Mary Christie Quarterly Issue 18 | Summer 2020

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Mary Christie Quarterly A publication of the Mary Christie Foundation

Health and Hope Owning your wellness in the age of COVID-19

Issue 18 | Summer 2020

Mary Christie Quarterly The Mary Christie Quarterly is a publication of the Mary Christie Foundation, a thought leadership organization dedicated to the health and wellness of young adults, with a particular focus on college students. The Mary Christie Foundation is funded, in part, by Christie Campus Health.

STAFF President Editor & Executive Director Program Manager Art and Layout Director Editorial Assistant

John P. Howe III Marjorie Malpiede Dana Humphrey Ashira Morris Anna Goodwin

ARTISTS Cover Illustration

Julia Emiliani


John P. Howe, III

Vice Chair

Mary Jane England


Marjorie Malpiede


Maryellen Pease


Frederick Chicos


Kenneth Chicos


Lisa Kelly Croswell


Terry Fulmer


Sarah Ketchen Lipson


Robert F. Meenan


Zoe Ragouzeos

Editor’s Desk Dear Readers: Welcome to the summer issue of the Mary Christie Quarterly. Much of our reporting focuses on the emotional and behavioral health of college students in the age of COVID-19. Our cover article describes how students are stepping up to manage their own mental health and support their peers during this unprecedented period of isolation and uncertainty. As experts in the article attest, COVID-19 has, in many ways, accelerated the trend toward self-care and personal accountability in student mental health. We have a host of interesting people in this issue, including Dr. Rachel Levine, Pennsylvania’s Secretary of Health who has worked non-stop since February as the state’s go-to on COIVD-19. Her background in children’s health and mental health, and her role as one of the top transgender public officials in the country, make her perspectives on public health and social justice particularly important. As always, thank you for your interest in the Foundation’s work. Take good care,

Marjorie Malpiede Editor

CONTE NTS 14 College Student Mental Health: What’s Faith Got To Do With It?

“One of the most important things we can do for students within the chapel is to create community for them – to increase their sense of belonging.” — Dean Bernard University

23 Q&A: Dr. Rachel Levine, Pennsylvania Secretary of Health

“Racism itself is a public health crisis or a public health emergency when you think about health equity and the social determinants of health.” — Dr. Rachel Levine, Pennsylvania Secretary of Health



CONTE NTS 06 The Children’s Grove 09 Owning Your Wellness: Self Care in the Age of COVID-19 14 College Student Mental Health: What’s Faith Got To Do With It? 23 Q&A: Dr. Rachel Levine 26 Interesting People Doing Important Work 31 Vaping on the Rise: How Colleges are Responding 34 Students with Chronic Illness Need Special Consideration in Re-opening Strategies 38 WE Strong: UVM’s Wellness Environment Then and Now 43 Science Summary

The Children’s Grove: Where Kindness and Mental Health Meet By Marjorie Malpiede


he Children’s Grove in Columbia, Missouri, started out as a memorial to victims of violence, but over the years it has transformed into a kindness incubator contributing to the emotional and mental wellbeing of children and young adults, from preschool to university.

just to honor those that were lost, but also for our own children?’” said Dr. Anne Deaton, who founded the Grove.

The Grove itself is a section of a downtown park lined with butterfly magnolia trees and butterfly-sculptured benches – a nod to the “butterfly effect” where small changes, like a single act of kindness, can have a large impact.

Deaton formally served as director of Missouri’s Division of Developmental Disabilities and was particularly concerned about mental health issues. She is the wife of Dr. Brady Deaton, who was then chancellor of the University of Missouri, whose main campus is in Columbia. She turned to her fellow citizens to create some form of memorial to bring the community together.

This happy place that attracts families throughout Boone County was built to honor the memory of the 26 people, mostly children, who died in 2012 in the tragedy at Sandy Hook Elementary School in Newtown, Connecticut.

“We asked ourselves, ‘How can we be there for our children in ways that are important to their social, emotional and mental health and increase the public’s understanding of the hardships they often face?’” she said.

“As a community, we were aching with the loss of all of those children and we just kept looking at one another saying, ‘what can we do not

Deaton said the response from the community was immediate and generous and, within three months, they had the money and the space


for the Children’s Grove. At the groundbreaking, citizens turned out in droves. “We talked about the simple trunks of those trees being like the determination of the adults in our community to stand up for our children and children everywhere,” she said. Once the Grove was established, Deaton formed a committee and drafted a two-pronged mission for what would soon grow into a non-profit organization: to promote a culture of kindness and to support the emotional and mental wellbeing of children and teens. “We had a very strong conviction about kindness and mental health because we understood how closely they were linked,” Deaton said. “Our operational definition of the attributes of kindness are mutual respect, sincere compassion, and meaningful inclusion. All of those connect to the social, emotional, and

mental wellbeing of young people.” From Place to Programs The group immediately explored how to use resources within the community to achieve its mission. Nearly eight years later, the mark of the Children’s Grove is seen throughout Columbia and into the rest of Boone County, with both physical symbols of kindness as well as school and community programming that leaders hope have made a difference. Kim Dude is the current president of the Children’s Grove. She has a background in behavioral health with a focus on alcohol and drug abuse prevention and spent 38 years at the University of Missouri, where she started the Wellness Resource Center. Dude said she is continuously amazed at how much the organization can accomplish with their all-volunteer staff. Their annual “Kindness Week” in April – featuring wrist band campaigns, kindness booths, and appreciation ceremonies – was cancelled this year due to COVID-19. But many of their other programming is ongoing, like the Kindness Library, where each year the best children’s books on kindness are collected and delivered to schools throughout the county. Much of their work focuses

on public art that promotes kindness. Its latest example is two butterfly murals painted on buildings in downtown Columbia by young artists from the community. Both murals are of a butterfly’s wingspan, one large, one small, allowing children and adults to step into the center. They are accompanied by the phrase “Kindness Changes Everything.” “We want people to know that what they do and how they treat others can have a positive effect way beyond what they can even imagine,” said Dude.

For the Children’s Grove, symbolic messaging meets tangible impact with the work of the Youth Kindness Ambassadors, a.k.a., YKA. Organized through the Children’s Grove, this corps of high school students has been spreading kindness among their peers for over five years, each class contributing new ways of letting teens know they are not alone. Yash Pal Khanna was named one of the two founding Youth Kindness Ambassadors by the Mayor of Columbia in 2018 after he and another student started the first chapter at Rock Ridge High

Photo courtesy of The Children’s Grove

A butterfly bench in The Children’s Grove, a nod to the “butterfly effect,” where small changes, like a small act of kindness, can have a large impact. 7

School. He is now studying to be a doctor. Mental health remains a priority for him, as does volunteering and community organizing, all of which he says he learned from the Children’s Grove.

I want our school to celebrate our kindest students just as we celebrate our amazing athletes and brilliant students.

“I believe that because of YKA’s influence in our high schools, students found a platform to be creative and to spread their ideas on how to help the community,” he said. “The initiatives I later started were all a result of a culture and foundation provided by the Children’s Grove.” There are currently over 50 active Ambassadors who carry out much of the work the Children’s Grove has developed, attending events promoting kindness, reading to children from the kindness library, and working in a variety of offshoots, like suicide prevention initiatives and mental health awareness activities. Khanna believes school programs like the YKA are critical to the healthy development of teens. 8

“Students developing in a culture that promotes kindness, diversity, and inclusion are being exposed to positive ideology early on. This is how caring school atmospheres are made — this aspiration to cultivate good works in the form of less bullying, more volunteering, more inclusion and more empathy.” Lydia Olmsted, a current Kindness Ambassador, is a good example of the Children’s Grove version of “paying it forward.” Asked why she got involved in the group, she said, “At one point, I was going through some challenging times, but was able to overcome them when someone was very kind to me. After that, I wanted to spread kindness to others because it had changed my life.” Nadia Lake joined the Youth Kindness Ambassador program her freshman year in high school but didn’t get really involved until her sophomore year when she stepped in to fill a void in leadership at her school. Since then, she has been organizing events and attracting new members. “For most students, high school is a rough time,” she said. “Small acts of kindness can break through angst and create a more positive environment in school.”

Lake referred to one program called the “Caught Being Kind Project” that celebrates people who have shown kindness to others by putting their ceramic handprint on a wall next to a “People you can look up to” mural. “I want our school to celebrate our kindest students just as we celebrate our amazing athletes and brilliant students,” she said. As to the impact of these programs, Olmsted said, “When we host events in the community and at schools, I am always amazed by how many people come up to us and say how much they enjoyed the event and want to get involved in the Children’s Grove. I think that just goes to show how contagious kindness is.” Every year during Kindness Week, the Children’s Grove celebrates their Ambassadors with a block party and award ceremony with the mayor and superintendent of schools. This year, Dude organized a lawn sign campaign instead due to COVID-19. One student had just returned home after losing her grandmother when she saw the sign on her lawn celebrating her role as a Kindness Ambassador. Her mother told the Children’s Grove volunteer, it meant the world to her daughter.

Owning Your Wellness: Self Care in the Age of COVID-19 By Nichole Bernier


achel Walker realizes she has it better than most college students whose 20192020 academic year was disrupted by COVID-19. As much as she likes Florida A&M University, she often felt a bit homesick for Atlanta. She has a close relationship with her family, so when COVID sent students packing mid-March, it wasn’t a tremendous hardship for her to finish the term at home. But she appreciates that’s not true for everyone. “Not everyone’s fortunate enough to have a good situation at home. They need someone to relate to, and listen,” says Walker, who is a psychology major and the incoming president of the Active Minds chapter at FAMU. During the COVID break, she said, chapter members have maintained a group text chat, something she feels is an important touchstone when people are far-flung in uncertain times. “It’s easy to get caught up with what’s going

on as a nation right now, and we miss the little things we’d do subconsciously to check in with each other constantly. We take for granted that it’s important to check in and make sure everyone’s ok.” The virus crisis hit campuses at a time that they were already struggling with student mental health. Suicide rates among youths ages 10 to 24 increased 56 percent in the 10-year period ending in 2017, according to CDC data. Chronic nationwide shortages of school mental health staff aren’t likely to get any easier with school budgets, shortfalls, and the pandemic economy. While adjusting to remote learning, students are contending with the uncertainty of what their classes will look like next year. Home may or may not be a comfortable place for them to be, and they may or may not have access to mental health resources available to them at school. For some, all this is ampli-

fied by the loss of valuable scaffolding — a schedule and routine, an institution, and support community to rely upon. But for many, it’s also been a wake-up call that the one thing they have to rely upon consistently is, in fact, themselves. And school faculty and administrators and mental health advocates want to support these self-help efforts. Because as they say, wherever you go in life, there you are. “The pandemic has affected students in varied ways,” says Dr. Chetan Joshi, director for the counseling center at the University of Maryland, who through remote contact with students has observed an increase in efforts towards healthy eating, consistent sleep, exercising, and engaging in hobbies. “We have seen students slowly move towards bringing intentionality to their lives. This has been our consistent messaging to all students. You need 9

to be intentional in establishing structure and engaging in healthy habits in this environment.” Will Meek, director of counseling center at Brown University, agrees. “There’s a quality some students have when they’re starting to thrive, of either reading something or listening to podcasts or YouTubers or Instagram accounts tuned into ways they want to grow. They’re using those channels the way people used to use bibliotherapy — to enhance wellness, a new level of selfhelp,” he says. “I can audio stream contemplative opportunities, think about what I’m doing and be more reflective, be a part of more intentional communities — all that’s a part of embracing and taking ownership of your own wellness.” Active Minds, a Washington-D.C.based organization dedicated to student wellness, has seen signs of this ownership since it was founded in 2003. Its membership body consists of chapters established at more than 800 colleges, universities, and some high schools, where students use resources and programming to raise aware10

ness of mental health among their peers. “What we see in our student networks is that for a long time, they have been very aware that they can’t just rely on a campus counseling center,” says Laura Horne, chief program officer at Active Minds. “As early as 2012, we saw students organizing to help themselves and each other. They’ve worked to add 800 numbers like the National Suicide Prevention Lifeline to student ID cards. They’ve

organized rideshare programs to help students who need longer-term counseling get off campus to where they need to go. They’ve advocated for more counselors on campus, and a greater diversity among counselors. And

now we’re seeing them as advocates for technology like apps and online self-assessment tools for them to access, themselves.” Horne points to programs different chapters have undertaken, some based upon resources and materials Active Minds makes available, and some of their own ingenuity. At Sacramento State, students who appreciate the importance of good sleep habits offer their peers “nap classes” to learn about the physical and psychological importance of getting enough rest. The Virginia Tech chapter offers a workshop on “Hokies Hiccups,” highlighting ways we grow through our mistakes. At U Penn, the chapter hosted a conversation about recovering from rejection — not being accepted into the fraternity or sorority you’d hoped for, not getting the internship you wanted, and what it really means in the longer narrative of life. Rachel Walker of FAMU is part of a women’s support group called “Between Sistahs,” a twice-monthly open meeting of students, some women from greater Tallahassee, with representatives from the counseling center.

“It’s a discussion group for things women are going through that they don’t always feel able to talk about with others — anxiety, being single mothers, all kinds of stresses in life,” she said. “Meetings start off very light in the beginning, to get everyone comfortable with each other, but they do get a little heavy at time, the things that are talked about. But everyone’s so supportive, it makes it a little lighter because of the nice people in the room.” Drexel University is one of the schools taking advantage of Active Minds’ program called VAR — which stands for Validating, Appreciating, and Referring — which aims to help students recognize when friends are in trouble, and know best how to respond. “Some students are uncomfortable when a friend talks about struggling, because they feel like they’re supposed to try to fix the problem, or minimize it, thinking that will make the friend feel better,” says Horne. Active Minds developed a package of educational resources and training for chapter members to share in campus workshops. “We’ve taken a broad approach to ‘referral’ to mean many kinds of self-care activities that might work for them.” For Freya Lindvall, a junior

at Franklin and Marshall and president of its chapter of Active Minds, having tools for helping peers is more than useful. It could be life-saving. “My first year taking over presidency, there was a death of a student, and they asked me to come speak at her funeral about mental health. There needs to be a student bridge for the gap to break the stigma of talking to peers and being afraid of going for counseling,” she says. The aid students provide for a friend could be dramatic, like helping them find professional help, or commonplace support, which can make a tremendous difference. “The coaching we’re taught about VAR referrals could mean doing something for a struggling friend that’s as calming as saying, ‘I hear you. That’s hard. Let’s go watch a movie’. It might seem like a little. But it might mean a lot to them at the right time.”

You need to be intentional in establishing structure and engaging in healthy habits in this environment.

Emma Smith, next year’s president of the Active Minds chapter at Drexel, is a big fan of the VAR program, in part because she knows friends have a critical point of access to the peers in their environment. “We did a presentation on it, and let folks know that 67 percent of peers turn to friends first when they’re feeling suicidal. It’s impor11

tant to know how to respond to distress within a friend group, and this is a good introductory tool.” There are many organizations currently working on putting tools for self-care — and self-awareness — in students’ hands. One of the new innovators is U-Thrive, an educational services firm beginning to contract with colleges to provide wellness programming that can be used in a wide variety of ways: self-paced online work, possibly a pre-requisite to coming to college; modules that can be facilitated with a faculty member, or resident advisor in a dorm; a creditbearing course.

Figeroa, the founder of UThrive. The full 16-module program is rooted in three pillars — positive psychology, mindfulness, and selfcompassion. “We want to be a thought leader in helping students be more resilient, be their own advocate, and their own agent for change. This content is always needed, but especially now with remote learning and schools scrambling to create meaningful online content.”

The name U-Thrive was inspired by the book, U Thrive: How to Succeed in College (and Life), written by NYU instructors Dr. Alan Shlechter and Dan Lerner. The book is based on the extraordinarily popular course they teach “Our ultimate hope is that together, “The Science of this would help lighten the Happiness.” The conversaload at counseling centers by tional, communication-based giving rich self-care informa- course already offered the tion to students who might pair an inside look at college have lesser problems related students’ well-being. The fact to being stressed-out, but not that the course continued suffering from a severe men- remotely through the remaintal health issue,” says Simone der of the spring, then through the summer term, gave them a frontrow perspective on how I talk to them about how students were handling you can do this perfectly quarantine.

and you’ll still experience discomfort. If your goal is never to experience discomfort you will fail.


“I think we were surprised at how effective it was from the get-go. We were able to see the chat fill up with people from halfway around the world and different time zones, willing to

share how they were doing, hand icons going up, and the text box filling,” says Schlechter. “There’s data coming back now that we don’t learn as well online, particularly younger kids. But I think there are components of this medium that won’t go away. There are times when those Zoom classes, in this context of tremendous pressure and uncertainty when you don’t have anything else for connection, are like a cold glass of water on a hot day.” Much of the wellness conversation in the class progressed from personal to the universal – and what you can do for your community. Lerner and Schlecter work from Martin Seligman’s Perma model of happiness (Positive Emotion, Engagement, Relationships, Meaning and Accomplishments). A cornerstone of their happiness work focuses on the sense of satisfaction and self-worth gained from helping others. “The definition of meaning is to be part of something greater than yourself. Being able to give back to a friend, a grandparent, your community,” says Lerner. “We ask, ‘How does what you do make the world a better place?’ When people think in that way, whether they’re going to help someone today, that tends to raise their level of meaning and purpose.” Another focus of their class

is achievement, which they define in two ways — and which is especially important in quarantine days when measured efforts are smaller than usual. “We can mark achievement in two ways. Achievement with a capital A is, ‘I was accepted to college, I found a partner, I got a job.’ Wonderful things, but those aren’t going to happen every day, week, year,” says Lerner. The little A things are daily tangible tasks that give you a sense of satisfaction for having completed by day’s end. “What did I set out to do today, and did I accomplish it? I got the laundry done. I read a chapter. I got a haircut. We need a sense of purpose during these times. It might be accomplishing three things on your list, or four. But recognize you did it,” he says. These are all tools in the practice of self-care — from meditation and mindfulness to yoga and gratitude journals — that may or may not resonate now, but students might come back to revisit later in life. “We want to provide a variety of empirically sound interventions, and let them try them, and choose. I have a student who still gets in touch years later, saying, ‘I’m still meditating,’ and that’s what we’re striving for,” says Schlecter. “Find what works

for the individual to use now, or in the future think back and say to themselves, ‘That mindfulness thing that didn’t work for me when I was in college? Let’s try that again and see if there’s anything in that for me.’ ” Above all, students need not to have their form of selfcare be a source of additional stress: the sense that they’re not doing the right thing. “Students are dealing with the anxiety of this time in very different ways, and it took me awhile to appreciate that,” says Madeline Nash, a counselor at Truman State University in Kirksville, Missouri. When students went home and the counseling sessions began to be conducted remotely, she initially advised them to think about a new hobby or something fun they could do with their spare time. After a few weeks of speaking with students, she realized this wasn’t the reality for those who were struggling in lower income households, taking on extra jobs that conflicted with class schedules, and dealing with food insecurity. It also wasn’t helpful for students who experienced a pressure in not doing COVID right — not learning a new language or taking up guitar or baking the perfect sourdough. “For high-achieving students, there was anxiety in the

expectations of accomplishment during their free time, when a lot of that so-called free time was spent worrying, or even getting some extra sleep,” she says. For some, the lack of structure wreaks havoc with impulse control. “I had to tell them things like, ‘This might not be the best time for Tinder hookups, let’s slow that down.’ And, ‘Now is not the time to be experimenting with hallucinogens, let’s back it up on that.” Even when it came to healthy strategies, like exercise and mindfulness, she came to see that many students had an unrealistic expectation of what it would accomplish if they were doing it “right.” “Many students are doing a phenomenal job of taking ownership and control of their mental health, but they have this expectation that if they’re doing it right, they won’t experience discomfort,” says Nash. “So I talk to them about how you can do this perfectly and you’ll still experience discomfort. If your goal is never to experience discomfort you will fail.” The goal, she says, is becoming comfortable with uncomfortable feelings, and having the skills to navigate it. “That’s much more powerful than never being uncomfortable.”


College Student Mental Health: What’s Faith Got To Do With It? By Marjorie Malpiede Photos by John Gillooly and Jonny Grave


ollege and religion don’t always go together.

Young people questioning their traditions and searching for their identities are less likely to fall in line among the faithful. But at a time when students are reporting mental illness and emotional distress as never before, three campus ministry leaders explain how the role of religion can be a powerful salve for many. The insights from each of the leaders reflect the different dynamics of their respective campuses but their messages about the role of religion in the mental health of young people are remarkably similar. They also expressed compatible comments on what may be causing the issues students are reporting. Note: These interviews took place in early March, prior to the impact of COVID-19 and the upset over continued racial injustice in this country.


Father Peter Martyr Yungwirth

Rabbi Liza Stern

The Reverend Dr. Bernard Richardson


Father Peter Martyr Yungwirth


ather Peter Martyr Yungwirth is a Dominican friar and the head of campus ministry at Providence College, a Catholic, liberal arts school in the capital city of Rhode Island. Providence was founded in 1917 by the Dominican Order to provide a higher education opportunity for Catholics and Jews who were barred from the more elite institutions in the state. The school’s social justice roots remain strong as the friars/ professors continue to teach service to God and neighbor along with their respective subject matter. Father Yungwirth fulfills two roles at Providence; one as head chaplain for the college, which he describes as seeing to the spiritual needs of the entire school community (including 4,000 students); the other is as head of Campus Ministry, which involves leading a group of 1000 or so students who are active participants in searching for God.

O.P., Providence College


At 35, Yungwirth is not so removed from the typical experiences of his students. Having only decided to enter the priesthood his senior year in college, he can relate to their stresses, be it relationships

or career planning. He notes one exception: the angst today’s students feel that is often generated by social media. Yungwirth reads and thinks a lot about this subject and while he embraces the value of technology platforms (particularly now that he runs the campus ministry remotely), he believes what students see and don’t see on social media drives much of their distress. “They’re living in an age where they are evaluating their happiness and their worth based on what they are seeing in other people,” he said. “If they are not living up to that joy, authentic or not, they get anxious. They start to feel sad. They start to get worried.” According to Yungwirth, faith in God can help. “The Lord can be super helpful in trying to navigate how to prepare our students to see something [other] than just how many friends or likes they have. If you see yourself as a loved child of God — if you start there — then you can better cope with all of these environmental versions of who you are.” Yungwirth says that religion

can be particularly important for college students who are in the prime period of identity formation. “Our relationship with God becomes the pie pan that holds all of the other pieces of our identity together. It supports them. It strengthens them. It helps them flourish. This can be a really helpful thing for students who are working through all sorts of questions regarding identity and intersectionality.” Yungwirth said a belief in a higher power can also be an antidote for what he sees as an unhealthy sense of control in some students who overschedule themselves with curated activities aimed at reaching ever-higher goals.

After joining the campus ministry, she met with other students bi-weekly and joined discussions, led by peer ministers, about how faith impacts college life. “I saw a big change in her when she began to trust in God’s ordering of things,” he said. “It is not that she just sat back and let things happen, but once she relinquished her attempt to control every aspect of her life, she found an immense sense of peace.” Yungwirth noted that service can be a positive factor in student mental health, particularly when intense selfintrospection becomes problematic.

He provides an example of one student whose college experience changed through her involvement in the campus ministry.

While service learning is a component of most colleges and universities, it is strongly emphasized and easily accessible in religious schools like Providence with strong service missions.

“Before she came to Providence, she was not at all active in her faith. When she first got here, she was so determined to craft her own future that she would not get much sleep because she was studying all of the time, building a social life — trying so hard to be in control of it all.”

“One thing that service allows you to do is to get out of yourself and interact with others,” he said. “It kind of forces you to see that there is something outside of you that is beautiful and good and can help you in those moments when you’re struggling to see those things.”



abbi Liza Stern might agree with many of Father Yungwirth’s observations, despite their credal differences. Stern is a congregational rabbi in Cambridge, Massachusetts and a counselor to Jewish students at the Harvard Divinity School where she also teaches. For many years, she was a chaplain at Brandeis University, a highly competitive school with a strong Jewish tradition, also in Massachusetts. When asked how much of her role at Brandeis had to do with student mental health, Stern said, “As chaplains, we really thought about how we could be helpful to the students who were so overwhelmed by what was happening to them. I can’t say where religion begins and where it ends but we tried to create opportunities for students to be spiritually centered.” Stern said she saw students coming to college more isolated, and less equipped to cope with being on their own. She


saw them as less able to make new bonds given their digital attachments to home and friends and believes these factors have led to a host of mental health problems.

Stern said that while the counseling center is “the tried and true resource for students who are experiencing problems,” the holistic work of chaplains is different.

Stern called Brandies a purpose-driven campus where students were often heavily involved in cause-related activities.

“We want students to learn how to have deep conversations with one another and to think about the big picture stuff like ‘Who am I? How did I get to be this way?’ Chaplains want to know who you really are. You can call it a therapeutic resource, but it’s not because we’re helping them with psychological issues as much as we are saying, ‘We love you.’”

While she, like Yungwirth, sees the value of service, Stern observed what can be its downside. “Sometimes I would encounter students who would value themselves based on how many things they were doing, but if you stripped that all away, they didn’t know who they were; They were caught in that ‘I am what I do’ phenomenon.” As a counter to that, Stern said she and the other chaplains tried to reverse the momentum. “Where the campus was encouraging students to ‘go, go, go,’ we were encouraging them to ‘slow down, slow down, slow down.’”

Like her peers, Stern believes religion is particularly important in helping young people understand they are part of something bigger than themselves when fear and uncertainty abound. “It is a source of inspiration in a world that seems to be crumbling in so many ways. They see Democracy crumbling. They see the planet crumbling. “When you consider the supernovas these young people

are living with, religion provides a possibility for hopefulness.”

Rabbi Liza Stern

Stern calls different religions “languages communicating with God,” and said she and her fellow chaplains used the aspects of established religions — such as peace, love, and community — to soothe some of the stress students were experiencing without focusing on one particular faith. A big part of their work was bringing students together. “Every month, we put out newsletters to the whole campus saying ‘this is what’s happening — come celebrate with us,’” she said, describing weekly dinners and a host of activities for students to break from their busy schedules. Brandeis has active studentled Jewish groups with a number of well-established opportunities for practice through the Hillel. While providing a comfortable and familiar environment for these students, Stern

Harvard Divinity School, formerly of Brandeis University


said the chaplains also sought opportunities for the majority on campus who consider themselves secular. “My work as a rabbi is in Judaism, but on campus my agenda is really inter-faith. I want to provide the comfort of traditional religions, but I don’t want students to stay there because I feel like if they leave college without having eaten together and learned from one another then they are not going to feel like whole, centered people.”

Dean Bernard Richardson

The chaplain’s outreach included the many students who profess not to believe in God. “I remember talking to a student once and I asked her, ‘Do you believe in God?’ and she said ‘No, I don’t believe in God.’ And I said, ‘Okay, if you believed in God, what would God want you to do in this moment?’ and she burst into tears. That was very informative to me about students’ yearning for some transcendent sense of being okay.”


Howard University


he Reverend Dr. Bernard Richardson is the fourth Dean of the historic Andrew Rankin Memorial Chapel (Rankin Chapel) at Howard University in Washington, DC. For 24 years, the ordained minister and mental health professional has presided over one of the most important pulpits in the country. Each Sunday during the academic year, renown guest speakers are invited to provide the sermon to a gathering of the Howard University community that includes students, staff, faculty, alumni and members of the broader community. These Sunday services garner a large national and international audience through their broadcast on WHUR radio, YouTube, and other social media outlets. In addition to great faith leaders — from Dr. Martin Luther King, Jr. to Bishop Desmond Tutu — the Rankin Chapel pulpit has been used by U.S presidents, foreign heads

of state, and exiled political activists. While Howard is not a religious school, Rankin Chapel serves as the epicenter of religious life and is transparent about the role it aims to play in the spiritual life of Howard students. According to its web site, “Most importantly, the Chapel has served as the spiritual haven for the vast number of students who leave the safety of home to enter the different world of college. The Chapel serves to ease the pain of transition and provides a community of worship for the displaced worshipers.” Dean Richardson is proud to note that the legacy of Rankin Chapel is to be the starting point for many of the significant movements that have changed Howard University and the world beyond its gates. On Sundays, Rankin Chapel is a place of great oration, beautiful music in the full range of the Black church tradition, connections to the

many constituent groups of the university community through “calls to chapel,” as well as special celebratory services. Much of the Chapel’s work extends beyond Sundays, both locally and globally, through the community service programs coordinated through the Office of the Dean of the Chapel, reflecting the strong tradition of social justice at Howard University and within the Black church. Richardson sees the Chapel’s role in community service programs as a unique benefit for the university and a major link to faith for all students. “For many people, their service is their spirituality,” he said. “It is their work of faith. For the Chapel, that means we can bring them in by meeting them where they are. So it is quite fulfilling when students return as alumni and share how the Chapel has shaped and pre-


pared them for the moments of social and civic engagement that we are witnessing now.” Richardson went on to say, “Many of today’s students don’t have the religious upbringing of past students. Their first religious experience may be through our social justice work, so we have to make sure we are inclusive of all students and all religious traditions.” He noted that HBCUs like Howard are more diverse than presumed, with students from many races and religious faiths even within the Black population. Richardson, a PhD, was awarded a mental health fellowship and had worked as a counselor before coming to Howard. He wrote his dissertation on behavioral health and religion within the African American community, a relationship that was not always in sync. Today, he says the commu-


nity is far more supportive of seeking help for their mental health and credits many in the faith community who have recognized the value of attending to these issues. Richardson sees religion and psychology as intertwined saying, “Our faith and spirituality are part of who we are as people.” He believes faith in God helps people to understand their worth in the midst of their struggles — particularly young people. His biggest worry for them is loneliness. “Loneliness is a real issue for students,” he said. “Faith plays an important role in that. One of the most important things we can do for students within the chapel is to create community for them — to increase their sense of belonging. “Young people today are very intent on being their own person — an identity sepa-

rate from everyone else. And yet, at the same time, they discover themselves through their communities.” Asked if belief in a higher power provides a mental health benefit, Richardson said, “Absolutely. It is at the core of all I do.” But the Dean makes an important distinction that not all religious gestures are welcoming or authentic. “Belief in God is more important than ever, but this country is so separated politically, people are using religion for different purposes. Young people see that and we’re going to lose them as a result. They may be able to handle our sins, but they can’t handle our hypocrisy.” Richardson says the challenge is to listen to students and help them to understand the importance of the spiritual in their lives. “There are many ways to talk to God,” he said.

Q&A: Dr. Rachel Levine, Pennsylvania Secretary of Health Interviewed By Marjorie Malpiede Nearly every day for the last four months, Dr. Rachel Levine has stood six feet away from Pennsylvania Governor Tom Wolf. As Secretary of Health, she appears with him at daily news briefings, providing the data and the detail behind the state’s policies regarding COVID-19. Levine’s turn in the public eye has brought her both praise and pushback. She has been lauded for her calm tone in delivering difficult news, something for which she credits her many years as a physician. But she has taken a lot of heat for the state’s restrictions, something she understands and accepts as part of her job as Pennsylvania’s public health czar.

the country, and the first in Pennsylvania, Levine is used to attention. She has become a national inspiration for the LGBTQ community, both for her bravery and her accomplishments. Before becoming secretary, Levine was Pennsylvania’s Physician General, and before that, an accomplished physician and academic, specializing in pediatric medicine.

But while she acknowledges the unpopularity of some of her decisions, she is disappointed that a public health crisis of this magnitude has become so politicized.

We spoke to Dr. Levine via Zoom from her post at the Pennsylvania Emergency Management Agency office, where she and the Governor’s other senior staff members have been working since March. We covered a lot of subjects — from the psychology of group behavior during a pandemic, to the mental health of young people, to the emotionally-charged resurgence of the Black Lives Matter movement and the vulnerability of underrepresented Americans.

As one of the highest-ranking transgender officials in

Here are highlights from our conversation:

Mary Christie Quarterly: What has life been like for someone in your position at this time? I’m guessing you haven’t had a lot of sleep? Dr. Rachel Levine: That is true. We all had to move out of our offices to where you can see behind me is the Pennsylvania Emergency Management Agency’s offices, and that’s where the governor’s senior staff is. I meet with them twice a day and talk with them about every hour. I talk or meet with the governor (Tom Wolf) every day about our response. I have been very front and center in terms of the media and the public. I’ve always enjoyed public speaking as a professor so, I think that that has been helpful. All of us as public health officials throughout the country have been thrust in the limelight, certainly more than we are used to given the scope and scale of the COVID-19 pandemic. 23

Racism itself is a public health crisis or a public health emergency when you think about health equity and the social determinants of health. But it’s not like we haven’t been thinking about these things. I would always say that public health preparedness has to be one of our top priorities because what would wake me up in the middle of the night is the risk of a global pandemic. MCQ: It has been reported that you have been able to deliver difficult news in a very calming manner. Would you agree? RL: I think that has to do with my clinical work, and then for many years, working in hospital emergencies where you have to stay calm under pressure. You can’t lose it during a clinical emergency, so, I think a lot of my background has served me very well in terms of responding to the crisis. In terms of talking to the public, I think of it as a doctor talking to their patients. I’ve done clinical work my entire life until the last five years. [As if] I were speaking with a teenager or a young adult, or a child with their parent, 24

I take a very calm, measured approach. I also draw on my experience in academia when I need to be professorial. Sometimes my communications director will say, “Go into lecture mode.”

MCQ: You’ve gotten a lot of pushback, particularly from conservatives, on your stay at home policies. What do you make of that? RL: A lot of it has to do with emotional, behavioral factors because we’re trying to convince people to do something that they don’t really want to do. “I know you want to go out and do this and do that, but no, you need to stay home.” The three things I would say at the end of all my talks was “stay calm, stay home and stay safe.” I’d repeat it the next day and I’d repeat it again and again. Some people would get annoyed at that, but that’s how it sinks in. It also became rapidly politicized and that didn’t help. Public health really should not be a political issue, but right now with this current climate, everything is political. I have taken a lot of heat and a lot of pushback, as other state health officials have, but I happen to be at the right hand of a democratic governor in the biggest swing state in the country during a very

contentious election, so the fact that this became politicized and fell into party lines was not completely surprising. MCQ: How have the protests over the death of George Floyd and other unarmed Black Americans at the hands of police affected your work? RL: Pennsylvania has been challenged by this, particularly in the cities, and that’s tough because you are not able to have proper social distancing during civil unrest. But certainly people have a perfect right to protest, so it’s about controlling public safety while allowing that. I would say racism itself is a public health crisis or a public health emergency when you think about health equity and the social determinants of health. MCQ: Do you think for Black Americans there is a link here to COVID-19 given the disparities that are emerging within the pandemic? RL: Yes. I think it taps into health equity and that has a lot to do with economic injustice and economic disparities. African Americans are disproportionately affected by any public health crisis, as are Latino communities and other vulnerable groups. The availability of testing and

treatments, health insurance — all of that relates. MCQ: What about other marginalized groups, like the LGBTQ community? RL: I think it is very challenging for our community right now. In times like this, vulnerable communities are more vulnerable. Marginalized groups are more marginalized. From a health equity point of view, from an economic point of view, all of those things are exacerbated given a public health emergency. MCQ: From your experience as a pediatrician, how do you think these two events – the pandemic and the upset over racial injustice – are affecting young people? RL: I think it is very natural for teens and young adults to have significant anxiety at the present time for many different reasons, one of which is the global pandemic and their worry about their health and their family’s health. The second is the uncertainty. I think when you are in an uncertain environment and you have a lack of control, that is very anxiety-provoking. They also have a significant sense of loss – the loss of their connections and activities. Young adults are hoping to develop independence from their parents, but it’s hard to

be independent when you can’t leave home. I think all of that is really challenging and then the civic unrest really exacerbates that tenfold because I don’t think any of us knows what’s going to happen. MCQ: What about college life in the fall? What will this look like? RL: Again, I don’t think any Photo courtesy of Dr. Rachel Levine of us knows for sure. To be Dr. Rachel Levine, Secretary of Health for the honest, we’re state of Pennsylvania. expecting a significant increase in MCQ: Will the world be difCOVID-19 in the fall. ferent after COVID-19? School might start, but what is the semester going to look like? What’s going to be online and what’s going to be inclass? You will have to wear masks and social distance. What happens to sports and drama club? What happens to the thousand different activities college students do? And what happens to their college experience? There is a lot of uncertainty.

RL: Yes. I think things are going to be different in a million ways. Education will change. Medicine will change. I think even when COVID is gone, the idea that global pandemics happen and could happen again is going to change everything.


Interesting People Doing Important Work By Marjorie Malpiede

Andrea Mercurio, Ph.D


r. Mercurio is a faculty member in the Department of Psychological and Brain Sciences at Boston University where she teaches a range of courses including social psychology, women and health, and psychology of eating. The research lab she directs is called “Healthy Minds, Healthy Bodies” reflecting a career-long devotion to physical and mental health and health equity. After earning a Ph.D from George Washington University, Mercurio began her post doc work in health behaviors and eating disorders in college-aged women. She later was tapped to do research on obesity when it was emerging as a national health crisis. Of that time, she said, “I went from focusing on young


women who are trying to be thinner to helping solve the weight problem in the United States.” Mercurio said her job at BU has been a great fit, allowing her to work with students and continue her research. The Healthy Minds, Healthy Bodies research lab combines both activities as her students work alongside her, and independently, on a range of projects including: body image and weight regulation tactics; the effects of appearance messages on exercise attitudes and behaviors; and discrimination and wellbeing among LGBTQ individuals and college student mental health. The lab’s college student mental health work involved a survey of over 2,000 BU stu-

dents that looked at a number of factors, including academic stress and help-seeking behaviors. Mercurio said it was motivated, in part, by the anecdotal evidence she found when interacting with her students. “I would see it every day in my office,” she said. “Students would come in to talk with me who were so anxious, stressed and sad and I thought, ‘There is something going on.’” For Mercurio, the survey revealed a number of concerning points. “One thing I thought was interesting is that a lot of the students who said they were experiencing sadness and symptoms of depression and anxiety also said they were not going to seek professional help. It looked like a lot of them were interested in finding someone outside of the mental health profession to support them — an advisor or friend.” Mercurio saw this as potentially problematic, particularly for first year and transfer students, as well as interna-

tional students who don’t always have a robust support system. “They seem to prefer social, informal supports, but for a lot of people, those just don’t exist,” she said. “BU is a big place, so even if you want to talk to say, your academic advisor, the student experience tells me that they have difficulty establishing an effective relationship with their professors. There are so many students. Professors’ time is so limited that students struggle making a connection for academic purposes let alone anything that’s more difficult like mental health.” When asked her theory on the source of students’ distress, Mercurio sees a strong correlation between mental health problems and academic stress. And while these dynamics exist in domestic students, she says she sees it more prominently reported in international students where the pressure to remain in a certain field, or even at university, hinges on grades. “The academic pressure is high on these students,” she said. “Some are putting that pressure on themselves, others are feeling it from their families, but it basically puts them in a place where their grades are their entire worth.” Mercurio said that aspira-

tions for graduate school, which require high GPAs, compound this obsession for many students. “They are emailing all the time, making sure they are getting an A because if they don’t, it dampens their chances of getting into graduate school which is their main goal.”

One thing I thought was interesting is that a lot of the students who said they were experiencing sadness and symptoms of depression and anxiety also said they were not going to seek professional help.

The survey report suggested that BU, like other schools, ought to examine how to improve pathways into the counseling center, as well as to tighten follow-up afterward so as to better support students who are reluctant to seek help or follow-though on what is recommended. Mercurio’s related work in body image and eating disorders in young women involves physical and mental health as well as social psychology. In a recent project, she looked at how women interpret and understand different types of messages that they receive in advertisements for exercising. “We were trying to understand what is the best way to motivate a girl to exercise without making her feel bad about her body,” she said. The lab has done consistent work in the area of body im-

age, which involves broadly looking at how women view themselves as well as how changing societal ideals affect their behavior. “For a long time, there’s been this sort of ideal body type, or as we call it in the literature, the ‘thin ideal.’ ‘You’re skinny, not curvy, and that’s what you should look like.’” If that weren’t anatomically challenging enough, Mercurio said there is now a new sort of ideal emerging which she thinks is even more dangerous as it is that much more unrealistic. “Now you’ve got to be thin, fit and curvy — rock hard but no fat. And to do that, you’ve got to spend an excessive amount of time working on your body.” While these messages are equally influential on women of all ages, they are particularly powerful on girls and young women who do not yet have competing priorities like children and careers. 27

When asked if the counter message should be about acceptance of self, not adherence to an ideal, Mercurio said it was not that simple. “What I’ve noticed in working with this research is that we’ve put women in a real paradoxical position,” she

said. “We like to preach, ‘Accept yourself. It’s not about beauty,’ yet we know from the research that women who adhere more to gender norms and traditional feminine ideals have better outcomes — they’re treated better by people. They are more likely

to get jobs. They are more likely to get married.” “In encouraging women to be true to themselves, Mercurio said, “we need to do that while we let them know what the data tell us.” Spoken like a true researcher.

Layne Scherer


s a senior program officer at the National Academies of Sciences, Engineering, and Medicine, Layne Scherer holds the kind of behind-the-scenes influence public policy is made of. What the National Academies says matters which is why many in the field of college student mental health are eagerly awaiting the committee report Scherer is currently leading on college student mental health, wellness and substance use. 28

Scherer has a masters degree in public policy from the University of Michigan, though her route to government policy work was not exactly linear. As an undergraduate, also at Michigan, she was a biology major then switched to english and the history of art. She spent four years before graduate school at different non-profits in D.C. where she did administration and fundraising, skills she said were great to learn but ultimately not for her.

“Instead of being the person writing the grants, I wanted to be on the other side, thinking about how to use the money – like how to take research and translate it into action,” she said. Scherer was eventually hired at the National Science Foundation (NFS) where she worked on policy with the assistant director for education and human resources in the front office, aka, the “control center.”

They oversaw a portfolio of nearly a billion dollars of investment in federal STEM education from K – G. Scherer was the executive secretary for the Committee on STEM Education where she worked on aligning the agendas of the numerous agencies that received funding in this area. “I got to understand, from a very top level, where the concerns of each agency were: what the specific programs were, what the challenges were, where the data were, and, more importantly, where they weren’t,” she said, referring to research gaps in one of the highest priorities in STEM education: closing disparities for women and underrepresented minorities. Her experience at NSF brought her to the National Academies where she was first the study director on a report on graduate STEM education. Released in 2018, Graduate STEM Education for the 21st Century led to her current work on college student mental health. “The one issue that came up repeatedly in working on that report was mental health,” she said. “We had a recommendation about support for the mental health of graduate students because everywhere we went, it kept coming up.” Their concern for the issue was shared by sponsors of

what would become the Committee on Supporting the Whole Student: Mental Health, Substance Abuse, and Well-being in Higher Education, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA); the National Institute on Drug Abuse (NIDA); the National Institute of Mental Health (NIMH) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Scherer, who was recently promoted to senior program director, said the team wanted to broaden the scope of the examination to undergraduate as well as graduate students and include community colleges and minority-serving institutions which are often overlooked in these kinds of efforts. As the study lead, Scherer does a little bit of everything, a role well suited to a self-described “expert generalist.” Committee reports typically take between a year and a half to two years during which staff convene a committee of experts several times, help them with the research they need, and facilitate their coming to a consensus around a series of evidence-based recommendations that go into a report. Scherer says the statement of work is what holds everything together.

According to its statement, the Committee aims “to examine the degree to which the support systems on campuses provide services, programming, and other resources to students and the faculty, staff, and health systems with whom students interact. “Under the auspices of the Board on Higher Education and Workforce, and in collaboration with the Health and Medicine Division, the National Academies will appoint a committee of experts to examine the most current research and consider the ways institutions of higher education, including community colleges, provide treatment and support for the mental health and well-being of undergraduate and graduate students in all fields of study.” The Committee is chaired by Dr. Alan Leshner, the renowned scientist and administrator who was also the chair of Scherer’s previous committee on graduate STEM, something Scherer says is a huge advantage. Leshner’s CV includes senior positions at the National Institute on Drug Abuse (NIDA), the National Institute of Mental Health and the American Association for the Advancement of Sciences where is the emeritus Chief Executive Officer.


The Committee includes top experts in the field of student mental including Daniel Eisenberg, S.J. Axelrod Collegiate Professor of Health Management and Policy, University of Michigan and Director, Healthy Minds Network; Benjamin Locke Senior Director, Counseling and Psychological Services, Penn State University and Executive Director, Center for Collegiate Mental Health as well as college presidents, provosts, and student affairs professionals from schools throughout the country. Scherer said that once the committee is convened, the members start with a set of questions that are the foundation of the examination. They continue from there with a steady eye on the scope: not too narrow or too broad. It is the work of the

study director is to try to find the balance. Scherer believes her past experience with agencies and in fundraising has helped maximize the committee’s work. “Getting people to articulate what they care about is really important,” she said. “You go through a process where you’re like ‘ok, I’m hearing you say this really needs to be in here. What’s driving that? Why is that so important to the outcome?’” The report is due out in November though Scherer says the dissemination plans are uncertain, given social distancing policies that prohibit a large in-person convening. What really matters to those in this field are the recommendations. While she did not divulge any details, she sees the Committee’s focus on

systemic change for “post-traditional” students an important and precedent-setting consideration in what they eventually release. Like most National Academies reports, it will likely call for additional research. “When I really dug into this and did the analysis, I realized there is substantially less information about community colleges and minority serving institutions than the big research universities even though this is where the students are likely to be,” said Scherer. “I hope the report puts a grounding on how important these schools are to the future of the country.” As for Scherer, she is not sure where her path will take her after November, but we can be assured it will be somewhere she can make an impact.

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Vaping on the Rise: How Colleges are Responding By Adam C. Powell, Ph.D.


merican high schools, colleges, and universities. These institutions are faced with the challenge of deciding whether they should adopt vaping-friendly policies, as a means of encouraging smoking cessation and harm reduction, or if they should ban vaping in order to protect students from the harms that vaping poses to both people that vape and to those who do not. Academic institutions must balance the interest of nonsmokers against those of smokers in order to decide upon a policy.

The use of electronic cigarettes has been promoted as a harm reduction strategy on the grounds that vaping does not expose smokers’ lungs to tar, unlike tobacco products. A study of 5,863 adults who had made at least one attempt to quit smoking over the prior twelve months found that electronic cigarette users were significantly more likely to have been able to abstain from smoking than people that used over-thecounter nicotine replacement therapy or attempted to quit smoking without an aide.

Vaping is a growing issue on campuses. While in 2017, 9% of college students surveyed reported that they had vaped nicotine in the prior month, by 2018, 15% of college students surveyed reported that they had done so.

While 20.0% of electronic cigarette users reported having been able to abstain from smoking, only 10.1% of people using nicotine replacement therapy and 15.4% of those using no aide reported having been able to do so. Thus, restrictions on vaping have the potential to make it more difficult for students to quit smoking.

In contrast, only 11% of the people aged 21 to 22 that were surveyed in 2018 reported that they had smoked cigarettes in the prior month.

While vaping has the poten-

tial to serve as an alternative to tobacco use, it introduces additional challenges. Vaping liquid has been sold in a variety of flavors, including fruit, menthol, and tobacco, leading vaping to be appealing to some people who might never have considered smoking tobacco products. There is research to suggest that inhaling the flavoring itself may be harmful, in addition to the harm posed by the nicotine and other additives. While flavorings have been demonstrated to be safe as food additives to be consumed, they have not been demonstrated to be safe for inhalation. Chronic exposure to diacetyl, a component of the artificial flavoring that gives microwave popcorn its buttery taste, has been shown to cause development of bronchiolitis obliterans. Diacetyl is used as a flavoring agent in some vaping liquids. Furthermore, vaping exposes people to secondhand smoke


and thirdhand smoke. People are exposed to secondhand smoke when they are near someone else who is smoking or vaping. Thirdhand smoke exposure occurs when molecules from smoking or vaping cling to the objects in an environment, and then act as an indoor pollutant to anyone interacting with an environment. This is of particular concern as institutions grapple with COVID-19, as any injury to the lungs — be it directly through vaping, or indirectly through secondhand or thirdhand smoke — has the potential to lead to worse outcomes.

issues, the U.S. Food & Drug Administration (FDA) announced on January 2, 2020 that it would take action against the manufacturers of cartridge-based e-cigarette products in flavors with the potential to appeal to children, namely in fruit and mint flavors. As a result of the policy, only the sale of tobacco-flavored and menthol-flavored e-cigarette products are permitted to be sold by manufacturers that have not had a premarket application to the FDA approved, pursuant to the Tobacco Control Act.

Many states have gone beyond the Federal regulations to create additional regulations regarding electronic cigarette use. In Massachusetts, there was a temporary in-store and online ban of the sale of vaping products in order to While vaping has the better study their harms potential to serve as an before reintroducing alternative to tobacco them to the market.

Given the benefits and harms of vaping, there have been policies created to regulate it.

use, it introduces additional challenges.

After a series of incidents of severe vaping-associated lung illness, which were believed to have likely been caused by the vitamin E acetate found in vaping liquid, there was a greater call for government action. In response to these 32

At the end of the ban in December 2019, the governor prohibited the sale of flavored e-cigarette products, including those flavored with menthol. Other states, including California and New York, have passed regulations prohibiting vaping in environments in which smoking is not allowed, such as in bars and workplaces.

Meanwhile, a number of states, including Florida and Texas, have not enacted any state-wide bans, but have permitted localities to enact bans if they wish to do so. In contrast, some states, including Tennessee and Nevada, have not issued any statewide bans and have prohibited localities from doing so. Campuses have varied in their willingness to prohibit the use of electronic cigarettes on their grounds. Duke University has enacted a policy of prohibiting the use of all combustible tobacco products on its grounds, effective July 1, 2020. The policy explicitly states that non-combustible nicotine products, including electronic cigarettes and chewing tobacco will not be included in the ban. While Duke has taken a middle ground approach, over 2,000 colleges and universities in the United States have enacted policies prohibiting electronic cigarette use on campus. There is variation at the state and campus level in policy towards vaping, as there are differing opinions as to how to weigh its benefits and harms. There are likewise different levels of cultural acceptance of tobacco and nicotine-based products in different parts of the country, which may be a source of policy variation. While 22.7%

of Southerners smoked cigarettes in 2016, only 16.3% of people in the West did so. As colleges and universities reopen their campuses after closures due to COVID-19, vaping policies need to be revisited. Vaping and smoking are incompatible with properly wearing a mask. The aerosols and vapors released by electronic cigarettes and other forms of smoking have the potential to both be a source of viral spread and to cause injury to the lungs that may worsen COVID-19 outcomes. Sharing electronic cigarette devices likewise could potentially lead to the spread of COVID-19. These hazards can be managed if students are required to only vape in isolated, outdoor locations. While there is some evidence that people with a history of any form of smoking may be more vulnerable to a COVID19 infection, and to develop serious complications if they contract one, there is currently limited research directly addressing the connection between vaping and COVID19 outcomes. In light of this, colleges and universities may wish to promote other forms of smoking cessation, such as nicotine gum and patches.

campus must decide the extent to which it wishes to permit vaping on campus. Institutions with pre-existing policies should revisit them to ensure that they are aligned with their COVID-19 prevention strategy. Regardless of the policies chosen, it is important for campuses to thoughtfully develop vaping policies consistent with their values, as vaping is playing an increasingly large role in the lives of students. Adam C. Powell, Ph.D., is President of Payer+Provider Syndicate. He holds a Doctorate and Master’s degree from the Wharton School of the University of Pennsylvania, where he studied Health Care Management and Economics.

Within the parameters of state and local law, each 33

Students with Chronic Illness Need Special Consideration in Re-opening Strategies By Christina Roth and Dana Humphrey


uch of the conversation around reopening colleges in the fall has focused on mitigating the risk of outbreaks and creating policies to keep the campus community safe as a whole. While these conversations are necessary and constructive, it is critical that colleges and universities put a particular focus on students who are vulnerable to serious illness as a result of the coronavirus. The College Diabetes Network (CDN) is a non-profit organization that advocates for and supports young adults living with diabetes. Its network of campus peer support groups, and guidelines for college leaders, address both physical, emotional and behavioral health for students on campus. Since COVID-19, the organization has supported its vast network of students living with T1D virtually via Zoom meetings, leadership development opportunities, social media posts, blogs, and text message groups.


CDN has a strong message for higher education leadership: students with T1D and other chronic illnesses have unique concerns about the return to campus, and colleges must take their needs into account when creating plans for reopening. Challenges for Returning to Campus Students returning to campus this fall will likely be under strict guidelines – keep a six-foot distance from others, avoid crowded areas and events, wear masks in public. But there is a growing concern among higher ed stakeholders that many college students, a group known for taking risks, will not abide by the guidelines laid out by their college or state. Additionally, some institutions may not even require the bare minimum social distancing guidelines. The University System of Georgia recently reversed a decision not to require masks

on their campuses after public criticism, but Arizona President Robert C. Robbins recently said that while he would encourage everyone to wear a mask, he can’t require it. It is reasonable that students with chronic illnesses would fear exposure to the coronavirus from other students who aren’t following social distancing guidelines, which could have drastic health consequences. Mental health is a heightened consideration. In its recent annual young adult survey, the College Diabetes Network (CDN) included a sub-section specifically on the impacts of COVID-19 and how it was influencing young adults with diabetes. Preliminary data analysis has reinforced the increasing need for mental health support from colleges and universities this fall. (CDN’s annual survey continues to be the largest study cohort providing data of this population. In an effort to make this data as actionable as possible, through CDN’s REACH™ initiative, Reducing Risk through Education, Advocacy, and Collaboration in Higher Education, CDN is currently in the process of publishing a white paper on its findings which will be available this summer.) The limits on social interaction in the coronavirus era have increased feelings of depression, loneliness

and stress among college students. And while many are looking forward to their return to campus as a light at the end of the tunnel, students with chronic conditions, whether they return to campus or not, are likely still facing months more of social isolation. Staying home from school while others return to campus life is sure to elicit feelings of loneliness and despair. But, for students vulnerable to COVID-19, returning to campus will also include some measure of social isolation - turning down plans that may put them in a vulnerable position and avoiding friends who act recklessly, all while worrying about contracting a virus that could be disastrous for their health. Students with chronic illness are already statistically more likely to suffer from depression, anxiety, and isolation than their peers. These mental health challenges will be further compounded by the pandemic, and the increased risk it poses to their mortality. The potential for exacerbated mental health issues among vulnerable students is concerning. If they contract the coronavirus, students with chronic diseases will need specialized medical care that college health centers are not set up for, or may have limited knowledge about. And at

some schools, particularly those in rural areas, the local hospital may not be equipped to meet the specific health needs of those with chronic conditions who are infected with COVID. While 20% of youth in the United States live with a chronic illness, students with type 1 diabetes are an obvious concern. David Walton, Chief Executive Officer of the T1D Exchange, noted that research from various organizations has demonstrated that COVID-19 initially led to reduced glucose testing by some staff in the inpatient setting and as a result, glycemic control was adversely impacted.” It has been widely documented that achieving well-controlled blood glucose levels is correlated with improved outcomes for hospitalized patients, including those with COVID-19. However, managing diabetes in the inpatient setting is challenging. “High blood glucose levels can compromise the immune system and impair the body’s ability to fight infection, thus leading to susceptibility of complications of COVID-19, therefore, optimal blood glucose management in the context of COVID-19 is urgently needed, especially in the hospital setting.” said Dr. Daniel DeSalvo, MD Director of Strategic Collaboration at Texas Children’s Diabetes and 35

Endocrine Center, Texas Children’s Hospital, and Assistant Professor at Baylor College of Medicine. Walton also shared that “based on early data from the T1D Exchange national surveillance study examining COVID-19 and Type 1 Diabetes, the outcomes of those with T1D who contracted COVID-19 correlated with the level of their glycemic control.” These findings are critical for the higher education community, as young adults with diabetes have been shown to have the highest glycemic averages of any other demographic with type 1 diabetes. The surveillance study also found that patients with diabetes were more likely to delay seeking treatment in an effort to manage illness from home and reduce additional covid-19 exposure, resulting in higher rates of more advanced Diabetic Ketoacidosis (DKA) when finally admitted to the hospital, and subsequently were more challenging to regain glycemic control management upon hospitalization due to this delay. Due to limited clinical education on symptoms and treatment, DKA has continued to be an ongoing risk of complications and mortality for young adults with diabetes on college campuses prior to the pandemic. These risks are now further compounded. 36

Finding Solutions for AtRisk Students What can be done to address the unique needs of students with chronic conditions in the COVID-19 era? First, higher education institutions must develop academic and residential accommodations for college students with chronic conditions that make them more vulnerable to COVID-19 complications. Some universities have begun publicizing their plans for the changes to campus life, including limits on roommates, mask requirements, altered schedules and more. Annie Tulkin, Founder and Director of Accessible College, an educational consulting firm that supports students with health conditions and physical disabilities with the transition to college, says this is both critical and as yet not guaranteed. this, saying “all of the students I work with who have health conditions (POTS, lupus, asthma, cancer, etc.) are in a high risk group. Most of the various plans from colleges they are attending do not directly address the needs of students with health conditions”. Whenever possible, high-risk students should be permitted remote access to all classes to ensure greatest possible safety. The safest place for high-risk students is off-campus; but in situations where they must return to campus

for academic (e.g. to take a class with a required in-person component) or personal reasons (e.g. an unstable life at home), the same remote access to classes should be permitted from on-campus residence. Schools should be prepared to provide academic accommodations (e.g. extensions on assignments and flexibility with attendance in the event of complications related to their condition or COVID-19 infection) for all classes regardless of whether the class can be accessed remotely. For students that must return, schools should also be prepared to provide high-risk residential students adequate housing accommodations (e.g. a ground floor single room and private bathroom) and dining accommodations (e.g. access to takeaway options). As an adjunct to the accommodations themselves, disability support offices should prepare themselves for an influx of students that they are serving and supporting and make efforts to encourage students to contact their offices for support. As Annie Tulkin notes, “many students with health conditions may not be registered with the college’s disability support office, either because they did not realize that their health condition could qualify them for accommodations, or they did not need accommodations in the past, prior to

Illustration: ApoevAndrey

COVID-19. Students with health conditions should not assume that remote access or other accommodations will be provided unless their college says that explicitly. Accordingly, students in need should start the process of requesting accommodations now.” Significant planning and consultation with experts will be needed to create and adjust these accommodations. In a recent call, Chief Executive Officer of the American College Health Association (ACHA), Devin Jopp reiterated that “remote learning options are strongly encouraged to be made available to all students with comorbidities and chronic conditions, given the risks they face.” Jopp also encouraged institutions to refer to the recently published ACHA GuidelinesConsiderations for Reopening Institutions of Higher Education in the COVID-19 Era, ACHA Guidelines- Preparing for COVID-19, and the Center for Disease Control (CDC)

Considerations for Institutions of Higher Education. College and university leaders must provide education and training for health center personnel on conditions, including diabetes, that compound the effects of the coronavirus. They should also partner with local hospitals to share information and education. Critical to these efforts is the effort to update specific treatment protocols for students with at-risk conditions, both for their health center, and in collaboration with local or city hospitals, based on covid-19 frontlines data being collected in real-time. According to Dr. DeSalvo, “Recently, the FDA made continuous glucose monitors (CGM) temporarily available for in-hospital use with COVID-19 patients. Use of CGM devices in the hospital setting allows the healthcare team to remotely monitor their patient’s glucose levels and receive timely alerts for glucose excursions, while

also reducing staff exposure to the infected patient and preserving personal protective equipment.” Use of this technology provides an extra layer of safety to both the patient and the hospital staff, however, requires intentional training that has not historically been available prior to the pandemic. Finally, due to the increases in mental health concerns across the board, colleges and universities should be prepared for heightened demand for treatment in the fall. And to ensure the safety of students with chronic illness, colleges should put a specific focus on providing care while maintaining social distancing. Precautions like telehealth and online treatment options will be necessary to treat students vulnerable to the effects of the virus. Christina Roth is the Chief Executive Officer of the College Diabetes Network. Dana Humphrey is the Program Director of the Mary Christie Foundation. 37

WE Strong: UVM’s Wellness Environment Then and Now By Dana Humphrey


he students on the Zoom platform take a deep breath in and then exhale with ear-piercing screams. They are doing the “WE Breath,” a unique way to let go of stress and anxiety practiced at the Wellness Environment from which they are graduating — remotely. They are the fifth first year class at UVM to celebrate such an accomplishment and the first to graduate in the COVID-19 era. Now in its sixth year, the Wellness Environment at the University of Vermont is a neuroscience-inspired, incentive-based behavior change program focused on health and wellbeing. The fact that it was designed for first year college students who tend not to prioritize healthy behavior is exactly the point. Its creator is Dr. Jim Hudziak, Chief of Child Psychiatry and Director of the Vermont Center for Children, Youth, and Families at UVM Larner College of Medicine and UVM Medical Center.


“There is no such thing as a bad college student,” said Hudziak. “There’s only an underdeveloped ventral, medial, prefrontal cortex,” referring to the developmental period between ages 18 and 26, in which the area of the brain that controls decision-making is still developing. Dr. Hudziak is an evidenceciting evangelist for the behavior change approach. The idea for the Wellness Environment grew out of 25 years of experience with the Vermont family-based model to promote health and prevent illness for children with mental health issues. The method treats parents alongside their children, on the basis that environment drives mood and behavior, and can have a huge impact on wellbeing. When one of his four children decided to attend the University of Vermont, Hudziak envisioned an environment that could provide an

enticing counter to the oftenunhealthy cultures of residential colleges where sleep, exercise, and nutrition take a back seat to illicit substances, risky sex, and late-night snacks. WE provides students with a living environment where they are not only encouraged to make healthy choices, they are supported in doing so. In their dedicated dorm, WE students have access to Peloton bikes, meditation rooms, daily yoga classes, nutrition and fitness coaches, mindfulness classes, and free ukulele and violin classes (along with their instrument of choice for the year). When WE students make healthy choices along any of the four pillars of wellness (fitness, nutrition, mindfulness, and relationships), they earn WE Coins, which can be used for program swag like sweatshirts and hats. WE combines incentives with health literacy and education.

Photo by Prasida Timsina

Incoming students took part in a daily yoga class during WEventure.

Every student in WE takes a three credit course, Healthy Brains, Healthy Bodies, where they explore how behavior and environment play a role in brain health and development. Hudziak says the class gives students the knowledge and skills to know how what they do is impacting the structure and function of their brain. Students learn from leading experts about the most current research in brain health. “Everything that we teach comes from high science literature synthesized by scientists to make sure it’s consumable by someone who isn’t a geneticist or a Ph.D.,” said Dr. Hudziak. “We don’t teach this sort of soft science.

We teach hard science in a consumable way and provide an evidence-base for every claim we have.” Students learn the neuroscience behind mindfulness and the effects of regular physical activity on brain health and wellbeing. Patricia Prelock, Ph.D., Provost and Senior Vice President of the University of Vermont, helped Hudziak design the program’s curriculum. The two play to each other’s strengths. “We got together, and Jim wasn’t familiar with curriculum development, but he knew everything about the brain and behavior change,” Prelock said. She offered,

“How can we collaborate to help you build a course and curricular plan that would make sense and achieve your goal for students to learn about brain-behavior connections?” In partnership with Prelock, Hudziak created an entire minor dedicated to Behavioral Change Health Studies. The minor includes classes like the Science of Happiness; Sex, Love, and The Neuroscience of Relationships; and Family Wellness Coaching. They have become popular courses at UVM. Prelock says the WE program has transformed UVM from a party school to a health-promoting institution, which she


says is more aligned with its nature-loving culture. Since implementing WE at UVM, there has been a dramatic reduction in conduct violations and detoxes related to alcohol. Students that participate in WE have higher retention rates than the campus as a whole, a metric that yields significant savings for the university.

If you’re going to engage in behavioral change or engage in disruptive education, you better be willing to take some shots.

“Jim has done what I don’t think anyone else could do,” she said, praising Hudziak’s combination of science, health, and chutzpah. Virtual WE

When we sat down to talk with Dr. Hudziak over Zoom, it came as no surprise that his custom background featured a floating rubber brain/football that has become a sort of mascot for the Healthy Brains, Healthy Bodies class. (Hudziak throws the brain to students to keep them alert and engaged in the discussion.) Hudziak started with COVID-19 and its substantial impact on the WE program, which is an integral part of its students’ everyday lives and necessitates in-person interaction. The program’s leaders have devoted much of their energy towards maintaining remote contact with the students and continuing some of the activities that they can


usually access in the dorm. “We created remote yoga, remote mindfulness, and remote contact with our team members so that even away from here, you can still see the same yogini and do yoga with Rebekah,” said Hudziak. “We created an online guitar lesson set, and online violin training.” The program ran “kindness and gratitude challenges” non-stop after leaving campus. “The number of connections a student has correlates most highly with their happiness scores, so we started immediately bombarding them with kindness and gratitude challenges,” said Hudziak, who encouraged students to “reach out to 10 friends, reach out to 10 people that you know kind of well, reach out to 10 people that you don’t know at all from the community.” “Amazingly, higher engagement in kindness and gratitude led to higher mood, higher social connections. Not surprising, right? If you’re trying to be kind and gracious to people you’re having connections.” They organized a virtual 4/20 5K on April 20th, an event usually held on campus as counter-programming to the marijuana-themed holiday. Over 150 students sent videos

of themselves running. And of course, they celebrated their WE graduation, completed with a WE breath. When UVM closed the campus, Dr. Hudziak quickly added a COVID-19 impact survey to his WE study, which usually tracks health behaviors like sleep, drinking, smoking, and students’ emotions. Now they are collecting data on percentages of students with family members with the virus, family members that have died, and the effects that being removed from campus and social networks has had on mood, mental health, and behavior. Fortunately, WE had some practice in converting to virtual pre-pandemic. Dr. Hudziak and his team created an app for the Wellness Environment research study that is offered to every UVM student (over half of the people on the app are not involved in WE). On the app, students can take daily surveys and report their wellness behaviors, track activities like exercise, mindfulness, nutrition, hydration and sleep, access over 125 meditations, and practice yoga or do a workout with instructor videos. By offering modules to the entire student body, WE expands its reach to those who aren’t able to fit the required three credit class into their already-packed schedules.

While Prelock says she would love for every student to be able to participate in WE, “Taking modules of some of the elements that are key can help other students who need credits for other disciplines but want to be part of the Wellness Environment in some way.” Hudziak has already created the WE M.D. app for medical students at UVM’s Larner College of Medicine, launching in the fall. Hudziak is currently designing modules to help prepare incoming UVM students for the dramatic transition from what he calls “highly-curated and overseen existences with environments that are predicted by your parents or your schools” to college life, an environment that can be corrosive to students’ wellbeing. “Our university, like every university, is deeply-invested in making the summer experience for our incoming class as engaging as possible without overwhelming our students,” he said. “And so I’m going to contribute four wellness models, three for students and one for parents, to that experience for all incoming first year students – and not just for the ones coming to the Wellness Environment.” Scaling WE The silver lining of push-

ing WE 100% virtual for the spring is that it offered a proof point for some of Hudziak and Prelocks’ plans going forward. They want to start disseminating the WE program, or parts of the program, to other colleges, universities, and anyone else who wants it. One way this may take shape is in creating online modules that embody the health promotion and illnessprevention strategies for the developing brain, offered to people outside of the UVM community. Or, Hudziak imagines, there is the possibility to expand on the distance learning that has become a necessity in 2020, and allow other universities to offer the Healthy Brains, Healthy Bodies course or other courses in the behavior change minor. He sees this as a chance to “foment the idea that all health comes from brain health and that we can, through lifestyle changes, improve brain health.” Prelock envisions UVM as a training site for other schools who want to take up this mission of behavior change. She sees an opportunity to train key people from other colleges and universities on the WE program’s structure and how best to support and coach the community, and then send them back to implement their own programs. 41

If UVM does become a training center, Hudziak and Prelock have plenty of wisdom to share.

nothing can replace the “analog.”

“I would hate to see whatever extensions of this that First and we develop, foremost, that anyone Photo by Prasida Timsina they say, thinks it leadership could exist Students walk their dogs on the UVM campus pre-pandemic. buy-in is just in a dignot just ital frameing how things are done on important – its critical. In work,” he said. He believes college campuses, and in conjunction with backing that one of the real messages residential programs in parfrom university presidents ticular, and programs like WE of WE’s success is that there and chief academic affairs can be digital and remote disrupt that. Hudziak is also officers, Prelock noted that components (like the app, well-accustomed to students working with student affairs or online educational modpoking fun at him on the is vitally important. She says internet, getting angry emails ules), but if it is not delivered the program isn’t meant to from parents and taking criti- in person or connected to a replace the meaningful work cism from his colleagues. coach, the ability to dissemithat student affairs does, but nate it will be deteriorated. “If you want to go down this rather support it, and enLastly, Hudziak advises othhance the student experience, road, if you’re going to eners looking to do similar gage in behavioral change or while adding an academic programs to evaluate and engage in disruptive educacomponent. evaluate again. Ongoing astion, you better be willing to Hudziak’s advice includes take some shots,” he said at a sessments can help continubracing for pushback, given ously improve the program, higher education convening the cultural shift a program and make the case for its conin the spring. like this forces on campus. tinued existence, something Hudziak says that while digiHudziak says that there is a that appears to be a lock at tal spaces are effective tools, certain belief system regardUVM.


Science Summary A recap of research worth noting. By Dana Humphrey


Coronavirus Impact on Student Success

According to several reports, the coronavirus and resulting economic downturn have harmed many students and impacted plans for attending or returning to school in the fall. According to a working paper from the National Bureau of Economic Research, undergraduate students at a large public university have suffered significantly and unequally as a result of the pandemic. In a survey of approximately 1,500 students, researchers found that low-income students were 55 percent more likely to delay graduation than their more affluent peers. Overall, 13% of students have delayed graduation, 40% lost a job, internship, or a job offer, and 29% expect to earn less at age 35 due to the pandemic. Lower income students are 55% more likely to have delayed graduation due to COVID-19 than their higher-income peers. According to a survey from the American Council on Education (ACE) and the

American Association of Collegiate Registrars and Admissions Officers (AACRAO), released in April, one in 10 college students reported that they weren’t certain they would return to school in the fall or had already decided not to attend because of the coronavirus. And an Art and Science Group survey of high school seniors found that one in six said they definitely or most likely will change their plans to attend college in the fall because of the coronavirus. Of those, 16 percent say they will take a gap year. About half of the students surveyed reported a parent or guardian had lost a job, been laid off, or been furloughed as a result of the pandemic. And a series of surveys from CIVIS Analytics in the spring found that high school parents, particularly black and Hispanics, reported their children’s plans after high school had changed.



Effectiveness of Mindfulness Interventions

A systematic review of mindfulness-based interventions (MBIs) published in the Journal of American College Health found that they show promise in promoting mental health in academic settings. In Mindfulness-based interventions in undergraduate students: a systematic review, the researchers observed that while most studies reported beneficial effects, many did not use physiological measures and follow-up assessments. One recent study, also published in the Journal of American College Health, found that an


Update on Hunger and Homelessness

According to a recent Gallup survey, only 17% of recent college graduates strongly agreed that their alma mater was passionate about the mental health of its students. Gallup conducted interviews in late 2019 with 1,617 U.S. college graduates who completed their bachelor’s degree between 2010 and 2019, finding that students’ views about their school were generally linked to supportive experiences with faculty and mentors. The data show that graduates who strongly agreed that their professors cared about them “as a person” were three times more likely to also strongly agree that their school was passionate about student mental health. And those who strongly agreed that they had a mentor who encouraged them to pursue their goals are more than twice as likely to


8-week mindfulness-based strengths practice improved student wellbeing and retention. The small preliminary, randomized controlled trial of 52 working undergraduates examined the effects of intervention along the five PERMA domains of well-being (Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment). It found that the intervention resulted in higher well-being, engagement, meaning, and health. Students in the intervention group also had higher retention rates for the following year than those in the control group.

also strongly agree that their school handles mental health issues strongly. Gallup also reports that students with mentors and caring professors are almost twice as likely to be thriving in their wellbeing as adults. While school size did not have an effect on students’ perception that their alma mater is passionate about mental health, non-profit versus for-profit status did appear to have an effect. Recent graduates of public and private notfor-profit schools are more than twice as likely as alumni from private for-profit schools to strongly agree that their alma mater is passionate about student mental health.


Coronavirus and Mental Health

In April, Active Minds, the nation’s premier nonprofit organization supporting mental health awareness and education for students, surveyed 2,086 college students about the impact of COVID-19 on their mental health. In the survey, 80% reported that COVID-19 had negatively impacted their mental health, and 1 in 5 said their mental health had significantly worsened. The most commonly reported impacts were stress or anxiety (91%), disappointment or sadness, and loneliness (80%). Over half (63%) reported that they were finding it challenging to stay connected with others, and 85% said that focusing on school and work


despite distractions was the most difficult challenge of the stay-at-home orders. However, 79% of college students felt hopeful about achieving their school-related goals and future job prospects despite the pandemic. The students surveyed highlighted several moves that school leaders should be considering for student mental health during and after the pandemic including increased academic support with accommodations and flexibility, additional mental health resources, more investment in counseling and coping resources, opportunities for social connection, and improved practices and protocols to pivot to remote learning in case of a future crisis.

Completion Rates and Disparities

According to a report from the National Student Clearinghouse Research Center, while the national six-year college completion rates continues to improve, there is a substantial disparity between full-time and part-time students. Only about one-third of part-time students who entered college in 2013 had graduated after six years, compared to about two-thirds of full-time students who graduated. After six years, more than half of part-time students

were no longer enrolled anywhere (51%), nearly two times more than the “stop-out rate� for full-time students (26%). Furthermore, the report states, the disparities are growing: the stop-out rate has increased for part-time students in recent years, while it has decreased for full-time students. Notably, the stop-out rate for part-time students was highest at for-profit, four-year colleges. 55.7% of students at these schools left by the sixth year without a credential.


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