traded or listed. Similar to any investment, private equity is used to buy shares in a particular firm, such as a hospital, with the hope that the company’s value will increase over time.

However, unlike a hedge fund or an asset management fund, private equity firms play a much more active role in increasing their company’s value. They will typically restructure the acquired company in order to increase its profitability and then sell it for a profit in an average of three to seven years.3 Since these firms are not traded publicly, they are exempt from the requirement to disclose information about their financial performance, ownership, or operation, unlike public companies.5 This lack of transpar-

The increase in PE has caused increased scrutiny among physicians and policymakers over how private equity has affected healthcare costs and patient care as well as other outcomes.2 There are potential benefits to healthcare delivery, such as greater capital to scale technology and reduced administrative burdens, but also risks, including possibly higher costs for patients with lower quality of care.3 This raises important questions: What is the impact of private equity on patient care? How have state and federal governments regulated PE firms in healthcare? What options do policymakers have moving forward? These concerns are particularly significant as private equity continues to play a growing role in consolidating healthcare providers. In this article, I argue that insufficient regulatory policies are contributing to reduced competition and higher prices for hospital

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care.

The Changing Role of Private Equity in Healthcare Private investment and ownership of healthcare facilities is not a new development.5 However, there have recently been two key shifts that have fundamentally changed the role that private equity plays in healthcare.5 First, who is investing has changed. Rather than physicians or small groups of individual investors, large firms now dominate, managing capital for wealthy individuals and institutions.5 These large firms may have limited knowledge of healthcare and simply treat it primarily as a marketing opportunity.5 Second, how they’re investing has changed.5 For example, some private equity firms will aggressively take out loans and use the healthcare facilities they’ve acquired as collateral. This means if the loan isn’t paid back, the lender could seize the facility as repayment. Private equity firms use loans to offer big payouts to their investors. Meanwhile, the healthcare facility is left with the responsibility to repay the loan, which can leave it in financial trouble.5 In other cases, the asset is flipped, meaning it is sold to a large buyer, such as CVS, for much more than they originally paid. However, in order to sell the asset and make it more attractive to buyers, the PE firm may use rapid cost-cutting measures, increases in price, or increases in the amount of services sold.5

Policy The Impact of Private Equity on Healthcare 1. Cost Private equity firms tend to increase both healthcare prices and utilization, resulting in higher costs for patients and society as a whole.5 From 2016 to 2020, private equity-acquired medical practices charged 20% more for each insurance claim and saw 26% more total unique patients on average, compared to independently owned medical practices.6 Some private equity investors provide capital to allow healthcare providers to invest in new technologies or implement cost-saving strategies such as reducing administrative burdens, which can lead to lower costs.5 However, PE ownership is consistently associated with overall increases in costs.7 The gains from improved efficiency are often offset by PE’s focus on pursuing short-term profits, which causes them to raise prices and emphasize high-margin services.

2. Quality Private equity has been associated with a negative impact on the quality of care.7 One widely cited study by the National Bureau of Economic Research found a 10% increase in patient mortality in nursing homes owned by private equity firms.8 Another study analyzed insurance claims data for all fee-forservice Medicare hospitalizations from 2009 to 2019.9 They showed that, once a hospital was acquired by private equity, hospital-acquired complications increased by 25%, the number of patient falls increased by 27%, and the number of bloodstream infections caused by central lines increased by 38% for Medicaid patients.9 With 79 million people on Medicaid nationally, it’s crucial to protect patient care in facilities affected by private equity ownership.10

3. Access Regarding access to care, there is an increasing concern over private equity causing potential bankruptcies and closures of hospitals, nursing homes, and other care centers because of financial pressures.5 Private equity firms often use leveraged buyouts (LBOs) to acquire companies by borrowing a significant portion of the purchase price. Companies acquired through LBOs, including healthcare facilities, are 10 times more likely to go bankrupt.11 This issue is particularly alarming for facilities serving low-income and rural communities, which are often less financially sustainable.5 Maryland’s Regulations of Private Equity in Healthcare Given the harmful effects of private equity on healthcare, it is important to consider the regulatory environment that governs these investments. Most private equity healthcare investments are regulated at the state level as opposed to the federal or local level.3 In fact, the federal government reviews less than 10 percent of private equity investments in healthcare.3 State governments face greater legislative efficiency and lower polarization, uniquely positioning them to be able to be the first to carry out new regulations on emerging healthcare issues.3 Therefore, by analyzing a case study of how Maryland regulates its private equity investments, we can gain insight into how states are shaping policies that may influence future federal-level regulations.

One method Maryland has used to regulate PE healthcare acquisitions is passing laws to increase state oversight.3 For example, Maryland’s new Noncompete and Conflicts of Interest law, which was made effective on June 1, 2024, re-

quires that the Maryland Health Care Commission study the effect of private equity firms on the healthcare market in Maryland.14 This study must include the effects of PE on the payer mix for physician groups, access to care, and hospital consolidations.14 The study aims to provide more information about the role of private equity and promote greater transparency for future policy decisions.

Another key way that Maryland has regulated private equity in healthcare is through Corporate Practice of Medicine (CPOM) laws, which restrict non-medical individuals or entities from owning medical practices.3 The goal of these laws is to improve and maintain the relationship between patients and physicians.3 CPOM laws are in place in 33 of the 50 states in the US.3 Although 22 of these states permit non-profit organizations to be exempt from CPOM laws, Maryland’s law is more restrictive and does not allow any such exemptions.3 Despite this regulation, private equity firms can still acquire healthcare systems in Maryland through “Friendly Private Corporation” loopholes in the laws.13 These arrangements allow a physician-owned Friendly Private Corporation to administer medical services and employ healthcare professionals, while there is a private equity-owned “Management Services Organization” that offers administration and billing support to the Friendly Private Corporation.13 Therefore, the private equity firm can generate revenue and own non-clinical assets including the clinic building and branding through the Management Services Organization.13 Policy Recommendations To address the negative impacts of private equity on healthcare, polVolume 22

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Policy icymakers should consider revising CPOM laws to close the loopholes that allow private equity firms to avoid these regulations.3 Addressing these gaps would strengthen the laws and reduce the focus on short-term profits in private equity-owned practices.3 Additionally, these reforms should be accompanied by more widespread efforts to increase transparency in healthcare ownership. In many states, there is a lack of data available that comprehensively provides information on the control of physician practices.1 Through complex corporate structures, the identity of investors is often hidden.1 Greater transparency would allow regulators, patients, and healthcare providers to better understand the influence of private equity on healthcare practices and hold firms accountable. Maryland’s new Noncompete and Conflicts of Interest law, discussed previously, provides an opportunity for greater insight into healthcare ownership through research and data collection. Therefore, it should be implemented in other states as well, especially in the 16 states that currently lack any similar transparency laws.3 Third, policymakers should explore regulating transactions to ensure that private equity’s objectives align with patient-centered outcomes.3 For example, if the goal identified is to lower costs for patients, policymakers could monitor private-equity acquisitions for potential anti-competitive impacts that lead to increased prices.3 This approach would help provide patients and payers with confidence that such acquisitions will not lead to higher healthcare costs.3 Conclusion The rapid rise of private equity investment in healthcare highlights

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a growing tension between prioritizing patient care and maximizing profits. While private equity can bring new innovation, it also raises concerns about overall cost increases and declining quality of care.

Striking a balance between these competing interests is essential for policymakers and stakeholders.

Although there is no single solution that can address the challenges posed by the rise of private equity in healthcare, a range of policy approaches exist that can tackle their impact on affordability, access, and the sustainability of the U.S. healthcare system. The key lies in policymakers and the public recognizing the scale and urgency of this issue and mobilizing the political determination needed to address it effectively.

Following the 2024 election, the landscape for federal regulation or investigation into private equity in healthcare could shift significantly.

The Biden administration has taken a more aggressive approach to antitrust. However, the shift in political leadership might result in a different approach to regulation, which could change the environment for private equity. With this uncertainty, it becomes even more critical for states to act within their powers to protect patients, ensure affordable care, and preserve the integrity of the healthcare system.

References

1. The Rise Of Health Care Consolidation And What To Do About It | Health Affairs Forefront. Health Affairs Forefront. Published 2024. https://www.healthaffairs. org/content/forefront/rise-health-careconsolidation-and-do 2. Care Costs More in Consolidated Health Systems. hcp.hms.harvard.edu. Published January 24, 2023. https://hcp.hms.harvard.edu/news/care-costs-more-consolidated-health-systems 3. Private Equity In Health Care: A StateBased Policy Perspective. Forefront Group. Published online November 8, 2024. doi:https://doi.org/10.1377/forefront.20241106.200283

4. Sedlar M. Private Equity in Healthcare: Profits before Patients and Workers. Center for Economic and Policy Research. Published February 1, 2022. https://www.cepr. net/private-equity-in-healthcare-profits-before-patients-and-workers/ 5. Blumenthal D. Private Equity’s Role in Health Care. www.commonwealthfund. org. Published November 17, 2023. https:// www.commonwealthfund.org/publications/explainer/2023/nov/private-equityrole-health-care 6. Singh Y, Song Z, Polsky D, Bruch JD, Zhu JM. Association of Private Equity Acquisition of Physician Practices With Changes in Health Care Spending and Utilization. JAMA Health Forum.

2022;3(9):e222886-e222886. doi:https://doi.org/10.1001/jamahealthforum.2022.2886 7. Borsa A, Bejarano G, Ellen M, Bruch JD. Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review. BMJ. 2023;382(1):e075244. doi:https://doi. org/10.1136/bmj-2023-075244 8. How Patients Fare When Private Equity Funds Acquire Nursing Homes. NBER. https://www.nber.org/digest/202104/ how-patients-fare-when-private-equityfunds-acquire-nursing-homes 9. Miller J. What Happens When Private Equity Takes Over a Hospital | Harvard Medical School. hms.harvard.edu. Published December 26, 2023. https://hms. harvard.edu/news/what-happens-whenprivate-equity-takes-over-hospital 10. Centers for Medicare & Medicaid Services. August 2024 Medicaid & CHIP Enrollment Data Highlights. Medicaid.gov.

Published 2024. https://www.medicaid.gov/medicaid/program-information/ medicaid-and-chip-enrollment-data/report-highlights/index.html 11. Cai C, Song Z. A Policy Framework for the Growing Influence of Private Equity in Health Care Delivery. JAMA. 2023;329(18):1545-1546. doi:https://doi. org/10.1001/jama.2023.2801 12. Gupta A. Knowledge for Action Private Equity and Its Growth in Healthcare.; 2023. https://mhcc.maryland.gov/mhcc/ pages/home/workgroups/documents/nh_ acq/nh_acq_Gupta_20230804.pdf 13. Wilburn S. Professional Medical Practice Acquisitions and the Corporate Practice of Medicine - Private Fund Insights.

Private Fund Insights. Published July 12, 2023. Accessed December 1, 2024. https:// www.privatefundinsights.com/2023/07/ professional-medical-practice-acquisitions-and-the-corporate-practice-of-medicine/ 14. HB 1388 Department of Legislative Services. Accessed January 5, 2025. https:// mgaleg.maryland.gov/2024RS/fnotes/ bil_0008/hb1388.pdf

Policy

Reproductive Healthcare Access: Voter Trends in the 2024 Election Abriti Chatterjee Background On 24th June 2022, the Supreme Court of the United States announced as part of their verdict on the Dobbs v. Jackson Women’s Health Organization case that the U.S. Constitution does not grant a federal right to abortion.1,2 By doing so, they essentially overturned the decisions in the landmark Roe v. Wade (1973) and Planned Parenthood v. Casey (1992) cases. As a result, the power to regulate most abortion laws returned back to federal and state legislatures. This decision of the Supreme Court led to swift and polarizing reactions from the two sides of the abortion debate: those supporting abortion restrictions celebrated the ruling, while reproductive rights advocates strongly condemned it. Owing to the Dobbs decision, reproductive health access was presented as a choice on the 2024 election ballots in multiple states, including Arizona, Colorado, Florida, Maryland, Missouri, Montana, Nebraska, Nevada, New York, and South Dakota, so the citizens of those states can decide on the specificities of the extent of reproductive healthcare access available within their states.3 The Ballots and the Outcomes In recent elections, several states proposed measures aimed at expanding or limiting access to abortion care, yielding a range of outcomes.3,5 States like Arizona, South Dakota, and Colorado sought to protect abortion access, with Colorado also advocating for public funding of abortion services.

In contrast, Montana, Nevada, and Florida introduced measures that supported abortion access but in-

cluded restrictions after fetal viability, which is generally considered to occur around 24 weeks of pregnancy.3,5 Nebraska presented a more complex situation, with voters facing two conflicting measures: one that would protect abortion rights up to fetal viability and another that would ban abortion after the first trimester.3,5 Meanwhile, Maryland, Missouri, and New York proposed broader reproductive autonomy measures, with New York’s proposition specifically targeting the prevention of discrimination in accessing reproductive healthcare.

This potentially signals a broader change in attitudes toward abortion rights across the U.S. The outcomes of these measures highlighted the divided support for reproductive rights.5,6 Arizona, Colorado, and Nevada successfully secured constitutional protections for abortion, with Colorado’s measure also ensuring public funding. Similarly, Maryland, Missouri, and New York passed broader rights measures. Additionally, Montana and Nevada approved abortion protection measures despite the inclusion of restrictions after fetal viability. On the other hand, in Nebraska, voters rejected Initiative 439, which aimed to protect abortion rights, while approving Initiative

134, which bans abortion after the first trimester. Florida’s Amendment 4, which sought to expand abortion rights, received 57.6% approval but fell short of the 60% threshold needed for passage. Likewise, South Dakota’s Amendment G, which proposed expanding abortion access, was decisively rejected, with 58.6% of voters opposing it. Figures 1 and 2 offer a detailed breakdown of these legislative efforts and voter outcomes.

Analysis Out of the 10 reproductive rights propositions on the 2024 ballots, 7 passed, underscoring what appears on first glance to be a shift of public opinion towards expanding reproductive healthcare access.7 What was particularly noteworthy in this regard was the results seen in traditionally conservative states such as Arizona, Missouri, and Montana, where voters supported amendments securing abortion rights.

This suggests that even in regions where populations have been historically opposed to abortion access, there is growing acceptance of reproductive healthcare. This potentially signals a broader change in attitudes toward abortion rights across the U.S. However, public opinion on abortion is multifaceted, with a percentage of voters supporting reproductive rights while others not doing the same due to complex reasonings. The results in Nebraska are especially telling as to how Americans’ position on this issue is still not unanimous by any means.

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Policy ment, they approved a measure that prohibits abortion after the first trimester. In addition, in other traditionally conservative states like Florida and South Dakota, amendments supporting reproductive health access also did not pass.

These complexities explain the ongoing tension in the national debate about abortion and other forms of reproductive care. The question of access is often intertwined with debates about when and under what conditions abortion should be permitted, with the reasonings from different sides in such debates stemming from personal beliefs on the issue based on one’s social environment in life. Adding to the tension is the influence of the government on the passing of such amendments. This is highlighted by Florida’s Amendment 4 not passing despite receiving 57.6% of votes due to the government continuing to support a 2006 amendment requiring 60% popular approval for constitutional changes, demonstrating a possible contrast between the will of the people and that of the conservative government.8 Implications These nuances in the reproductive freedom debate are likely to influence future legal and policy conflicts. The 2022 Dobbs decision left the regulation of abortion to the states, but as these ballot results show, views vary across states, despite there seeming to be an overall move towards growing acceptance of reproductive freedom and individual reproductive rights. Legal and individual challenges to these state constitutional amendments are inevitable, particularly in deeply polarized states where voter support is nearly split. Several states could be victims to this, as the percentages of votes for either side being roughly equal in many states, as shown by the election results. These challenges could lead to further re-

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finements or restrictions on abortion rights in some states, while others may build on their protections.

For example, during the same point of time as the Dobbs case, the Center for Reproductive Rights filed a lawsuit on behalf of Florida’s healthcare workers against Florida’s HB-5 law, which bans most abortions after 15 weeks and imposes penalties on doctors who violate it.9 Health care providers appealed to the Florida Supreme Court after lower courts allowed the law to stand. On January 23, 2023, the Court agreed to hear the case. The lawsuit argued that HB 5 violates Florida’s constitutional right to privacy, which has historically protected abortion rights. On April 1, 2024, the Florida Supreme Court ruled that the state’s privacy protections no longer extend to abortion, upholding the 15-week ban.

This decision also paved the way for a 6-week abortion ban to take effect 30 days later. This highlights how legal challenges to abortion laws in states where the population is divided on the issue can set the stage for large-scale changes in the reproductive healthcare landscape in the state. With the growing number of such legal challenges, such upholding or alteration of laws will continue, leading to new benchmarks for each state, which are in turn likely to cause even further conflict.

In the present day, advocacy groups and grassroots movements play a crucial role in shaping public opinion and influencing legal and political outcomes, and will continue to do so in the future. Over the past few years, such groups have become increasingly adept at mobilizing voters and convincing lawmakers to expand or restrict reproductive rights. The increased visibility and effectiveness of these organizations have made reproduc-

tive rights a central issue in many state elections, ensuring that the topic is constantly on the public’s mind as about one-fourth of the voters in the election mentioned that abortion policy was the single most important factor for their vote.10 In the state of Maryland, for example, organizations such as Planned Parenthood of Maryland (PPMD) and American Civil Liberties Union Maryland play crucial roles in the expansion of reproductive healthcare rights in the state by advocating for candidates and policies that protect abortion access and reproductive freedoms.11,12 Furthermore, the role of social media platforms and digital organizing in influencing this debate cannot be overstated. These platforms have provided a means of communication for both sides of the reproductive rights argument. Platforms such as TikTok have proven to be effective tools in shifting public opinion, especially among young Generation Z voters, who have taken an active role in influencing the debate by creating content on the topic themselves.13 A 2024 study on how TikTok is being used to discuss abortion in the aftermath of the Dobbs decision analyzed the top 200 most liked, publicly available TikTok videos from a search for “abortion” on September 26, 2022 and found that they collectively garnered around 164 million likes, nearly 10 million shares, and 4 million comments. This emphasizes the wide reach of social media rights in guiding the abortion debate, and shows that the future of reproductive rights will depend in large part on interaction in these platforms.14 Conclusion Moving forward, views regarding reproductive rights in the U.S. will likely continue to evolve, with ongoing legal and social battles,

Policy along with state-level policy shifts.

The passage of reproductive rights amendments in multiple states, including conservative ones, indicates a growing momentum for change towards the expansion of reproductive rights, but this path forward will not be without obstacles. As seen in the 2024 election results, the fight for abortion access is increasingly a nationwide issue, with people on different sides having nuanced perspectives. Whether the trend towards expanding access will continue depends on the outcome of future state-level elections, ongoing legal challenges, and the continued efforts of advocacy groups and social media campaigns working to protect reproductive health access for all Americans.

Summary The Supreme Court’s 2022 Dobbs decision overturned Roe v.

Wade, eliminating the federal right to abortion and leaving regulation to individual states. In response, the 2024 state elections featured various reproductive rights measures.

Arizona, Colorado, and Nevada approved constitutional amendments protecting abortion access, with Colorado also securing public funding for abortion services. Other states saw more restrictive proposals gain traction. Nebraska passed a measure limiting abortion after the first trimester, while Florida’s proposed amendment fell short of the 60% threshold, and South Dakota rejected a measure expanding abortion rights. These outcomes suggest a shift in public opinion toward expanding reproductive rights, even in conservative states.

However, significant divisions remain, as shown in Nebraska, where voters backed restrictions but rejected broader protections. Legal challenges, especially in polarized states like Florida, where court battles over abortion laws continue, will shape future policies. Advocacy

groups and social media platforms, particularly TikTok, have been key in mobilizing voters and shaping the debate. The future of reproductive rights in the U.S. will depend on state-level elections, ongoing legal challenges, and the continued efforts of activists on both sides.

References

1. SUPREME COURT OF THE UNITED STATES. Dobbs v. Jackson Women’s Health Organization.; 2022. https:// www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf 2. CRS Legal Sidebar Prepared for Members and Committees of Congress Congressional Authority to Regulate Abortion.; 2022. https://crsreports.congress.gov/ product/pdf/LSB/LSB10787 3. What’s on your ballot? Voting guides to public health issues | University of Maryland | School of Public Health. Umd.edu.

Published October 22, 2024. Accessed November 30, 2024. https://sph.umd.edu/ news/whats-your-ballot-voting-guidespublic-health-issues 4. KFF. States with Gestational Limits for Abortion. KFF. Published August 31, 2020.

5. h t t p s : / / w w w . k f f . o r g / w o mens-health-policy/state-indicator/gestational-limit-abortions 6. Ballot Tracker: Status of Abortion-Related State Constitutional Amendment Measures. KFF. Published November 6, 2024. https://www.kff. org/womens-health-policy/dashboard/ ballot-tracker-status-of-abortion-related-state-constitutional-amendment-measures/ 7. 2024 Election Ballot Measures: Abortion, Immigration and More. Nbcnews. com. Published November 5, 2024. https:// www.nbcnews.com/politics/2024-elections/ballot-measures 8. Guarnieri I, Leaphart K. Abortion Rights Ballot Measures Win in 7 out of 10 US States. Guttmacher Institute. Published November 6, 2024. https://www.guttmacher. org/2024/11/abortion-rights-state-ballotmeasures-2024 9. Perry M. Florida lawmakers recall what led to 60% threshold to pass constitutional amendments • Florida Phoenix. Florida Phoenix. Published November 6, 2024. https://floridaphoenix.com/2024/11/06/ fl-lawmakers-recall-what-led-to-60threshold-to-pass-constitutional-amendments/ 10.Planned Parenthood of Southwest and Central Florida, et al. v. State of Florida, et al. Center for Reproductive Rights. https:// reproductiverights.org/case/planned-pare n t h o o d - s o u t h w e s t - c e n t r a l - f l o r i-

da-v-state-florida/ 11. MULVIHILL G, FERNANDO C. Abortion rights advocates win in 7 states and clear way to overturn Missouri ban but lose in 3. AP News. Published November 5, 2024. https://apnews.com/ article/abortion-ballot-measures-harris-trump-florida-missouri-49c9073cbb6056b66a8a7d0d099795d1 12. Planned Parenthood Advocates for DC, Maryland, and NoVa Announces Endorsements for 2024 DC General Election.

Plannedparenthoodaction.org.

Published October 2024. Accessed January 4, 2025. https://www.plannedparenthoodaction.org/planned-parenthood-advocates-dc-maryland-nova/press-room/ planned-parenthood-advocates-for-dcmaryland-and-nova-announces-endorsements-for-2024-dc-general-election 13. Reproductive Freedom. ACLU of Maryland. Published October 11, 2017. Accessed January 4, 2025. https://www.aclu-md. org/en/issues/civil-rights/reproductive-freedom 14. Kingsberry J. Gen Z is influencing the abortion debate — from TikTok. Washington Post. Published June 28, 2022. https:// www.washingtonpost.com/nation/interactive/2022/gen-z-tiktok-abortion-debate/ 15. Pleasure ZH, Becker A, Johnson DM, Broussard K, Lindberg L. How TikTok is Being Used to Talk About Abortion Post-Roe: A Content Analysis of the Most Liked Abortion TikToks. Contraception. 2024;133:110384. doi:https://doi. org/10.1016/j.contraception.2024.110384

Author’s Biography

Abriti Chatterjee is a Freshman majoring in Public Health and minoring in Writing Seminars on the DMP in Global Health Studies track. She enjoys reading, writing YA novels, watching Bengali detective shows, and listening to Rabindrasangeet. Abriti aspires to become an epidemiologist and publish her novels in the future.

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Policy

Baltimore Therapeutic Treatment Center & Inmate Mental Health Anahat Goraya Background 1. Legal Issues A cause of controversy in Baltimore’s correctional system has been the poor quality of life in its pre-trial facilities, locations where individuals awaiting a hearing on their case reside. Currently, the city’s pre-trial facilities are under the jurisdiction of the Maryland Department of Public Safety and Correctional Services.1 Those awaiting trial are held in the Baltimore pretrial complex which consists of the Baltimore Central Booking and Intake Center (BCBIC) and the Metropolitan Transition Center (MTC).1 Overflow from these two buildings is directed outside to the Maryland Reception Diagnostic and Classification Center (MRDCC), the Jessup Detention Institution, and the Maryland Correctional Institution for Women (MCIW).1 Baltimore’s pre-trial facilities have been under litigation for around six decades.2 The first lawsuits were Collins v. Schoonfield and Duvall v. Lee regarding the poor conditions faced by those within the jail such as delays in medication for chronic conditions and inaccessible medical care.3 After the lawsuits were closed in 1999, they were re-opened under the name Duvall v. Hogan in 2002 after the Department of Justice published a report demonstrating that the Baltimore City Detention Center was unsafe and did not provide adequate mental health care.2 This case reached a settlement in 2016, which mandated that the city improve medical and men-

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tal health care within the pre-trial infrastructure via compliance with nine healthcare provisions regarding inmate medication, inmate sick calls, disability accommodations for inmates, and mental health to name a few.2, 4 To comply with the settlement, the state closed down the Baltimore City Detention Center, which was located in the pre-trial complex.1 The state also implemented reforms such as building an effective system to answer inmate sick calls.5 However, this provision for sick calls is the only one the state has met full compliance for; the remaining eight provisions regarding healthcare in the settlement remain unfulfilled.5

Such an outcome will only add to the mental health care delivery problems the city is already facing.

To meet these provisions, the city will construct the Baltimore Therapeutic Treatment Center (TTC) by 2029.1 This building will be a combination of a mental health treatment center, jail, and community resource center to address the inadequacies of the current mental healthcare system.1 The TTC will implement a new infrastructure called the “three door jail” to

do so.1 The three door jail is a model aimed at reducing the interaction of individuals needing mental health support with the criminal justice system.1 It does so via three “doors” of detention, deflection, and reintegration.1 Deflection focuses on connecting individuals with mental and behavioral health resources before arrest.6 Detention focuses on providing resources and treatment during trial/incarceration.6 Reintegration focuses on ensuring individuals can re-enter society after serving time to prevent future re-arrests.1,6 This article aims to understand the effectiveness of the new center in resolving the state’s inability to provide mental health care to individuals and evaluate the effectiveness of its “three door jail” policy in doing so.

2. Mental Health Issues In the 2002 report that reopened the lawsuits against the city’s facilities, the Baltimore City pre-trial system suffered from a myriad of challenges in providing necessary mental health care to detainees, specifically a lack of access to medication, care, and suicide prevention resources.3 For example, 65% of detainee records included inadequate or non-existent health screening records, which are mandatory and necessary to complete upon a detainee’s arrival to ensure proper medical needs are met.3 Additionally, 25% of the male detainees in the mental health unit were admitted due interruptions in medication.3 This was a common occurrence for detainees

Policy who had prescriptions before arriving at the facilities.3 Residents also experienced vast delays in receiving mental healthcare treatment due to staffing shortages even when submitting emergency sick call requests which allow inmates to request medical attention.3 Specifically, a shortage of psychologists for women led to a considerable lack of treatment.3 The reality of the situation still remains dire over 20 years later as many of these issues remain unresolved.5,7 Because of this, the Duvall v. Hogan settlement created the following provisions for mental health: 1) mental health professionals will be provided for timely evaluations for medications and suicide risks; 2) individuals with approval to receive psychotropic medications will be seen by a provider within 14 days; 3) individuals with urgent mental health referrals will be seen in 24 hours; individuals on psychotropic medications will be seen by a provider at least every 90 days; 4) individuals requiring close monitoring due to mental health conditions will be seen by a provider as often as clinically indicated; 5) establishment of a mental health plan of care documenting major mental health problems and a plan for treatment in an electronic medical record will be implemented; 6) plans of care will include information about scheduled follow-ups with providers; plan of care will be accessible to any provider giving treatment; 7) individuals currently diagnosed with mental health problems will be enrolled in chronic care clinics; 8) new mental health screenings will be given to those reentering the pretrial facilities after two weeks or more.5 Currently, provisions 1,2, and 6 are not in full compliance due to personnel shortages and the lack of a standardized electronic med-

ical record system.5,7 As such, the mental health provision of the settlement agreement remains out of compliance.5 Baltimore Therapeutic Treatment Center Given the state’s inability to meet compliance for the above mentioned policies, Maryland has planned to establish the Baltimore Therapeutic Treatment Center in place of the Baltimore City Detention Center.1 The goal of the project is to be an all-purpose facility that will provide mental health treat-

ment to non-violent individuals facing criminal charges while they are detained with the goal of diverting those who will not be detained to proper resources.1 To do so, the facility will be based on the model of a “three-door jail.”1 The three door jail model is an incarceration infrastructure model based on diversion and deflection and can be best understood by the Sequential Intercept Model (SIM).1,6 SIM diagrams how individuals with mental health and/or substance abuse disorders are funneled through the justice system.6 At each of the six inter-

sequential intercept model Crisis Lines

Crisis Care Continuum

911

Local Law Enforcement

Intercept 0 Community Services

Intercept 1 Law Enforcement

(ARREST)

Initial Detention

Intercept 2

First Court Appearance

Initial Court Hearing Initial Detention

Jail

Intercept 3

Speciality Court

Jails/Courts

Dispositional Court

Prison Reentry

Jail Reentry

Parole

Probation

Intercept 4 ReEntry

Intercept 5 Community Corrections

Community Figure 1. Sequential Intercept Model from SAMHSA8

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Policy cepts (Figure 1), individuals can be funneled out of the justice system or given resources to prevent re-entry into the system.6 The first door of the TTC is Deflection.1 Deflection is a process that occurs before arrests are made and consists of law enforcement officers connecting individuals to treatment centers/facilities so they can recover and prevent future contact with the criminal system.6 These programs usually are initiated at intercept 0 or 1.6 The TTC will invoke principles of deflection by creating a deflection center with 50 beds for those needing mental health interventions but who are not under arrest.1 At this location, they will be given a nursing assessment, care, and crisis stabilization.1 The second door is detention and it invokes principles of diversion.1,6 Diversion programs try to connect those who are facing trial or have been arrested with mental health resources and this occurs at intercept 2 and 3.6.

Oftentimes connections to community resources allow for the waiving of charges.6 If not, diversion programs allow for individuals to refrain from criminal behavior upon discharge.6 The last door of the TTC is Reentry/Day Reporting.1 This is set up for those leaving the jail to be integrated back into society via resources for mental health, education, and employment and occurs at intercepts 5 and 6.1,6 What makes the TTC unique is the placement of all three types of interventions under one roof.1 Benefits Diversion and deflection programs in jails have long been lauded as an effective means to reduce pre-trial populations and reduce incarceration rates for individuals suffering from mental illness and/ or substance abuse.6 Specifically, it has been found that diversion and detention programs are most effec-

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tive when individuals are supported after their release and continue with practices that promote diversion from the criminal justice system.9 Co-location of services such as mental health facilities for individuals and community resources has had past success.10 The diversion program in Bexar County, Texas integrates a crisis care center and a restoration center to offer medical care as well as resources for those with mental health concerns.10 Not only has the program been able to save the county more than $10 million dollars due to reduced trips by law enforcement to the ER, but also redirects 2,200 people per month from the pre-trial system.10 Because the TTC co-locates both its detention and Day Reporting center, similar successes may be seen in Baltimore.1 Individuals are provided with support even after their release, making the model of the three doors effective theoretically.1 This is in large part because it is able to target all six intervention points as outlined by the Sequential Intercept Model, allowing for comprehensive care.1 As described above, a large part of Baltimore’s pre-trial facilities’ issues lie with a lack of timely care and resources for individuals due to an increasing number of individuals entering the system.3 By establishing the TTC, Baltimore could reduce the number of individuals entering the criminal system and ease the strain on its limited mental health resources.1 Drawbacks However, despite potentially reducing the number of pretrial detainees in the system, an issue the creation of the TTC does not address is the staffing shortages. A large part of the mental health issues suffered within the system occur due to long wait times for care as there are not enough personnel

to support the system.3 Currently, the Corrections Department of Maryland is facing a staffing shortage of around 3,417 personnel and the TTC will create additional staffing needs.1,11 The current plans for the TTC do not include definitive staffing numbers and instead only include an estimated $50 million to be spent on staffing.1 The Maryland Department of Public Safety and Correctional Services currently allocates $1.1 billion out of its $1.6 billion budget to staffing for the state.12 The TTC staffing, that will support the pretrial system of Baltimore alone, will create a 4.5% increase to the state’s correctional staffing budget.1 This is a cause for concern as the cost of building the TTC has risen by $443 million to be around $1 billion dollars, making it the most expensive project the state has overseen.13 Given the rising costs and the pre-existing shortage of personnel within the system, it is doubtful whether the center will have enough staff to run.13, 14 Such an outcome will only add to the mental health care delivery problems the city is already facing.

The decrease in the amount of beds in the facility also presents a notable issue. The rising costs of the project have resulted in the shutting down of phase 1 of 2 of the construction phases of the TTC.13 As such, instead of adding 1462 beds, the TTC will only add 854, a reduction of around 41%.13 The TTC was meant to provide 1462 beds to be used in conjunction with the BCBIC’s 954 beds and the MTC’s 400 beds, allowing a total of 2816 beds to house the pre-trial population (Table 1).1,13 Although the number of deflection beds is still retained at 50, the the number of beds available to those who are detained within the facility has been decreased to 804.13 Those in the detention facil-

Policy ity were meant to have stratified housing depending on their medical condition, ranging from acute to needing therapeutic assistance.1 As such, the decrease in beds will reduce the TTC’s ability to support inmates who are detained and by extension it will decrease its ability to properly divert this population, putting a crack in one of its fundamental “doors.”1 This decrease in beds signals that overcrowding may return in the pre-trial population.14 The pre-trial daily population within the complexes in 2023 was 2,181.15 The overflow of individuals that are diverted outside the pre-trial complex would have fit comfortably in the new 1462 beds, allowing for the co-location model of the TTC to function effectively, which aims to house all pre-trial inmates within the same complex for more efficient care.1 The projected number of beds the system will need by 2035 is 2,819.1 With the current state of the TTC, only 2,208 beds will be available at that point, causing overcrowding.1 Lastly, many, including the ACLU, have pointed out that the construction of a new facility will not address the issues faced by the state in meeting compliance standards.14 Under the Duvall v. Hogan settlement, the state was required to meet all compliance standards by 2020.7 However, the state failed to do so and has repeatedly asked for extensions since then.7 Currently, Maryland has been granted until 2026 to meet the ten standards.7 One of the main standards the state is lagging in is the creation of a mental health plan of care.5 The state is experiencing delays in creating a standardized system of entering and recording such information into patients’ electronic health records, which is fundamental to individuals receiving accurate and effective care.5 Instead of allocating resources to speed up such processes, the

investment of $1 billion dollars towards a new building which may not reduce overcrowding is cause for concern.12 Conclusion The TTC’s approach to pre-trial healthcare using the three doors focused on deflection and diversion does have merit when considering past success with similar programs and the positive impacts of diversion and deflection strategies.10 However, the logistical challenges being presented with its establishment, namely the reduction of the number of beds signals towards the potential undermining of its established goal of providing individuals with adequate mental healthcare.14 In the long term, the TTC could help reduce the number of pre-trial individuals in Baltimore.1,10 However, without short-term spending by the state to increase compliance with standards set by the 2016 settlement such as creating a robust mental health care intake form for inmates, the jail system may be left with a building conceptually advantageous yet suffering from a lack of resources to effectively run itself.6 References

1. Baltimore Therapeutic Center Part 1 and Part 2 Report.; 2021. Accessed January 12, 2025. https://emma.maryland.gov/ page.aspx/en/bpm/process_manage_extranet/40384 2. Duvall v. Glendening (Duvall v. Hogan) 1:94-cv-02541 (D. Md.) | civil rights litigation clearinghouse. Accessed January 12, 2025. https://clearinghouse.net/case/758/ 3. Civil rights division | i. Background.

August 6, 2015. Accessed January 12, 2025. https://www.justice.gov/crt/i-background-1 4. Duvall v. Hogan Settlement Agreement.(U.S. District Court for the District of Maryland 2015). ACLU. Accessed January 12, 2025. https://www.aclu.org/ cases/duvall-v-hogan?document=duvall-v-hogan-settlement-agreement 5. Duvall v. Hogan Report of the Court’s Mental Health Monitor Dr. Jeffry Metzner.

ACLU. Updated 2022. Accessed January 12, 2025. https://www.aclu.org/ cases/duvall-v-hogan?document=duvall-v-hogan-order-extending-dead-

line-compliance-settlement-agreement 6. Widgery A. The Legislative Primer Series for Front-End Justice: Deflection and Diversion.; 2023. Accessed January 12, 2025. https://documents.ncsl.org/wwwncsl/Criminal-Justice/Deflection-Diversion-f02.pdf 7. Duvall v. Hogan Order Extending Settlement Agreement (U.S. District Court for the District of Maryland 2024). ACLU. Accessed January 13, 2025. https://www.aclu. org/cases/duvall-v-hogan?document=duvall-v-hogan-plaintiffs-reply-support-motion-enforce 8. The Sequential Intercept Model (SIM).

Substance Abuse and Mental Health Services Administration. Published May 24, 2024. Accessed January 12, 2025. https:// www.samhsa.gov/communities/criminal-juvenile-justice/sequential-intercept-model 9. Steadman HJ, Morris SM, Dennis DL. The diversion of mentally ill persons from jails to community-based services: A profile of programs. Am J Public Health.

1995;85(12):1630–1635. https://doi. org/10.2105/AJPH.85.12.1630. doi: 10.2105/AJPH.85.12.1630.

10.Mental Health and Criminal Justice Case Study: Bexar County, Texas. National Association of Counties 11. American Federation of State, County and Municipal Employees. Correctional Institution Security and Staffing Report.; 2023:4. Accessed January 12, 2025. https://www.afscme.org/2022-23_afscme_staffing_analysis_-_final_0.pdf 12. Department of Public Safety and Correctional Services Fiscal 2025 Budget Report.; 2024:10. Accessed January 12, 2025. https://mgaleg.maryland.gov/pubs/budgetfiscal/2025fy-budget-docs-operating-Q00-DPSCS-Overview.pdf 13. Janesch S, Jensen C. Replacing the Demolished Baltimore City Detention Center Could Cost a Historically High $1 billion.

The Baltimore Sun. March 14, 2024. Accessed January 12, 2025.https://www. baltimoresun.com/2024/03/14/replacing-the-demolished-baltimore-city-detention-center-could-cost-a-historically-high-1b/.

14. Ben Conarck, Pamela Wood. Baltimore’s new $1 billion jail will be the most expensive state-funded project in history. The Baltimore Banner. 2024.

Accessed 12/01, 2024https://www.thebaltimorebanner.com/community/ criminal-justice/batlimore-new-jail-detention-center-LIQZZS27PND2ZM2O73JLBDL72Y/..

15. DPDS annual data dashboard. Maryland Department of Public Safety and Correctional Services. https://www.dpscs.state. md.us/community_releases/DPDS-Annual-Data-Dashboard.shtml. Accessed January 12, 2024.

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Research

Shannon Xiao

Research

Potential Options for Managing Long COVID: A Literature Review Wanli Tan Abstract The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was a public health crisis that lasted from 2020 to 2023 and prompted drastic global action to curb the virus’ transmission. Those who contracted the virus suffered from acute symptoms and either died or fully recovered within a few weeks, most of whom developed natural immunity that protected them from a re-infection. As vaccines proliferated and incidence rates and mortality rates declined over the next few years, societies gradually returned to pre-pandemic states with the belief that SARS-CoV-2 was gone.

While it is true that new SARSCoV-2 infections are decreasing in frequency, the long-term health effects of a SARS-CoV-2 infection (also known as “long COVID”) have not received adequate attention.

More than 5 years after the pandemic’s onset, a substantial body of research into possible ways of managing long COVID has been established and it deserves to be reviewed. A literature search was conducted in PubMed, yielding studies proposing potential treatments of otolaryngological, cardiopulmonary, neurological, and general fatigue-related long COVID symptoms. Further research is needed to explore other avenues of treatment and determine the effectiveness of the proposed methods.

Introduction The COVID-19 pandemic is traditionally perceived as a global phenomenon caused by the transmission of and infection by

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the SARS-CoV-2 virus. As a public health issue of great significance, research quickly identified the most common acute symptoms that patients suffered from, including cough, fever, fatigue, diarrhea, muscle pain, taste disorder, smell disorder, sputum production, headache, difficulty breathing, and sore throat.1 It was also determined that they resolved along with the full recovery of patients, which typically took no longer than 6 weeks.2 Nevertheless, many of those who were pronounced “recovered” after their SARS-CoV-2 infection and expected to resume their normal daily lives found themselves debilitated by further symptoms attributable to their infection. Soon, the phrase “long-COVID” was born and spread on social media as an umbrella term to encapsulate the collection of symptoms that were experienced by patients after their supposed recovery and reflect the chronic nature of the infection. Scientific research has since followed, identifying and classifying 10 key symptoms under ear, nose, and throat (altered hearing, smell, and taste), heart and lung (difficulty breathing, fast heart rate, chest tightness, and chest pressure), brain (brain fog, difficulty speaking), or general fatigue (mild fatigue).3 The widespread prevalence of persistent symptoms highlights the urgent need for a review of methods of treat the chronic health effects of SARS-CoV-2 infection.

A literature search was conducted in PubMed using the keywords “long COVID,” “treatment,” and a

keyword for each of the aforementioned symptoms, such as “taste”.

The results included research pertaining to methods of treating symptoms classified under each of the four aforementioned categories.

Studies included in this review were published in English and focused on efficacy in human subjects.

In this literature review, no personal information pertaining to any of the research subjects was collected and/or disclosed. All of the research articles reviewed in this paper were subject to review from appropriate ethics review committees as needed and published in international peer-reviewed journals.

Therefore, an ethical review is unnecessary for this study.

Results 1. Ear, Nose, and Throat Two randomized controlled trials have separately proposed using plasma (the liquid component of blood) rich in platelets (a protein found in the blood and involved in wound clotting) to return long COVID patients’ sense of smell to normal.4-5 The results of an earlier longitudinal study likewise support the potential efficacy of umPEALUT, supplements that reduce inflammation and swelling, in treating problems with smelling.6 Another randomized controlled trial found that local and systemic photobiomodulation, a therapeutic method that uses low-power light-emitting sources like lasers and LEDs to trigger enhanced cellular function, can improve losses in the sense of taste.7 No study has yet proposed a potential treatment

Research

Fig. 1. Photobiomodulation therapy.8

for problems with hearing, yet the results thus far suggest promise for improving otolaryngological issues.

fy treatments specifically targeting hypertension, as well as other cardiopulmonary symptoms.

2. Heart and Lung A recent systematic literature review concluded that there are now a variety of physiotherapy interventions, such as high-intensity ones (using an ergometer or treadmill), low to moderate intensity (walking, stretching, etc.), respiratory muscle training, and low-level laser therapy, for physicians to choose from.

This will allow them to develop a more personalized plan for improving the difficulty breathing experienced by each long COVID patient.9 Another review found that stimulation of the vagus nerve (a vital nerve that runs down the right of the neck to connect the brain to many organs) can help treat the chronic pain experienced by patients suffering from type 2 diabetes, which is the most common comorbidity of long COVID.10 Nonetheless, further research is needed to identi-

3. Brain The aforementioned longitudinal study also proposes platelet-rich plasma as a potential treatment of long COVID-induced brain fog. Additionally, a randomized control trial conducted in the United Kingdom from 2021 to 2023 found that over 163 1:1 sessions, 26 patients shared diverse mental health strategies for effectively alleviating their brain-related symptoms, such as conversing with others, note taking, deep breathing, planning, completing word puzzles, assessing fatigue level, and listening instead of reading.11 Otherwise, research into treatments for neurological disorders unfortunately remains limited.

4. General Fatigue A retrospective case series identified parallels between the mechanism underlying long COVID and

that of chronic fatigue syndrome and demonstrated that a nebulized antioxidant/anti-pathogen agent may therefore also be effective in treating the fatigue experienced by long COVID patients.12 In this vein, a prospective study drew a similar parallel and found success with an oxaloacetate (a metabolic intermediate) treatment.13 A third group of researchers found that transcutaneous (through skin) electrical nerve stimulation (TENS) may also be effective in alleviating fatigue.14 From a fourth angle, a randomized controlled trial experimented with a supplement that combined extracts of plants such as key lime, and marijuana, and black pepper and found that it can ameliorate fatigue.15 Other studies have suggested various strategies, including transcranial (through the brain) magnetic stimulation (TMS),16 creatine-glucose supplements,17 resistance exercise intervention,18 online supervised group physical and mental health rehabilitation programs,19 cognitive-behavioral therapy,20 a combination of sound therapy, light therapy, and coach-guided meditation,21 and biosound therapy (various forms of aural stimulation),22 as potential methods for treating fatigue. Nevertheless, their effectiveness and feasibility in the clinical setting require further investigation.

Conclusion The acute effects of a SARSCoV-2 infection, while understandably subjected to intense public health attention since the beginning of the COVID-19 pandemic, have now undeservedly overshadowed its long-term consequences. Though the current body of research has provided promising results in treating various key symptoms of long COVID, it is hoped that further collaboration between clinicians, researchers, and policymakers into potential methods of Volume 22

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Research countering and/or alleviating the long-term effects of SARS-CoV-2 infection, especially with regards to the neurological effects, can lead to the development and availability of effective treatments in the near future. For the countless patients suffering from long COVID, this may mean that they will finally be freed from the shackles of the pandemic.

Acknowledgements Wanli Tan conceptualized, performed all of the necessary research, and drafted this literature review independently, without working with any collaborator and/ or assistant. No grant and/or funding was applied for or received for this study.

References

1. Çalıca Utku A, Budak G, Karabay O, Güçlü E, Okan HD, Vatan A. Main symptoms in patients presenting in the COVID-19 period. Scottish Medical Journal.

2020;65(4):003693302094925. d o i : h t t p s : / / d o i . org/10.1177/0036933020949253 2. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19).;14. Accessed December 18, 2024. https://www.who.int/docs/default-source/coronaviruse/who-chinajoint-mission-on-covid-19-final-report.pdf 3. Wang Y, Alcalde-Herraiz M, Güell KL, et al. Refinement of post-COVID condition core symptoms, subtypes, determinants, and health impacts: a cohort study integrating real-world data and patient-reported outcomes. EBioMedicine.

2024;111:105493-105493. doi:https://doi. org/10.1016/j.ebiom.2024.105493 4. Yan CH, Jang SS, Lin HC, et al. Use of platelet-rich plasma for COVID-19 related olfactory loss, a randomized controlled trial. International Forum of Allergy & Rhinology. 2022;13(6). doi:https://doi. org/10.1002/alr.23116 5. Cantone E, Luca D’Ascanio, Pietro De Luca, et al. Persistent COVID-19 parosmia and olfactory loss post olfactory training: randomized clinical trial comparing central and peripheral-acting therapeutics. European archives of oto-rhino-laryngology/ European archives of oto-rhino-laryngology and head & neck. 2024;281. doi:https:// doi.org/10.1007/s00405-024-08548-6 6. De Luca P, Camaioni A, Marra P, et al. Effect of Ultra-Micronized Palmitoylethanolamide and Luteolin on Olfaction and Memory in Patients with Long

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COVID: Results of a Longitudinal Study.

Cells. 2022;11(16):2552. doi:https://doi. org/10.3390/cells11162552 7. Fernandes L, Sérgio Luiz Pinheiro, Carlos Eduardo Fontana. Photobiomodulation in the Treatment of Dysgeusia in Patients with Long COVID: A Single-Blind, Randomized Controlled Trial. Photobiomodulation Photomedicine and Laser Surgery. 2024;42(3):215-224. doi:https://doi. org/10.1089/photob.2023.0148 8. Accessed January 13, 2025. https://animalrehabhealth.academy/wp-content/uploads/2022/01/PBM.jpg 9. Romanet C, Wormser J, Cachanado M, et al. Effectiveness of physiotherapy modalities on persisting dyspnoea in long COVID: A systematic review and meta-analysis. Respiratory medicine. 2024;236:107909. doi:https://doi. org/10.1016/j.rmed.2024.107909 10.Li R, Liu W, Liu D, Jin X, Wang S. The involvement of the dysfunctional insulin receptor signaling system in long COVID patients with diabetes and chronic pain and its implications for the clinical management using taVNS. Frontiers in Pain Research.

2024;5. doi:https://doi.org/10.3389/ fpain.2024.1486851 11. Hiyam Al-Jabr, Thompson DR, Castle D, Ski CF. Experiences of people with long COVID: Symptoms, support strategies and the Long COVID Optimal Health Programme (LC-OHP). Health Expectations.

2023;27(1). doi:https://doi.org/10.1111/ hex.13879 12. Gil A, Hoag GE, Salerno JP, Hornig M, Klimas N, Selin LK. Identification of CD8 T-cell dysfunction associated with symptoms in myalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS) and Long COVID and treatment with a nebulized antioxidant/anti-pathogen agent in a retrospective case series. Brain, behavior, & immunity Health. 2023;36:100720100720. doi:https://doi.org/10.1016/j. bbih.2023.100720 13. Cash A, Kaufman DL. Oxaloacetate Treatment For Mental And Physical Fatigue In Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (ME/CFS) and Long-COVID fatigue patients: a non-randomized controlled clinical trial. Journal of Translational Medicine. 2022;20(1). doi:https://doi.org/10.1186/s12967-02203488-3 14. Zulbaran-Rojas A, Bara RO, Lee M, et al. Transcutaneous electrical nerve stimulation for fibromyalgia-like syndrome in patients with Long-COVID: a pilot randomized clinical trial. Scientific Reports.

2024;14(1). doi:https://doi.org/10.1038/ s41598-024-78651-5 15. Lukkunaprasit T, Satapornpong P, Kulchanawichien P, et al. Impact of combined plant extracts on long COVID: An exploratory randomized controlled tri-

al. Complementary therapies in medicine. 2024;87:103107. doi:https://doi. org/10.1016/j.ctim.2024.103107 16. Noda Y, Sato A, Shichi M, et al. Real world research on transcranial magnetic stimulation treatment strategies for neuropsychiatric symptoms with longCOVID in Japan. Asian Journal of Psychiatry. 2023;81:103438. doi:https://doi. org/10.1016/j.ajp.2022.103438 17. Jelena SLANKAMENAC, Marijana RANISAVLJEV, TODOROVIC N, et al. EightWeek Creatine-Glucose Supplementation Alleviates Clinical Features of Long COVID. Journal of nutritional science and vitaminology. 2024;70(2):174-178. doi:https:// doi.org/10.3177/jnsv.70.174 18. Morrow A, Gray SR, Bayes HK, et al.

Prevention and early treatment of the longterm physical effects of COVID-19 in adults: design of a randomised controlled trial of resistance exercise—CISCO-21. Trials.

2022;23(1). doi:https://doi.org/10.1186/ s13063-022-06632-y 19. McGregor G, Sandhu H, Bruce J, et al.

Clinical effectiveness of an online supervised group physical and mental health rehabilitation programme for adults with post-covid-19 condition (REGAIN study): multicentre randomised controlled trial.

BMJ. 2024;384:e076506. doi:https://doi. org/10.1136/bmj-2023-076506 20.

Kuut TA, Müller F, Csorba I, et al.

Efficacy of cognitive behavioral therapy targeting severe fatigue following COVID-19: results of a randomized controlled trial.

Clinical Infectious Diseases. 2023;77(5). doi:https://doi.org/10.1093/cid/ciad257 21. Hausswirth C, Schmit C, Rougier Y, Coste A. Positive Impacts of a FourWeek Neuro-Meditation Program on Cognitive Function in Post-Acute Sequelae of COVID-19 Patients: A Randomized Controlled Trial. International Journal of Environmental Research and Public Health. 2023;20(2):1361. doi:https://doi. org/10.3390/ijerph20021361 22.

Korapatti C, Vera L, Miller K. Biosound Therapy as a treatment for long COVID patients: A pre-post pilot study. EXPLORE. 2024;20(5):103000. doi:https:// doi.org/10.1016/j.explore.2024.04.004

Author’s Biography Wanli Tan is a junior from North Potomac, MD majoring in Biology.

He has been researching COVID-19 since its onset in 2020, when he was a high school sophomore, and is broadly curious about the social determinants and biological mechanisms of infectious diseases.

After Hours, Out of Options: Overcoming Barriers to Accessible Childcare

Research

Annabelle Huang Abstract The United States faces a pervasive childcare crisis characterized by exorbitant costs and limited accessibility, which disproportionately affect single-parent households and disadvantaged communities.

With childcare expenses often exceeding $10,000 annually, many families face financial strain and struggle to balance essential needs.

This situation leaves parents, particularly single mothers, trapped in cycles of poverty and economic insecurity. The financial burden also directly impacts health inequities by limiting access to healthcare, and its associated negative health consequences span generations. This literature review investigates the various impacts of childcare inaccessibility, focusing on its influence on public health determinants such as parental mental health, workforce participation, gender employment gaps, and early childhood development. The review will evaluate the current state of childcare in the United States and analyze the effectiveness of policy interventions, from subsidies, universal child care programs, and child tax credits to more innovative approaches such as community-based home daycare. Furthermore, the review explores the societal ramifications of neglecting early childhood investment, which can lead to widening educational disparities and long-term economic stagnation.

Special attention is paid to the burden childcare barriers impose on women, who often juggle caregiving responsibilities and income gener-

ation, particularly in single-parent families. This challenge amplifies gender inequalities in career advancement and lifetime earnings.

The findings highlight the necessity of targeted reforms, including subsidized childcare, extended flexible-hour daycares, and increased investments in early education. The overarching goal of this review is to advocate for the reimagination of childcare as a public good, emphasizing its critical role in fostering healthier families and promoting equitable opportunities.

The Cost of Care: A National Crisis Childcare in the United States stands as a glaring contradiction.

Families require reliable care to thrive, yet it remains financially unattainable for millions. The current U.S. childcare system assumes that families can afford its high costs, but the steep price of childcare is fundamentally at odds with the economic reality many families face.

Despite its critical role in supporting families and enabling workforce participation, the U.S. childcare system is hindered by prohibitive costs, limited access, and insufficient policy interventions. This issue is not only a family concern but also a reflection of broader systemic societal inequities. Consider a single mother in Chicago who works two part-time jobs but spends over 40% of her income on childcare.

Her experience mirrors the struggles of countless Americans who are forced to choose between financial stability and securing safe, reliable care for their children. The

U.S. childcare system ranks among the most expensive globally, with median expenses far outstripping federal affordability benchmarks.

In 2019, the median annual cost of childcare surpassed $10,000 per child, consuming more than a third of income for low-income families.1 In low-income households and disadvantaged communities, these costs perpetuate cycles of poverty, limit economic mobility, and contribute to growing inequality.

These barriers also disproportionately impact women, who typically bear the brunt of caregiving responsibilities. For single mothers working non-traditional hours, the challenges are even greater: limited care options, inflexible daycare schedules, and rising costs force many to choose between employment and caregiving.2 These struggles underscore the systemic inadequacies of the U.S. childcare system, which fails to accommodate the diverse scheduling needs of working families. This dilemma is further explored in the context of parents working non-traditional hours, as detailed in a subsequent section of this review.

The Invisible Weight: Childcare’s Public Health Toll on Single Mothers and Their Children The crisis of obtainable childcare reaches past financial strain and into the realm of mental health, family dynamics, and children’s long-term development. For single mothers, the lack of affordable and accessible care exacerbates stress, Volume 22

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Research anxiety, and depression, often leading to poorer mental health outcomes.3 Studies show that access to subsidized childcare significantly reduces stress levels and increases workforce participation, while its absence undermines mothers’ ability to provide stable and nurturing environments for their children.3 Balancing caregiving responsibilities with income stability presents another difficulty. Single mothers often earn substantially less than their male counterparts over their lifetime due to career interruptions caused by childcare responsibilities. This effect reinforces the “motherhood penalty,” a cultural bias that assumes women are primary caregivers and disproportionately subjects them to career setbacks following childbirth.4 On average, single mothers earn 30% less than dual-income households, compounding financial difficulties and directly distributing to higher poverty rates.5 Reduced working hours and workforce exits due to childcare responsibilities also slow career progression and limit access to leadership roles, further widening employment gaps. These challenges have lasting effects even into retirement, where lower lifetime earnings and limited access to retirement plans leave many women, especially single mothers, financially vulnerable in old age. Women who leave the workforce due to

caregiving responsibilities lose an average of $600,000 in lifetime earnings.6 Figure 1 illustrates how poverty rates for women significantly widen compared to men during the childbearing years (mid-20s and 40s) as caregiving-related career interruptions take a toll. This widening gap continues into old age, where diminished retirement savings intensify financial insecurity for women.

Elderly single mothers over 65 face the highest rates of poverty, underscoring how these lifetime inequities accumulate over time.6 Addressing childcare costs and accessibility is therefore essential, not only for immediate economic stability but also for long-term financial resilience.

Children are also profoundly impacted by the shortcomings of the childcare system. High-quality early childhood care is essential for cognitive development and lays the foundation for future educational success, yet children in low-income households often lack access to these programs. Without access to high-quality childcare, children are more likely to start school unprepared, struggle with basic literacy and numeracy skills, and fall behind their peers academically.7 Research shows that universal childcare could reduce child poverty by 25% and significantly improve

Figure 1: SPM pre-tax/transfer poverty prevalence across the life course, by gender. Data from National Women’s Law Center.6

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long-term educational and economic outcomes, including higher graduation rates and increased lifetime earnings.8 By missing out on these opportunities, children in disadvantaged families are more likely to remain trapped in cycles of poverty, with limited career prospects and diminished earning potential as adults. These findings highlight the urgent need for investment in early childhood education, creating lasting benefits for individual families and future generations.

Beyond 9-to-5: How Non-Traditional Work Schedules Shape Childcare Inequities To fully dissect the childcare dilemma, it is crucial to understand the lives and daily realities of lower-income and single-parent families who face unique challenges balancing work and caregiving responsibilities. The rigid 8 a.m. to 6 p.m. daycare model, which dominates the current U.S. childcare system, fails to accommodate the demands of non-traditional work schedules, leaving these families underserved. Figure 2 illustrates the extent of this misalignment, showing that 64% of single parents work non-traditional schedules.9 Also, 53% of non-traditional childcare users have a highschool or less parental education.9 This limited educational attainment often confines individuals to blue-collar jobs, which are characterized by long hours, night shifts, and inflexible schedules. These work conditions create a pressing need for childcare options that extend beyond the standard operating hours. Additionally, Figure 2 shows that 53% of families live below 100% of the Federal Poverty Level (FPL), making the current high-cost childcare system unattainable for the majority of these households.9 The need for flexible childcare is further emphasized by Fig-

Research

Figure 2: Share of children under six in the U.S. in working families with non-traditional-hour work schedules by child, parent, and family characteristics. Data from CCEEPRA Research Translation.9

ure 3, which provides insight into the specific times when childcare is most needed. A significant portion of non-traditional-hour child care use occurs on weekends, with 55% of families relying on it during this time. Evening care is also in high demand, with usage peaking between 6-7 p.m. and 7-8 p.m.9 The data underscores the inadequacies of the current childcare model, which remains rigidly anchored to traditional work hours despite the growing prevalence of non-traditional schedules among low-income and single-parent households. Addressing this gap requires innovative solutions that prioritize flexibility and affordability.

Policy Patchwork: Evaluated the United States’ Childcare System While supported by some subsidies and tax credits, the current U.S. childcare system remains insufficient in addressing the scope

Figure 3: Share of children younger than six in non-traditional-hour care, among those who use any non-traditional-hour care. Data from CCEEPRA Research Translation.9

of the existing challenge. A report from the United Nations International Children’s Emergency Fund (UNICEF) reveals chronic underinvestment in U.S. childcare. In 2020, the U.S. ranked fifth from the bottom in child poverty among 41 advanced nations, far beneath where similar countries in prosperity ranked.10 The U.S. currently relies on a fragmented network of subsidies, tax credits, and state-funded programs to tackle the crisis of obtainable childcare. However, these measures often fall short of meeting the needs of disadvantaged families.

The Child Care and Development Block Grant (CCDBG) is the largest federal funding source for childcare assistance to support low-income families.11 Unfortunately, the program suffers from funding shortages and less than 15% of eligible families receive assistance due to budgetary constraints.10 State-level variations in how CCDBG funds are allocated further complicate the issue. For instance, some states prioritize families with lower incomes or children with disabilities, while others limit eligibility based on work requirements or prioritize families already receiving public assistance.8 These inconsistencies leave millions of families without access to support.

The Child Tax Credit (CTC) has

played a pivotal role in easing childcare expenses, especially following its temporary expansion during the COVID-19 pandemic. The expanded CTC lifted nearly 3 million children out of poverty in 2021, providing families with up to $3,600 per child annually.12 However, the expiration of the expanded credit in late 2021 reversed much of its progress.

The original CTC, which remains in place, offers limited relief to the poorest families, as eligibility is tied to earned income.12 This restriction renders the program less effective in addressing systemic childcare inequities.

State-funded initiatives, such as universal preschool programs in Oklahoma and Georgia, have demonstrated the potential of state-level solutions to address childcare gaps. Oklahoma’s program, which integrates preschool into public schools, has significantly reduced family costs while improving early childhood education outcomes.14 Similarly, Georgia’s Pre-K program, funded by state lottery revenue, has expanded access to free early education for fouryear-olds.15 While these programs show promise, their scalability is limited by state budgets, and they often exclude younger children who require full-day care.

Moreover, existing government childcare programs do not adequately meet the needs of families working non-traditional hours. In fact, less than 10% of licensed childcare providers offer care outside standard business hours.11 This limitation disproportionately impacts low-income families and single parents who work irregular schedules. Federal programs like CCDBG have attempted to incentivize non-traditional-hour care, but uptake remains low due to logistical challenges and limited provider interest.

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Research Case Studies: Community-Based Daycare Initiatives Case studies from community-based daycare initiatives demonstrate the potential for localized solutions to address childcare inequities. The Hope Starts Here program has transformed childcare availability in underserved neighborhoods in urban Detroit.

Funded through a combination of public and private partnerships, Hope Starts Here provides subsidized care to over 1,000 families each year.16 Its flexible hours and sliding-scale payment model have made it a lifeline for single mothers working non-traditional shifts.

Another effective model, the Robin Hood Foundation, operates in urban New York neighborhoods.

This initiative addresses the unique needs of low-income families by providing flexible, subsidized care tailored to non-traditional work schedules. Robin Hood’s initiative empowers caregivers to establish small-scale daycares in their homes, supported by training, startup grants, and ongoing oversight.17 This approach increases access to affordable childcare and creates economic opportunities for providers. A recent impact report from Robin Hood revealed that the program had served over 5,000 families annually, reducing childcare costs by 40% for participating households.17 Additionally, many parents noted the program’s flexible hours as a critical factor in maintaining stable employment.

Despite the promise of these models, scalability remains a significant challenge. Hope Starts Here, for instance, relies heavily on local philanthropic funding, limiting its replicability in regions without similar resources.16 Overcoming these limitations requires a concerted effort to secure sustainable funding and develop frameworks for scaling

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Figure 4: Share of providers serving young children who offered non-traditional-hour care, by provider type. Data from CCEEPRA Research Translation.9

Figure 5: Share of children younger than six in childcare, by care arrangement and whether they used non-traditional- or traditional-hour care only. Data from CCEEPRA Research Translation.9

successful initiatives. Federal investment could play a vital role in this endeavor by providing grants to replicate effective models across diverse geographic and socio-economic contexts.

Home Daycares: A Critical Yet Overlooked Solution Home daycares represent a widely used but underfunded alternative to traditional daycare centers, particularly for families needing non-traditional hour care. The programs are often run by relatives or community members, offering families a more affordable and flexible option. Nearly 20% of low-income families rely on home daycares due to their accessibility and lower costs.18 Figure 4 points out that unlisted, unpaid home providers, such as family, friends, and neighbors (FFN), account for the majority of non-traditional hour childcare.9 These providers are far more likely to offer care during evenings, overnight, and weekends compared to

licensed centers or listed home providers. For example, 82% of unpaid home providers are open at least one hour during evenings, overnight, or weekends, compared to only 8% of centers.9 Similarly, FFN providers lead in offering overnight care, with 64% providing services during 11 p.m. to 6 a.m., compared to just 6% of centers.9 Figure 5 further emphasizes the reliance on home-based and FFN care for non-traditional schedules.

Among children younger than six, 57% of those using family, friend, or neighbor care relied on it exclusively for non-traditional hour coverage, compared to 37% for center-based care.9 These statistics emphasize the importance of flexible, home-based childcare options for families navigating irregular work hours, particularly for single parents and low-income households who cannot afford the high costs of licensed care.

Research The reliance on FFN providers exposes a significant gap in the childcare system: these unlicensed providers often operate without subsidies or regulatory support, leaving families with limited assurance of safety and quality. While licensed providers must adhere to stringent safety and quality standards, their higher operational costs make them more expensive to families. In contrast unlicensed providers offer a more cost-effective and flexible solution but often lack oversight. Subsidies primarily target licensed daycares, leaving unlicensed providers, and the families they serve, without financial assistance.9 This disparity is particularly pronounced in low-income and rural neighborhoods, where families have few alternatives and unlicensed home daycares fulfill critical childcare needs. The result is a system where families often must choose between unaffordable licensed care and unregulated, yet more accessible, options. To bridge this gap, policymakers must create pathways for unlicensed providers to achieve licensure without sacrificing affordability or flexibility.

Building a Path Forward: Proposals for a Sustainable Childcare System Based on the preceding analysis, three actionable solutions emerge to address the childcare crisis, each designed to tackle accessibility, affordability, and quality while meeting the diverse needs of low-income families, single parents, and disadvantaged communities. The first and most flexible solution is to provide direct subsidies to low-income parents as an immediate relief measure. Direct subsidies empower families to allocate funds according to their unique needs, whether for traditional childcare centers, licensed home daycares, or unlicensed home daycares. This method prioritizes

the autonomy of families, acknowledging that one-size-fits-all childcare solutions often fail to address varying geographic, financial, and cultural considerations. By granting families the freedom to decide what works best for them, this option accommodates the realities of low-income households, many of whom rely on unlicensed providers for affordability and convenience.

However, the flexibility does come with certain drawbacks. Without sufficient oversight, funds might be directed toward care providers with inconsistent quality standards, particularly in the case of unlicensed home daycares. To maximize the effectiveness of this solution, careful regulation is necessary to ensure that families have access to safe and reliable childcare environments.

The midterm approach focuses on increasing subsidies for licensed home daycares, enabling these providers to expand capacity, improve quality, and maintain affordability in underserved communities.

Licensed home daycares offer a practical path forward because they are a middle ground between cost and quality, with more flexible schedules than larger centers.

Targeted funding could encourage more home daycare operators to pursue licensing, thus improving overall accountability and regulation within the system. However, this option has its own limitations.

While this approach strengthens the regulated sector of the childcare system, it may take time for unlicensed providers to transition to licensed care, making this a vital but intermediate step.

A final solution involves government investment in establishing community-based daycares in disadvantaged areas as a long-term strategy. These daycares would cater to families with non-traditional work schedules, offering ex-

tended hours, affordable rates, and high-quality early education, inspired by the success of the Robin Hood initiative. The implementation of this solution presents significant commitment. Developing these centers necessitates substantial upfront investment in infrastructure, workforce training, and ongoing operational costs. Sustainability may also be a concern, particularly in ensuring competitive wages for caregivers willing to work evenings and weekends while keeping childcare affordable for families.6 While this solution presents significant upfront costs, its potential to address systemic childcare inequities makes it a crucial investment of the future. By operating seven days a week and prioritizing flexibility, these centers could serve the distinctive needs of working parents while bridging developmental disparities for children in low-income neighborhoods.

Each of these proposals addresses critical gaps in the childcare system, but their effectiveness depends on the priorities and resources available. Direct parental subsidies provide the greatest flexibility and swift relief, making this the most practical short-term solution for many families. Conversely, establishing more community-based daycares holds the potential for transformative change, addressing structural inequities in the childcare system, though this approach requires careful planning and sustained investment. Together, these proposals outline a roadmap for systemic reform that prioritizes family needs while tackling the long-standing inequities in childcare access and quality.

Conclusion: The Road Ahead for the Childcare Reform Moving forward, the U.S. must prioritize childcare reform as a fundamental aspect of equitable policy.

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Research Key steps include expanding federal subsidies, incentivizing state-level innovation, and replicating successful community-based models.

Future research should assess the long-term effects of localized childcare initiatives and explore innovative funding mechanisms to ensure sustainability. Additionally, technological advancements represent an exciting avenue for future exploration to address gaps in rural and underserved regions.

Investing in sustainable childcare solutions has the potential to narrow gender and racial employment gaps. Accessible and affordable childcare can empower more women to pursue higher-paying opportunities, fostering greater gender equality in the workforce. For families of color who are affected by childcare inaccessibility, reform is a critical tool for addressing systemic racial disparities in income and economic mobility. Notably, Black women, who face some of the largest gender earnings gaps, could see benefits, including a 15 to 25 percent reduction in income disparities for women with less than a high school degree.6 Alleviating the childcare crisis not only promotes equity but also generates substantial economic benefits, from increasing workforce participation to reducing long-term reliance on social safety nets, ultimately creating greater economic opportunities for historically disadvantaged groups.

The crisis of inaccessible childcare is a microcosm of broader societal inequities and reflects systemic underinvestment in underserved families and children. Confronting this challenge requires a shift in perspective: from viewing childcare as solely a private responsibility to recognizing it as a public good essential to fostering healthier families, equitable opportunities, and a thriving society. By investing in

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comprehensive solutions, the U.S. can pave a road forward where no family is forced to choose between economic security and their child’s well-being.

References

1. Malik R. Working Families Are Spending Big Money on Child Care. Center for American Progress. Published June 20, 2019. https://www.americanprogress.org/ article/working-families-spending-bigmoney-child-care/ 2. Doran, Bartel, Waldfogel. Gender in the Labor Market: The Role of Equal Opportunity and Family-Friendly Policies. RSF: The Russell Sage Foundation Journal of the Social Sciences. 2019;5(5):168. doi:https:// doi.org/10.7758/rsf.2019.5.5.09 3. Schmitz S. The Impact of Publicly Funded Childcare on Parental Well-Being: Evidence from Cut-Off Rules. European Journal of Population. 2019;36(2):171-196. doi:https://doi.org/10.1007/s10680-01909526-z 4. AAUW. The motherhood penalty.

AAUW : Empowering Women since 1881.

Published 2024. https://www.aauw.org/issues/equity/motherhood/ 5. Salas-Betsch I. The Economic Status of Single Mothers. Center for American Progress. Published August 7, 2024. https:// www.americanprogress.org/article/ the-economic-status-of-single-mothers/ 6. The Effects of Affordable, High-Quality Child Care on Family Income, the Gender Earnings Gap, and Women’s Retirement Security the CURRENT STATE of WOMEN’S ECONOMIC and RETIREMENT SECURITY the CURRENT STATE of CHILD CARE the ROLE of CHILD CARE for ALL. https:// nwlc.org/wp-content/uploads/2021/04/ALifetimes-Worth-of-Benefits-_FD.pdf 7. Strengthening Head Start: What the Evidence Shows. ASPE. Published 2022. https://aspe.hhs.gov/reports/strengthening-head-start-what-evidence-shows-0 8. H. Luke Shaefer, Sophie Collyer, Greg Duncan, et al. A Universal Child Allowance: A Plan to Reduce Poverty and Income Instability among Children in the United States. RSF: The Russell Sage Foundation Journal of the Social Sciences.

2018;4(2):22. doi:https://doi.org/10.7758/ rsf.2018.4.2.02 9. CCEEPRA Research Translation (2023).

Understanding families’ access to nontraditional-hour child care and early education.

OPRE Report #2023-219. Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

10.Child Poverty in the Midst of Wealth Innocenti Report Card 18. https://www. unicef.org/innocenti/media/3296/file/

UNICEF-Innocenti-Report-Card-18-ChildPoverty-Amidst-Wealth-2023.pdf 11. Henly J, Adams G. Insights on Access to Quality Child Care for Families with Nontraditional Work Schedules.; 2018. https://www.urban.org/sites/default/ files/publication/99148/insights_on_access_to_quality_child_care_for_families_ with_nontraditional_work_schedules_0. pdf 12. The impacts of the 2021 expanded child tax credit on family employment, nutrition, and financial well-being. Brookings. https://www.brookings.edu/articles/ the-impacts-of-the-2021-expanded-childtax-credit-on-family-employment-nutrition-and-financial-well-being/ 13. Hungerford TL, Thiess R. The Earned Income Tax Credit and the Child Tax Credit: History, Purpose, Goals, and Effectiveness. Economic Policy Institute. Published September 25, 2013. https://www.epi.org/ publication/ib370-earned-income-taxcredit-and-the-child-tax-credit-historypurpose-goals-and-effectiveness/ 14. Universal Pre-K in Tulsa: A Surprising Success. NASBE - National Association of State Boards of Education. https://www. nasbe.org/universal-pre-k-in-tulsa-a-surprising-success/ 15. Long-term Impacts of Universal Pre-K— Understanding Conflicting Research. Gafcp.org. Published May 31, 2024. https:// gafcp.org/2024/05/31/long-term-impacts-of-universal-pre-k-understanding-conflicting-research/ 16. Detroit’s Community Framework for Brighter Futures. Accessed January 14, 2025. https://hopestartsheredetroit.org/ wp-content/uploads/2017/12/HSH-Executive-Summary-final-1.pdf 17. Swartz M. Robin Hood’s Child Care Quality and Innovation Initiative: “There Is No Better Investment” - Early Learning Nation. Early Learning Nation. Published January 30, 2024. https://earlylearningnation. com/2024/01/robin-hoods-child-carequality-and-innovation-initiative-there-isno-better-investment/ 18. Bureau UC. About 1 in 5 Parents Relied on a Relative for Child Care. Census.gov.

Published November 29, 2023. https:// www.census.gov/library/stories/2023/11/ child-care.html

Author’s Biography Annabelle Huang is a freshman majoring in Public Health Studies and Economics at Johns Hopkins University. She enjoys working out and exploring new places with friends.

Research

OSRX Atropine+ to Treat Myopia: A Literature Review Arjit Singh Abstract Myopia, or nearsightedness, is a growing public health concern, affecting over 41.6% of Americans, particularly in urban areas and younger populations. This study reviews the development of OSRX Atropine+, a new atropine eye drop formulation for myopia management, which includes customizable treatment concentrations, color-coded bottles, reduced benzalkonium chloride (BAK) content, and more flexible storage requirements.7 Traditional atropine eye drops, while effective, face compliance challenges due to confusing labeling and strict handling rules.

The OSRX Atropine+ formulation addresses these issues, enhancing patient adherence by offering personalized treatment options and ease of use.3 This literature review highlights the potential of OSRX Atropine+ to improve treatment outcomes and patient compliance in managing myopia progression.

Introduction Myopia, also known as nearsightedness, is a refractive error that results in clear vision for close

objects but blurred vision for distant ones. The prevalence of myopia has surged in recent years, especially in urban environments where screen time has increased and outdoor exposure has diminished.7 Studies show that prolonged close-up activities, particularly on digital devices, and reduced natural light exposure may contribute to this upward trend in myopia cases.

With its prevalence rising, particularly among young people, managing myopia progression has become a significant concern in ophthalmology.3 Atropine eye drops have been extensively studied as a treatment option to slow myopia progression in children. Low-dose atropine (typically 0.01% to 0.05%) has been shown to reduce myopia progression effectively, though challenges remain in ensuring patient compliance.2 Common issues include confusion about labeling and strict storage requirements, which can lead to unintentional non-compliance. Effective myopia management requires user-friendly, accessible treatments to address

Unsplash/v2osk

these challenges and ensure consistent use.

The development of OSRX Atropine+ eye drops aims to address these barriers to compliance. This new formulation introduces color-coded bottles, customizable concentrations, reduced BAK (benzalkonium chloride) content, and flexible storage conditions, potentially transforming myopia management.6 Advances in Treating Myopia The development of OSRX Atropine+ eye drops represents a significant innovation in myopia treatment, aimed at enhancing patient usability and compliance. Traditionally utilized in concentrations ranging from 0.01% to 0.05%, atropine eye drops have been effective in slowing myopia progression with minimal side effects, such as light sensitivity and blurred near vision.6 The OSRX Atropine+ formulation extends these benefits through its unique features: By offering doses of 0.01%, 0.025%, and 0.05%, OSRX Atropine+ allows for personalized treatment plans. This adaptability helps healthcare providers fine-tune therapies to individual patient needs, optimizing efficacy and minimizing adverse effects. Such customization underscores the shift towards personalized medicine in eye care, providing more precise control over myopia progression.

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Research utilizes a color-coding system to distinguish between concentrations. This method features red for 0.05% concentration, orange for 0.025% concentration, and white for 0.01% concentration.5 This straightforward coding aids in reducing medication errors and enhancing compliance by making it easier for patients to identify and follow their prescribed treatment regimen.

Benzalkonium chloride (BAK) is commonly used as a preservative in eye drops. While effective as a preservative, higher BAK concentrations can cause ocular surface irritation, leading to symptoms such as dryness, redness, stinging, and burning. OSRX Atropine+ contains 50% less BAK (0.005%), reducing the potential for ocular surface toxicity while maintaining efficacy. Ac-

cording to the American Academy of Ophthalmology, this adjustment makes the drops more comfortable for patients, promoting long-term use and reducing the risk of side effects that could deter adherence.

Traditional atropine drops often require refrigeration, which can be inconvenient for patients who lack access to refrigeration or are frequently traveling. OSRX Atropine+ eye drops offer a more practical solution by allowing storage at room temperatures not exceeding 25°C (77°F). This flexibility minimizes storage complications, making it easier for patients to comply with treatment regimens, even under varying conditions.

These features combine to make OSRX Atropine+ a more patient-centered option in myopia

Table 1: Summary of Changes from Baseline in Eye Dryness/Irritation and Comfort Across Weeks 4 and 8 for Control and Atropine+ Groups

Figure 1: Average Comfort Score by Treatment Group1

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management, with enhancements to improve compliance and treatment efficacy.

Case Study on Efficacy In a randomized experiment, one cohort of 40 eyes used Atropine+ 0.01% every night for 8 weeks with a second control cohort. All the subjects were evaluated on day 1, day 14, day 30, and day 60. Subjects were measured for visual acuity, refraction, and other markersThe subjects were asked additional subjective questions on comfort. These questions were measured on a 1-10 numerical rating scale, with one being the least likely and 10 being the most likely.

By the end of the experiment, they determined the Atropine+ drops were well tolerated in the study and non-inferior to standard low-dose Atropine for myopia control.1 The Atropine+, with its lower BAK concentration and additional lubrication formulation, may improve quality of life by lowering corneal and conjunctival toxicity and improving ocular surface health. They measured eye dryness/ irritation and comfort on a scale from 0-100 where 100 represents more dryness and irritation as well as more comfort. The mean is then calculated as the change from the baseline measurements. The negative value from the mean represents decreased dryness and irritation or comfort, while a positive value would show increased dryness and irritation or comfort. Both the control and Atropine+ groups reported no significant change in eye dryness/irritation scores from baseline at week 8, with a mean change of 0.0 and a wide 95% CI of (-13.5, 13.5).1 This indicates that Atropine+ did not increase symptoms of eye dryness or irritation compared to the control, demonstrating good tolerability. Additionally for comfort, at week 4, the Atro-

Research pine+ group reported a mean comfort score improvement of 4.2 (SD 13.29) with a 95% CI of (4.3, 12.6), showing that patients experienced increased comfort using Atropine+ compared to the control group, which had a similar improvement.

By week 8, however, the Atropine+ group showed a decrease in comfort (mean change -2.5, SD 9.26), but still within a non-critical range as indicated by the 95% CI of (-10.2, 5.2).1 This suggests that while there was a variation over time, the initial positive response indicates an adjustment phase to the treatment with no long-term negative impact on comfort.

These points suggest that Atropine+ is not only effective in controlling myopia similar to standard treatments but does so while maintaining or improving patient comfort and minimizing additional irritation, which could be attributed to its lower BAK concentration and enhanced lubrication formulation.

This aligns with the study’s goals to improve ocular surface health and overall quality of life for patients undergoing myopia treatment.

Discussion The introduction of OSRX Atropine+ eye drops marks a notable advancement in myopia management, combining customizable dosing, enhanced usability, and a safer profile to meet the needs of a growing pediatric population. Myopia, particularly in children and adolescents, poses increased risks for serious ocular conditions like retinal detachment and glaucoma, making effective and user-friendly treatments essential. Zadnik et al4 highlights the design features of OSRX Atropine+ that address key compliance barriers—its color-coded bottles simplify dosage identification, and the elimination of refrigeration requirements enhances convenience. These improvements, along

with customizable concentrations, align with personalized medicine trends, allowing ophthalmologists to tailor treatments to individual needs while reducing adverse effects. Notably, the formulation reduces benzalkonium chloride (BAK) content, decreasing potential ocular surface irritation and making the drops particularly suited for young patients, who may be more sensitive and less compliant. This reduction in preservatives, combined with practical storage conditions, positions OSRX Atropine+ as a superior choice for managing myopia in the digital era, where increased screen time is a pervasive risk factor.5 Economic and Social Impact The primary demographic for OSRX Atropine+ includes children and adolescents at risk of developing myopia, a condition exacerbated by modern lifestyle habits such as prolonged digital device use and limited outdoor activity. By effectively managing myopia progression, OSRX Atropine+ not only reduces the likelihood of developing severe ocular diseases but also the healthcare costs associated with treating these conditions.3 Moreover, this treatment can address social disparities in healthcare by providing a more accessible and easier-to-manage option for families who may lack resources for frequent medical visits or specialized care. Improved compliance and effectiveness in myopia control can lead to better long-term visual health outcomes and reduced socioeconomic burdens on families and healthcare systems. In conclusion, OSRX Atropine+ eye drops present a significant innovation in eye care, promising enhanced treatment adherence and optimized outcomes in myopia management.3 As the prevalence of myopia continues to rise among young populations, adopting user-friendly and clini-

cally effective solutions like OSRX Atropine+ is crucial for preventing severe myopia and its complications, thereby improving quality of life and easing future healthcare challenges.

References

1. Tsang S, Wen J, Leung D, Ma J, Shih P, Goldberg D. U.S. Multicenter, Observational Study of Atropine+ 0.01% Eye Drops in Reducing Corneal Toxicity and Surface Disease in a Pediatric Population. Accessed January 7, 2025. https://www.osrxpharmaceuticals.com/sites/default/files/AtropinePlus-Poster.pdf 2. Chia A, Lu QS, Tan D. Five-Year Clinical Trial on Atropine for the Treatment of Myopia 2. Ophthalmology. 2016;123(2):391399. doi:https://doi.org/10.1016/j. ophtha.2015.07.004 3. Low-Dose Atropine for Kids with Myopia. Low-Dose Atropine for Kids with Myopia. American Academy of Ophthalmology.

Published August 31, 2017. https://www. aao.org/eye-health/news/low-dose-atropine-kids-with-myopia 4. Zadnik K, Schulman E, Flitcroft I, et al.

Efficacy and Safety of 0.01% and 0.02% Atropine for the Treatment of Pediatric Myopia Progression Over 3 Years. Published online June 1, 2023. doi:https://doi. org/10.1001/jamaophthalmol.2023.2097 5. Yam JC, Jiang Y, Tang SM, Law AKP, Chan JJ, Wong E, Ko ST, Young AL, Tham CC, Chen LJ, Pang CP. Low-Concentration Atropine for Myopia Progression (LAMP) Study: A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control. Ophthalmology. 2019 Jan;126(1):113-124. doi: 10.1016/j.ophtha.2018.05.029. Epub 2018 Jul 6. PMID: 30514630.

6. Wang, Y., Zhu, X., Xuan, Y. et al. ShortTerm Effects of Atropine 0.01% on the Structure and Vasculature of the Choroid and Retina in Myopic Chinese Children.

Ophthalmol Ther 11, 833–856 (2022).

7. Milner MS, Beckman KA, Luchs JI, Allen QB, Awdeh RM, Berdahl J, Boland TS, Buznego C, Gira JP, Goldberg DF, Goldman D, Goyal RK, Jackson MA, Katz J, Kim T, Majmudar PA, Malhotra RP, McDonald MB, Rajpal RK, Raviv T, Rowen S, Shamie N, Solomon JD, Stonecipher K, Tauber S, Trattler W, Walter KA, Waring GO 4th, Weinstock RJ, Wiley WF, Yeu E. Dysfunctional tear syndrome: dry eye disease and associated tear film disorders - new strategies for diagnosis and treatment. Curr Opin Ophthalmol. 2017 Jan;27 Suppl 1(Suppl 1):3-47. doi: 10.1097/01.icu.0000512373.81749.b7.

PMID: 28099212; PMCID: PMC5345890.

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The Impact of Urbanization on Hyderabad’s Lakes and Water Pathways Surya Panyam Abstract As someone passionate about GIS, a digital mapping tool, I wanted to use the tool to help communities experiencing flooding in Hyderabad, India—where my family is from. So, I reached out to Hyderabad Urban Labs (HUL), a non-profit organization in India dedicated to providing relief for social issues that individuals face, and interned with them from the winter of 2022 to the summer of 2023.

I learned about how Hyderabad has recently been experiencing high levels of flooding because increased urbanization has been causing lakes to shrink, meaning that lower rainfall causes higher flooding. Eventually, I wrote a report using Google Earth, QGIS, and other mapping tools, that depicted quantitative data depicting how urbanization caused various lakes to shrink and change location over time, causing unpredictable flooding that occurred more frequently and often impacted low income households. I traveled to Hyderabad, India in December 2022 conducting fieldwork there. My report was submitted to Hyderabad Urban Labs’s database of internal publications. This article provides a condensed summary of my report, highlighting key findings and suggesting potential solutions to mitigating unpredictable flooding.

Introduction Hyderabad is the capital and the largest city of Telangana State. It is located on the banks of Musi River, a tributary of the Krishna River.

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Hyderabad is a major hub for the IT industry, with large multi national companies like Microsoft, InfoSys, and Hitachi expanding into the city. As a result, Hyderabad is a rapidly growing city with a population exceeding 10 million people.1 Typically, Hyderabad has “a dry climate and does not possess snow-fed rivers to irrigate its lands”.2 As a result, Hyderabad gets water mainly from monsoons and groundwater.

In the sixteenth and seventeenth century, those in power created “artificial tanks” (lakes) in order to retain the water. Known as the City of Lakes, Hyderabad used to include over 7000 water bodies (ponds, tanks, lakes, rivers).3 All the water bodies are interlinked in such a way that the lakes in the higher elevation are connected to the lakes in the lower elevation through a network of drainage called nala and finally all drain to the Musi river, which passes through the center of the city. The Musi river takes the water away from the city whenever there is an extreme rainfall, thereby averting flooding of the urban land. Every lake has a small temple, known as the Katta Maisamma Temple (“Goddess of the bund”), which was prayed to in order to protect the lake bund from breaching. Historically, the interconnected-lakes in Hyderabad played a vital role in managing both the drinking water supply in Hyderabad and also providing staging or draining excess water due to heavy rainfall. Without maintaining lakes and carefully regulating lake inflows and outflows, massive floods

damage property and cause death.

Hyderabad’s terrain mainly slopes towards the Musi river, which is the lowest point of elevation in the city.

As a result, rainfall and other water sources will move, if in excess, towards the Musi river and empty into it. Until the late twentieth century, Riverine flooding was the only type of flooding in Hyderabad.

Riverine flooding is when streams and rivers exceed the capacity and spill out into adjacent low-lying dry land.

Shaikpet Cheruvu Katta Maisamma Temple

In 1908, Hyderabad faced floods known as the Great Musi floods, where the Musi river had significant flooding that caused nearly 15,000 deaths. As a result, an engineer proposed creating two water dams, now known as Osman Sagar and Himayat Sagar, for excess wa-

Research ter. The flood prevention plans were initially successful. However, urbanization started to increase in Hyderabad towards the latter part of the 1900s, and in this urbanization, lakes were encroached and water bodies were altered. This resulted in common occurrences of Urban Flooding, which is flooding in dense cities due to water bodies not being able to hold excess rainfall. The Urban Flooding in recent years has been significantly more frequent and more devastating than previous riverine flooding, devastating flooding events occurring regularly in the 2000s, and most recently, with the devastating 2020 floods.

Objective of Study Hyderabad has transitioned from primarily agricultural land to highly developed industrial and high tech hub, thereby seeing a huge growth in population and urbanization. The goal of this study is to determine how urbanization has impacted water bodies and water drainage systems in Hyderabad, and to thereby determine why Hyderabad has been experiencing more floods more recently Methods In my study, I analyzed the impact of urbanization for three lakes in Hyderabad, which are Shaikpet, Malkam, and Ambir Lakes. Shaikpet Lake, which once was a clean water lake has now become a stagnant dirty lake due to real estate development. Malkam lake, which was considered a dirty lake, has been transformed by the government into a clean lake and devel-

oped as a park, thereby creating a permanent lake boundary, with regulated inlets and outlets. Ambir is a huge lake, but is partly subjected to sewage and urbanization.

1. Location of Hyderabad and it’s lakes After gathering general historical context about urbanization in India from researchers at Hyderabad Urban Labs, I conducted a field study of Shaikpet, Malkam, and Ambir Lakes by visiting them in person and gathering data regarding stream locations and other liquid sources entering or exiting the lakes. I specifically took notes of points of interest, including inlets, outlets, religious items (ex.

Katta Maisamma temples), and uploaded information to ArcGIS field maps, which stored data points I inputted at my various locations with descriptions and pictures of the relevant information. I talked with a few residents about their firsthand experience with flooding, sources for flooding, and other relevant information. I then used Google Earth and QGIS to conduct deeper analysis on the lakes. I analyzed elevation profile data to determine the direction of the water, and looked at historical imagery to compare how water inflow and outflow changed over time.

Results 1. Malkam Cheruvu Change in elevation from Malkam to Musi: 32.9 m (approx) Malkam Cheruvu is located in the commercial area of Hyderabad and used to be a lake solely used for the purposes of irrigation.

However, due to the impacts of urbanization, the lakes, as noted by local residents, used to have sewage coming in, which in turn heavily polluted the lake. As a result, a restoration project, starting in 2017 and ending in early 2022, was done, which significantly cleaned the lake. In addition to the lake itself being cleaned, it also became safer in the event of future floods; a sewage line parallel to the lake was created to divert sewage from the lake, which is known as a “ring sewer”.4 Additionally, inlets and outlets into the lake were better developed, resulting in more preparedness for future flooding; an underground inlet exists from Durgam Cheruvu in the north, and above ground outlets eventually lead to the Musi River.5 Aside from future preparedness, the lake is now somewhat like a park; there are jogging areas, areas for kids to play, an open gym, and other amenities. Furthermore, invasive weeds, such as the Hyacinth, are removed regularly.6

Malkam Cheruvu Water Flow and Elevation Profile

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Malkam Cheruvu Urbanization between 2010 to 2022

Inflow and Outflow of Water Water flows into Durgam Cheruvu into Malkam Cheruvu from the north, and the only structures between both lakes, both in 2010 and now, is just one major road.

Lake changes between 2010 and 2022 In 2010, as shown by Google Earth Imagery, water flowed out of two streams, one heading southwest and the other heading southeast. As a result, buildings would likely not be impacted during a flood, since multiple outlets exist, and, as seen by the image, buildings are not tightly encroaching the lake. In 2010 more water bodies were observed near the lake. The observed lake in the Western side of Malkam Cheruvu is at a higher elevation and stores a good amount

of water during the monsoon season. However, those water bodies disappeared in the 2020 images.

As a result, more water will get into Malkam Cheruvu during the monsoon, resulting in an increase of a risk of flooding downstream or in the catchment area of Malkam Cheruvu. Furthermore, only a small outlet exists from Malkam Cheruvu now, which will result in less rainfall required for flooding. Since a bund, as shown, prevents water from flooding the southern buildings, water will likely flood the low income households in the east. This is especially concerning since individuals from low income households have a harder time recovering from flooding due to having less resources to pay for damages and buy necessary supplies.

Shaikpet Cheruvu Water Flow and Elevation Profile

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2. Shaikpet Cheruvu Change in elevation from Shaikpet to Musi: 39.9 m (approx) Shaikpet Cheruvu faces the consequences of urbanization and encroachment. The area is heavily polluted as a result of inflow of sewage from nearby areas. Specifically, a Nala (stream) nearby contains a significant amount of sewage, which impacts Shaikpet and causes significant pollution. Recently, a wall has been built around most of the lake, which allows for encroachment to be mitigated and for impact to the lake to be limited. However, buildings impact both inflow and outflow into the lake, resulting in a lack of preparedness in the event of flooding.

Research Inflow and Outflow of Water Water flows into this lake from a northwest lake called Batula Kunta, and water leaves the lake through a stream carrying it east.

Lake changes between 2010 and 2022 In 2010, a stream surrounded most of the lake; however, less of the stream exists today. This may be impactful as less water bodies means less areas acting as “sponges” to absorb excess water, which results in more frequent flooding. Between 2010 and now, a significant number of buildings were built, meaning that the impact of flooding will likely increase drastically. Furthermore, encroachments increased, resulting in impacts on the lake as well. In summary, individuals around the lake have always been at risk in the event of flooding, but recently, the potential impact has increased due to increased urbanization.

3. Ambir Cheruvu Change in elevation from Ambir to Musi: 75.0 m (approx) Ambir Cheruvu, also unlike Malkam Cheruvu, is facing the consequence of urbanization and a lack of maintenance. Hyacinth, the invasive weed regularly removed at Malkam Cheruvu, is growing on the

surface of the lake, and toxic chemicals are also present. Residents of the area consider the area to smell bad and contain a high amount of mosquitoes. Furthermore, the size of the lake is significantly reduced as a result of encroachment, which poses potential threats for flooding.7 Thankfully, the lake empties into Pragathi Nagar, which has outlets that carry water eventually into the Musi river, and as a result, the lake is less prone to flooding than other lakes. In fact, the outlet into the lake is large, spanning nearly the whole width of the east side of the lake.

Inflow and Outflow of Water Water indirectly flows into Ambir Cheruvu from Nizam Talaab; small water bodies exist between Nizam Talaab and Ambir Cheruvu, and water flows between them as well. Meanwhile, water leaves Ambir Cheruvu via Pragathi Nagar, another large lake next to Ambir Cheruvu. Water leaves Pragathi Nagar via streams that eventually reach the Musi River.

Lake changes between 2010 and 2022 As a result, outflow is not impacted by urbanization and will likely not cause flooding. Meanwhile, inflow is significantly impacted by urbanization, which has only increased in the past ten years;

some buildings existed between Nizam Talaab and Ambir Cheruvu in 2010, but in the modern day, a significant number of gated communities exist, and as a result, the areas are at risk for flooding. Furthermore, the small lakes northwest of Ambir Cheruvu are constantly changing location, which shows the unpredictable nature of the area’s water bodies. Overall, the impact of flooding will impact areas northwest of Ambir Cheruvu due to the high number of buildings between water bodies.

Discussion Unfortunately, Hyderabad now has less than 1/10th of the number of lakes it used to have just a few decades ago. These lakes have been eliminated as a result of encroachment onto previous water areas, as well as illegal drainage for personal gain by government or other organizations. Furthermore, to complicate matters, some of these lakes and nalas are even being used for sewage disposal.

1. Contamination of Hyderabad lakes due to urbanization Increased construction in the lake bed and conversion of drainage channels into sewage reduced the carrying capacity of the lakes and led to flash floods during the extreme events. As a result of flood-

Ambir Cheruvu Urbanization between 2010 to 2022

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ing, vulnerable communities are most impacted. Those who are economically vulnerable will have to resettle and rebuild their houses, which will cost a significant amount of money that is likely taken out of important long term considerations, such as children’s education, retirement plans, and other family needs. Those who are less economically vulnerable, however, will likely be able to settle in areas less prone to flooding, and the flood will be much less impactful for these individuals as a result.

Hyderabad depends on lakes and the nalas that interconnect them to store and drain the excess water from the monsoon to the Moosi river to carry it beyond the city. However, rapid urbanization without streamlined water body considerations have changed the land cover and land use profiles of the lakes.

The lake beds are encroached for buildings and sewage is dumped into the nalas and lakes. This has impacted the water drainage system severely and also led to foul smell and dirty water in the nalas.

The gated communities are always built in the command area of the lake (across the bund) and low income housing is usually encroaching on the nearshore area of the lake. When there is heavy rainfall, since the water drainage system is inadequate, the water level rises in the nearshore areas, flood-

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ing the low income households.

This has led to an increased number of floods in the past twenty years, compared to the previous fifty years.

Programs to allow for those in low income households to be able to relocate to areas that are not in the midst of a water pathway would really help with preparedness for future flooding events. Furthermore, action that would allow for artificial water pathways to be installed would again allow for increased preparedness for future rain events.

Acknowledgements A huge thanks to Hyderabad Urban Labs (HUL) for training, guiding and hosting me to work on this project. HUL is an amazing hub where people with various backgrounds come together to identify, analyze and find solutions to impact communities locally. I really appreciate that Dr. Ananth Maringanti provided me with an internship opportunity at HUL and patiently taught me about the history and current issues with Hyderabad lakes and nalas. Also, I am thankful for my mentor Ebin Paul at HUL, who helped me navigate QGIS and other tools.

References

1. Hyderabad, India metro area population 1950-2024. MacroTrends. 2024. Accessed January 2, 2023. https://www.macrotrends.net/global-metrics/cities/21275/hyderabad/population.

2. Hyderabad: A city shaped by its historic water reservoirs. The Siasat Daily. July 15, 2022. Accessed January 3, 2023. https:// www.siasat.com/hyderabad-a-city-shapedby-its-historic-water-reservoirs-2369863/.

3. Hyderabad: Over 3,000 water bodies disappear in 2 decades. Deccan Chronicle. March 19, 2019. Accessed January 2, 2023. https://www.deccanchronicle.com/ nation/current-affairs/050518/hyderabadover-3000-water-bodies-disappear-in-2decades.html.

4. Hyderabad: Malkam Cheruvu Springs back to life; to woo tourists. The Hans India.

April 5, 2022. Accessed January 4, 2023. https://www.thehansindia.com/news/ cities/hyderabad/hyderabad-malkamcheruvu-springs-back-to-life-to-woo-tourists-736558?infinitescroll=1.

5. K P. Malkam Cheruvu, the new attraction in Western Hyderabad. The New Indian Express. April 20, 2022. Accessed January 4, 2023. https://www.newindianexpress.com/cities/hyderabad/2022/ apr/21/malkam-cheruvu-the-new-attraction-in-western-hyderabad-2444607.html.

6. Hyderabad: Malkam Cheruvu Springs back to life; to woo tourists. The Hans India.

April 5, 2022. Accessed January 8, 2023. https://www.thehansindia.com/news/ cities/hyderabad/hyderabad-malkamcheruvu-springs-back-to-life-to-woo-tourists-736558?infinitescroll=1.

7. Iyer S. Kukatpally’s prominent lakes are now stinking cesspools: Hyderabad News - Times of India. The Times of India. February 18, 2017. Accessed January 7, 2023. https://timesofindia.indiatimes. com/city/hyderabad/kukatpallys-prominent-lakes-are-now-stinking-cesspools/ articleshow/57215418.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst.

Author’s Biography Surya Panyam, is a freshman at Johns Hopkins majoring in ChemBE and minoring in Computer Integrated Surgery. He’s also interested in the various applications of GIS and other spatial analysis tools, including in disaster preparedness and in tracking impacts of urbanization.

Research

COVID-19’s Impact on Pediatric Dry Eye Syndrome Incidence Arjit Singh Introduction Dry Eye Syndrome (DES) is a condition where the eyes do not produce enough tears or retain sufficient moisture, resulting in symptoms such as stinging, burning, redness, and stringy mucus around the eyes. Pediatric DES has become an increasing concern as children spend more time on digital devices, which has been exacerbated by the COVID-19 pandemic. Before the pandemic, DES was relatively less common in children, with prevalence and incidence rates ranging from 3.5% to 7.8% in the general population during the 2010s.1 However, the pandemic significantly increased screen time for children due to remote learning, virtual interactions, and limited outdoor activities, potentially accelerating DES onset.2 The pathophysiology of DES in children differs slightly from adults due to behavioral factors such as decreased blink rates during prolonged screen exposure. This study aims to assess whether these lifestyle changes have contributed to a higher incidence of DES in pediatric patients post-pandemic compared to pre-pandemic levels.

Furthermore, the study seeks to understand the demographic patterns and trends in DES, emphasizing

Table 1: Incidence Pre and Post Pandemic per Age Group

2,856 total pediatric patients aged 5-18 diagnosed with DES

286 exclusions due predisposition to DES

2,570 pediatric patients aged 5-18 diagnosed with DES

Figure 1: Total Cohort for Dry Eye Syndrome

the importance of adopting preventive eye health practices to combat this emerging public health issue in children.

Methods A retrospective chart review was conducted on 2,570 pediatric patients aged 5-18 diagnosed with DES at the Pediatric Ophthalmology Clinic at Children’s Hospital of Orange County. The data collection spanned from March 2017 to March 2023, covering a period that included both pre-pandemic (March 2017–March 2020) and post-pandemic (April 2020–March 2023) phases. There were 286 exclusions from the study. Patients were excluded if they had any underlying systemic or ocular condition that predisposed them to DES, or if they were taking medication known to induce DES. Clinical data gathered included each patient’s age, the date of their first visit, and the diagnosis date.

DES was confirmed via a slit-lamp examination for all patients, which

allowed clinicians to assess the tear film and ocular surface health. In children who could tolerate additional testing, the Schirmer’s Test and Tear Break-Up Time (TBUT) test were also performed to quantify tear production and stability.

Data were analyzed to compare the incidence rates of DES before and after the pandemic onset. The age distribution of DES cases was also examined to identify any shifts in the affected demographic.

Results Analysis of the data revealed a substantial increase in the incidence of DES among pediatric patients post-pandemic. Before the pandemic, from March 2017 to March 2020, 27% (687/2,570) of the patients were diagnosed with DES. However, in the post-pandemic period from April 2020 to March 2023, the number of new DES diagnoses rose sharply, with 73% of the patients developing DES, reflecting a 2.7-fold increase.

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Research geted interventions for schools and parents. As digital devices remain integral to education and social interaction, it is critical to adopt eye health practices early in life to prevent chronic eye conditions in later years.

Figure 2: Incidence of Dry Eye Disease Post Pandemic

Further demographic analysis indicated a notable shift in the age distribution of DES patients. Prior to the pandemic, the majority of cases out of those affected with DES were found among adolescents aged 15-18 years. Post-pandemic, however, the highest incidence occurred in younger children, specifically in the 10-14 age group. Additionally, an upward trend in DES was observed in the 5-14 age group post-pandemic out of those with DES, suggesting that younger children became increasingly susceptible to DES during this period. This demographic shift may be attributed to the younger cohort’s adaptation to extended digital usage as part of remote schooling and social engagement during the pandemic.

Additionally, the younger cohort would be less knowledgeable about healthy digital habits.3

changes, particularly the increase in screen time, have significantly contributed to a rise in DES among pediatric patients. The data align with concerns that prolonged exposure to digital devices can exacerbate DES by reducing blink rates, which is essential for tear film distribution and eye lubrication.5 More time spent indoors can also expose individuals to air conditioning or heating, which reduces humidity and can dry out the eyes. Additionally, wearing masks can direct airflow over the eyes when breathing, increasing tear evaporation.

These findings underscore a potential causal link between increased digital exposure and DES in younger children. The significant rise in incidence highlights the need for awareness and preventive measures targeting digital eye strain and DES in pediatric populations.4

This increase in DES incidence among younger children poses a substantial public health concern, as DES can impact a child’s quality of life, affecting daily activities and academic performance. Preventive strategies, including the promotion of the 20-20-20 rule (taking a 20-second break to look at something 20 feet away every 20 minutes), are essential in mitigating digital eye strain in children.1 Additionally, limiting screen time, encouraging regular breaks, and providing proper lighting during screen use can help reduce DES risks.

Discussion The findings from this study suggest that the COVID-19 pandemic and its associated lifestyle

Further research is warranted to investigate the long-term effects of increased screen exposure on pediatric eye health and to develop tar-

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Conclusion This study demonstrates a marked increase in the incidence of Dry Eye Syndrome in the pediatric population following the COVID-19 pandemic, with a notable shift towards younger age groups. The findings emphasize the importance of establishing healthy digital habits, limiting screen time, and encouraging breaks to protect children’s eye health. Regular eye exams are recommended for early detection and management of DES symptoms. Given the growing digital landscape, pediatricians and ophthalmologists should work together to educate families on preventing DES and promoting eye health.

References

1. McCann P, Abraham AG, Mukhopadhyay A, et al. Prevalence and Incidence of Dry Eye and Meibomian Gland Dysfunction in the United States. JAMA Ophthalmology.

2022;140(12):1181-1181. doi:https://doi. org/10.1001/jamaophthalmol.2022.4394 2. Mayo Clinic. Dry eyes - Symptoms and causes. Mayo Clinic. Published 2019. https://www.mayoclinic.org/diseases-conditions/dry-eyes/symptoms-causes/syc20371863 3. Lovering C. How COVID-19 Lockdowns May Have Increased Chronic Dry Eye Diagnoses. Healthline. Published August 26, 2021. Accessed January 7, 2025. https:// www.healthline.com/health/chronic-dryeye/chronic-dry-eye-diagnoses-may-havegone-up-in-covid19-lockdown 4. Ji H, Yang Y, Lu Y, et al. Prevalence of dry eye during the COVID-19 pandemic: A systematic review and meta-analysis. PLOS ONE. 2023;18(12):e0288523-e0288523. doi:https://doi.org/10.1371/journal. pone.0288523 5. National Eye Institute. Dry Eye | National Eye Institute. Nih.gov. Published 2019. https://www.nei.nih.gov/learn-about-eyehealth/eye-conditions-and-diseases/dryeye

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Policy Memo: Increasing Funding Toward Sexual Health Screenings Tim Huang As sexually transmitted infection (STI) cases and costs only increase with time, it is time that we look into the limitations on accessible STI testing in our healthcare system. Through my research, I drafted this particular policy memo that could be brought to federal legislation: I write this policy memo as a call to reduce the cost of sexual health screenings and STI testing primarily through expanding the current STI program fund under section 318 from $153 million to $220 million. Currently, sexually transmitted infection (STI) testing costs range from $25 to $450, and only 25% of individuals who test annually are insured.1 While there have been advances in insurance coverage and test development to reduce costs, public funding for STI services has decreased by 40% over the past 20 years, specifically the CDC’s available funding for STI programs.2 Additionally, while Medicaid coverage has expanded to include STI testing, over 20% of the remaining states in the US (such as Texas, Indiana, and more) still have not expanded their Medicaid access to accommodate increased STI testing.3 All of this places additional burden on patients and clinics alike to provide essential STI services.

Thus, if Congress expands overall funding for sexual health programs within STI clinics, we would be able to provide clinics a decreased burden of cost in providing essential STI testing service.

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Background & Methodology The rise of STIs is well documented in the United States, with campaigns like the HIV advocacy program bringing awareness to such diseases to millions of Americans. We have found that STI costs are extremely damaging to both our nation’s public wellbeing and economy, as total lifetime direct medical costs for STIs were near $16 billion in 2018.4 Yet, despite the danger that STIs can cause, STI tests are still rather costly, with an average cost of $119 per test.2 This memo will document a few points regarding the difficulty of accessing STI testing, why these points exist, and what changes should be made to address these public health officials.

Throughout the past 20 years, national funding for STI prevention has steadily declined

Data for this analysis comes from reviewing recent CDC reports, Medicaid studies, and other comprehensive research studies on the effects of STIs on the United States.

We evaluated the articles for citations about STI costs, health disparities, and other notable facts. From the data presented in the various

articles, this document will describe what has been addressed regarding STI testing, and what further recommendations can be made.

Key Findings Throughout the past 20 years, national funding for STI prevention has steadily declined. The CDC dedicates $160 million for STI prevention programs, which is barely an increase from the starting amount of $153 million set in 2003.4 If we consider inflation, this is an overall 40% decrease in funding. This has led to over half of specialty clinics reducing their hours, reducing overall screenings and increasing testing costs.4 This is primarily because only a single stream of congressional funding, section 318 of the HPSA, contributes to STI funding that is funneled to the CDC. This has also caused many specialty clinics to focus strictly on HIV testing, ignoring other kinds of STIs such as HPV, gonorrhea, and syphilis.3 This is not to say that there have not been attempts made by the United States to combat the growing STI problem. The Medicaid expansion based on the Affordable Care Act allows anyone under the 138% of the federal poverty limit to enroll in federal insurance.3 The expansion also includes new preventative services for anyone on Medicaid, including STI testing. As the majority of STI tests are covered

by Medicaid, states that have adopted these changes would overall reduce costs for clinics to enact STI preventative programs.2 However, only 38 of the eligible 50 states have

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Unsplash/Reproductive Health Supplies Coalition

adopted the new Medicaid guidelines.3 This has led to a few negative outcomes, including an 22% increase in uninsured adults under 65, an increasing percentage of patients without insurance seeking testing, and more clinics struggling to afford costs of STI testing.2,3 Recommendations While an argument can be made to enforce Medicaid coverage nationwide, this has been an incredibly difficult task to complete. Thus, a possible recommendation is an alternative route to decrease STI costs: increase federal funding by either updating section 318 to account for inflation or create a new stream of congressional funding to aid specialty STI clinics. This would mean increasing STI funding by $64 million per year and allowing the CDC to allocate these costs to combat the STI testing costs. We can verify that these CDC costs are allocated to STI testing through the CDC’s yearly reports on spending.

This change would allow states that do not want to adopt Medicaid to still fund their clinics and will allow those without insurance to get tested safely and efficiently. Creating an extra stream of funding will alleviate many states from the rising costs of STI healthcare, allow for greater awareness about these diseases, and can even prompt expansion of more STI testing.

Conclusion Overall, STI testing costs are only increasing while funding for these programs have only decreased with time. Although there have been some strides to alleviate costs for specific clinics and testing, the nation still lacks a true uniform coverage of insurance and STI testing for every person. Adding additional funding from the national level that reaches all states, such as increasing existing support for STI programs or creating a new avenue of funding, can be the short-term solution to this problem.

References

1. Sti testing in 2024: a guide to free, low cost, at-home tests and more. Healthline. July 9, 2020. Accessed October 5, 2024. https://www.healthline.com/health/ healthy-sex/free-sti-testin 2. Dean LT, Montgomery MC, Raifman J, et al. The affordability of providing sexually transmitted disease services at a safety-net clinic. Am J Prev Med. 2018;54(4):552558.https://doi.org/10.1016/j.amepre.2017.12.016 3. National Academies of Sciences E, Division H and M, Practice B on PH and PH, et al. Paying for and structuring sti services.

In: Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. National Academies Press (US); 2021. Accessed October 5, 2024. https://www.ncbi.nlm.nih. gov/books/NBK573144/ 4. National Academies of Sciences E, Division H and M, Practice B on PH and PH, et al. Sti economics, public-sector financing, and program policy. In: Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. National Academies Press (US); 2021. Accessed October 5, 2024. https:// www.ncbi.nlm.nih.gov/books/NBK573155/

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Public Health Research Highlights Developments in Understanding Early-Onset Alzheimer’s Disease Recent research on early-onset Alzheimer’s disease (EOAD) is shedding light on its unique challenges, with studies like the Longitudinal Early-Onset Alzheimer’s Disease Study (LEADS) uncovering key genetic and biomarker insights. Advances in diagnostics, including transformative biomarkers and amyloid-modifying drug therapies, are improving early detection and potential treatment pathways, while growing awareness emphasizes the need for better support systems and tailored interventions for affected individuals and their families. Griffin P, Apostolova L, Dickerson BC, et al. Developments in understand-

ing early onset Alzheimer’s disease. Alzheimers Dement. 2023;19 Suppl 9(Suppl 9):S126-S131. doi:10.1002/alz.13353

Urban Congestion Pricing: A Policy Shift Reshaping City Traffic and Air Quality New York City’s adaptation of congestion pricing in 2024 aims to reduce traffic and pollution, improving urban public health. By charging vehicles to enter high-traffic zones, the policy seeks to decrease emissions, encourage public transportation use, and generate revenue for infrastructure improvements.

Khreis H, Sanchez KA, Foster M, et al. Urban policy interventions to reduce traffic-related emissions and air pollution: A systematic evidence map. Environment International.

2023;172:107805. doi:https://doi. org/10.1016/j.envint.2023.107805

The Alarming Rise of Early-Onset Cancers in Young Adults Global studies have identified a concerning rise in early-onset cancers among young adults, with colorectal cancer showing the most significant increase.

Groundbreaking research is now uncovering potential envi-

ronmental and lifestyle contributors, including diet changes, pollution, microplastics, antibiotic exposure, and disrupted sleep cycles, offering critical insights that could shape future prevention strategies. Ugai T, Sa-

Environmental Factors Play a Greater Role Than Genetics in Premature Mortality Studies led by Oxford Public Health revealed that environmental factors are approximately ten times more influential than genetics in predicting premature death, emphasizing the critical role of lifestyle and socioeconomic conditions in health outcomes. Austin AM, Amin N,

Nevado-Holgado, Alejo J, et al. Integrating the environmental and genetic architectures of aging and mortality. Nature Medicine. Published online February 19, 2025:110. doi:https://doi.org/10.1038/ s41591-024-03483-9

samoto N, Lee HY, et al. Is early-onset Cancer an Emerging Global epidemic? Current Evidence and Future Implications. Nature Reviews Clinical Oncology. 2022;19:1-18. doi:https:// doi.org/10.1038/s41571-022-00672-8

FDA Grants Approval for First Schizophrenia Treatment in Decades The 2024 approval of Xanomeline-Trospium marked a breakthrough in schizophrenia treatment as the first non-dopaminergic antipsychotic. By targeting muscarinic receptors instead of dopamine pathways, this novel therapy provides a safer and potentially more effective option for millions affected by this mental health condition. FDA Approves Drug with New Mechanism of Action for Treatment

of Schizophrenia. U.S. Food and Drug Administration. Published September 26, 2024. https:// www.fda.gov/news-events/press-announcements/fda-approves-drug-new-mechanism-action-treatment-schizophrenia

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Community Organizations in Baltimore, Maryland “There is no better teacher than adversity.” -Malcolm X

Baltimore Harm Reduction Coalition (BHRC): An advocacy organization for “people targeted by the racist war on drugs and anti-sex worker policies.” BHRC has services that provide Maryland residents with Narcan kits and syringe kits for hormone management through the mail, in addition to kits for safe drug use, sex, and menstruation.

Charm City Care Connection (CCCC): A community organization that aims to promote health and self-determination for those affected by drug use, stigma, poverty, and inequities. They recently celebrated their launch of the Harm Reduction Vending Machine, which contains free Naloxone kits, Fentanyl Test Strips, Hygiene Kits, Wound Care Kits, and pregnancy tests with 24/7 access.

Sex workers Promoting Action, Risk reduction, and Community mobilization (SPARC): A community health organization that supports “people whose gender identities include woman, agender, gender-nonbinary, and all other non-men identities who engage in street-based, survival activities including trading sex, selling or using drugs, and sleeping rough.” SPARC provides a variety of services, including Narcan, fentanyl testing, wound care, safer sex supplies, STI testing, case management, free psychiatric services, emergency contraception, and treatment of vaginal and yeast infections.

Violet Project: A program founded by students from Johns Hopkins Medicine. The Violet Project aims to create better sexual and reproductive healthcare and education for youth, providing STI Tests, menstruation supplies, and contraception.

Red Emma’s: The radical workers collective behind the bookstore and coffeehouse on Greenmount Ave. Not only does this business aim to act as a safe third space for historically marginalized voices, catering year-round events and talks, but also provides free emergency contraception, masks, and condoms at their location.

Baltimore Safe Haven (BSH): A trans-led dropin wellness center that has a plethora of services for transgender, lesbian, gay, bisexual, and queer (TLGBQ) individuals; including safe and affirming housing, workforce development opportunities, and mobile outreach. Founded in 2018 by Iya Dammons, a Black trans woman activist, BSH aims to create a better, more compassionate Baltimore for TLGBQ communities.

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Epidemic Proportions Staff 2024-2025

Wassim Bouhsane Editor-in-Chief

Neha Skandan Editor-in-Chief

Martine Bigos Secretary & Treasurer

Tim Huang Social Chair

Tanisha Taneja Marketing & Publicity Chair

Connie Huang Marketing & Publicity Chair

Annie Huang Copy Editor

Pranav Kotamraju Copy Editor

Shannon Xiao Photography Editor

Editorials Staff Samuel Yeboah-Manson Sittha Cheerasarn Annie Huang Anannya Sharma Maegan Sojan Ahla Bommareddy Anita Zhu Danielle Walters Alex Campus Jeffrey Mathew Jasmine Wu

Tim Huang & Tanisha Taneja Editorials Team Leads

Editorials Staff Policy Staff Jason Soo Tanisha Taneja Pranav Kotamraju Kristin Cho Conner Feng Indu Bodala Abriti Chatterjee Anahat Goraya Shreya Kesarwani Isabelle Jouve Uma Narendra-Nathan Cherry Chen

Shaan Shabbir Policy Team Lead

Policy Staff Features Staff Hyeongmin (Eric) Cho Nancy Yan Ameerah Jones Kay Mi Joanie Ryu Ishanika Damani Gaayathri Nadarajah Kevin Zhang Chloe Lee Clara Pan Marvi Rajar Connie Huang

Habin Hwang Features Team Lead

Features Staff Layout Staff Pearl Shah Niki Zouzoulas Rose Chen Annmary Antony Lydia Lung

Carlos Haring Layout Team Lead

Eric Cho & Wilson Huang Research Team Leads

Layout Staff Research Staff

Research Staff

Angela Deng Curie Lee Akshita Kikkuru Rongrong Yan Wanli Tan Sumin Han Reshub Pendyala Annabelle Huang Krishna Mukunda Arjit Singh Justus Alfaro Surya Panyam Rohan Shrishrimal Booseong Eric Seo Daniel Nabizadeh

Closing Letter

Ellen J. MacKenzie, PhD, ScM, Dean of the Johns Hopkins Bloomberg School of Public Health and Bloomberg Distinguished Professor To the Readers of Epidemic Proportions, This past academic year, I was honored to join a celebration for the fiftieth anniversary of the Public Health Studies Program, where we reflected on the program’s history and looked ahead to its very bright future.

With the creation of this program, Johns Hopkins University opened new doors to the field of public health and expanded the reach of our educational mission. What began as an experiment grew into one of the most popular undergraduate majors. Over the past half a century, the program has put thousands of committed and innovative public health experts out into the world. They are spread across the globe, in labs, classrooms, clinics, and more—and those ranks are ever growing.

Proud as we are of these achievements, I am writing to you at a time of great challenge and change for public health. Federal funding cuts and agency actions are causing deep disruptions to the work of our university and our field. This is a very difficult moment and uncertainties abound, but we know how crucial it is that we continue to educate and empower future public health leaders.

The world needs our PHS students now more than ever, and as this issue shows, they are ready to serve and to lead. The authors of these articles are bright and passionate problem-solvers, with the expertise to take on some of today’s biggest challenges. What’s more, these students are deeply committed to collaborations and community-building—both of which are fundamental to public health progress.

As our current challenges have made clear, public health needs to broaden its outreach and engage a wider range of people and organizations in all aspects of what we do. We need to bring more backgrounds and perspectives into the conversation, as it is only through wide-ranging and comprehensive discussions that we can reach innovative, actionable solutions.

Looking back at my own career, my best work was always driven by my engagement with those from other backgrounds and experiences. When I first began my research in trauma services and outcomes, I realized I had much to learn from trauma surgeons, rehabilitation specialists, and—importantly—from the injured persons themselves. I took a sabbatical to spend time at the University of Maryland Shock Trauma Center, and the experience led to new partnerships and new directions for my work. I was also privileged to partner closely with military groups and service members, as we searched for ways to better understand the impact of serious limb trauma and support the long-term recovery of those injured in combat and on our streets. By collaborating with those inside and outside of public health, I was able to work on deeply collaborative projects that helped people with life-changing injuries.

And of course, as dean, I see the power of connecting communities every day in the work of the faculty, staff, and students of the Bloomberg School. In Baltimore City, our Centro Sol initiative works with our Latino neighbors to improve health and expand opporwtunities. In Arizona, our Center for Indigenous Health partners with the Navajo Nation on advancing clean water projects. In Uganda, our School, together with the School of Medicine, has been collaborating with Makerere University since the late 1980s on high-impact HIV studies. And of course, these are only a few examples.

Moving forward, we must continue to bring more communities together and unite voices around the value of public health. This is a big ask, but I know our PHS students are ready. In the next fifty years—and far beyond— they will lead the way in creating new connections and building stronger partnerships, improving health for everyone in ways that we can’t yet imagine.

The road ahead will be challenging, but their research and scholarship—and more importantly their inclusive, open approach to public health—make me feel deeply hopeful.

Acknowledgements Epidemic Proportions would like to thank the Public Health Studies Program, the Krieger School of Arts and Sciences, and the Johns Hopkins Bloomberg School of Public Health for making this journal possible.

We would like to extend our appreciation and recognition to: President Ronald J. Daniels Dean Christopher S. Celenza at the Krieger School of Arts and Sciences Dean Ellen J. MacKenzie at the Bloomberg School of Public Health The members of the Public Health Studies Advisory Board: Marie Diener-West, Scott Zeger, Beth Resnick, Sydney Van Morgan, and Eileen Haase The members of the Krieger School of Arts and Sciences Public Health Studies Program: Maria T. Bulzacchelli (Director), Katherine Henry (Assistant Director, Head of Advising), Natalie Boyd (Program Administrator), Moira Cahan (Academic Advisor), Cara McNamara (Academic Advisor), Keri Frisch (Applied Learning Manager), and Njeri Murugi-Kamau (Administrative Assistant)

Shannon Xiao