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Medical Dialogue Review Volume 13, Issue 2


Reviewers

PRESIDENT

VICE PRESIDENT himari gunasinghe

zachary friedrich

CLUB ADVISOR emily anderson

EDITOR-IN-CHIEF

ART DIRECTOR

SENIOR EDITORS

CREATIVE Staffers

zelda p blair

aparna alankar maria goetz zahin ahmed jordan wilcox anette kaminaka

sora nithikasem

jessica gai zahin ahmed andy m=arino chris wu amodhya samarakoon sean li

Loren Kita Aastha Vasa Andrea Ouyang Aditi Desai Natalie Zhu Bailey Q Hall Richa Patel Lily Ge Md M Fahim Nicholas M Fell Eitan Natanzon Tiffany Truong Tom Zhang Simran Bharadwaj Jamie L Karns Ashmitha Mathukumar Tafaani Khan Ajay Jagjivan

Medical Dialogue Review SPRING 2019 | Volume 13 Issue 2 MDR is a New York University (NYU) student publication. We publish bianually and accept articles, essays, literary pieces, reviews, art and photography relevant to healthcare. Cover Art

ethics by Sorasicha Nithikasem Water Color Painting

This piece asks the reader to consider all the potential consequences, good and bad, of technological and scientific discoveries. The writing in the piece discusses ethics, and how this is intertwined with our progress in society.

Disclaimer: The contents of the journal, Medical Dialogue Review (MDR), represent perspectives of students, professionals, and patients on issues in healthcare. These ideas represent neither the opinions of the entire MDR membership nor of the institution, New York University (NYU). Information presented is reviewed for accuracy but should not be used for medical diagnosis or as a substitute for medical advice. NYU is not responsible for its contents.


Dear Reader: New York University’s mission statement emphasizes a value of cultivating cultural and intellectual diversity, “thriving beyond borders and across academic disciplines.� In line with this goal, the Medical Dialogue Review endeavors every semester to provide a platform for contributors to explore the overlap between medicine and the humanities. The Medical Dialogue Review is proud to present its twenty-fifth edition covering topics ranging from the effects of pollution on reproductive health to the bioethical considerations of animal research. We have put together articles that we believe cover highly relevant contemporary issues in hopes of encouraging further discussion among our readers and beyond. We hope that you find this publication both engaging and inspiring. We would like to thank all of the talented writers, reviewers, and artists that make up the editorial and creative teams for their efforts and their commitment to the Medical Dialogue Review. Additionally, we thank you, our readers, for your continued support and interest in this endeavor.

president

Zachary Friedrich

vice president

Himari Gunasinghe

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...in this ISSUE Clinical practice

The White Coat: A Necessary Garment or Mere Tradition?

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Restructuring Healthcare, One Block at a Time

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Anecdote vs Evidence Based Medicine: A Bioethical Dilemma

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Devarshi Vasa

Brendan Hyslop

Geet Shukla

Biomedical Research A Study on the Bioethics of Milk

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A Love-Hate Relationship between Drugs and the Brain

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Dan Ediriweera Erica Nebet

The Role of Nutrition in Limiting the Progression of Multiple Sclerosis 21 Julia Matthews

Contemplating Anesthetic Potential Nadja Zakula

Public Health & Policy

26

Marketing Homeopathic Medication

30

The Dangers of Diet Soda and Other Processed Foods

34

The Effect of Exercise on Cognitive Function

38

Sleep

40

Mismatching Markers: Why Minorities Need to Register

44

Sophie Spector

Karol Woloszyn

Anna-Maria Trachuk

Johanna Lim

Oishi Goswami

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Table of contents To Spit Or Not To Spit

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The Ramifications of Antimicrobial Resistance in India

50

Leen Azeez

Olivia Polk

Bioethics Contest Winner & Creative Section Do We Have a Duty to Die?

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Shadow

60

Insomnia

62

Apoptosis

63

Joseph Montesano

Jahnavi Tatachar

Chris Wu

Andy Marino

Artists

jessica gai

chris wu

P 38. 44

amodhya samarakoon sora nithikasem

P1, 15, 23, 27, 35,

sean li

41, 59

zahin ahmed

P 62

P 60

P 13, 52

P 9, 32

andy marino

P 63

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Medical Dialogue Review Volume 13 | Issue 2

The White Coat: A Necessary Garment or Mere Tradition? By Devarshi Vasa

"The Gross Clinic" byThomas Eakins Until the late 19th century, doctors were expected to wear formal, black clothing. While effective in concealing stains from bodily fluids, this apparel reflected the somber nature of the profession as black was “clearly the color of death and mourning” according to Dr. Dan Blumhagen, author of “The Doctor’s White Coat” (1979). Yet perhaps, such a drab choice in attire may have been apt for the 19th century, as medicine during this time period was based on an inaccurate understanding of the human body when now-archaic therapies were common. With little medical insight and high patient mortality, the profession as a whole was associated with death and suffering, and the physician’s black coats only helped in reinforcing this perception. When health care made its transition to a

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discipline anchored to scientific understanding and insight, the image of the hospital changed from “a place where social outcasts died” to “the only place where the sick could be healed” (Blumhagen, 1979). This transformation in the hospital’s image “from death to life” was bolstered by a change in the clothing of the “healing staff ” as hospitals made the switch from the black, dark attire to white laboratory coats (Blumhagen, 1979). Although the white coats were far more “difficult to launder,” they became commonplace in the medical field and “associated with the institutions of healing.” (Blumhagen, 1979). Eventually, the white coat replaced the black apparel of physicians and began to represent “bilateral protection, purity, [and] goodness” (Blumhagen, 1979).


clinical practice devarshi vasa

The coat instantly became a symbol of compassion and the image of doctors transformed into that of trustworthy professionals. Despite this, there has been a recent trend in pediatrics where the white coat is being replaced for everyday apparel. The DO magazine reveals that many pediatricians choose to not wear the white coat as they fear that their young patients will be more intimidated than they already are. According to Dr. Michelle Curtin, pediatricians such as herself were told during their residency training to never wear a white coat (Selby, 2018). She claims that wearing the white coat would trigger an “immediate and visceral fear reaction from young children” making it “impossible to get anything else accomplished” (Selby, 2018). However, it is important to consider whether this line of thinking is justified and if white coats truly hinder patients from perceiving their pediatrician as compassionate and trustworthy. While some pediatricians believe so, research suggests that the white coat may actually help benefit the physician-patient relationship and promote positive perceptions of pediatricians. Herbert Obu et al.’s (2013) investigation in particular reveals that in the pediatric setting, patients prefer their doctor to wear the white coat. By showing children three pictures of doctors: one dressed casually, one dressed formally, and another in a white coat, they reveal that almost 40% preferred the white coat which made it the most popular choice of attire (Obu et al., 2013). The children were then asked whether they wanted their pediatricians to continue wearing white coats, in which 62.1% replied positively (Obu et al., 2013). Moreover, children described pediatricians who wore white coats as more scientific and skilled, and stated that the coat made them feel more safe (Obu et al., 2013). Thus, the white coat may help subdue the propensity for children to be fearful when encountering a healthcare professional. However, one may argue that young children will be inherently afraid of injections and other painful procedures associated with the pediatrician and that this fear will overwhelm

any positive perceptions brought upon by the white coat. In other words, they claim that children will be unable to pick up the subtle connotations of good health and compassion that the white coat represents due to their fear of being in an unfamiliar atmosphere. However, this supposed inability of young children to associate the white coat with the image of an empathetic, reliable individual does not equate to their inability to notice displayed compassion or trustworthiness. Such a distinction gains value when given the process known as “enclothed cognition.” According to psychologist Hajo Adam and Adam Galinsky, the phenomenon known as enclothed cognition describes the influence that clothes have on the wearer’s thought processes and overall actions (2012). In fact, Adam and Galinsky found that randomly selected undergraduate students who wore a lab coat when completing a task made around half as many errors as those who did not wear the coat (2012). While this in itself is sufficient evidence in support of the white coat, their other finding may be even more compelling: the researchers found that when subjects wore a white coat described to them as an artist’s coat there was no increase in accuracy. That is, it was only when they wore the coats described to them as those of doctors that the accuracy of the participants significantly increased. Thus, wearing the lab coat resulted in “heightened attention during the task” only when physically worn and symbolically connected to healthcare (Adam and Galinsky, 2012). In other words, by both wearing the coat and identifying with the values, ideals, and responsibilities it embodies, the individual is more likely to fulfill the role that is assumed when putting it on. This simultaneity of two factors—the symbolic identifying and the physical wearing—demonstrates how wearing the white coat in a healthcare environment can allow a pediatrician to more efficiently fulfill his or her responsibility of being attentive and careful, a key ideal of pediatric care. Being psychologically encouraged to be more attentive to their task, they will be perceived as more trustworthy by their patients since the

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Medical Dialogue Review Volume 13 | Issue 2 child will be met with a more dependable individual. Nevertheless, one may claim that it merely serves to promote an elitist view of doctors and establish a hierarchy between physician and patient. However, recent research surrounding the white coat and its implicit subtexts do not corroborate such line of thinking. Through semantic analysis of White Coat Ceremonies of medical schools across the country, Orit Karnieli-Miller et al. (2012) determined that white coat ceremonies emphasized “obligations rather than privileges” (Karnieli-Miller et al., 2012). They also revealed that “statements about pride of place, selectivity, privileges and honour [were] rare” as the ceremonies emphasized “the importance of humanism” instead (Karnieli-Miller et al 2012). This finding shows that the white coat does not in fact serve to create a hierarchy or reflect elitism, but rather, serves as a “cloak of caring and compassion” (Karnieli-Miller et al 2012). Additionally, some argue that even if white coats did indeed establish a hierarchy between the child and pediatrician, it would be irrelevant since there is already a prominent, pre-existing hierarchy due to the sharp age gap. Sociologists Jan Mason and Sharon Bessell go as far as to say that such hierarchy may actually be beneficial for the child as a generational gap is “crucial to children's social positioning” (2017). That is, “age‐based hierarchies under-

pin social relations” and this “generational positioning is understood as fundamental to the social processes in which children's lives are lived” (Mason and Bessel 2017). Thus, this age-based hierarchy might in fact be necessary for the child to understand the role that the physician fulfills and help nurture the pediatrician-patient relationship. Ultimately, while the current trend in pediatrics is to abandon the white coat, research indicates that the coat in fact promotes a positive relationship between the pediatrician and the patient. All pediatricians are highly skilled individuals who have gone through decades of training to learn how to effectively treat children. They must not only represent highly educated individuals, but also those who are caring and compassionate. The white coat serves to complete this image of a pediatrician and allows patients to garner the necessary trust and confidence for their healthcare provider. This would benefit the patient’s psychological well-being, eventually translating to physical healing. Understanding the centrality of the white coat in the physician-patient dynamic, and acknowledging that something as seemingly insignificant as the physician’s attire has the potential to affect the quality of care is crucial if we wish to set a higher standard in the field of healthcare.

Adam, H., & Galinsky, A. D. (2012). Enclothed cognition. Journal of Experimental Social Psychology,48(4), 918-925. doi:10.1016/j.jesp.2012.02.008 Blumhagen, D. W. (1979). The Doctors White Coat. Annals of Internal Medicine,91(1), 111. doi:10.7326/0003-4819-91-1-111 Chinawa, J., Eke, B., Ekwochi, U., Agwu, S., Obu, H., Manyike, P., & Obi, I. (2013). Pediatrician wearing a white coat: A survey of preferences among children and their care givers. Annals of Tropical Medicine and Public Health,6(5), 508. doi:10.4103/1755-6783.133699 Eakins, T. (1875). The Gross Clinic [Painting]. Philadelphia Museum of Art, Philadelphia, Pennsylvania. Karnieli-Miller, O., Frankel, R. M., & Inui, T. S. (2012). Cloak of compassion, or evidence of elitism? An empirical analysis of white coat ceremonies. Medical Education,47(1), 97-108. doi:10.1111/j.13652923.2012.04324.x Mason, J., & Bessell, S. (2017). Children’s Lives: Taking Account of the Social. Children & Society,31(4), 257-262. doi:10.1111/chso.12226 Shelby, L. (2018, April 23). Physician dress: Is the white coat becoming a fashion don't? Retrieved March 8, 2019, from https://thedo.osteopathic.org/2015/04/physician-dress-is-the-white-coat-becoming-afashion-dont/

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clinical practice brendan hyslop

Restructuring Healthcare, One Block at a Time By Brendan Hyslop

Photograph by Sean Li Three blocks of uniform mass are connected by massless strings and suspended from a hook. What is the tension in the string between the middle and bottom blocks? Problems of this type are common in physics courses when classical mechanics are being investigated, though this schematic extemporaneously illustrates another technical concept—that of blockchain. Blockchain is a fairly novel technology in which blocks of data are chained together chronologically in a database (Fortney 2019). For a block to be added to the top of the chain, a network of computers must first verify its information and assign it a unique code called a hash, coupled with the hash of the block immediately downstream to it (Fortney 2019). This makes editing the information contained within a block highly improbable, as doing so

would generate for it a new hash that would in consequence force every block upstream from the changed block to need to also be edited to still fit into the chain (Fortney 2019). The network of computers connected to the blockchain each receive a new, updated copy whenever a block is added (Fortney 2019). Information on a blockchain is displayed openly—to those with access to said blockchain—only on the basis of general information referred to as an entity’s public key (Fortney 2019). Everything else is only accessible by a private key held by said entity (Fortney 2019). Though commonly associated with cryptocurrencies like Bitcoin and Ethereum, as a standalone technology blockchain has numerous prospects for broader application, including in healthcare (Fortney 2019).

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Medical Dialogue Review Volume 13 | Issue 2 Picture this: a middle-aged professional travels frequently on extended business trips, and sometimes faces health complications while away from home. He has been to hospitals and clinics in Chicago, Phoenix, Boston, Los Angeles—all over the country. With current electronic medical records it can be easier for providers in different cities on different computer systems to access his medical history than before, though it is still a lengthy and convoluted process that hinders the delivery of care. There are no centralized systems or methods of rapid communication that ensure health data is available when clinical decisions may be highly influenced by it. This is not only a system of inefficiency, but can put patients at risk. Blockchain offers a potential solution. A national blockchain for patient information can offer a secure medium by which data can be stored and shared among providers, while only being identifiably accessible to those with the patient’s private key (Yukhymenko 2018). The hurdles of current medical record sharing—time, security, trust, authenticity—can be overcome (Yukhymenko 2018 & Sharma 2017). Additionally, it is understood in healthcare that medical data is owned by the patient to which it belongs, though it is often hard to grant the patient access to their data (Yukhymenko 2018). Since the blockchain would contain minimal public information, and each block would be stored across the network and unchangeable, patients could be securely given access to their data without worries of loss or manipulation (Yukhymenko 2018). Additionally, wearable medical technologies that allow for remote patient monitoring have become popular in the past decade, and blockchain prospectively offers an efficient solution to transferring data collected to a patient’s electronic medical record (Dwivedi et al. 2019). As such, using blockchain for electronic medical record management could serve as a catalyst for interoperability and drive better health outcomes (Krawiec & White 2016 & Vazirani et al. 2019).

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Following this same broad model for data management, blockchain opens new doors for clinical trials and the field of genomics. Errors in clinical trial data—whether deliberate or not—can be challenging to identify given the immense volume of information collected and stored (Yukhymenko 2018). Clinical trials cost millions to billions of dollars, and given these high stakes that rely on positive outcomes, fraud is an issue worth noting (Yukhymenko 2018). Data can be omitted, manipulated, fabricated—anything to make it look better than it actually is (Yukhymenko 2018). This can be dangerous to patients hoping to benefit from products or pharmaceuticals being tested, as they may spend huge amounts of money on ineffectual therapies, or worse, be subjected to ones with understated adverse effects. Blockchain provides a solution for regulators in its unchangeability, making fraud much harder to commit if all data is to be kept in such a verifiable and open manner (Yukhymenko 2018). It also provides a solution to researchers who are looking to more easily collaborate cross-institutionally, for the same reasons that it works well with electronic medical records (Yukhymenko 2018). Genomics data is also substantial in size and in the computational power required to generate and reference it, and faces the same issues as electronic medical records regarding data ownership and accessibility (Ozercan et al. 2018 & Shabani 2019). Blockchain can distribute computational power across the computers on the network hosting it, alleviating that burden from a single system (Ozercan et al. 2018). It can also, like with electronic medical records, allow for shared, secure access to genome data (Ozercan et al. 2018). Another, often understated problem in healthcare is the prevalence of counterfeit drugs, largely in developing countries, which produce a $200 billion market annually (Yukhymenko 2018). The most severe problem with these fakes is that they are low-quality, low-detail replicas that often contain unbalanced or even omit therapeutic agents (Yukhymenko 2018).


clinical practice brendan hyslop

This can prevent people from getting better from an illness, and in some cases, even make them worse, so it is in the interest of global health to curb this fraudulent sector. Blockchain can allow for authentication of pharmaceuticals by creating a public ledger to which only authorized drug manufacturers, wholesalers, and pharmacists can contribute, allowing for tracking and verification of the entire product supply chain (Yukhymenko 2018). Without this capability, fake drugs can enter at any point of the supply chain, ultimately making their way to patients in need (Yukhymenko 2018). Blockchain is a revolutionary technology with a wide array of prospective applications in the realm of healthcare. However, it is important to note that all its proposed solutions are just that, proposed, and hence wide-scale implementation has yet to be observed. Translation from paper to practice may not be seamless

and will certainly mandate time and broad collaboration. Blockchain is also computationally-expensive—it requires significant technical power and infrastructure—and hence systems that do not have these resources will struggle to benefit from it (Dwivedi et al. 2019). Creating a new blockchain can be quite hefty financially (McFarlane 2019). It is also still a mostly unfamiliar technology—many may have heard of it, but inherently associate it with cryptocurrencies—so expanding public knowledge is also a challenge (Vazirani et al. 2019). Nevertheless, however, blockchain is a promising technology that has the potential to transform the healthcare space, allowing for data to be used more efficiently and effectively.9 It can drive better health outcomes (McFarlane 2019). It can further healthcare towards reaching its intrinsic goal—health for all.

References Dwivedi, A. D., Srivastava, G., Dhar, S., & Singh R. (2019). A Decentralized Privacy-Preserving Healthcare Blockchain for IoT. Sensors, 15(2). pp. 326. Fortney, L. (2019, February 10). Blockchain, Explained. Retrieved from https://www.investopedia.com/terms/b/ blockchain.asp Krawiec, R. & White, M. (2016, August). Blockchain: Opportunities for health care. Retrieved from https://www2. deloitte.com/us/en/pages/public-sector/articles/blockchain-opportunities-for-health-care.html McFarlane, C. (2019, February 7). Why The Next Evolution Of Global Health Care Will Be Blockchain-Based. Retrieved from https://www.forbes.com/sites/chrissamcfarlane/2019/02/07/why-the-next-evolution-of-globalhealth-care-will-be-blockchain-based/#55f3fcbb43ac Ozercan, H. I., Ileri, A. M., Ayday, E., & Alkan, C. (2018). Realizing the potential of blockchain technologies in genomics. Genome Research, 28(9). pp. 1255-63. Shabani, M. (2019). Blockchain-based platforms for genomic data sharing: a de-centralized approach in response to the governance problems? Journal of the American Medical Informatics Association, 26(1). pp. 76-80. Sharma, U. (2017, October 30). Blockchain in healthcare: Patient benefits and more. Retrieved from https://www.ibm. com/blogs/blockchain/2017/10/blockchain-in-healthcare-patient-benefits-and-more/ Vazirani, A. A., O'Donoghue, O., Brindley, D., & Meinert, E. (2019). Implementing Blockchains for Efficient Health Care: Systematic Review. Journal of Medical Internet Research, 12(2). pp. 12439. Yukhymenko, C. (2018, December 17). What are the use cases for blockchain tech in healthcare? Retrieved from https://www.ibm.com/blogs/blockchain/2018/12/what-are-the-use-cases-for-blockchain-tech-in-healthcare/

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Medical Dialogue Review Volume 13 | Issue 2

Anecdote vs Evidence Based Medicine: A Bioethical Dilemma By Geet Shukla Modern medicine is a scientific discipline aimed at merging accurate diagnoses with cutting-edge clinical care, but this hides the fact that doctors tell stories too. Currently, there has been an increased push for standardization of medicine and the downfall of private practice in the United States and other first world countries, which is strikingly displayed by the 24% decrease of private practice from 2000 to 2015 (Francis 2015). Considering this, there has been a gradual shift away from anecdotal medicine towards evidence-based medicine in the United States and in other first world countries, necessitating discourse on the merits of both systems. On the one hand, anecdotal medicine sends a very clear message: people pass on knowledge through stories about what worked and what didn’t. Anecdotes are real events passed on through the use of stories in everyday life. In the case of medicine, this story is an individual’s experience with a disease and which treatment proved most effective. Evidence based medicine, by contrast, demands a more rigorous method of treatment through randomized controlled trials and data analysis (Yusuf 2004). This dichotomy becomes especially relevant in public health policy and bioethics. Both of these forms of medicine are influential in the field but encounter problems in their implementation, meaning that a balance of the two must be practiced to successfully provide care in the most effective way possible. Anecdotal medicine has long been the standard of care that practicing physicians are expected to meet. This type of clinical practice inherently makes a lot of sense: it is a story by which we can derive conclusions and learn from the experiences of others (Novella 2008).

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The case study is a perfect example of how anecdote-based medicine is an effective tool for medical inquiry: it is a very detailed consideration of only one patient or small group of patients. Let us consider the treatment for a certain rare disease that has been investigated using heavy clinical research trials, which are required for evidence-based medicine. A patient affected with this disease is most likely to go to a specialist, someone who has seen a case of this before or who has experience dealing with similar diseases. Moreover, this patient, upon going to a specialist, is likely going to be prescribed an “experimental drug”. However, this drug may be vulnerable to circumstance: the treatment may have worked for the last patient not because of the effect of the drug, but rather because the condition improved on its own. Is it then ethical to prescribe something that might not work or could potentially have negative consequences? At the same time, isn’t taking the drug better than doing nothing and hoping that the disease will run its course? Anecdote-based medicine, which relies on a doctor’s personal experience with prior treatments and medical knowledge, is less time-consuming for the doctor but removes accountability in the sense that doctors cannot confirm their results with hard evidence. On the other hand, there is also an increased sense of responsibility because the doctor has to rely on their own anecdotes and defer to their own experience. It relies more on intuition and experience of the individual doctor, meaning that there is more of a personal stake in the matter but that fewer variables can be controlled and more of the result is up to chance.


clinical practice

geet shukla

"Anecdotal" by Zahin Ahmed This introduces the possibility of confounding variables due to lack of randomization and other experimental measures. Anecdotes are subject to problems such as: dealing with multiple treatment options from conflicting or ambiguous anecdotes; qualitative measurement because of the lack of experimental measures; the placebo effect which provides another confounding variable that could potentially the cause of a treatment working; and the fallibility of memory (Enkin 1998). It may be possible to address a few of these problems through proper education on publishing and interpreting case reports, but the fact remains that anecdotes inherently carry these dangers. Despite these failings, anecdotal medicine has upsides as well. First of all, anecdotal medicine is easier to implement and more cost effective. Moreover, anecdotes play such a large role in current thinking that it would be worth implementing into public policy. Anecdotes influence unconscious biases on a very minute level, so that a medical professional might advertise and even prescribe a treatment just because it has worked before. From a public policy perspective, evidence-based medicine is the preferred method for developing new treatments. Policies target-

ed towards physicians specify large cohorts of randomized controlled trials to limit any biases under the strict supervision of medical research councils (Guyatt et. al. 1992). However, these types of trials are becoming increasingly complicated and time-consuming, because of the built-in bureaucracy and costs involved. Each study costs upwards of 50 million dollars, a price tag that is even higher in specialties such as oncology and respiratory system diseases (U.S. Department of Health & Human Services 2014). The caveat of evidence-based medicine is in the merger of scientific research with medicine: that concrete conclusions can be derived reliably. While this conundrum may seem unsolvable, there is a significant amount of time and money invested in solving them. Realistically, both evidence-based medicine and anecdotal medicine must be used together to diminish the ethical risks of both and allow for better treatment of patients. This combination of practices is best exemplified in a case study done in 2001 (Kosko et. al. 2006). In this study, a four-year-old boy with autism was given a treatment known as secretin that was given based on anecdotal evidence.

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Medical Dialogue Review Volume 13 | Issue 2 This treatment ended up improving the symptoms of the patient and underwent clinical trials under the guidelines of evidence-based medicine to find out why the patient had improved, leading to a new treatment option for autistic patients. Both anecdotal and evidence-based medicine can be combined in the sense that a new treatment could be developed anecdotally and then tested using evidence-based guidelines. This also brings up another interesting point: that different specialties can incorporate different levels of both of these types of medicine. Psychiatry, for example, might use more anecdotal medicine since evidence-based information is harder to come by and where research is still new and untested in the field (Gupta 2007). Oncology research, by contrast, is highly regulated via evidence-based medicine. Each type of cancer and each treatment is carefully selected based on what worked, leading to a large volume of data in this field (Lewis 2004).

Anecdotal medicine and Evidence-based medicine both present a new way of analyzing problems in the medical field. While anecdotal medicine encounters problems in deriving solid conclusions, it is easier to implement, and it plays into how humans think. Evidence-based medicine introduces academic rigor and puts treatments under scrutiny but is extremely expensive and time-consuming. The most ethically viable incorporation of these two types of medicine would be to use them in combination, but the specialty within medicine, the specific disease being treated, and the effectiveness of treatment strategies must all be taken into consideration. However, with these systems in place, we can create a better healthcare system that emphasizes the importance of controlling confounding variables with evidence-based medicine while allowing doctors to tell their stories.

References

Enkin, M. W., & Jadad, A. R. (1998). Using anecdotal information in evidence-based health care: Heresy or necessity? Annals of Oncology,9(9), 963-966. doi:10.1023/a:1008495101125 Francis, J. (2015, July 29). Many U.S. Doctors will Leave Private Practice for Hospital Employment, Accenture Reports. Accenture. Retrieved from https://newsroom.accenture.com/ne ws/many-us-doctors-will-leave-private-practice-for-hospital-employment-accenture-reports.htm Gupta, Mona (2007). Does evidence-based medicine apply to psychiatry? _Theoretical Medicine and Bioethics_ 28 (2):103 Guyatt G, Cairns J, Churchill D, et al. Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine. JAMA. 1992;268(17):2420–2425.doi:10.1001/jama.1992.03490170092 032 Kosko J, Klassen TP, Bishop T, Hartling L. Evidence-based medicine and the anecdote: Uneasy bedfellows or ideal couple?. Pediatric Child Health. 2006;11(10):665–668. Lewis, S. J., & Orland, B. I. (2004). The Importance and Impact of Evidence Based medicine. Journal of Managed Care Pharmacy, 10(5 Supp A). doi:10.18553/jmcp.2004.10.s5-a.s3 Masic I, Miokovic M, Muhamedagic B. Evidence based medicine - new approaches and challenges. Acta Inform Med. 2008;16(4):219-25. Novella, S. (2008, April 27). The Role of Anecdotes in Science-Based Medicine. Retrieved from https://sciencebasedmedicine.org/the-role-of-anecdotes-in-science-based-medicine/ U.S. Department of Health & Human Services. (2014). Examination of Clinical Trial Costs and Barriers for Drug Development. Retrieved from: https://aspe.hhs.gov/report/examination-clinical-trial-costs-and-barriers-drug-development Yusuf S. Randomized clinical trials: slow death by a thousand unnecessary policies?. CMAJ. 2004;171(8):889-92; discussion 892-3.

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biomedical research dan ediriweera

A Study on the Bioethics of Milk By Dan Ediriweera

"Milk" by Sorasicha Nithikasem Abstract: Glancing at the ingredients for milk, one reads that it is a soup of protein, calcium, and vitamins. Until recently, little was mentioned of the possible harm that may exist in this simple product. Even less has been explored on the political implications of milk. This study analyzes the evolution of research on the use of growth hormones, antibiotics, and pesticides on milk and the effects and implications on humans.

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Medical Dialogue Review Volume 13 | Issue 2 An exploration into the components of milk, cannot commence without an exploration into its most popular contender-- the growth hormone, rBGH. The recombinant bovine growth hormone is synthesized using genetic technology, to mimic the natural form (BST) found in cattle which promotes growth and cell replication. Thus, rBGH was marketed towards dairy farmers, to increase milk production (“Recombinant Bovine Growth Hormone”, 2014). This hormone brought attention to the existence of possibly harmful ingredients in milk, with people advocating for more research and explanations on the purpose of rBGH, and other added ingredients. Common questions include why rBGH was approved by the FDA in 1993, when it is not allowed in the European Union, Canada, and other countries (“Recombinant Bovine Growth Hormone”, 2014). The simple answer is -- it does not directly harm people. BGH is not active in people, as humans do not have receptors for BGH, so even when it’s absorbed by the human body via milk, it would not directly have any health effects (“Recombinant Bovine Growth Hormone”, 2014). However, rBGH is not a completely harmless contender, as rBGH causes cows to develop more udder infections (mastitis) --the primary reason Canada banned it (“Position Statement on rBGH”). It is animal cruelty to use this growth hormone knowing that it causes mastitis. However, this also affects humans as these cows require more antibiotics than cows not given rBGH. This is worrisome as antibiotics used in animals that provide food ultimately lead to antibiotic resistance in humans. Antibiotic resistance is humans, from their food sources, has become a global crisis. This is especially an issue in milk products, because if the 3% of resistant bacteria that can’t be killed through pasteurization, contained a drug-resistant strain, the human host will adapt to this and consider it, and similar bacteria strains, not harmful (“Position Statement on rBGH”). Furthermore, both the natural and recombinant forms of the hormone stimulate milk production in a cow by increasing the levels

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of another hormone known as insulin-like growth factor, IGF-1. IGF-1 is a hormone that stimulates cell growth, but at the high end of the normal range, IGF-1 can influence the development of tumors as it may continue to stimulate excess cell growth (Malekinejad 2015). Early studies have also found relationships between blood IGF-1 levels and the development of prostate, breast, colorectal, and other cancers (“Recombinant Bovine Growth Hormone”, 2014). Furthermore, the IGF-1 found in milk is not denatured by pasteurization and the extent to which active IGF-1 is absorbed by the human digestive tract is uncertain (“Recombinant Bovine Growth Hormone”, 2014). It is unclear if the consumption of rBGH milk causes significant levels of blood IGF-1 in comparison to other products, as some studies found similarly high levels of blood IGF-1 from the consumption of soy milk (“Position Statement on rBGH”). Also, IGF-1 levels are found to be slightly higher in rBGH milk, but the level difference is too small to conclude that it wasn’t caused by chance or other natural factors. Thus, rBGH could potentially be carcinogenic—but further research is needed before such a conclusion can be made. Milk with rBGH—this potentially carcinogenic, common household good was on the shelves until the 2000s. Until 2007, the lowcost milk option in Walmart and Great Value, contained rBGH (Mikkelson 2008). Moreover, until 2011 the store brand, Lucerne, in Safeway contained rBGH (“Safeways Lucerne Dairy Brand Goes rBST Free”). Thus, today, while the use of rBGH is still allowed in the United States, it has become an increasingly unpopular option fortunately. The use of rBGH becoming unpopular does not, however, mean that it is the same case for the use of antibiotics. Today, the low-cost rBGH milk option versus normal conventional milk has evolved into a distinction between organic and conventional milk. Organic milk is given the label organic based on there being no chance of the cows being given antibiotics or growth hormones.


biomedical research dan ediriweera

With conventional milk, once a cow gets sick and requires antibiotics, the cow will be given that antibiotic and the milk they give while on antibiotics is ridden of. Then, several days after the cow is off the antibiotic, the cow’s milk is accepted. However, with organic products that are antibiotic-free, when a cow requires antibiotics, they are given the antibiotics and their milk is not used again (Dahl 2013). Organic milk is also healthier for individuals as it has an omega-6 to omega-3 ratio of 2.3 to 1, which is the best balance for heart health. This is especially important as a omega-3 helps maintain a healthy heart and low blood pressure, and a balance with too much omega-6 is linked to heart disease, cancer, inflammation and autoimmune diseases (Dahl 2013). When comparing these continuing patterns, it becomes clear that one gets what they pay for. To make the best decision for one’s health, they must be willing to pay extra—for

milk that does not potentially cause cancer. Thus, there is one group that is most at risk— the group that cannot afford the alternative. Low income individuals make up the majority of those that choose the store brand milk. They are the ones that bought milk with rBGH for the longest time. Also, low income individuals are the ones with a statistically significant higher chance of developing breast, prostate, and lung cancer (Clegg 2008). Not enough research has been conducted to clearly distinguish milk -- a staple food item -- as a reason for the high correlation between low income and cancer. There are, most likely, many other factors at play here -- but milk could be one of them. More research is necessary before any conclusion can be made. The debate over rBGH is an old one, but it not over.

References Clegg, L. (2008, November 12). Impact of socioeconomic status on cancer incidence and stage at diagnosis: Selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711979/ Dahl, M. (2013, December 10). Yep, organic milk really is better for you than regular milk. Retrieved from https://www.nbcnews.com/healthmain/yep-organic-milk-really-betteryou-regular-milk-2D11712970 Health Care Without Harm. Position Statement on rBGH. Retrieved from https://noharm.org/sites/default/files/lib/downloads/food/HCWH_Position_on_rBGH.pdf Malekinejad, H. (2015, June). Hormones in Dairy Foods and Their Impact on Public Health - A Narrative Review Article. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4524299/ Mikkelson, D. (2008, March 23). FACT CHECK: Wal-Mart Milk and rBST. Retrieved from https://www.snopes.com/fact-check/wal-mart-milk/ Recombinant Bovine Growth Hormone. (2014, September 10). Retrieved from https://www.cancer.org/cancer/cancer-causes/recombinant-bovine-growth-hormone.html Safeway's Lucerne Dairy Brand Goes rBST Free. (2011, June 4). Retrieved from https://storebrands.com/safeways-lucerne-dairy-brand-goes-rbst-free

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Medical Dialogue Review Volume 13 | Issue 2

A Love-Hate Relationship between Drugs and the Brain By Erica Nebet “Don’t do drugs,” they told us. “Drugs are bad.” “What does this mean? How can drugs be bad if my doctor prescribed them? How are we to discern whether a drug is good or bad?” we think. Neuroactive drugs are everywhere. From the coffee your sibling brews every morning to your friend’s anxiolytic medication and your parent’s cigarette addiction that they just can’t kick, these drugs play a role in modulating neuronal networks in order to achieve the effects that they produce. But how are we to distinguish the good from the bad? Sigmund Freud was a cocaine addict, Mozart and Beethoven were alcoholics, and former U.S. president Thomas Jefferson grew opium (1). Even in pop culture, Arrested Development’s Lucille Bluth almost always has a drink in her hand, a number of Marvel and DC superheroes would not have attained their powers if it were not for experimental drugs, and Breaking Bad would not exist without methamphetamine (2,3). Still, what determines if a drug will be bad for us? The answer to this question lies within an understanding of the mechanism of action of the drug in question. Neuropharmacology is the study of the effects that drugs have on neuronal networks within the brain. The nervous system is composed of individual cellular units known as neurons, but, in addition to the cell bodies that contain the nucleus, these have processes that extend off of the cell body, known as axons and dendrites. It is these other features, collectively referred to as neurites, which allow for the transfer of electrical signals from neuron to neuron via the exchange of chemicals between the two. When two neurons connect, they form a synapse, which is where they communicate with each other through neurotransmitters. In every case, there is a pre- and post-synaptic cell. Usually, the signal is received by the post-synaptic cell on its dendrites, and it moves to the cell body.

"Happy Pills" by Sorasicha Nithikasem

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biomedical research erica nebet

Figure 1:Schematic of a neuron

Figure 2:Schematic of a Synaptic Transmission

If it is of sufficient strength, a new signal called an action potential will be generated to propagate down the axon, which will then form the presynaptic side of a synapse between itself and the next cell (4). The majority of drugs serve to modulate this process of synaptic transmission. When a spreading signal reaches the end of the axon, vesicles full of neurotransmitters are released from the axon terminal. Neurotransmitters go on to bind receptors on the post-synaptic cell, and these molecules can either serve as agonists, which activate the receptor, or antagonists that block the receptor. In doing so, they initiate what can be thought of as a love or a hate relationship wherein agonists love and antagonists hate the receptor in question. In the brain, drugs act through synaptic receptors as either agonists or antagonists. Through this, they too can engage in the love-hate relationship model of neurotransmission (4). Xanax According to the Drug Enforcement Administration, Xanax is both the most prescribed and most abused drug in the United States (5). As a nervous system depressant, it serves as an effective treatment for anxiety, primarily for panic disorder and generalized anxiety disorder. During heightened states of stress, the amygdala, an almond-shaped brain structure, responsible for emotional, especially fear, responses, becomes overactive. Xanax is effective in such cases because it works to suppress nervous system activity. It does so by serving as an agonist for Îł-amminobutyric acid-A (GABAA) receptors in the brain (6). The activation of these receptors leads to the quick inhibition of the postsynaptic cell. In the case of overactive excitatory activity in the amygdala, the action of this drug will reduce the firing of these cells and, thus, the stress response. So, this treatment is most effective for patients who exhibit a lack of inhibitory brain activity. Therefore, when Xanax is abused, an individual may experience cognitive deficits or psychomotor impairment. This is because one who unnecessarily takes the drug will experience an increase in GABAA receptor activity, leading to more inhibition than experienced neurotypically. Such inhibition can prevent them from executing a variety of essential functions. Furthermore, depending on the individual who uses Xanax, it can either serve as an effective treatment or have deleterious effects.

Figure 3:A loving relationship between Xanax and GABA (A) Receptors

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Medical Dialogue Review Volume 13 | Issue 2 Lysergic Acid Diethylamide Lysergic acid diethylamide, also known as LSD, is a hallucinogenic compound that leads to altered thoughts, feelings, and awareness of one’s surroundings. It was first accidentally synthesized by Albert Hoffmann, who was studying lysergic acid derivatives and synthesized LSD by chance. Without yet knowing its effects, he went home and reported not feeling very well – he actually experienced a hallucinogenic trip. A lot of the specifics concerning LSD’s mechanism of action remain unknown (7); it has been shown to activate a variety of receptors, including serotonin, dopamine, epinephrine, and glutamate receptors. Its hallucinogenic effects are due primarily to the fact that it serves as an agonist of serotonergic receptors, but why this leads to hallucinations is unknown. Still, the drug is often used recreationally to induce such trips, though many who partake claim that it also sharpens their thinking and enhances creativity. These effect have contributed to the increasingly popularized practice of microdosing, or taking a very small amount, of psychedelic drugs to increase one’s ability to focus. Yet, it is unknown whether this is a direct effect of microdosing, and many scientists are beginning to pioneer studies to explore this question. Thus, LSD may have a therapeutic potential. Even Hoffman is believed to have microdosed LSD in his old age (8). Figure 4: A loving relationship between LSD and serotonin receptors.

Cannabis When people think of cannabis, commonly referred to as marijuana, one of the first things that comes to mind is the ‘high’ it produces. However, the plant Cannabis stavia consists of two major components: tetrahydrocannabinol (THC), the major psychoactive component, and cannabidiol (CBD), the major non-psychoactive component. When ingested together, cannabis will often produce the expected ‘high’ as well as lead to changes in perception and an increased appetite though its components act on two different receptor systems. THC activates cannabinoid-1 (CB1) receptors, which function to reduce inhibitory transmission due to GABA receptors (7). Through its agonism of these receptors, cannabis is able to produce its psychoactive effects. Yet, in cases wherein one experiences an increase in excitatory activity in various brain regions, this action can be therapeutic as it works to establish a neurotypical balance between excitation and inhibition. Most cannabinoids achieve such effects by activating cannabinoid receptors; however, CBD has a low binding affinity for these receptors. Instead, it has been shown to effectively bind to the receptor GPR55, which is part of a class of receptors knows a G-coupled protein receptors that function through the activation of various G-proteins. CBD, in particular, acts as an antagonist of the receptor GPR55, and this action has been shown to decrease the extent of excitatory activity in a variety of brain regions, including the hippocampus (9). Since the hippocampus is a major seizure focus, many believe that CBD can be used as an effective anticonvulsant therapeutic. In fact, double-blind placebo clinical trials have demonstrated that CBD is an effective treatment for two forms of refractory epilepsy: Dravet and Lennox-Gastaut syndromes(10,11) Therefore, CBD is being increasingly recognized as a treatment for seizures. Moreover, dissecting apart the major components of cannabis allows scientists to interrogate their specific effects, and doing so has shown that CBD can alleviate symptoms of a variety of disorders without causing the patient to endure a ‘high,’ which is not essential to their treatment. Overall, the answer as to whether a specific drug is bad is not as simple as ‘yes’ or ‘no;’ it depends on the action of the drug and the status of the person at hand. This is because every drug acts to modulate certain receptor systems, which can affect individuals differently.

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biomedical research erica nebet Therefore, the best way to obtain a clearer response to this question is to better understand of how drugs function, such as through a model of love-hate relationships. This manner of thinking poses the idea that a drug can either love, to excite a receptor or hate, to inhibit, a receptor. With this dichotomy, the general public can more easily assess what drugs such as Xanax, LSD, and cannabis, among others, will do to make a more informed decision as whether to use them. Figure 5: A loving relationship between THC and CB1 receptors

Figure 6: A loving relationship between CBD and GRP55 receptors.

References (1) How Drugs Are Affecting American Pop Culture. Evergreen Drug Rehab Blog. https://www.evergreendrugrehab.com/blog/how-drugs-are-affecting-american-pop-culture/. Published January 30, 2019. Accessed March 9, 2019. (2) Raynor M. 31 Fictional Characters Who Battled Drugs and Alcohol. Mashable. https://mashable.com/2014/06/23/fictional-characters-substance-abuse-infographic/#1ByY8Yw5Kgq1. Published June 24, 2014. Accessed March 9, 2019. (3) Mitchell N. Super-High: 16 Superheroes RUINED By Drugs. CBR. https://www.cbr.com/superheroes-ruined-bydrugs/. Published July 19, 2017. Accessed March 9, 2019. (4) Meyer JS. Psychopharmacology: Drugs, the Brain, and Behavior. New York, NY: Oxford University Press; 2019. (5) DrugAbuse. The Effects of Xanax Abuse. DrugAbuse. https://drugabuse.com/xanax/effects-use/. Published December 3, 2018. Accessed March 20, 2019. (6) Meyer JS. Psychopharmacology: Drugs, the Brain, and Behavior. New York, NY: Oxford University Press; 2019. (7) Meyer JS. Psychopharmacology: Drugs, the Brain, and Behavior. New York, NY: Oxford University Press; 2019. (8) Boseley, Sarah. First ever trials on the effects of microdosing LSD set to begin. The Guardian. https://www.theguardian.com/science/2018/sep/01/first-ever-trials-on-the-effects-of-microdosing-lsd-set-to-begin. Published September 1, 2018. Accessed March 30, 2019. (9) Sylantyev, S. et. al. Cannabinoid- and lysophosphatidylinositol-sensitive receptor GPR55 boosts neurotransmitter release at central synapses. PNAS. Published March 16, 2013. Accessed March 30, 2019. (10) Devinsky, O. et. al. Trial of Cannabidiol for Drug-Resistant Seizures in the Dravet Syndrome. NEJM. Published (11) Devinsky, O. et. al. Effect of Cannabidiol on Drop Seizures in the Lennox–Gastaut Syndrome. NEJM. Published May 17, 2018. Accessed March 30, 2019. Figure 1: https://socratic.org/questions/how-is-a-neuron-adapted-to-perform-its-function Figure 2: http://www.somerealitybites.com/the-snappy-synapse/ Figure 3: https://pubchem.ncbi.nlm.nih.gov/compound/2118#section=Top https://www.google.com/search?q=gaba+receptor&client=firefox-b-1-ab&source=lnms&tbm=isch&sa=X&ved=0ahUKEwj7-Yi0n_TgAhUhh-AKHZjlAGkQ_AUIDigB&biw=1280&bih=578#imgrc=RP5j_6TQffv_KM: Figure 4: https://pubchem.ncbi.nlm.nih.gov/compound/3981#section=Top https://en.wikipedia.org/wiki/5-HT_receptor Figure 5: https://pubchem.ncbi.nlm.nih.gov/compound/2978 https://www.google.com/search?q=cb1+receptor&client=firefox-b-1-ab&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjep_LxoPTgAhXGhOAKHc6FAfgQ_AUIDygC&biw=1280&bih=578&dpr=2.5#imgrc=R5ONkta_aiV3mM: Figure 6: https://pubchem.ncbi.nlm.nih.gov/compound/cannabidiol http://www.iqm.csic.es/transferencia-de-tecnologia/?lang=en

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Medical Dialogue Review Volume 13 | Issue 2

The Role of Nutrition in Limiting the Progression of Multiple Sclerosis By Julia Matthews Across the globe, more than 2.3 million people suffer from Multiple sclerosis, an autoimmune, neurodegenerative disease(Gilgun-Sherki et al 1). Multiple sclerosis has a wide ranging impact on a person’s body. Those with the disease may experience difficulty speaking, walking, balancing, and with general motor functions. The disease can also damage a patient’s vision, cause extensive nerve pain, and result in immense fatigue. These symptoms result from immune system mediated damage to the central nervous system. Inflammation in nerve cells is triggered by an immune response, which ultimately damages the protective protein-phospholipid sheath, known as myelin, which surrounds neurons (Riccio, Rossano). Normally, the myelin sheath simultaneously protects the neuron and aids neural communication. Without it, neurons struggle to send messages as rapidly and correctly as they normally would. In addition to breaking down the protective layer of myelin, immune cells damage the corresponding oligodendrocytes, which manufacture myelin, further impairing the ability of the central nervous system to bounce back from the initial damage. Exactly why the immune system would incorrectly attack nerve cells remains unclear to researchers. In the 150 years since the disease was initially identified, scientists have attempted to better understand its pathology in order to develop increasingly effective therapies against it. Developing multiple sclerosis research has focused on the relationship between the health of the gut microbiome and host cells, which have been found to interact closely, impacting disease progression; additionally, the maintenance of vitamin A and D levels have been shown to

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impact inflammatory response, a process at the root of the disease. When studying the relationship between a patient’s diet and multiple sclerosis progression, medical professionals focus their attention on two key aspects: nutrition and the composition of the gut microbiome. Nutrition and dietary habits have become particularly interesting to multiple sclerosis researchers because the disease epidemiology appears to follow a geographical trend, occurring more commonly in areas inhabited by people who consume diets with a higher fat and meat consumption rate: primarily, the northern hemisphere of the globe (Hadgkiss et al). Environmental factors in disease development often play into the structure-function relationships between molecules in the body: if an external molecule, such as a protein in food, shares structural similarities with a molecule the body has an existing receptor for, it can bind to the receptor and disrupt the body’s function. In a study published in the Nutritional Neuroscience journal in 2014, one such instance of this molecule interception was suggested to occur in MS patients who consume dairy. The proteins found in the milk fat globule membrane, butyrophilin, shares structural similarities with the myelin oligodendrocyte glycoprotein( MOG) , a protein expressed on the outside of the myelin sheath. As a result of the body confusing one protein for another, these milk fat proteins have been shown to activate T-cell attacks on the myelin sheath, ultimately causing damage and inflammation in the central nervous system (Hadgkiss et al).


biomedical research julia matthews

Artwork by Sorasicha Nithikasem

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Medical Dialogue Review Volume 13 | Issue 2

Alternatively, antioxidants and plant fibers can play a protective role in patients suffering from MS. Biochemically speaking, oxidative stress plays a major role in the progression of MS. When highly reactive oxygen species are produced in excess by overactive macrophages, a type of immune cell, the body struggles to keep up with their production rate and reduce oxygen radical prevalence (Gilgun-Sherki). Antioxidants render these highly reactive oxygen species unreactive, reducing oxidative stress and indirectly mediating destruction of the myelin sheath and reducing inflammation (Hadgkiss et al). Considering these dietary factors, MS patients are often encouraged to limit fat and dairy intake and increase vegetable consumption, potentially even relying on a plant based diet. Another approach to nutrition-based mitigation of MS progression focuses on monitoring Vitamin A and D levels.. Similar to the previously discussed dietary factors, vitamin A and D levels play a role in regulating inflammatory immune response, which is primarily responsible for the nervous system damage that leads to symptoms in MS. In a 2018 study conducted at the University of Basilicata, dietary intervention for MS patients specifically by administration of vitamin D and A concurrently was recommended. This logic behind this specific combination of vitamins is two-fold: both vitamins have been shown to have anti-inflammatory effects but vitamin D is more effective when bound and coupled with vitamin A. Vitamin D’s anti-inflammatory properties depend on the correct binding and formation of a heterodimer with Vitamin A. The resultant heterodimer forms a inhibitor for genes that control the inflammatory response, specifically by regulating the involved transcription factor NF-κB (Riccio, Rossano). By inhibiting transcription, synthesis of inflammatory molecules, such as cytokines, is minimized, resulting in less aggressive MS symptoms. Additionally, research pathways continue to explore the role of nutrition in MS pathogenesis, turning to look at the role of the gut microbiome.

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The gut microbiome refers to all of the microorganisms-such as bacteria- and all of their associated genetic material, metabolic products, and proteins, that exist in the human digestive tract at a particular point in time(Kirby et al). These organisms play a vital role in the body’s ability to digest food and absorb nutrients. But scientists have recently begun investigating how these seemingly distinct functions could be related to the development and progression of multiple sclerosis. In a study published by Eastern Washington University in 2018, researchers determined that the gut microbiome of multiple sclerosis patients was slightly altered. Certain microorganisms were found to have greater populations than in normal gut conditions, such as Dorea bacteria. Dorea bacteria and others with increased presence v have been associated with higher levels of inflammatory cytokines, which initiate the inflammatory immune response (Kirby et al). Researchers have considered the possibility that the relationship between the gut microbiome and MS is bidirectional, meaning that each has an equal impact on the other; however, current evidence points to disruptions in the gut microbiota balance fueling neuroinflammatory responses. A deeper understanding of this relationship opens the door for more homeopathic, and ultimately more accessible, forms of MS disease prevention and mitigation.


biomedical research julia matthews

References Gilgun-Sherki, Yossi, et al. “The Role of Oxidative Stress in the Pathogenesis of Multiple Sclerosis: The Need for Effective Antioxidant Therapy.” SpringerLink, Steinkopff-Verlag , link.springer.com/article/10.1007%2Fs00415-004-0348-9. Kirby, Trevor O, and Javier Ochoa-Repáraz. “The Gut Microbiome in Multiple Sclerosis: A Potential Therapeutic Avenue.” Medical Sciences (Basel, Switzerland), MDPI, 24 Aug. 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC6163724/. Riccio, Paolo, and Rocco Rossano. “Diet, Gut Microbiota, and Vitamins D + A in Multiple Sclerosis.” SpringerLink, Springer US, 24 Oct. 2017, link.springer.com/article/10.1007/ s13311-017-0581-4. Hadgkiss, Emily, et al. “The Association of Diet with Quality of Life, Disability, and Relapse Rate in an International Sample of People with Multiple Sclerosis.” Taylor & Francis, www.tandfonline.com/doi/full/10.1179/1476830514Y.0000000117?src=recsys.

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Medical Dialogue Review Volume 13 | Issue 2

Contemplating Anesthetic Potential By Nadia Zakula Anesthesia and the usage of anesthetic agents are commonplace and often vital in surgical procedures although potentially introduce toxicity and long-term implications concerning brain development (NIGMS, 2017). Different types of surgeries require administering a variety of anesthetics and medical procedures but the main purpose of anesthesia is to prevent the sensation of pain and reduce stress. Anesthetic drugs may be utilized in correspondence with other medications as well as with sedation. Though many surgical procedures mandate the use of anesthesia, individuals should perform further research on what anesthetic drugs are composed of as well as the precautions that may be taken before and after surgery to promote well-being. Patients may respond differently to prolonged exposure to anesthesia over successive periods of time and anesthesia overall due to risk factors such as physical characteristics and genetic components. The usage of anesthetics may increase the risk of brain damage particularly if used improperly or for the duration of multiple procedures. To reduce the severity of toxicity and negative impacts due to anesthesia, there should be more research on what anesthetic agents are composed of and whether alternatives may reduce risks or provide more effective recovery post-surgery. To begin with, there are several types of anesthesia: general, regional, local, and monitored anesthesia care (MAC) (Verywell Health, 2018). The type of anesthesia utilized depends on the health of the patient, purpose, risks, and length of surgery, and recommendations of the physician and anesthesiologist. Regional and local anesthesia target smaller portions of the body and are typically not paired with sedation as sedation is not required to prevent the sensation of pain or a localized region of a

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reduced size. Likewise, MAC is referred to as twilight sleep in which patients are conscious and remain able to follow instructions if necessary. Conversely, general anesthesia reduces sensation in the body entirely and patients are unconscious in order for physicians to perform life-saving or lengthy and intricate emergency procedures. General anesthesia is most commonly provided intravenously or inhaled, the latter of which leads to longer recovery times, increased drowsiness, and an increased risk of long-term complications. Prior to the provision of anesthesia, physicians survey their patient’s medical history, body mass index (BMI), age, previous alcohol and drug usage, and any indicator for impediments of recovery. For this reason, accuracy in recording one’s medical history is essential as the presence of prolonged drug usage, whether prescribed or otherwise, may lead to an insufficient amount of anesthesia to be utilized or an off-target effect in mixing an anesthetic agent with other substances. Once provided with the anesthetic drug, patients enter a state of analgesia and are unable to feel pain prior while also acquiring adjustments in breathing patterns, heart rate, and eye movement as the muscles assume a relaxed state (American Statistical Association, 2017). Proper dosage is essential in this process and requires monitoring for the entire duration of surgical procedures in order to prevent regaining of consciousness or awareness of pain during surgery and allow for recovery and subsequent resumption of consciousness. General anesthesia affects several regions of the central nervous system (CNS) in order to reduce sensation throughout the body. These regions have an increased risk of being exposed to toxicity due to the chemicals present in anesthetic agents (Verywell Health, 2018).


biomedical research nadia zakula The cerebral cortex and thalamus in the brain and spinal cord are responsible for consciousness, memory, attention, and the overall perception of pain and movement. These regions of the body control sleep-wake cycles and are targeted to ensure that patients remain unconscious for the duration of the operation. Neurotransmitters and their receptors are implicated in contributing to the presence of grogginess and foggy memories in post-surgery experiences (Verywell Health, 2018). The most common complications following anesthesia include nausea and vomiting, sleepiness, and aching muscles due to prolonged muscle relaxation and lack of movement. Furthermore, general anesthesia may cause impaired mental status and confusion as the body processes the remainder of the anesthetic agent. In other cases, blood clots may form and lead to deep vein thrombosis which can be fatal as well as pneumonia or complications in removing patients off of ventilators and breathing tubes to continue independent breathing (Verywell Health, 2018). A Mayo Clinic study on 2,000 older patients demonstrated the link between anesthesia and impaired thinking/memory that can precipitate long-term changes in the brain that lead to Alzheimer’s disease (Mayo Clinic, 2018). A study by the University of Queensland has also provided insight on how anesthetics may impact individuals at a cellular level through imaging microscopy by impairing signal transduction in nerve pathways which is also a symptom of Alzheimer’s (Medical News Today, 2018). Certain risk factors can aid in determining the impact of anesthesia on individuals’ short and long-term experiences. Older patients and those suffering from obesity often experience more complications in resuming to breathe independently following ventilation as well as sleep apnea which may impede breathing and require a higher dosage of anesthetics or medications. Individuals with illnesses such as heart failure, Alzheimer’s, and Parkinson’s disease may also experience impaired cognitive function. A recent study has revealed that women’s

Artwork by Sorasicha Nithikasem

brains are approximately three years younger than men’s which reduces the risk of cognitive impairment due to enhanced metabolic pathways in the brain (Washington University School of Medicine, 2019). Men are at a greater risk of neurodegenerative diseases and proper brain development despite starting adulthood at a later age (Washington University School of Medicine, 2019). Understanding why women experience less metabolic issues and whether therapies or alterations in anesthetics may lead to positive outcomes requires further research.

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Medical Dialogue Review Volume 13 | Issue 2 Potential alternatives are also available to substitute for anesthesia in certain procedures. A study revealed that regional anesthesia may be a promising alternative for abdominal surgery in patients likely to suffer from pulmonary complications (Savas, Litwack, Davis, & Miller, 2004). Out of eight surgeries performed, only one patient developed pneumonia who underwent therapy and less than half of the patients required extensive postoperative oxygen treatment. In an alternate study, physicians utilized conscious sedation for 196 patients at UCLA during heart valve procedures, medical procedures often required for older patients with cardiac issues (UCLA, 2017). The success of these procedures, however, may be due to their minimally invasive nature resulting in shorter recovery periods. Another study on 150 cancer patients in France suggested that hypnosedation, sedation through a hypnotic or induced trance-like state, may serve as an alternative to anesthetics (European Society of Anesthesiology, 2018). Physicians provided an opioid as well as anti-sickness drugs, painkillers, and local anesthetics to patients to allow them to remain conscious without feeling pain. Hypnosedation allowed for comfort during surgery and postoperative care in 99% of the procedures and may be promising for the future performance of invasive procedures such as brain and heart surgery though longer preoperative preparation may be required. Other alternatives to anesthesia include nerve blocks, sedation, epidurals, and spinal anesthesia which numb specific portions of the body must be administered precisely to target the nervous system and reduce sensation in patients (NIGMS, 2017). Finally, reducing the number of opioids utilized as anesthetics can reduce the potential complications in high-risk surgeries which in turn can decrease postoperative nausea, confusion, and dependency on other forms of pain management after surgery (ASAHQ, 2017). Patients often take opioids such as fentanyl and ketamine with other anesthetic medications which can be addictive or increase pain sensitivity. Several studies have aimed to reform the

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anesthetic medications utilized and involved a lower percentage of patients who experienced pain, nausea, or required a hospital stay following surgical procedures with reduced opioid use (ASAHQ, 2017). In cases in which anesthesia is necessary, certain measures may be taken to reduce postoperative complications and better ensure successful operations. A study by NYU Langone Medical Center disclosed a compound which reduces brain damage following repeated exposure to anesthesia in mice which may be beneficial for individuals that require numerous surgeries and have a heightened risk from the toxicity of general anesthesia (NYU Langone Medical Center, 2016). The experimental drug targeted and improved nerve signaling and memory by monitoring signal transmission in nerve cells after exposure to anesthesia. A recent study involving 1,200 older patients at Washington University School of Medicine revealed that reducing the amount of anesthesia did not significantly decrease postoperative cognitive impairment, but a better outcome with fewer complications and lower incidence of mortality ensued following closer brain monitoring through electroencephalogram (EEG) during surgery (Washington University School of Medicine, 2019). Additional research by the American Society of Anesthesiologists introduced a nociception level index which allowed for monitoring reflexes and responses to painful stimulation in patients under anesthesia which can assist in determining the impact that anesthetics have on patients in real-time (American Society of Anesthesiologists, 2016). Monitoring brain function and pain response are as essential as routinely monitoring cardiac and lung function. Because brain regions are specifically involved in regulating consciousness, studying how the brain responds to anesthetics in the duration of their provision and following surgery is important. By introducing regular usage of EEGs during surgeries, physicians may obtain a better understanding of the reasons behind the susceptibility of older and at-risk patients to cognitive dysfunction and how such conditions may be prevented


biomedical research nadia zakula without compromising safety during medical procedures. Though the usage of anesthetics can be vital and beneficial in surgical procedures, it can also lead to toxicity and postoperative risks which require further research and consideration. A variety of risk factors determines whether certain types of anesthesia and sedation are appropriate for a patient. Furthermore, it is crucial to consider all components involved in surgical procedures from start to finish and the preparations that must be taken by both the physicians and anesthesiologists and the patients. Truthful medical histories

must be provided to ensure proper dosage and evaluation of eligibility, rest, and care must be taken following surgery as anesthetics remain in the body following surgery (NIGMS, 2017). Additional research on alternatives to anesthesia may be valuable, particularly for patients requiring otherwise repetitive usage and for those with an increased potential to develop cognitive damage. In summary, it is essential to evaluate the impact of anesthesia prior to surgery and in postoperative care as well as the long-term consequences as the influence of anesthesia are not limited to the duration of a medical procedure.

References American Society of Anesthesiologists. (2016). Noninvasive monitor assesses patients' response to painful stimulation during surgery. ScienceDaily. Retrieved March 7, 2019, from https://www. sciencedaily.com/releases/2016/05/160513112146.htm. American Statistical Association. (2017). Statistical analysis to explain mechanism in state of general anesthesia. ScienceDaily. Retrieved March 7, 2019, from https://www.sciencedaily.com/releases/2017/07/170731164442.htm. Anesthesia. (n.d.). Retrieved March 7, 2019, from https://www.nigms.nih.gov/education/pages/factsheet_anesthesia.aspx Anesthesia warning[Photograph found in Neuromuscular Centre Maastricht]. (n.d.). Retrieved March 7, 2019, from http://www.neuromuscularcentremaastrichtumc.nl/wp-content/uploads/2016/02/ iStock_000040158594_700x500-500x500.jpg Eliminating opioids from anesthesia decreases post-surgery nausea, study shows. (n.d.). Retrieved March 7, 2019, from https://www.asahq.org/about-asa/newsroom/news-releases/2017/10/eliminating-opioids-from-anesthesia-decreases-post-surgery-nausea Less anesthesia during surgery doesn't prevent post-op delirium. (2019, February 06). Retrieved March 7, 2019, from https://medicine.wustl.edu/news/less-anesthesia-during-surgery-doesnt-prevent-post-op-delirium/ Mayo Clinic. (2018). Anesthesia, surgery linked to decline in memory and thinking. ScienceDaily. Retrieved March 7, 2019, from https://www.sciencedaily.com/releases/2018/07/180719112024.htm. NYU Langone Medical Center. (2016). Compound shown to reduce brain damage caused by anesthesia in early study. ScienceDaily. Retrieved March 7, 2019, from https://www.sciencedaily.com/ releases/2016/06/160622144816.htm. PhD, C. P. (2018, January 09). How general anesthetics affect the brain. Medical News Today. Retrieved March 7, 2019, from https://www.medicalnewstoday.com/articles/320564.php Savas, J., Litwack, R., Davis, K., & Miller, T. (2004). Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment. NCBI. Retrieved March 7, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/15546579. Staff, S. X. (2018, June 04). Study reveals hypnosedation as an effective alternative to general anesthesia for various surgeries. Retrieved March 7, 2019, from https://medicalxpress.com/news/2018-06-reveals-hypnosedation-effective-alternative-anesthesia.html UCLA. (2017). Conscious sedation is a safe alternative to general anesthesia for heart valve procedure. ScienceDaily. Retrieved March 7, 2019, from https://www.sciencedaily.com/releases/2017/04/170411130659.htm. Washington University School of Medicine. (2019). Women's brains appear three years younger than men's. ScienceDaily. Retrieved March 7, 2019, from https://www.sciencedaily.com/releases/2019/02/190204172217.htm. Whitlock, J., Fogoros, R. N., Msn, & Fn. (n.d.). Know the Risks of General Anesthesia Before Surgery. Retrieved March 7, 2019, from https://www.verywellhealth.com/general-anesthesia-side-effects-and-complications-4141168 Whitlock, J., & Msn. (n.d.). Types of Anesthesia Used During Surgery. Retrieved March 7, 2019, from https://www.verywellhealth.com/anesthesia-and-surgery-3157215

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Medical Dialogue Review Volume 13 | Issue 2

Marketing Homeopathic Medication: History, Ethics, and Policy Implications By Sophie Spector Introduction to Homeopathy When we think about ‘medicine,’ we often see it through a scientific view, characterized by rigorous studies and treatments like drugs or surgeries. Despite our mass perception of what qualifies as medicine, the truth is that many Complementary and Alternative Medicine (CAM) practices outside of our conventional understanding have existed for centuries as healing tools, and are still popular options today. While CAM in the U.S. encompasses a multitude of practices, the recent rise in the usage of homeopathy, a field which focuses on holistic care and uses diluted medications made of natural substances, lends itself as a fascinating case study into the world of alternative medicine pharmaceuticals. In 2016, homeopathy was used by an estimated 6 million people in the U.S. (1), and the homeopathy product market is expected to be worth over $17 million in the U.S. by 2024 (2). Despite its prevalence, homeopathy is a largely unsubstantiated ‘science,’ based solely on a few dubious theories. The most basic belief that underlies homeopathy is the “law of similars,” which mandates that ‘like cures like.’ In other words, it’s believed that if a substance causes certain symptoms then a patient with the same symptom would be cured by this same substance in small amounts (1). For example, red onion, which causes your eyes to water, is used as a treatment for allergies (11). The notion of a small amount is another important principle; a key practice of homeopathy is dilution. The “law of minimum dose” dictates that the lower the dosage of a treat-

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ment, the more potent it will be. To obtain very low doses, homeopaths dilute one part of the given substance to ninety nine parts water. Then they take a part of this solution, and dilute again with ninety nine parts water. Each dilution increases what is called the “C scale”: for example if you dilute a substance in this manner 3 times, your medication is a 3C dilution. However, most homeopathic medications are far more weak; the founder of homeopathy advocated for dilutions of 30C (3) and one of the most popular homeopathic medications on the market, Oscillococcinum, is diluted to 200C (4). For reference, mixing one dose of aspirin in a body of water equal to all the great lakes combined would be between only about 8C and 9C (12). The ratio of one molecule to all the molecules in the observable universe would be a dilution of 40C (5). So, if there is (mathematically) no molecule of the active ingredient in most of the medicines, how can it work? Traditionally, homeopaths argue that shaking while diluting triggers the ‘vital energy’ of the substance, and that water retains the ‘memory’ of a substance even after it’s diluted (6). With these two claims in mind, it seems like it should be clear that homeopathy shouldn’t work. While, there is some minor research to suggest that homeopathy has beneficial effects that surpass that of placebo, these tend to be weaker quality, less funded, and smaller studies (6). Much more work needs to be done in CAM research before a clear answer is found, and for now, we must take any individual claims with caution.


public health & policy sophie spector

Science as of now can’t explain the mechanisms of action, if any, of homeopathy dilutions, and yet these poorly understood remedies are still sold on drugstore shelves right next to allopathic (traditional) medications. From an ethical perspective, we must critically assess the marketing of these untested medications, and bring into question the agencies that have permitted their existence. Before we can do this however, we must analyze our modern practices within the long history of homeopathy and the events that influenced how we market and sell homeopathic medications today. Brief History of Homeopathy Homeopathy came about in an era of quack medicine: bloodletting, leeches, and surgical hacks. The creator of homeopathy, Samuel Hahnemann, realized the need for holistic and safe treatments that focus on the patient’s well being- in many ways he had modern ideas about healthcare (6). After his first publication in 1814, homeopathy quickly grew in popularity in Europe, despite opposition from orthodox doctors. It was brought over and popularized in the U.S. by the 1830s, and remained at a low level of popularity for the next century, despite increasingly effective traditional medicine. Then, in 1938, an important law that forever changed the homeopathic pharmaceutical industry was passed. The precursor to the FDA, called the Food, Drug, and Cosmetics Act, was passed by senator Royal Copeland. Part of this act included homeopathic medications under the official definition of drugs (8) but allowed homeopathy to be openly sold on the market, forgiving all medications on the official Homeopathic Pharmacopoeia from government regulation (6). The law still holds today, and it’s why homeopathic medications can be marketed as cures to diseases, and without any warning. You may wonder, in an industry so highly patrolled, how did something like this get passed in the first place? It’s primarily because Royal Copeland was an avid homeopathic physician before becoming a senator. In the 70’s and beyond, homeopathy saw another rise in popularity, particularly in the

US (6). In the 70’s and 80’s the FDA made a few notable large scale attempts to scrutinize homeopathic over the counter (OTC) drugs, but repeatedly failed to effectively do so (8). Since then, there have been many petitions, push backs, and propositions that have failed to come to fruition. The FDA, since its origin, has had a marked lack of control over the homeopathic industry, despite calls to action nearly every year. It is perhaps because of this, that homeopathy continues to be a remarkably popular option- between as recently as 2002 and 2009 homeopathy use grew an estimated 500% percent, and the market continues to expand (6). Questioning the Ethics of Marketing Homeopathy Today, we live in a country where treatments brought to market must be proven safe and effective, as well as clinically lab tested through years of animal trials and double blind studies. Yet, despite the assurances we receive on most of our medications, homeopathic remedies that fail to provide evidence of their efficacy are displayed on drugstore shelves right alongside those that are stringently regulated (8). To someone without prior knowledge of homeopathy, a homeopathic flu remedy on drugstore shelves which claims to have no side effects and cure all flu symptoms seems a lot better than something like Aspirin, whose information panels are peppered with warnings and drug interactions. While there are some studies that have varying results on effectiveness, we simply don’t have any rational justification for why homeopathy could ever workthe bottom line is that we do not have enough research yet to prove homeopathic medications effective. The first point to bring into question is the distinction between safety and efficacy. We know that (most) homeopathic medications have almost no active substances in them and are essentially sugar pills supposedly containing the ‘memory’ of the substances they once contained.

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Medical Dialogue Review Volume 13 | Issue 2

Photograph by Sean Li However, this would also ensure that the medications are guaranteed safe. This raises the question, does the FDA have an obligation to regulate these OTC medications if they aren’t actively causing harm? I would posit that even if they are just sugar pills, they are causing harm, albeit indirectly. When people opt for CAM over allopathic medicine, they are proven to have worse health outcomes (9). By existing on shelves as a viable option to a uneducated audience, homeopathy markets itself as an equally effective alternative to real fever reducers, cough suppressants, and anti-emetics. While it is true that the average person will not die of a cough, and that failing to treat minor symptoms does not imply a bad outcome

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the same way that failing to treat progressive cancer does, there is still a loss of productivity, comfort, and long term health. In other words, while acid reflux or a headache will not kill you if you choose homeopathic products over traditional medications, your symptoms will not be cured, and repetitive occurrences may cause long term irritation, health issues, and create risk factors increasingly severe disease. If your symptoms are severe enough that you went to the store for medication, one can expect that any reasonable consumer wants to be cured of their ailments. By homeopathy’s nature as an equally viable, if not more natural option, it is a danger to the health (and the wallet) of the customer by solely existing.


public health & policy sophie spector

Furthermore, some homeopaths argue that rigorous double blind studies don’t matter, and that efficacy should be based off of patient satisfaction alone (6). This poses an interesting debate in medical ethics. Does deception in medicine matter if it ultimately makes the patient feel better? Incurable symptoms, such as chronic back pain, are some of the most popular ailments to be treated by homeopathy; it makes sense why somebody fed up with traditional medicine’s failure to cure their ailment might turn to homeopathy. Many homeopathic patients reported feeling more in control of their health, more able to cope with their illness, and overall better health (10). It is interesting to ponder if a placebo is bad medicine if it ultimately treats how the patient is feeling (granted the symptoms are not dangerous)- after all, the end goal of medicine

is to make your patient feel better. Unfortunately, while these are questions worth raising, I alone cannot answer them. The field of homeopathy begs for further research and discussion and analysis. However, in the meantime, the U.S. has an important role to fill in protecting the health of their citizens when it comes to unstudied medication. While a nationwide ban against homeopathic companies may be severe for now, changing current marketing laws is an important intermediate step. Consumers should push the FDA and FTC to mandate that homeopathic medications label their concentrations in terms more understandable to consumers, not advertise for use on children, and most importantly, not make claims about cures without substantial evidence.

References 1. Homeopathy. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/homeopathy#hed2xc. Published August 1, 2018. Accessed March 9, 2019. 2. Homeopathy Product Market is Expected to Reach US$17,486.2 Million by 2024, Exhibiting a CAGR of 18.2% Over the Period Between 2016 and 2024. PR Newswire: news distribution, targeting and monitoring. https://www.prnewswire.com/news-releases/homeopathy-product-market-is-expected-to-reach-us174 862-million-by-2024-exhibiting-a-cagr-of-182-over-the-period-between-2016-and-2024-600000861. html. Published November 4, 2016. Accessed March 9, 2019. 3. Hahnemann S. Aphorism 121-130. The School of Homeopathy. https://www.homeopathyschool.com/the-school/editorial/the-organon/aphorism-121-130/. Accessed March 9, 2019. 4. Schwarz J. Homeopathy-Delusion through Dilution. McGill Office for Science and Society. https://www.mcgill.ca/oss/article/homeopathy/homeopathy-delusion-through-dilution. Published June 7, 2017. Accessed March 9, 2019. 5. Park RL. Superstition: Belief in the Age of Science. Princeton, NJ: Princeton University Press; 2010. https://books.google.com/books?id=1XocNrUN_K4C&pg=PA145&lpg=PA145&dq=dilution one molecule to visible universe&source=bl&ots=8UzavpyNn3&sig=ACfU3U0KO6gDrgfZ8AM40IPbRyx3vhu6mg&hl=en &sa=X&ved=2ahUKEwic8bjtju7gAhWhl-AKHTidCBsQ6AEwC3oECAcQAQ#v=onepage&q=dilu tion one molecule to visible universe&f=false. Accessed March 8, 2019. 6. Loudon I. A brief history of homeopathy. Journal of the Royal Society of Medicine. 2006;99(12):607-610. doi:10.1258/jrsm.99.12.607. 7. Thomas P. Homeopathy in the USA. British Homeopathic Journal. 2001;90(02):99-103. doi:10.1054/homp.1999.0474. 8. White Junod S. An Alternative Perspective: Homeopathic Drugs, Royal Copeland, and Federal Drug Regulation . Food and Drug Law Journal. 2000;55:161-184. https://heinonline.org/HOL/Page?handle=hein.journals/foodlj55&id=187&collection=journals&inde x=. Accessed March 8, 2019. 9. Ong CK, Petersen S, Bodeker GC, Stewart-Brown S. Health status of people using complementary and alternative medical practitioner services in 4 English counties. Am J Public Health. 2002;92(10):1653-6. 10. Rhee TG, Ng JY, Dusek JA. Utilization and perceived benefits of homeopathy and herbal therapies in U.S. adults: Implications of patient-centered care. Complementary Therapies in Clinical Practice. 2017;29:9-15. doi:10.1016/j.ctcp.2017.07.003. 11. Wat is Homeopathy?. WebMD. https://www.webmd.com/balance/what-is-homeopathy#1. Accessed March 9, 2019. 12. Great Lakes. Wikipedia. https://en.wikipedia.org/wiki/Great_Lakes.Accessed March 9, 2019.

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Medical Dialogue Review Volume 13 | Issue 2

The Dangers of Diet Soda and Other Processed Foods By Karol Woloszyn Take a look in your refrigerator or pantry; what do you see? If you’re anything like most Americans, you probably see some of the food you’ve been eating your entire life: Honey Bunches of Oats cereal, Tostito’s Pizza Rolls, Chips Ahoy chocolate chip cookies, Lay’s potato chips, and perhaps some cup noodles, if you’re a stereotypical college student. These are all examples of processed foods that have been a part of the typical American diet and culture for decades now. In fact, in 2016, 57.9% of American caloric intake, on average, came from ultra-processed foods (foods that have undergone multiple culinary processes, contain many added ingredients, and are highly manipulated), such as cereals, sodas, instant soup, microwave dinners, etc (1). Another 9.4% came from processed foods (packaged foods with added oils, sugars, or herbs), such as canned or preserved foods (1). In comparison, minimally processed or virtually unprocessed foods, such as fresh meat, fruits, vegetables, eggs, pasta and dairy products, made up 29.6% (1). Despite our incessant gorging, it is common knowledge that such ultra-processed junk food is unhealthy; an estimated 2.8 million people die each year from weight-related complications (heart disease, diabetes, stoke, etc.) brought about by junk food (2). Compare this to the 2.2 million people who died of HIV/ AIDS in 2005 at the peak of the pandemic3. The over-processing and artificiality of food is one of the worst public health crises in modern history and it is being masked as a modern marvel of human ingenuity. Perhaps this is a hyperbole; food processing has, of course, had an integral part in forming and developing civilization. However, increases in population and

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improvements in technology have spawned an overreliance on artificial food, whose detrimental effects are just being discovered. In a commercial that aired in 2018, actress Gillian Jacobs casually buys a diet coke, then turns to the camera and says, “Look, here’s the thing about Diet Coke. It’s delicious. It makes me feel good. Life is short.” A standard, if not a tad cheesy, soda advertisement, were it not tinged with an appalling irony. Life may indeed be short if one drinks diet soda. A possible link between these artificially sweetened drinks and long-term health consequences have long been the subject of rumor and speculation, with many conflicting reports and studies being produced since nearly the first diet soda was invented in 1963. Such speculation entranced mainstream media once more on February 15th, 2019, with the release of a new study by the American Heart Association and American Stroke Association. According to this study, which observed over 80,000 women between the ages of 50 and 79 over a period of 12 years, drinking two or more diet sodas a day is linked to an increased risk of ischemic strokes and heart attacks. The study was adjusted for various risk factors, such as age, smoking, high blood pressure, and obesity. Specifically, the researchers discovered that women who consistently indulged in diet soda were 23% more likely to suffer a stroke than women who drank less than one a week, as well as 29% more likely to develop heart disease, and 16% more likely to die from any cause during the trial period (4). Although there were flaws in this study that will be analyzed shortly, it does not stand alone in its results.


public health & policy karol woloszyn

Artwork by Sorasicha Nithikasem

A study published in the journal Stroke in April 2017 claimed that people who drank at least one diet soda every day were three times more likely to suffer a stroke or dementia. The study consisted of 4,300 people, observed over a period of 10 years, during which 97 cases of stroke and 81 cases of dementia (63 of which were Alzheimer’s disease) were recorded5. Another study in 2014, consisting of 320,000 subjects, concluded that those who drank four or more diet sodas a day were approximately 30% more likely to be diagnosed with depression than those who didn’t (6). Two studies in 2012 further support the mounting evidence for the negative side effects of diet drinks: one, consisting of 2,600 subjects, concluded that daily diet soda consumption was linked to a 45% higher risk of heart attack, stroke, and early death; and the other concluded that daily diet soda consumption increased hemorrhag-

ic stroke risk by 30% in a sample of 130,000 subjects (6). Furthermore, three more studies published between 2007 and 2009 who drank diet sodas on a regular basis were more likely to develop type-2 diabetes and had a 30-55% higher chance of developing Metabolic Syndrome, a cluster of conditions that include as increased blood pressure, high blood sugar, etc. that increase the risk of heart disease, stroke, and diabetes6. With such seemingly irrefutable evidence of long-term health consequences brought about by diet sodas, why, you may ask, is there still speculation, and not the conclusive condemnation of diet drinks? This is because all the aforementioned studies were flawed on multiple aspects. Firstly, every study was purely observational, as is the nature of any large study on long-term health issues. They also relied on the participants self-reporting their dietary habits,

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Medical Dialogue Review Volume 13 | Issue 2 which is obviously not a truly accurate method of data collection. Thus, these studies failed to establish any causation between diet drinks and long-term health issues, merely correlation, nor did they propose any specific explanation for how diet sodas increase disease risk. Furthermore, none of the studies determined the specific artificial sweetener that may be detrimental. Different diet drinks contain different sweeteners, and the studies did not focus on or adjust for one specific brand or type. Most damning of all is the possibility that those who regularly consume diet soda may already be at an increased risk for obesity, diabetes, heart disease, and strokes. After all, diet soda is marketed towards people who are attempting to lose weight or get healthier, and diet sodas are sold as an alternative to ease them off non-diet sugary drinks and eventually onto water. Nevertheless, the absence of concrete, causational evidence is not evidence of absence. The eight studies previously discussed, and the dozens that hint at other detrimental effects not mentioned in this article, warrant the development of larger, more rigorous and more concrete studies. So why focus on diet soda in an article chastising all ultra-processed foods? Several reasons: (1) the February 2019 study previously mentioned has been widely popularized by media such as CNN, CBS, and Time Magazine, (2) consumption of artificially sweetened drinks has increased drastically since the release of the iconic diet coke in 1982, with over 3 billion gallons drunk by Americans in 2018 (7), and, most importantly, (3) unlike most other ultra-processed food like instant noodles, hot dogs, pizza, etc., which are advertised for convenience and are widely known to be unhealthy, diet sodas are marketed towards well-meaning health-conscious people as healthy alternatives to sugary drinks. They’re even recommended by certain nutritionists8! In a sense, they embody our overreliance on the processed nature of food. Rather than focusing on limiting our regular soda consumption, we have developed (only 56 years ago!) completely artificially sweetened drinks

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without fully studying the possible long-term consequences these artificial sweeteners could cause. But let’s widen our perspective on the rest of ultra-processed foods so as to gain a greater hold on the enormity of this issue. Refined sugar intake has skyrocketed from barely 5 kg per individual per year in 1700 to roughly 67 kg (150 lbs.) in 2000, correlating to a nearly 40% increase in obesity prevalence between 1900 and 2000 (9). Caloric intake of processed grains, such as the ones used in granola bars, has increased by 200 calories a day, and traditional fats such as butter and lard have also been replaced in the last 100 years by processed vegetable oils, such as soybean oil, which is used in many processed foods because of its lower cost (9). In fact, soybean oil alone made up 7% of American caloric intake in 1999. Total caloric intake has also increased by 400 calories a day within the last 40 years, thanks to the empty calories provided by junk food9. So, what are the health effects? In 1985, no state in the United States had an obesity rate higher than 15%. In 2016, five states had rates over 35%, with obesity in children aged 6-11 increasing dramatically as well, from 6.5% in 1980 to 19.6% in 2008 (10). Globally, nearly 1.5 billion people were estimated to be overweight or obese in 2008 (11). Each year, obesity related conditions such as heart disease, stroke, diabetes, etc. cost the United States over 150 billion dollars and cause 300,000 preventable deaths (11). Yet, without the development of fire and cooking, or farming and domestication, we would not have civilization. Millions of people would have died without the development of refrigeration and food preservation. Our society today, composed of over 7.5 billion individuals, would not survive without food processing; it is simply too integral a part of our evolution, both past and contemporary. So, what are we to do when the thing that’s kept us, and is keeping us, alive is now causing so much death and suffering? Frankly speaking, not much. We simply cannot go around closing every McDonald’s, or banning every diet soda, microwave dinner,


public health & policy karol woloszyn

or other processed food. What if we invest more in producing unprocessed and nutritious foods, such as fresh fruits and vegetables, and have them slowly edge their way back into our diets? This too would be difficult to accomplish for a couple reasons. Firstly, it is simply more expensive to produce such food over ultra-processed junk food, as evidenced by a study published in 2013 that discovered that a day’s worth of healthy diet patterns cost, on average, $1.50 more than unhealthy ones (12). For many, that $547.5 a year is just too precious a commodity to throw away on healthier food. Secondly, our cultural and technological evolution has long since surpassed our biological evolution, and our over processing of food reflects this. Insatiable biological desires to crave sweet and fatty foods, and to eliminate exertion, have been hijacked and used to develop these ultra-processed foods. This development and indulgence will not end any time soon. For this reason, I propose a better solution: research and education. As already mentioned, there is a need for more rigorous

and causational studies on the health effects of diet soda, as well as other processed foods and their components. Furthermore, with ever-increasing technology, we have to research more nutritious and healthy processed foods that are both cheap to produce and purchase. But none of this is possible without educating the public on the health consequences of the today’s processed food, and by establishing strict guidelines for creating and maintaining healthy diets. This is not an empty argument: a 2016 study, consisting of 350 mothers whose children attended daycare, found a positive correlation between the mother’s nutritional knowledge, and the healthiness and frequency of their child’s dietary habits and activities (13). The obesity epidemic exacerbated by our overreliance on processed foods may not have had the same impact on our minds as the opioid epidemic or the HIV/AIDS pandemic, but it is just as, if not more, serious. This particular epidemic can only be conquered by our divorce from ultra-processed foods.

References Beck, J. More Than Half of What Americans Eat is ‘Ultra-Processed’ The Atlantic. https://www.theatlantic.com/ health/archive/2016/03/more-than-half-of-what-americans-eat-is-ultra-processed/472791/ March 10, 2016. 2.8m people die annually from eating junk food – UN. Daily Nation. https://www.nation.co.ke/news/2-8m-peopledie-annually-from-eating-junk-food-UN-obesity/1056-2345470-14wkpwwz/index.html June 12, 2014. Outbreak: 10 of the Worst Pandemics in History. MPHonline. https://www.mphonline.org/worst-pandemics-in-history/ Hosie, R. There’s even more evidence that drinking diet soda is bad for you. INSIDER. https://www.thisisinsider.com/ diet-soda-linked-to-higher-risk-of-stroke-and-heart-disease-older-women-study-2019-2 February 15, 2019. Bakalar, N. Diet Sodas Tied to Dementia and Stroke. The New York Times. https://www.nytimes.com/2017/04/26/ well/diet-sodas-tied-to-dementia-and-stroke.html April 26, 2017. Calderone, J. The Mounting Evidence Against Diet Sodas. Consumer Reports. https://www.consumerreports.org/ soda/mounting-evidence-against-diet-sodas/ May 24, 2017. LaMotte, S. Drinking two or more diet beverages a day linked to high risk of stroke, heart attacks. CNN. https://www. cnn.com/2019/02/14/health/diet-soda-women-stroke-heart-attack/index.html February 16, 2019. Hosie, R. A sports nutritionist says drinking Diet Coke will help you lose weight, despite a new study that suggest the opposite. INSIDER. https://www.thisisinsider.com/drinking-diet-coke-will-help-you-lose-weight-sports-nutritionist-claims-2019-1/ January 3, 2019. 11 Graphs That Show Everything Wrong with the Modern Diet. Healthline. https://www.healthline.com/nutrition/11-graphs-that-show-what-is-wrong-with-modern-diet#section6 Blumenthal, D., Seervai, S. Rising Obesity in the United States is a Public Health Crisis. https://www.commonwealthfund.org/blog/2018/rising-obesity-united-states-public-health-crisis April 24, 2018. Popkin, B.M., Adair, L.S., Ng, S.W. NOW AND THEN: The Global Nutrition Transition: The Pandemic of Obesity in Developing Countries. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257829/ 2012. Eating healthy vs. unhealthy diet costs about $1.50 more per day. Harvard School of Public Health. https://www. hsph.harvard.edu/news/press-releases/healthy-vs-unhealthy-diet-costs-1-50-more/ 2013. Lee, Y., Joo, N. The awareness level and needs for education on reducing sugar consumption among mothers with preschool children. Nutrition Research and Practice. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4819135/ 2016.

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Medical Dialogue Review Volume 13 | Issue 2

The Effect of Exercise on Cognitive Function By Anna-Maria Trachuk

Artwork by Jessica Gai

Over the years, physical inactivity has become an increasing health concern. In fact, it is a primary factor contributing to chronic disease and associated health risks. This notion has proven to be crucial when examining the college student population, which, uncoincidentally, has an increased rate of depression and anxiety, a statistic that only seems to grow every year (1). According to a 2010 study (2)

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conducted by Dr. Janet Buckwork and Dr. Claudio Nigg, participation in exercise regimes may positively modify cognitive performance, leading to higher exam grades, increased positive mood, and reduced stress levels. Exercise may be the leading solution to a stressful university life, and could act as a mediator when targeting mental disorders to elevate dopamine and serotonin levels (3).


public health & policy anna-maria trachuk

The study conducted by Buckworth and Nigg recruited a sample size of 493 students at a Midwestern university to test for behavioral changes after exercise intervention. Exercise interventions included aerobic dance, weight training, stretching activities, and jogging exercise labs for a 45-minute timeframe, three times a week. The intervention took place throughout the fall and spring semesters, with two similar populations that had no significant difference in age, race, or class rank. Questionnaires, related to participation in exercise, physical activity history, and sedentary behaviors, were administered at a ten-week academic quarter. At the conclusion of the semesters, results demonstrated increased mood scores correlated to increased exercise sessions per week. Ultimately, the study design was able to confirm the positive effects of exercise on the brain, a significant finding especially when conducted in a high-stress environment such as a university campus. In another 2011 study in Zabol, Southeastern Iran, stress levels were compared between non-athletes and athletes that attended the University of Zabol. The data collected at the conclusion of the study defined a significant relationship between student athletes and non-athletes “regarding their utilization of emotion-based and problem-based coping strategies.” (4). Student athletes demonstrated better ability to solve problems and handle high-stress environments, whereas the stress intensity was shown to be elevated in students who did not participate in exercise. Similarly, a study done by Dr. Dennis Egget, Dr. Michael Barnes, and Mickey Trockell, M.S., measured

the relationship between health related variables and academic performance among first year college students at a large private university in Iowa (5). In a sample involving 200 first year undergraduates, aerobic exercise and strength training demonstrated a positive correlation with GPA, while anxiety, depression, and anger demonstrated a negative correlation with GPA. Ultimately, through an indirect causal relationship, Egget and his peers were able to confirm that exercise plays a positive role in an individual’s life, allowing cognitive function to flourish while minimizing the effect of stress factors. Exercise plays a dominating role in stress levels, which is an important notion to be considered in a college-student population. There is no need for evidence to prove the high stress that is entailed in university life; there is familiarity with the concept of eating ramen noodles on the floor at midnight studying for tomorrow’s final, while a roommate cries over a boy in the other room. Especially during the notorious midterm seasons, when students are not particularly concerned with their diet and workout routines, mental health plummets to a sickly low. Truly, as countless studies have shown, the incorporation of acute exercise into a weekly routine significantly improves not only cognitive function, which is indeed an important factor for a college student, but also mental health. College students are only “college students” for a few years, but mental health is carried with an individual for the rest of their lives- the ultimate reason why exercise is necessary and important.

1 https://www.csc.edu/bit/resources/statistics/ 2 Buckworth, Jane. “Physical Activity, Exercise, and Sedentary Behavior in College Students.” 2010. 3 Azizi, Masume. “Effects of doing physical exercises on stress-coping strategies and the intensity of the stress experienced by university students in Zabol, Southeastern Iran.” 2011. 4 Azizi, Masume. “Effects of doing physical exercises on stress-coping strategies and the intensity of the stress experienced by university students in Zabol, Southeastern Iran.” 2011. 5 Trockel, Mickey.“Health-Related Variables and Academic Performance Among First-Year College Students: Implications for Sleep and Other Behaviors”. 2000.

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Medical Dialogue Review Volume 13 | Issue 2

SLEEP by Johanna Lim Sleep is a basic need for humans; when one goes too long without sleep, it starts to affect functionality and health. Yet, of the billions of people on Earth, there are many that struggle with sleep, whether due to lifestyle choices or due to inherent problems with their health. For example, many people suffer from insomnia, laying awake in their beds throughout long hours of the night, and in fact, in many cases, insomnia can be an indicator of other health issues. At the same time, the opposite extreme is also problematic, as having an excess of sleep is also not necessarily a good thing, with more subtle health issues appearing. To begin with, let’s address the issue that plagues millions of people within the modern world: lack of sleep. Whether it is students that are dealing with heavy workloads or those who suffer from insomnia, a lack of sleep has a severe impact on the body in the long run. Recent research has found that lack of sleep is likely to impact teenagers via their appetite as their energy expenditure is adjusted to adapt to the lack of rest. To compensate, a shift in hormone balance affects an increase in appetite in an attempt to take in more energy for bodily functions, thus causing “excess food intake, poor diet, and obesity” (1). Following that, fatigue is likely to decrease the amount of exercise done, further extending the detrimental effects of the lack of sleep as one is unable to use up the extra calories taken in. Research by Chaput and Dutil from the Children’s Hospital of Eastern Ontario Research Institute suggests that sleep, sedentary behavior, physical activity, and diet are all deeply interconnected; lack

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of sleep is a stressor that leads to sedentary behavior and decreased physical activity due to fatigue, as well as overconsumption, while decreased physical activity and poor diet may cause a lower quality of sleep, thus perpetuating a never-ending cycle. (1,p.5) Furthermore, researchers affiliated with the Center for Disease Control and Prevention have found that insufficient sleep increases risk-taking behavior. Findings in Wheaton et al show that injury-related risk behaviors was associated with high school students who slept less than 7 hours (2). For those with insomnia, their problems could go beyond those caused by lack of sleep. Coveney et al explains how many GPs categorize insomnia into primary insomnia – in which insomnia is the primary issue being dealt with – and secondary insomnia, in which insomnia is a symptom of an underlying cause (3, p.274) Insomnia is often an indicator of other health issues, with a prominent example being that of mental disorders such as depression and anxiety. These in particular are able to easily affect the patients’ sleep cycles as their minds are occupied by many thoughts throughout the night. In fact, sleep issues are a primary indicator of depression, with a lack of energy being another warning sign that can be seen in many preliminary questionnaires regarding the disorder. Liu et al. provides data to back up this assertion, showing that having difficulty sleeping was the most prevalent symptom of depression, with a rate of 14.68%


public health & policy johanna lim

Artwork by Sorasicha Nithikasem of survey participants struggling with sleep troubles everyday, another 12.11% having issues more than half the time (4, p.192). Several methods have been explored in the process of treating insomnia; two management methods that have shown results include medication and sleep restriction therapy. Medication has such a wide variety that it is able to treat both primary and secondary insomnia. However, with medication, there is the constant concern regarding side effects, as seen when Coveney et al describes the current situation regarding sleeping pills as treatment for insomnia in the UK – many measures are in place to reduce the prescription of hypnotics due to its addicting properties (3. p.278). Often, in cases of secondary insomnia, the pharmaceuticals utilized are those to treat the underlying disorder that cause it – such as sedative antidepressants, antipsychotics, among others –, with hypnotics sometimes paired with the medication to compensate for the time before the primary medication can kick in.3(p.276) In

addition, the currently prescribed hypnotics tend to be for short-term use, which decreases GP’s willingness to prescribe them even more as they will only provide temporary relief without dealing with the actual issue (3, p.277) As a result, the medicated treatment is not very favored for primary insomnia; researchers tend to look into other options that treat the psychological face of insomnia, in order to adjust neurological and hormonal imbalances. Sleep restriction therapy is one such treatment, having been used for several decades without understanding of the process by which it works. Researchers from the University of Oxford explore the mechanism by which sleep restriction therapy functions in Maurer et al, suggesting that by regulating sleep and wake times, as well as the time spent awake in bed, one can adjust psychological associations with one’s sleeping area, influencing cognitive-behavioral pathways that may lead to further physiological improvements (5, p.134).

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Medical Dialogue Review Volume 13 | Issue 2 On the other hand, is there anything wrong with sleeping a lot? In fact, yes! Many people may not realize it, but sleeping too much could also cause health issues just as severe as those from sleeping too little. Similarly, sleeping too much is correlated with obesity, diabetes, and cardiovascular risk, along with other mortality risks.6 This can be seen in a study referenced earlier regarding risk-related behaviors, where Wheaton et al also indicated that students who reported sleeping more than 10 hours also showed increased risk-taking behavior.2 Oversleeping, also known as hypersomnia, may be caused by neurological disorders or external circumstances, as well as mental illnesses, much like insomnia. For example, a relatively well known disorder related to oversleeping is narcolepsy, in which patients afflicted by this suffer from bouts of extreme sleepiness and muscle weakness during the day regardless of how well-rested they are, often due to emotional fluctuation.7 (p.94) In addition, Dye et al shows that hypersomnia is often also correlated with damage due to injury or illnesses of either genetic and infectious sources.7 Other neurological disorders such as sleep apnea and Restless Leg Syndrome (RLS) may cause a decreased quality of sleep, thus leading to an increase in the amount of sleep. In addition, a common behavior that may cause occasional oversleeping can be found in how students often find themselves sleeping too little during school days and oversleeping during weekends to compensate. However, there are also times where the cause of oversleeping is unknown, in an affliction called idiopathic hypersomnia, which was first described as “sleep drunken-

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ness” in 1956. 8 Recent research such as a recent study by Sforza et al at the University of Lyon suggests that the condition may be caused by damage from a viral infection, disrupting immunological or inflammatory processes.9 Excessive daytime sleepiness also appears in patients suffering from hormonal imbalances – such as the abnormal melatonin secretion within the Smith-Magenis Syndrome.7 (p.100) Treatments for hypersomnia generally appear to utilize medications such as tricyclic antidepressants and stimulants, in order to treat the excessive sleepiness or to target the underlying causes.7 Exploring the various treatments, the lack of options available to people suffering from insomnia can be seen; society is generally undereducated on the severe damage done by insufficient sleep and thus not many resources are devoted to the treatment and management of sleep and its related disorders. Both extremes of abnormal amounts of sleep can lead to health issues, both physically and mentally, and should be addressed more seriously as sleeping issues are an extremely prevalent problem in a society that values efficiency and thus prioritizes work completion over sleep.


public health & policy johanna lim

References Chaput J-P, Dutil C. Lack of sleep as a contributor to obesity in adolescents: impacts on eating and activity behaviors. International Journal of Behavioral Nutrition & Physical Activity. 2016;13:1-9. doi:10.1186/s12966-016-0428-0. Wheaton AG, Olsen EO, Miller GF, Croft JB. Sleep Duration and Injury-Related Risk Behaviors Among High School Students--United States, 2007-2013. MMWR: Morbidity & Mortality Weekly Report. 2016;65(13):337-341. doi:10.15585/mmwr.mm6513a1. Coveney C( 1 ), Williams SJ( 2 ), Gabe J( 3 ). Medicalisation, pharmaceuticalisation, or both? Exploring the medical management of sleeplessness as insomnia. Sociology of Health and Illness. 41(2):266-284. doi:10.1111/1467-9566.12820. Liu Y, Ozodiegwu ID, Yu Y, Hess R, Bie R. Research paper: An association of health behaviors with depression and metabolic risks: Data from 2007 to 2014 U.S. National Health and Nutrition Examination Survey. Journal of Affective Disorders. 2017;217:190-196. doi:10.1016/j.jad.2017.04.009. Maurer LF, Espie CA, Kyle SD. How does sleep restriction therapy for insomnia work? A systematic review of mechanistic evidence and the introduction of the Triple-R model. SLEEP MEDICINE REVIEWS. 42:127-138. doi:10.1016/j.smrv.2018.07.005. Léger D, Beck F, Richard J-B, Sauvet F, Faraut B. The Risks of Sleeping “Too Much”. Survey of a National Representative Sample of 24671 Adults (INPES Health Barometer). PLoS ONE. 2014;9(9):1-12. doi:10.1371/journal.pone.0106950. Dye TJ, Jain SV, Kothare SV. Central Hypersomnia. Seminars in Pediatric Neurology. 2015;22:93-104. doi:10.1016/j.spen.2015.03.004. Billiard M, Sonka K. Clinical review: Idiopathic hypersomnia. Sleep Medicine Reviews. 2016;29:23-33. doi:10.1016/j.smrv.2015.08.007. Sforza E, Hupin D, Roche F. Mononucleosis: A Possible Cause of Idiopathic Hypersomnia. Front Neurol. 2018;9:922. Published 2018 Oct 31. doi:10.3389/fneur.2018.00922

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Medical Dialogue Review Volume 13 | Issue 2

Mismatching Markers: Why Minorities Need to Register By Oishi Goswami

Artwork by Jessica Gai The likelihood of finding a matching donor for a stem cell transplant should you be part of a minority ethnic group is much lower compared to your Caucasian counterparts. Because the basis of the transplant requires the human leukocyte antigens to match between the donor and recipient – the differentiation of which is inherited – many are currently facing a significantly lower chance of survival due to the fact that black, Asian, and other minority

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ethnicities make up a very small percentage of the donor population. These transplants are exceedingly necessary for various blood diseases and disorders, some of which include leukemia, lymphoma, sickle cell anemia, and thalassemia. The unfortunate reality is that minority patients who require a stem cell transplant stand a much lower chance of survival because of the lower likeliness to score a donor match.


public health & policy oishi goswami

Most commonly the stem cell transplants are necessary for those with leukemia — the cancer of white blood cells that are made in the bone marrow and are necessary for fighting infection. According to the National Cancer Institute (NCI), acute lymphoblastic leukemia is the most common cancer in children, representing 23 percent of cancer diagnoses among those younger than 15 (Sigel Miller & Jamal 2018). With the disease being so prevalent, its treatment options should and must be more accessible. The jarring reality is that stem cell and bone marrow matches rely heavily on inherited ancestral tissue, so matches typically occur between people of similar heritage. Around 30 percent of patients find a match within their own family (Institute for Justice). The rest are forced to rely on unrelated donors. The most important matching factor is called human leukocyte antigen (HLA); there are HLA multiple markers that must align for the donors to be compatible. In the United States, the National Marrow Donor Program (NMDP) or private histocompatibility laboratories make this donation process possible: “histocompatibility laboratories support transplantation programs in several ways. They identify organ and stem cell recipients and donor human leukocyte antigens (HLA) for matching purposes, they screen waiting recipient sera for anti-HLA antibodies, and they perform cross-matches between recipient sera and donor cells just before a potential transplant procedure” (Williams 2001). According to Be The Match, ten typical markers are analyzed and different doctors have various standards of practice. Some require at least 6 markers to match, as the NMDP does, while some practices require 8 markers to match; the benefits of quality HLA allows for a smoother transplant process including “[helping] your donor cells engraft (grow and make new blood cells in your body) [and reducing] the risk of complications like graft-versus-host disease (GVHD). GVHD happens when the immune cells from the donated cells (the graft) attack the recipient’s cells (the host)” (BeTheMatch 2019). The

necessity of the matching markers increases the more severe the disease progresses thus shortening the timeline the patient needs the transplant and for it to be successful. According to the Institute of Justice, “only 2 percent of [the] population is on the national registry,” but those who can be located or even willing to donate within the 2 percent is even less. The statistics on availability for transplants for minorities is abysmal, and the disparity is international. Countless articles have been released from the U.K., China, India and Canada regarding an urgent cry for more people to register on donor repositories. Since technology has helped ease the collecting/transplanting process, the fear which permeates around bone marrow transplants must be re-envisioned. Instead of the commonly-heard-about procedure of extracting bone marrow from potential donors, the nonsurgical process of apheresis developed to extract peripheral blood stem cells for donation is significantly less painful and more effective. Many are intimidated by the idea of staying awake during the bone marrow extraction procedure and fear that the local anesthetic will not prevent them from feeling a “sharp pain,” however there is a lack of information regarding any alternative procedures that may exist like apheresis (Mayo Clinic 2018)/ The statistics show that the donor pool available for minorities is radically smaller than their white counterparts. African-American patients have a 25 percent chance of finding a match, Asian patients have a 40 percent chance and Hispanic patients find a donor about 45 percent of the time (Institute of Justice 2009). All the while, caucasian patients find a donor about 75 percent of the time (Institute of Justice 2009). This disparity can be attributed to many factors, but through more education about the methods of becoming a donor and lessening any potential stigma that may exist about cultivating stem cells and bone marrow, the disparity may be resolved..

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References BeTheMatch. (n.d.). HLA matching. Retrieved March 10, 2019, from https://bethematch. org/patients-and-families/before-transplant/find-a-donor/hla-matching/ Bone Marrow-NOTA Challenge. (2017, August 7). Retrieved March 10, 2019, from https:// ij.org/case/bonemarrow/ Bone Marrow Statistics. (n.d.). Retrieved March 31, 2019, from https://ij.org/bonemarrowstatistics/ Kรถrbling, M., Katz, R. L., Khanna, A., Ruifrok, A. C., Rondon, G., Albitar, M., . . . Estrov, Z. (2002). Hepatocytes and Epithelial Cells of Donor Origin in Recipients of Peripheral-Blood Stem Cells. New England Journal of Medicine,346(10), 738-746. doi:10.1056/ nejmoa3461002 M. (2018, November 28). Bone marrow biopsy and aspiration. Retrieved March 31, 2019, from https://www.mayoclinic.org/tests-procedures/bone-marrow-biopsy/about/pac20393117 McKenna, D., & Sheth, J. (2011). Umbilical cord blood: current status & promise for the future. The Indian journal of medical research, 134(3), 261-9. Siegel, R. L., Miller, K. D., & Jemal, A. (2018). Cancer statistics, 2018. CA: A Cancer Journal for Clinicians,68(1), 7-30. doi:10.3322/caac.21442 Thomas M. Williams, Human Leukocyte Antigen Gene Polymorphism and the Histocompatibility Laboratory, The Journal of Molecular Diagnostics, Volume 3, Issue 3, 2001, Pages 98-104, ISSN 1525-1578, https://doi.org/10.1016/S1525-1578(10)606587.

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public health & policy leen azeez

To Spit Or Not To Spit By Leen Azeez With every gift-giving occasion often comes the struggle of choosing our loved ones gifts that are sentimental, valuable and above all, personalized. In our day and age, a potential gift that doesn’t break the bank and is arguably the most personalized gift you could ever give anyone is insight into their own genetic code. For a mere $99, you could buy a collection kit that comes complete, with one “saliva collection tube”, a clear bio-specimen bag (for packaging the filled saliva tube) and return shipping materials. The steps seem sufficiently straightforward, the price cannot be beat, and the kits themselves seem to be sold at convenience stores that are around almost every corner. So, why not purchase one of these test kits? Why not indulge, or facilitated a loved one’s indulgence, in what has been dubbed “curiosity genetics”? Why not give an original gift that many will think twice before re-gifting. To begin our discussion, it is essential to first introduce genotyping, the technology underlying genetic tests. According to 23andme, a company that offers these genetic tests with particularly well-known simplicity, genotyping refers to the “process of determining which genetic variants an individual possesses” (“How Does 23andMe Genotype My DNA?”, 2014). Genetic tests collect epithelial cells by way of that saliva sample you provided, isolate the genetic DNA within them, amplify the genetic information via a polymerase chain reaction, fragment it into shorter pieces and later attach those pieces via primers unto a “genotyping chip” that allows one to discern genetic variants, or single nucleotide polymorphisms, at little cost and with relatively little effort. One could imagine that technological advancements, such as the ones employed by these

at-home-genetic-testing-services, bring us closer to personalized medicine, a model that promises the tailoring of medical decisions, interventions and treatments to a patient’s specific genetic reality. Instead of grouping patients by symptom and illnesses, the model of personalized medicine aims to stratify them according to their genetic and molecular makeup, relying on the collection and analysis of genetic data to do so. Perhaps the essence of personalized medicine, even if this mission hasn’t been fully realized yet, is that patients could access their genetic code and benefit from such access through treatment or prevention strategies. But with companies like 23andMe, the data reported is clearly limited and comes with disclaimers that abolish the data’s immediate utility: generated reports are not able to be used to “diagnose” an illness, tell you if you have 2 copies (one from each parent) of any variant, decisively state your risk of developing a health condition, or cover all variants that affect an individual’s risk of developing any illness (“What Health-Related Information Can I Learn from 23andMe?”, n.d.). Instead, the reports tell you whether you have any specific genetic variants that you could pass onto your children or if you have SNPs that may increase your risk “of developing certain health condition” (“What Health-Related Information Can I Learn from 23andMe?”, n.d.). So if the reports themselves have no immediate diagnostic or preventative value, could a customer potentially take the raw data generated to a trained genetic counselor or other healthcare provider to learn more? According to 23andMe, although the raw data generated “has undergone general quality review”, only a subset of the markers “have been individually validated for accuracy” which means the data

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Artwork by Sorasicha Nithikasem is “only suitable for research, educational and informational use” and “not for medicinal use” (“Accessing And Downloading Your Raw Data”, n.d.). The website also recommends consulting with a healthcare professional before making any major lifestyle adjustment. In short: the data and reports provided are not useful by any medicinal means but may be interesting if you want to know your inherited genetic variants and how said variants may manifest. However, aside from utility, another major concern when considering customers’ genetic information is privacy. Potential issues include how samples provided are protected, whether generated reports are secured to only allow their intended audiences to view them, and whether such sensitive data is protected from online hacks and attacks. Also under privacy comes the question of what 23andMe intends to do with the large database they’re not so slowly building? According to 23andMe, “personal and registration information” is separately stored from the genetic information obtained, in an effort to “reduce the likelihood” of identification (“Privacy and Data Protection”, n.d.). Furthermore, genetic information

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“is only identified using a barcode system” and personal information is “assigned a randomized customer identification number” which also protects customers, by limiting intrusion and seemingly abolishing violation concerns (“Privacy and Data Protection”, n.d.). What the website does not detail, however, is what they intend to do with all the data they’re accumulating. Given that both 23andMe and Google have access to large amount of personal, sensitive data and that some of their inner workings are to some degree lacking in transparency, perhaps we can learn something about 23andMe from Google. When it first launched, “Google billed itself as a faithful servant of the consumer, a company devoted only to building the best tool to help us satisfy our cravings for information on the web” (“23andMe Is Terrifying, but Not for the Reasons the FDA Thinks”, 2013). And while Google’s search engine did indeed help us search and learn, the company’s hoarding tactics soon became apparent: “every search query entered into [any] computer is stored indefinitely” (“23andMe Is Terrifying, but Not for the Reasons the FDA Thinks”, 2013).


public health & policy leen azeez

The data is then used to generate targeted advertisements that predict your needs and fuel your wants, pushing you to make a purchase you wouldn’t have otherwise made. Targeting is fundamentally enabled by the hoarding of private, sensitive information that places each consumer into a number of categories which range from the seemingly innocuous such as “listens to Apple music” and “has Amazon prime” to the more intrusive like “lives away from family” (“Digital Ads Are Starting to Feel Psychic”, 2018). Breaking consumers down into such categories then allows retail companies to finely tune their advertisements so that they appeal to one or more of our respective categories and the desires they entail. Similarly, it could very well be that 23andMe is now generating a database that re-defines this targeting technique, no longer to one’s search history and double-clicks, but rather to one’s own genes and genetic variants. In a 2017 interview with Kate Black, 23andMe’s Head of Privacy, Black mentioned that 23andMe has “a lot of research partnerships”, some of which “include financial remuneration” (“23andMe Is Selling Your Data, But Not How You Think”, 2017). Black says that more than in 2017, 80% of 23andMe’s two million-plus consumers “consented to having their data used for research”. Note that the data Black reference is de-identified and aggregated, regardless however: 23andMe has already sold some form of their customers’ data for financial gain to research entities likes Genentech and not for profit organizations like

the Michael J. Fox Foundation. If 23andMe starts selling data to commercial companies responsible for the targeted posts that plague our every search, then the categories we are placed into could now include “is likely allergic to lactose”, “is caffeine intolerant” or “likely has curly hair”. If 23andMe reports you having a single nucleotide polymorphism that might mean you have curly hair, you might soon see advertisements for hair products that tame unruly curls. While companies like 23andMe offer services that truly provide access into what it is that makes us so uniquely us, the field itself is relatively young, lacking laws that encompass all the nuances of genetic testing and its future consequences. The choice of whether or not to buy a kit remains yours, but before you do, make sure to read all the tedious fine print and ask yourself all the important questions: are you being sufficiently protected? Do you really care about the generated information, and how will you utilize it? Are you ready to learn information that may be “inactionable”? In case one of your reported SNPs proves dangerous, will you consult a genetic counselor? Or are you merely doing it because it’s fun to know what type of earwax your variants encode and don’t care about the rest? However you choose to look at it, a $99 starter kit, on its own, is unlikely to help you discover your genetically encoded self in any actionable way without guidance and professional counseling.

“How Does 23andMe Genotype My DNA?” 23andMe Customer Care, customercare.23andme.com/hc/ en-us/articles/202904610-How-does-23andMe-genotype-my-DNA-. “What Health-Related Information Can I Learn from 23andMe?” 23andMe Customer Care, customercare.23andme.com/hc/en-us/articles/115013843028-What-health-related-information-can-I-learnfrom-23andMe-. “Accessing and Downloading Your Raw Data.” 23andMe Customer Care, customercare.23andme.com/ hc/en-us/articles/212196868-Accessing-and-Downloading-Your-Raw-Data. “Privacy and Data Protection.” 23andMe, www.23andme.com/privacy/. Seife, Charles. “23andMe Is Terrifying, but Not for the Reasons the FDA Thinks.” Scientific American, 27 Nov. 2013, www.scientificamerican.com/article/23andme-is-terrifying-but-not-for-the-reasonsthe-fda-thinks/. Schwartz, Oscar. “Digital Ads Are Starting To Feel Psychic.” The Outline, The Outline, 2018, theoutline.com/post/5380/targeted-ad-creepy-surveillance-facebook-instagram-google-listening-not-alone?zd=2&zi=dhnjepkr. Brown, Kristen V. “23andMe Is Selling Your Data, But Not How You Think.” Gizmodo, Gizmodo, 14 Apr. 2017, gizmodo.com/23andme-is-selling-your-data-but-not-how-you-think-1794340474.

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Medical Dialogue Review Volume 13 | Issue 2

The Ramifications of Antimicrobial Resistance in India By Olivia Polk Antimicrobial Resistance Definition Antimicrobials have been defined as agents preventing growth of microorganisms carrying pathogens (Merriam-Webster). They have contributed in an immensely positive way to public health; with incredibly high success rates, they have “extended average life expectancy by two decades, shifting the paradigm from communicable to non-communicable diseases” (Shallcross 2014). Antimicrobials have been the reason for outstanding advancements in a number of areas that have redefined the capability of modern medicine. Unfortunately, the very thing keeping humanity alive and healthy is also enabling an enormous global threat that could end up killing more people annually by 2050 than cancer (de Kraker et. al, 2016). There is an increasingly large problem where microorganisms are now capable of resisting the antimicrobials that were once effective against them. This crisis is known as antimicrobial resistance (AMR). A journal article on AMR from the US National Library of Medicine defines AMR as: “the increasing global incidence of infectious diseases affecting the human population, which are untreatable with any known antimicrobial agent” (Michael et al., 2014). Evidently, AMR renders previous methods for bacterial infection or disease treatment essentially useless. The Reason AMR is a Global Burden This crisis proves to be a serious threat to the health of humanity according to the same journal article that explains how the population will face many great challenges in the future. There have been numerous casualties in the past that were a direct result of epidemics in history and this has simply always been an aspect of civilization (Michael et al., 2014). However, an estimated 10 million people will die annually by 2050 because of AMR (de Kraker et al., 2016). This will prove to be true without national policy and commitment to managing this issue. Without successful medicine, quick treatment of infections will no longer be a reality. In addition to this, the economy will be negatively impacted as the rise of people being infected with diseases will lead to a decline of people in the workforce (Michael et al., 2014). The issue will also strike the economy with higher cost of lengthened treatment due to people staying sick for a longer period of time when the antibiotics prove to be ineffective. Furthermore, trade and the manner that it has grown has authorized widespread exposure to the bacteria with developed resistance (Kumar et al., 2013). The Role of Carbapenems There are many known reasons for the cause of AMR. Carbapenems are one type of antibiotic in a collection of many that work incredibly well to combat bacteria that are gram-positive and gram-negative (which refers to the thickness of bacteria’s cell wall) (Papp-Wallace et al., 2011). Due to the high success rate of these antibiotics, they are often used to treat bacterial diseases and infections. While this may appear to be the solution to many problems, the over-prescription of Carbapenems has actually given rise to evolutionary responses in the bacteria.

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public health & policy olivia polk

What NDM-1 is and Why it is Creating a Global Threat There was an emergence of a gene called New Delhi Metallo-β-lactamase (NDM-1) in India. This gene alone is not the direct cause of illness, but can alter bacteria causing them to secrete an enzyme that forms an aggressive resistance to negate treatment from antibiotics (Nordqvist 2016). Nordqvist’s article discusses a patient who acquired a bacterial infection that was unresponsive to all treatment from antibiotics which led to the discovery of the gene. It is unknown how it originated in India’s capital, but quite clearly NDM-1 poses a huge threat to human health as it has been said that, “A bacterium carrying the NDM-1 gene is the most powerful superbug in existence” (Nordqvist 2016). In fact, it has now been found in over 70 countries 5 years after its first appearance. The possession of such a gene will result in bacterial strains producing an enzyme that neutralizes the effects of antibiotics and forms a resistance to even some of the most powerful antibiotics (Mitka 2013). There exists a process called horizontal gene transfer, or HGT, that allowed the DNA code to move from bacterium to bacterium according to Norqvist’s article. The issue arises when this process occurs in bacteria that have already acquired antibiotic resistance because it can lead to infections with no cure. Why India is Particularly Impacted Developing countries are particularly impacted by this public health crisis because there is a “disproportionately higher incidence of inappropriate use of antibiotics and greater levels of resistance compared to developed countries” (Kumar et al., 2013). According to the World Health Organization, in each country there is a prevalence of AMR, however, it proves to be a particularly greater burden in developing countries such as India. A report on AMR states that in 2014, the highest consumer of antibiotics was India (Gandra et al., 2017). Many people in India lack information about the appropriate use of antibiotics, and a vast number are self-medicating. There are a multitude of reasons given for why India is particularly impacted by AMR. An article that examines AMR specifically in India states that; “A mix of poor public health systems and hospital infection, high rates of infectious disease, inexpensive antibiotics, and rising incomes is coming together to increase prevalence of resistant pathogens and is increasing the burden of untreatable neonatal sepsis and health-care-associated infections” (Sumanth 2016). There are a lot of societal factors in a developing country that do nothing to reduce the burden of AMR. As an example, the general public in India as well as consumers of antibiotics lack the information about the correct uses. In terms of hygiene, India’s substandard practice of prevention of infections does not create an environment to stop the transmission of resistant bacteria. This article also discusses how, “Inadequate national commitment to a comprehensive and coordinated response and ill-defined accountability with respect to antimicrobial use and resistance is an issue to be considered” (Kumar et al., 2013). The health system is also to blame for the problem of AMR. The pharmaceutical companies provide compensation in exchange for a prescription of the antibiotics which provides high incentive for the doctors to do so (Michael et al., 2014). This high incentive leads to high prescription rates which leads to an overexposure to the antibiotics leading to the likelihood of bacteria developing resistance. Physician prescriptions are not the only factor contributing to the issue. Antibiotics are highly accessible over the counter as well. With no prescription necessary in India, extensive and unrestrained self-medication leads bacteria to have

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Medical Dialogue Review Volume 13 | Issue 2 over-exposure to antibiotics which enables the build up of resistance (Dutta 2017). By examining the ramifications of AMR in India, it is clear how needed new legislation and policy reform are for this incredibly large and dangerously unrecognized global burden. Management of AMR There is an obvious need for new legislation and policy reform to shed light on this pressing issue. There are a number of groups known to help with this process, by creating awareness of this issue, such as the Indian Association of Pediatrics and the Global Antibiotic Resistance Partnership (Laxminarayan 2016). Many other strategies have been employed over the last 10 years, in order to regulate this problem. IIMAR, the Indian Initiative for Management of Antibiotic Resistance, began in the spring of 2008 and have supported the issue with efforts from the World Health Organization (Kumar 2013). Although significant, recommendations for how to manage AMR are only part of the solution. Education is an incredibly important tool that can make a great impact on the future of humanity. Awareness about the gravity of this issue and the extent to which it will impact civilization is not only important, but also necessary. The Gandra et al., article about AMR in India also discusses the importance of education. He notes that, “Behavior change is needed among physicians and patients. India has achieved remarkable reductions in smoking in buildings and workplaces through regulation and behavior change communication. Similar campaigns could work to educate the public and physicians about the dangers of uncontrolled antibiotic use, as has been the case in high-income countries, but more research is needed to see how well this could work in India” (Sumanth 2016). A large part of the problem is the alarming number of people who can make a difference, but are unaware of how pressing the issue has become. Due to the global impact that AMR is having, the strategy for the containment of AMR is one that requires global action. Surveillance is “fundamental to any strategy for AMR containment” and there is also a great need for the global enforcement of the correct usage of antimicrobials through policy (Smith et. al, 2018). Establishing a connected global strategy through education, surveillance, regulations, and policies are vital for the containment of AMR.

Artwork by Zahin Ahmed

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public health & policy olivia polk

Conclusion At first introduction, antimicrobials were considered revolutionary as they treated a number of bacterial diseases, worked rapidly and were highly effective. Because of the high success rates, they were almost always prescribed in order to treat patients. This over-prescription is just one reason why bacteria are now developing antimicrobial resistance. AMR is a tremendous threat to our world that has a particularly large effect on developing countries. Due to the unsatisfactory living conditions and little regulation of antibiotics, among many other reasons, developing countries are pounded by the effects of resistance. Without any known treatment to combat this resistance that impacts so many people in India, there are few ways to contain and manage AMR. Surveillance is one important method that can monitor data. Education is another method to spread awareness about the alarming impacts that resistance can have in a society that desperately needs help. New legislation and reform have proven to be important and effective in regulating the use of antibiotics. By looking into the ramifications that AMR has in India, it is clear that there is a need for a global effort from stakeholders all over the world to help regulate and relieve the burden of this issue.

References Antibiotic / Antimicrobial Resistance. (2017, September 19). Retrieved April 08, 2018, from https://www.cdc.gov/drugresistance/about.html Antimicrobial resistance. (2018, January). Retrieved April 08, 2018, from http://www.who.int/mediacentre/factsheets/fs194/en/ Carbapenems: Past, Present, and Future . Antimicrobial Agents and Chemotherapy, 55(11), 4943–4960. http://doi.org/10.1128/AAC.00296-11 de Kraker MEA, Stewardson AJ, Harbarth S (2016) Will 10 Million People Die a Year due to Antimicrobial Resistance by 2050? PLoS Med 13(11): e1002184. https://doi.org/10.1371/journal.pmed.1002184 Dutta Sumi S. India launches strategy to curb antimicrobial resistance BMJ 2017; 357:j2049 Ghafur, A. (2012). Can India be the Wing Commander in the Global Fight Against Antimicrobial Resistance? International Journal of Scientific Research, 60, 42-43. doi:10.15373/22778179/jan2014/5 Maragakis, L. L., Perencevich, E. N., & Cosgrove, S. E. (2008, October). Clinical and economic burden of antimicrobial resistance. Retrieved April 08, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/18847410 Michael, C. A., Dominey-Howes, D., & Labbate, M. (2014, September 16). The Antimicrobial Resistance Crisis: Causes, Consequences, and Management. Retrieved April 08, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4165128/ Mitka M. Indian Public Health Leaders Move to Reduce Antimicrobial Resistance. JAMA. 2013;309(6):531–532. doi:10.1001/jama.2013.297 Nordqvist, C. (2016, August 16). "What is superbug NDM-1?." Medical News Today. Retrieved From https://www.medicalnewstoday.com/articles/197616.php. Oberoi, L., Singh, N., Sharma, P., & Aggarwal, A. (2013, January 1). ESBL, MBL and Ampc β Lactamases Producing Superbugs – Havoc in the Intensive Care Units of Punjab India. Retrieved April 07, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576754/ Papp-Wallace, K. M., Endimiani, A., Taracila, M. A., & Bonomo, R. A. (2011). Shallcross, L. J., & Davies, D. S. C. (2014). Antibiotic overuse: a key driver of antimicrobial resistance. The British Journal of General Practice, 64(629), 604–605. http://doi.org/10.3399/bjgp14X682561 Smith, Richard D, and Joanna Coast. “Antimicrobial Resistance: a Global Response.” SciELO - Scientific Electronic Library Online, 12 May 2018, www.scielosp.org/journal/bwho/about/#about. Strategic and Technical Advisory Group on antimicrobial resistance (STAG-AMR) (pp. 1-9, Issue brief). (n.d.). World Health Organization. Retrieved April 7, 2018, from http://apps.who.int/iris/bitstream/handle/10665/204274/WHO_DGO_AMR_2016.1_eng.pdf;jses sionid=E30F7B05587B1D1BAA86AF0CD3436070?sequence=1 Sumanth Gandra, Jyoti Joshi, Anna Trett, Anjana Sankhil Lamkang, and Ramanan Laxminarayan R, Chaudhury RR (2016) Antibiotic Resistance in India: Drivers and Opportunities for Action. PLoS Med 13(3): e1001974. https://doi.org/10.1371/journal.pmed.1001974

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Medical Dialogue Review Volume 13 | Issue 2

Do We Have a Duty to Die? Joseph Montesano Seton Hall University Winner of the Bioethics Undergraduate Essay Contest

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bioethics undergraduate essay contest joseph montesano

Introduction Philosophers and ethicists alike commonly discuss whether terminally ill patients have the moral right to commit suicide. A less frequent debate concerns whether individuals could ever have a duty to die, rather than a right to do so if they choose. It seems commonsensical that older individuals would be more likely to possess this duty than younger individuals who have years of potentially good life remaining. John Hardwig proposes that we have a duty to die if our condition reduces us to a constant burden for our loved ones, regardless of age. In contrast to Hardwig, Michael Cholbi claims that our burdens must threaten the lives of our loved ones to a substantial degree for us to have a duty to die. In this paper I shall argue that Cholbi’s view is too narrow to deal with certain cases in which a person has the duty to kill herself, although others could not permissibly kill her. In the following section, I will briefly explore the main arguments of both Hardwig and Cholbi. After, I will address a novel example to demonstrate that Cholbi’s self-defense claim does not adequately account for a duty to die. Hardwig’s Account of the Duty to Die In this section, I will consider Hardwig’s argument that we, as social beings, have a duty to die in some circumstances. Because medicine has allowed humans to live longer, we may now persist longer than we can feasibly care for ourselves and sometimes longer than we are able to be salient of our personhood (Hardwig 1997, 35). As we age, our deteriorating health does not only affect us, but also the people around us. Hardwig asserts that claiming otherwise would be “morally obtuse” (Hardwig 1997, 35). We function as members of family and friend groups, and our condition affects those groups as much as it may affect us. As Hardwig asserts, sometimes our “loved ones would be much better off… if [we] were dead. The lives of our loved ones can be seriously compromised by caring for us” (Hardwig 1997, 36). This claim makes intuitive sense—we can imagine the situation of a stressed woman raising both her children and

taking care of her mother under the same roof. The woman’s life would seemingly be better off had her mother not required the caregiving. The mother’s care would pose a significant burden on the woman, restricting her family’s income, her career aspirations, her ability to socialize, and her time to engage in activities she may enjoy. Naturally, it seems wrong for me to expect or plead for my family to care for me just so I could get a few extra years of life—especially if I had a lower well-being and little autonomy during that additional time. Contrary to popular belief, Hardwig believes it would even be morally wrong for me to allow my family to care for me in such a state. I would have a duty to die and must act upon it. This scenario happens quite frequently today, despite that most people do not desire to become a burden. Hardwig’s argument briefly addresses the issue of competence in determining whether a person has the duty to die. He asserts that we must act upon our duty to die before we become incompetent in order to prevent unnecessary absolution of the duty. But, what happens when one endures an injury where they are left mentally incompetent and unable to care for themselves? According to Hardwig, their duty to die seemingly disappears with their mental capacities. This assertion seems like the right conclusion. Accordingly, the duty dies along with the mental capacities. Cholbi’s Response to Hardwig’s Account: Self Defense At this point, I will consider Cholbi’s objection to Hardwig’s argument. In his writings, Cholbi rejects no specific premise of Hardwig’s argument. Yet, he asserts that people have a duty to die in a narrower range of cases than Hardwig proposes. To support his argument, he presents the Captain Oates example (Cholbi 2010, 415). In the example, Captain Oates was suffering from a previous war wound during an expedition of the South Pole in 1912. His condition was worsening as he succumbed to frostbite, and his team members refused to abandon him.

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Medical Dialogue Review Volume 13 | Issue 2 Knowing that his deteriorating condition risked the lives of his colleagues, Oates walked out into the blizzard—knowing he would die—as an attempt to prevent burdening the team further (Cholbi 2010, 415). The Captain Oates example, although unfortunate, displays Oates as a competent, moral agent recognizing and acting upon his duty to die. Cholbi contends that this duty exists because Oates’ colleagues would have been “morally permitted to kill Oates” (Cholbi 2010, 415). In doing so, the team members would act upon a form of self-defense proportional to the potential harm that Oates could cause. Oates could have a duty to kill himself if and only if his team members had the need to kill him, in that his very existence posed a threat to their lives. Cholbi’s self-defense claim is designed to specify Hardwig’s broader claim in deciding when individuals possess a duty to die. Although “prolonged, costly, or debilitating conditions” may place great burdens on loved ones, none of these conditions are substantial enough to permit us to kill a loved one “on the grounds of self-defense” (Cholbi 2010, 417). Thus, according to Cholbi, a person who requires caregiving and places these burdens upon family members does not have a duty to die. Unlike Hardwig, he argues that the only time we could have the duty to die is if the burdens of us on our family could reasonably permit a family member to kill us. The burdens inflicted must be proportional to death so that our families could ethically kill us in self-defense. Cholbi asserts that Hardwig’s claim involves cases outside this reasonable proportionality. In the Captain Oates example, the team members would have had no choice but to kill Oates had they wanted to survive. However, in the majority of cases that are not as extreme, most people would not reach a point where they could have a duty to die. Depressed Gerald Has a Duty to Die Now that I have outlined the positions of both Hardwig and Cholbi, I will place Cholbi’s self-defense claim under scrutiny. Namely, I reject that self-defense alone can determine whether a person has a duty to die. First, I will

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review Hardwig’s response and compare it to the deprivationist Ben Bradley. Deprivationism asserts that death can be bad for a person if it deprives her of a good that she would have otherwise received had she not died. Here I will utilize the unique case of Depressed Gerald: Depressed Gerald: Suppose an unfortunate teenager, Gerald, is suffering from a genetic mutation that subjects him to a constant, crippling depression once he reaches age fourteen. According to his doctor, Gerald will be unable to recover from this depression as no treatments are or will become available for his condition. His depression is so bad that it would be better for Gerald not to exist during the times that he is depressed. Gerald is unable to function properly in society, so he never leaves his house. His mother is required to leave her dream career when Gerald reaches fourteen, and his father will be the only source of income. Once his parents pass away, Gerald’s younger sister—who wishes to become a lawyer—will need to watch over and provide for him both physically and financially.

For the sake of argument, we should assume that Gerald is competent before his depressive condition takes hold. According to Hardwig, Gerald has a duty to die before he turns fourteen given that he is competent. Suggesting that an almost-fourteen-year-old has a duty to die seems strange as he is only a teenager. But, Hardwig’s argument does not rest upon age, so his premises lead to the conclusion that Gerald possesses the duty.


bioethics undergraduate essay contest joseph montesano

Here I shall utilize Ben Bradley’s difference making principle to briefly determine whether Gerald would be better off acting upon his duty to die. Bradley’s difference making principle (DMP) states that the value of an event can be determined by comparing the outcome of the event to another outcome in the “nearest possible world” where that event did not occur (Bradley 2009, 50). DMP allows us to make claims about the goodness or badness of death for a person, such that “the more of a good life [death] takes away, the worse [the death] is; the more of a bad life it takes away, the better it is” (Bradley 2009, 50). Through DMP, it seems Depressed Gerald would have been better off had he died before turning fourteen. Gerald’s life after the depression mutation takes hold would be on the whole bad for him. Any positive well-being level would necessarily have to come from before he was fourteen. If he were to die at age fourteen, Gerald would retain that positive well-being level; if not, his well-being would turn permanently negative and his life would not be worth living. It follows then that DMP agrees with Hardwig’s argument. Gerald would actually benefit from dying and could have a duty to die before becoming depressed (image derived from Bradley 2009, 158). Now that I have illustrated the arguments for the benefits of death and a duty to die in Depressed Gerald, I will discuss why Cholbi’s self-defense argument produces unsatisfactory results in this example. This case poses an interesting dilemma for Cholbi. In most circumstances, we would presume that being cared for is seemingly good for the person being taken care of, but bad for the family because of the burden caring entails. It seems Cholbi had not considered a case where the continued life of the incompetent person is both bad for the person on the whole (see Figure 1) and for the family. In any case, Cholbi makes the claim that for a person to have a duty to die, she must inflict a burden on others that would gravely threaten their lives in some way. As such, the others would be morally permitted to kill her in self-defense. In Depressed Gerald, the lives

of Gerald’s parents and sister are not at risk due to his condition, merely their livelihoods. Consequently, Cholbi would argue against Gerald having a duty to die. But this claim seems counterintuitive: why should someone who will continue to live with permanent, crippling depression that acts as a burden to others and with a negative well-being level not consider suicide, or even a duty to die? According to DMP, Gerald’s well-being from his life on the whole would be greater if he were to die before the depressive condition, regardless of whether that positive well-being occurred only in his short fourteen years. It seems that Gerald would benefit from dying before coming of age, resulting in an overall positive well-being level for his life. It follows that Gerald has a duty to die, if not only for his family, but also, rationally, for the sake of his own well-being. Yet, Cholbi might still contend that because Gerald did not threaten the lives of his family through his depression, he would have no explicit duty to die. Here we must examine not only what is better off for Gerald, but his family as well. Depressed Gerald forces us to consider whether we can be utilitarian in considering a person’s duty to die. Allowing Gerald to die would allow his mother to continue working in her dream career, and his sister would no longer need to feel the burden of the oncoming expectation to care for him. These burdens result in severe financial and emotional drains on the family. Again, Cholbi does not consider these drains substantial enough to conclude that Gerald has a right to die, as effects on livelihood are not proportional to death itself. I disagree with Cholbi’s claim and will defer to DMP to demonstrate why. Suppose DMP is true, and that the nearest possible world in Depressed Gerald where Gerald does not die before reaching age fourteen is one in which he does die beforehand (i.e., acts upon his duty to die). This nearest possible world is doubtlessly better off for all involved parties. Not only will Gerald’s mother and sister be relieved of their duties of care and live happy lives in their careers, but Gerald himself would also

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Medical Dialogue Review Volume 13 | Issue 2 have a higher well-being over the course of his shortened life than if he were to have lived to the age of 80 with constant depression. It cannot be denied that Gerald’s family would have a decrease in well-being immediately following his death. Despite this decrease, they would experience a greater increase in well-being after some time compared to that of the nearest possible world where Gerald did not die. His family would no longer have the obligation to burden themselves with his necessary and permanent care. As rational individuals, we ought to presume that people will choose to have the life full of a greater positive well-being compared to one with a lesser. It seems that in Depressed Gerald, Gerald’s death would be unfortunate but better for himself and his family. Nevertheless, Cholbi defends that a case of livelihood could not permit killing as it is not proportional to the loss of an entire life. As a result, we ought not rely on Cholbi’s self-defense argument in determining whether a person has a duty to die. In order to respond to this dilemma, Cholbi would need to consider why it might be important to keep Gerald alive. Gerald would prudentially act upon his duty to die before reaching age fourteen based on his well-being alone. If not, his well-being would drop to a negative level where it would be better off for him to not be alive. But the question remains whether, if Gerald had not acted upon this duty, it would be permissible for his family to kill him after his well-being level turned negative. Killing Gerald does not seem to be a moral response to the dilemma, as this could have poor implications on whether families have the right to end the lives of relatives not yet close to their deaths. Unfortunately, the moral thing to do is not always the prudent action we should take. Above all, proportionality is pivotal to Cholbi’s claim, but I argue that he should consider the well-being and livelihood of all those involved rather than solely the risk to their lives. The fact remains that if Gerald would persist after fourteen, both him and his family would forfeit great goods in their lives—namely, their overall well-beings.

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Conclusion If my critiques Cholbi are compelling, we ought to acknowledge that a duty to die does not exclusively apply to the elderly or dying individuals. In this paper, I have contended with the narrowness of Cholbi’s assertion in that a person can only have a duty to die if she poses a great threat to the lives of those she will burden. After demonstrating Hardwig’s and Cholbi’s views, I contested Cholbi’s claim for a necessary self-defense feature in a duty to die through the novel example Depressed Gerald. Throughout the critique I have provided comments on how both Cholbi could revise his claims to fit a larger range of situations. In the end, the duty to die lies in the hands of the person who will take her life. She must ask herself if she wishes to be a burden for the rest of her existence, or if she should sacrifice herself for the well-beings of her loved ones, and in some cases, herself.


bioethics undergraduate essay contest joseph montesano

References Bradley, B. (2009). Well-Being and Death. Oxford; New York: Clarendon Press; Oxford University Press. Cholbi, M. (2010). The Duty to Die and the Burdensomeness of Living. Bioethics, 24(8), 412–420. https://doi.org/10.1111/j.1467-8519.2008.00723.x. Hardwig, J. (1997). Is There a Duty to Die? The Hastings Center Report, 27(2), 34. https:// doi.org/10.2307/3527626.

Artwork by Sorasicha Nithikasem

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Medical Dialogue Review Volume 13 | Issue 2

Shadow by Jahnavi Tatachar

Artwork by Amodhya Samarakoon

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creative section jahnavi tatachar

My friend comes and goes without reason. If I think of her, she readily appears, acting as if she never left in the first place. She brings with her many questions, ones that I could never think of, and unfortunately, never answer either. I tell her to stop visiting, as I have no room for her and her belongings. She insists that we can both fit, squeezing into my wardrobes, drawers, and eventually, veins. I tell her I have no time for her puzzling inconsistencies and spontaneous eruptions She simply tells my clock to move over and make room for the main event. As we spend months together, I get used to feeding her every day Before I take a test, perform a song, or even speak, I must open her jar She devours the contents inside faster and faster, but I grow smaller and smaller. I cannot tell anyone else to take care of my friend, because only I can see her. After a while, her constant probing feels normal to me. I no longer remember what it feels like to live alone. Her skeptical stare, sudden panics, and sharp breaths are now mine too. One day, I step into the sun while she is still asleep The yellow gem’s gaze dances across my face and I am as light as a cloud I walk to the water and dip my foot into the blue. The cold playfully pokes at my toes, and I feel laughter bubble up in my throat. Suddenly, my hands wrap around her jar I pour the contents into the river beside me, watching it all slowly dissolve She appears before me, distraught and shocked by my impulse. “I have nothing for you,� I say it calmly, looking her in the eye She turns around and marches away, saying nothing in return. I am confident that she will come back. But now I know I can leave.

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Medical Dialogue Review Volume 13 | Issue 2

"Insomnia" by Chris Wu "Living in a busy and noisy part of the campus, I often find it hard to fall asleep. In this imaginary city, bars don’t close, transportation systems never stop, and lights in people’s homes are always on. The city never sleeps."

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creative section andy marino

"Apoptosis" by Andy Marino

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Medical Dialogue Review, Volume 13, Issue 2  

The Medical Dialogue Review is thrilled to present its Spring 2019 Issue!

Medical Dialogue Review, Volume 13, Issue 2  

The Medical Dialogue Review is thrilled to present its Spring 2019 Issue!

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