Journal for Domestic and Global Health Volume I, Issue 2
Do you think that it should be illegal for a person with HIV to have sex with somebody else without disclosing their HIVpositive status to their sexual partner first? The intuitive answer is “yes”. However, should this really be a legal matter? Does the government need to get involved? While we encourage everyone to know their status, to engage in safe sexual behaviors, and to be honest with their partners, the criminalization of HIV only propagates stigma. Current legislation allows for discrimination, persecuting HIVpositive individuals by branding them as felons and sexual offenders regardless of their circumstance and the context of their behavior. Assault with intent to kill, attempt at poisoning, unlawful use of a harmful device? The criminalization of HIV undermines the work of public health professionals, as it discourages at-risk individuals from knowing their status: “take the test and risk arrest”. We should advocate for a change in the legislation to take into account the state of mind of the accused, the degree of risk, and an assessment of the inflicted harm. Imprisoning a young man with an undetectable viral load for having protected sex with a consensual partner simply dehumanizes HIV-positive individuals into nothing more than viral vectors. Visit http://seroproject.com/ for more information.
If human health were to exist in a vacuum, there would be no need for this journal. There would be no need to discuss health in the context of sociology, economics, policy or education because the solution to every health problem would stem exclusively from innovation in biomedicine. There would be no need to discuss regulatory policy concerning human exposure to bisphenol A (BPA), a toxic substance and endocrine disruptor found in food packaging and other consumer products. Or to consider the implications of rising unemployment rates and rising housing costs on the historically high levels of homeless New Yorkers in recent years. Or to share novel behavioral interventions to reduce HIV viral loads by improving patient adherence to antiretroviral therapy. But health (and public health, for that matter) does not exist in a vacuum, but rather within a larger social structure ridden with stigma, and within a legal framework that institutionalizes disparity. We have recently learned, thanks to Sean Strub and NYU’s chapter of United Against Infectious Disease (http://uaidintl.org/), that disease can sometimes carry a legal burden. The issue is further expanded on in the adjoining panel. But ultimately, as public health scholars we are called to challenge deeply rooted societal perceptions of the determinants of health and well being. How can a methamphetamine addict be predisposed to drug-abusing behavior? When insecticidetreated nets are distributed in fishing villages in Africa to combat malaria, why do some residents misuse the mosquito nets as fishing nets? What makes gang violence in Central America as much of a public health issue as Chagas disease or chronic kidney disease in the region? Promoting the health of entire populations takes on much wider dimensions than just developing and refining breakthrough solutions in medicine. The contents of this journal reflect the multidisciplinary nature of public health. It provides a forum for interdisciplinary scholarly dialogue to better understand the roots of health problems in our society. But most importantly, it aims to push the NYU community to take action. We would like to take this opportunity to share with our readers the good news that the editors of The Torch have been awarded the President’s Service Award. Many thanks to our advisor Dr. Diana Silver; to the members of our Editorial Staff, Katie Nolan and Tara Azizi, without whom there would be no journal; and to you, the readers of our journal. Sincerely, Renán Orellana Jorge Zárate
Table of Contents
Public Policy The Dartmouth Atlas Memo: Diabetes Discharges in New Jersey Erica Humphrey | Steinhardt 2014 Traffic Safety in the United Arab Emirates: The Road to “Zero Vision” Olivia Bergen | NYU Abu Dhabi 2015
Fighting for Autonomy: The Struggle for an Improved Quality of Living Amidst a System of Imposed Poverty on HIV-Infected New Yorkers Catherine Alex Merrill | College of Arts and Science 2013 10 Contrasting HIV Prevention Across the Atlantic: The United States vs. The United Kingdom Jay C. Liu Jr. | Steinhardt 2014 13 Economics and Development The Other Half: Hong Kong’s Housing Problem Nathaniel Johnson | College of Arts and Science 2014
Global Network University Plain Packaging in Australia: A Global Role Model for Smoking Prevention Cara Bradley | Steinhardt 2014
Nutrition Food Fraud Lillian Udell | College of Nursing 2014
The Societal Perception of Obesity: An Analysis of Misconception Aleena Zahra | College of Arts and Science 2011
Hydration Richard Hsu | Steinhardt 2015
Health and Society Maternal Health, Birth Models, & Midwifery: A Proposed Solution Mary Kern | College of Nursing 2015 Bumsters and Prostitutes: Intersectionality at Work Jasmine Boutros | NYU Abu Dhabi 2014
Analyzing Speech Samples of New York Latino English from Assimilating Latin Americans Hugo Rodas | Steinhardt 2013 32
Editorial Team Renán Orellana | Co-Editor-in-Chief, NYU Steinhardt ‘14 Jorge Zárate | Co-Editor-in-Chief, NYU Abu Dhabi ‘14 Katie Nolan | Associate Editor, NYU Steinhardt ‘14 Tara Azizi | Associate Editor, NYU College of Nursing ‘13
PUBLIC POLICY The Dartmouth Atlas Memo: Diabetes Discharges in New Jersey Erica Humphrey | Steinhardt 2014
The Dartmouth Atlas Project has documented variations in the distribution of medical care and resources throughout the United States for more than 20 years. 1 Researchers at The Dartmouth Institute for Health Policy and Clinical Practice use data to reveal differences across states, regions, counties, and from one hospital to the next, controlling for factors related to a lack of insurance by focusing exclusively on Medicare patients. The project aims to understand why such differences exist, as well as how physicians, hospitals, and policy-makers can change the way the healthcare system functions in order to increase both its efficiency and effectiveness. A closer look at the Health Service Areas (HSAs) of the state of New Jersey, for example, shows wide differences in diabetes discharges for ambulatory-sensitive care per 1,000 Medicare enrollees from 2008-2010. Because diabetes affects an estimated 25.8 million people in the U.S.—8.3% of the population—and has direct annual costs estimated at $116 billion dollars, understanding how patients with the disease can be treated most effectively and efficiently is crucial to a well-functioning and lower-cost health care system. 2
national average of 2.62, and the state’s county with the lowest rate of discharges, Princeton, at 2.00 per 1,000. Perth Amboy even sits 3.12 discharges per 1,000 than the second highest HSA, Hoboken. This could suggest a number of scenarios. Perhaps diabetics in Perth Amboy control their disease better than do those in Princeton, and therefore they present at the hospital with less severe diabetic complications and do not require admission. Or perhaps, doctors in Princeton hospitals are overly cautious and unnecessarily admit patients, either because they do not understand the severity of diabetes and its complications or because they have a greater number of available beds; or maybe the situation is that doctors in Perth Amboy are in fact not cautious enough or do not have the facilities required to admit all of the patients that do actually need inpatient care. It is difficult to know which of these discharge rates hospitals should be striving for, and even whether the U.S. average is a good indicator of proper procedure. All of these unknowns and possibilities present different implications for improved medical practice and how that can be achieved through policy change. For this reason it is essential to analyze and understand these variances.
Figure 1 (see Appendix) represents the Dartmouth Atlas data regarding diabetes discharges per 1,000 Medicare enrollees in the state of New Jersey by HSA. The Dartmouth Atlas defines an HSA as local health care markets for hospital care; “a collection of ZIP codes whose residents receive most of their hospitalizations from the hospitals in that area.” This distinction divides the United States into 3,436 HSAs, with 65 in the state of New Jersey. The clear outlier in the state is Perth Amboy, with 9.22 discharges, compared to the U.S.
Differences Among Patients It is possible that wide variance in discharge rates for diabetes is due to similarly wide variance among patients—broad factors relating to socioeconomic status might affect their prioritization of health or their economic means to eat well, exercise, and control their disease; the existence of other conditions might complicate their health; and perhaps random factors such as an individual’s personal diligence in managing diabetes would affect how the
disease impacts one's overall health. According to the U.S. Census Bureau, the median household income in Perth Amboy from 2007 to 2011 was $45,369, whereas in Princeton it was $112,808. 3,4 Similar disparities are reflected in percent of persons living below the poverty line, with 19.9% in Perth Amboy and 5.4% in Princeton. 3,4 HSAs do encompass more than the city limits that confine the collection of this Census data, but the differences in economic status between the two areas are clear. While individuals are eligible for Medicare despite income or poverty level, it is true that a vastly different socioeconomic status in Perth Amboy could potentially affect an individual’s ability to purchase healthy food, as well as find a time and a place to exercise. This, however, would suggest that residents of Perth Amboy are less healthy than those of Princeton, and therefore more likely to require hospitalization. This particular theory of personal differences among patients, then, must not be true, because the data shows the opposite. Despite socioeconomic differences, the data might be suggesting that diabetics in Perth Amboy are in fact drastically healthier and have better control over their disease than the rest of New Jersey and even the rest of the country and are therefore less likely to require admission when presenting at a hospital with a diabetic incident or complication. But the Dartmouth Atlas data that indicates the average annual percent of diabetic Medicare enrollees age 65-75 having a hemoglobin A1c test in 2010, as a measurement of how closely an individual’s disease is being monitored, indicates that this is unlikely to be true. According to the American Diabetes Association’s (ADA) Standards of Care, the A1C is thought to reflect average glycemia over several months and has strong predictive value for diabetes complications. For this reason it “should be performed routinely in all patients…as part of continuing care.” 5 An HSA’s percentage of A1C testing can therefore be associated with that area’s quality of physician attention and patient management, $! !
which would also be associated with better control over diabetes. In this measure, Perth Amboy ranks in the 14 percentile, while Princeton ranks in the 92 percentile throughout the state. With Perth Amboy on the low end of diabetes control and Princeton on the upper end, the theory that Perth Amboy patients are less likely to require hospitalization due to initial better rates of health is most likely untrue. Professional Uncertainty If patient control over diabetes cannot explain the wide variation between Princeton and Perth Amboy in diabetes discharges, then doctors’ decisionmaking might warrant consideration as a cause. The ADA’s “Hospital Admissions Guidelines for Diabetes Mellitus” that are relevant to those of Medicare age dictate that “inpatient care may be appropriate for the following”: - Life-threatening acute metabolic complications of diabetes. - Substantial and chronic poor metabolic control that necessitates close monitoring of the patient to determine the etiology of the control problem, with subsequent modification of therapy. - Severe chronic complications of diabetes that require intensive treatment or other severe conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes. - Institution of insulin-pump therapy or other intensive insulin regimens. 6 Largely due to the nature of the disease and its potential to cause any number or severity of complications, these guidelines are vague and leave much discretion to doctors. Even the circumstances under which a physician should consider a patient to have “uncontrolled diabetes,” which would imply a generally poor state of health due to poor blood sugar control, are unclear—the ADA recommends categorizing diabetics as uncontrolled if they exhibit any combination of seven criteria, which include
anything from recurring episodes of severe hypoor hyperglycemia to experiencing psychosocial issues that interfere with work. Even less clear is whether such a state should automatically necessitate hospitalization. Ultimately, individuals’ attention to their care for diabetes and personal experience of the disease are widely varied, and where there exists so much difference there is bound to exist inconsistency in practice from one hospital to the next and even from one doctor to the next. In contrast to a simple situation such as a hip injury, which has a single agreed upon treatment and thus sees little variation across hospitals, the complexity of a chronic disease such as diabetes does not allow for the same universal course of treatment, or an ability to easily predict or understand complications. Resource Availability The Dartmouth Atlas observes a trend of supplysensitive care across the nation’s Medicare data—“in regions where there are more hospital beds per capita, patients will be more likely to be admitted to the hospital” and “in regions where there are relatively fewer medical resources, patients get less care.” 7 According to Fisher et al, however, additional utilization of care in highspending regions, including treating patients with chronic disease in inpatient units, has “been demonstrated to be associated with the local supply of physicians and hospital resources.” 8 Looking at the range of discharge rates across New Jersey, it might then be worth questioning whether the numbers of discharges in the lower regions is actually warranted, or whether areas such as Princeton are more likely to admit patients, simply because they have the space, for a situation that could be handled through outpatient care. Perth Amboy is the sole outlier far above the data of the rest of the state, and it is hard to believe that this HSA would be the only area not unnecessarily admitting patients. But perhaps in fact it faces the opposite problem hypothesized to be taking place in Princeton, and has resource limitations that lead to increased discharges. The question then must be where the !
ideal level lies and what can be done to reach that more universally across the United States. Recommendations Variation in diabetes discharges is most likely related to the combined factors of professional uncertainty regarding a disease as complex as diabetes and resource availability. Efforts to rectify these issues, which have the potential to improve patients’ health as well as decrease Medicare spending, must therefore focus on an effort for streamlined and enforceable science-based guidelines by which physicians can approach their work. Creating a universally accepted authority on best practices of care and implementing it through Electronic Health Records (EHRs) would be efficient and effective in addressing many issues of hospital variance. David Eddy writes in Health Affairs that EvidenceBased Medicine (EBM) is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” 9 Eddy notes that many of the guidelines that physicians currently follow are informal, with origins unrelated to medical evidence. The integration of current science and research with individual clinical expertise is in fact crucial to eliminating personal decision-making factors among doctors that are not based in science but cause overutilization of health care. Such standards can be disseminated and enforced through evidence-based decision support systems operating through EHRs. The Patient Protection and Affordable Care Act (ACA) mandates health plans’ adoption of EHRs for the purposes of reducing paperwork and administrative burdens, cutting costs, reducing medical errors and improving quality of care. 10 Additionally and more specifically, however, if implemented with EBM in mind, the policy has the potential to reduce unnecessary variations in care. In addition to the wide range of quality and efficiency issues that EHRs are said to address, variations in handling diabetes cases will specifically be addressed by the use of checklists, alerts, and predictive tools as well as embedded clinical guidelines that promote standardized, evidencebased practices. A 2012 study by the %!
Commonwealth Fund reports high levels of consistency across multiple hospitals with the implementation of an EHR system, which presents prompts and alerts to set reminders and guide care based on clinical guidelines that gain consensus from staff. 11 Cebul et al’s 2011 report to the New England Journal of Medicine also found that across 46 practices, “achievement of composite standards for diabetes care was 35.1 percentage points higher at EHR sites, and achievement of composite standards for outcomes was 15.2 percentage points higher.” 12 Diabetes is a complex disease, and the complexities of managing it as a physician are not easy to overcome. The technology’s ability to consider every factor of a patient’s health against the guidelines for caring for a patient with diabetes can aid doctors in avoiding overand under-utilization of care. And as the use of EHRs expands, evidence-based guidelines can span across states to cohesively guide doctors throughout the U.S. in their administration of care.
studied, but further examination of their potential to prevent unnecessary use of resources would encourage the uptake of this method to alleviate the current situation.
The widespread use of EHRs does present some barriers, such as economic feasibility in some hospitals as well as the compatibility of systems from hospital to hospital. The American Recovery and Reinvestment Act of 2009, however, addressed some of these issues by allocating $1.2 billion to aid hospitals in implementing the technology targeted at technical assistance and information sharing. 13 The ACA’s further push to implement this technology is necessary in a time when Medicare spending adds up to $556 billion a year, 26% of which went to hospital inpatient services in 2012. 14 If the U.S. as a whole can achieve spending levels comparable to those of the lowest-spending regions highlighted by the Dartmouth Atlas Project, annual Medicare expenditures could be reduced by up to 30% of Medicare expenditures could be achieved. 15 Further research on this topic should include investigating the association in these HSAs between number of beds and other hospital resources with the number of discharges. Additionally, the effects of EHRs on certain quality and efficiency measures have been
The Dartmouth Atlas of Health Care. (2013). from http://www.dartmouthatlas.org/tools/ 2
Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. 3
U.S. Census Bureau: State and County QuickFacts. (2013). Perth Amboy (city), New Jersey. 4
U.S. Census Bureau: State and County QuickFacts. (2013). Princeton (borough), New Jersey. 5
American Diabetes Association. (2009). Standards of Medical Care in Diabetes—2009. Diabetes Care, 32(Supplement 1), S13-S61. doi: 10.2337/dc09-S013 6
Hospital Admission Guidelines for Diabetes Mellitus*. (2002). Diabetes Care, 25(suppl 1), s109. doi: 10.2337/diacare.25.2007.S109 7
Supply-Sensitive Care. (2013). from http://www.dartmouthatlas.org/keyissues/issue.aspx?con=2937 Fisher, E. S., Wennberg, D. E., Stukel, T. A., Gottlieb, D. J., Lucas, F. L., & Pinder, E. L. (2003). The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Annals of Internal Medicine, 138(4), 288-298. 9
Eddy, David M. (2005). Evidence-Based Medicine: A Unified Approach. Health Affairs, 24(1), 9-17. doi: 10.1377/hlthaff.24.1.9 10
Key Features of the Affordable Care Act, By Year. from http://www.healthcare.gov/law/timeline/full.html 11
Silow-Carroll, S., Edwards, J. N., & Rodin, D. (2012). Using electronic health records to improve quality and efficiency: the experiences of leading hospitals. Issue Brief (Commonw Fund), 17, 1-40. 12
Cebul, Randall D., Love, Thomas E., Jain, Anil K., & Hebert, Christopher J. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365(9), 825-833. doi:10.1056/NEJMsa1102519 13
Vice President Biden Announces Availability of Nearly $1.2 Billion in Grants to Help Hospitals and Doctors Use Electronic Health Records. (2009). 14
Billings, John. (2013). Medicare: The basics and issues for reform [PowerPoint slides]. Retrieved from NYUClasses website: https://newclasses.nyu.edu/portal/site/c224e502-bb1c- 4e62-a6542eff3989c1cc/page/2f88d928-13de-40c9-afa1-a412561883ea# 15
Fisher, E. S., Wennberg, D. E., Stukel, T. A., Gottlieb, D. J., Lucas, F. L., & Pinder, E. L. (2003). The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Annals of Internal Medicine, 138(4), 288-298.
Appendix Figure 1: Diabetes discharges per 1,000 Medicare enrollees (2008-10) by NJ HSA
Figure 2: Average annual percent of diabetic Medicare enrollees age 65-75 having hemoglobin A1c
Traffic Safety in the United Arab Emirates: The Road to “Zero Vision” Olivia Bergen | NYU Abu Dhabi 2015 With one of the world’s highest road traffic accident rates relative to population, road safety has become a critical public health challenge in the United Arab Emirates. The current annual fatality rate is 12.7 per 100,000 people, equating to hundreds of deaths and thousands of injuries each year. Strategies for reducing accidents are being continuously implemented and evaluated throughout the UAE, including successful behavior campaigns and increased policing, but policies can still be strengthened to protect road users. Traffic police in Fujairah, in association with a daily newspaper Al Ittihad, reported at the end of 2012 that in a study period from 2006 to 2011, 5,514 people died on the roads, averaging two deaths per day in the Emirates. Abu Dhabi was the largest contributor to national totals, the site of 38% of all the fatal accidents in the country. In total, 51,200 accidents were on the police record in the sixyear period, in which 63,406 people were injured. Road accident incidences have been declining since a recent peak in 2008, in part due to intensified road patrols, a greater number of speed cameras, awareness campaigns, and stricter penalties for traffic violations. Traffic police across the UAE issue an average of 9,500 penalties per day to violators, most frequently for speed offenses. Other common violations include ignoring red signals, recklessness and negligence, and failure to leave sufficient distance between vehicles. In early March 2013, the Abu Dhabi Police Traffic and Patrol Directorate announced that despite having 6% more vehicles and 8% more licensed drivers on the road, traffic accidents had decreased by 10% since the previous year. Fatal accidents had decreased by 19%. The
downward trend of accidents and fatalities in the last four years has been promising, and is in no small part the result of government initiatives. Abu Dhabi’s Traffic and Patrols Directorate is executing a comprehensive traffic procedures plan, titled the Abu Dhabi Integrated Plan, which focuses on traffic control, educational campaigns, road engineering development, rapid emergency response, and evaluation of road safety. The directorate’s goal is to reduce fatalities by at least four percent annually, reaching zero fatalities by 2030—“Zero Vision”. In the initiative’s first three years, they have already dropped by 34%. Awareness programs to encourage safe driving behavior emphasize seatbelt use, speed reduction, safe road crossing, and observance of red lights. In 2012, the directorate carried out 766 lectures and events reaching over 63,000 people. Whether such outreach is sustainable, as well as whether it is reaching the road users who most need such messages, is indeterminate. However, it is clear that some combination of this communication and tightened enforcement of violations has successfully curbed accidents. Traffic safety worldwide is such a prominent health concern that in 2009, the United Nations’ World Health Organization declared a “Decade of Action” around reducing fatalities. WHO hopes that by 2020, initiatives in countries around the world might reduce the current 1.3 million annual deaths by 50%. Traffic accidents kill more people around the world than malaria, and for people aged 5-29 this is the leading cause of death. Annually, they result in a worldwide economic loss of USD 520 billion, a result of many factors including health and
emergency services cost, lost productivity, and infrastructure damage. WHOâ€™s 2013 Global Status Report on Road Safety emphasizes the importance of policies on five key risk factors â€“ speed, drunk driving, motorcycle helmets, seat belts, and child restraints. Safe mobility for pedestrians and cyclists is also essential as automotive vehicles share road space with alternative transport in greater numbers. Seat belt use is an essential factor in reducing the rate of injury and death on the roads. While there is a national seat belt law in the Emirates, compliance is not widespread, especially among UAE nationals. Regarding child safety restraints, there are no laws at all, resulting in low rates of use. The main cause of death for UAE children under 14 is fatal injury, 63% being traffic related, indicating a major gap to be closed in the goal of reducing deaths and injuries. Awareness campaigns such as the Integrated Plan should continue encouraging seat belt and child safety restraint use, while legislation should be instituted that requires child restraints up to a given age. Considering 29% of traffic fatalities are pedestrians, the UAE must also creatively consider how to better protect pedestrians.
The design of Emirati cities does not foster safe or convenient walking routes. Meanwhile, drivers rarely yield to pedestrians in crosswalks. The burden of safe passage through the city lies completely on pedestrians, ignoring the role of drivers and of engineers who plan the road design. Much of the UAE will be built up in the coming decades, and it may be an important priority for the nation to engineer safer walking routes. For the time being, modification of driver behavior should focus on reducing speeding and reckless behavior, and increasing awareness to prevent pedestrian collisions. There have been improvements to be admired in the condition of the UAEâ€™s road safety in the past few years, and the seriousness with which the government takes traffic problems is heartening. The continuation of successful coordination plans and road policing will be essential to continuing the decreasing trend of accidents and fatalities. In order to approach Zero Vision, however, Abu Dhabi and the UAE must more closely examine driving culture, encourage greater use of safety devices, and take action to protect pedestrians in road design and traffic laws. With each new change toward the goal of greater road safety, the Emirates become a happier and healthier place to live.
Fighting for Autonomy: The Struggle for an Improved Quality of Living Amidst a System of Imposed Poverty on HIV-Infected New Yorkers Catherine Alex Merrill | College of Arts and Science 2013 The epidemic of HIV/AIDS throughout New York City has been a persistent subject of public policy interventions since the 1980’s, where access to adequate and affordable health care can be severely limited for those of lower socioeconomic strata. New York City currently has the largest HIV/AIDS problem in the United States1. The low-income population is a strongly represented demographic among those living with HIV/AIDS in New York City. However, the public insurance options for this population maintain tight requirements and often exclude those who are newly diagnosed with HIV, limiting their eligibility until the condition has progressed to AIDS. This paper will examine the role of the lowincome individual within HIV/AIDS care in New York City. The Affordable Care Act, set to go into effect in 2014, will significantly improve lowincome patients’ access to care for their condition by expanding the eligibility requirements for Medicaid. Medicaid and HIV: The Problems Insurance coverage among those living with HIV/AIDS is crucial to their survival. Often, many low-income individuals with HIV/AIDS encounter numerous barriers in accessing health insurance. Modern HIV treatments, known as highly active antiretroviral therapy (HAART), are very expensive and strictly regimented, which places the low-income population at a severe disadvantage if they are unstably insured. Delays and interruptions in treatment significantly jeopardize a patient’s health, “having health insurance coverage reduces the probability of sixmonth mortality among HIV patients by as much as 85%.”2 Thus, expanding Medicaid’s eligibility requirements for those with HIV/AIDS may turn out to be more cost-effective for the program in the future. Medicaid currently stands as the largest source of coverage for people living with HIV/AIDS in the United States, in addition to more than half of the *+! !
federal government’s spending on HIV/AIDS.3 Therefore, as a program that exists for a vulnerable population, it is crucial to examine its effectiveness by assessing areas where it may lack the ability to serve those for whom it is intended. Although Medicaid had approximately 212,892 enrollees with HIV in 2007, amounting to less than 1% of all Medicaid enrollees, they account for a significant portion of Medicaid spending, “with per capita costs almost five times greater ($24,867 compared to $5,091) than their non-HIV counterparts [in Medicaid].”3 As a share of people with HIV in regular care, Medicaid enrollees account for 47% of those seeking treatment. In order to be eligible for Medicaid with HIV, you must be legally classified as disabled. Current rules, as mandated by the federal government across all states, categorically exclude nondisabled adults without dependent children from access to Medicaid, even if they lie within the income limits. In other words, the diagnosis of HIV alone is not enough to be classified as disabled. However, once the disease advances to the AIDS stage, an individual can be considered legally disabled. This is what the Kaiser Family Foundation calls the “Catch 22” of Medicaid: after receiving an HIV diagnosis, and individual should immediately seek treatment to delay the onset of AIDS as much as possible. However, a lowincome person cannot access Medicaid benefits to pay for treatments until the disease has progressed to AIDS. Thus, most individuals are structurally excluded from accessing treatment for their condition necessary for their long-term survival, something that can be substantially aided by proper antiretroviral treatments. The demographics of those living with HIV/AIDS show adult males to be overwhelmingly excluded from access to treatment. The representation of Medicaid enrollees shows men at 57% and women 43%. However, this fails to reflect the actual demographics of the disease, where three quarters
(75%) of those living with HIV/AIDS in the United States are male.3 In the Medicaid population with HIV, women are overrepresented at 43%, when in reality they only make up 25% of the HIV population. In addition, “17% of people with HIV and 12% of those without the disease qualified as nondisabled adults, reflecting eligibility limitations for this group.”3 These figures are concrete examples of how men without dependent children face substantial barriers with enrollment into Medicaid and subsequently accessing treatment. Accessing Care for those in New York City It is crucial to understand the important role that HIV plays within the context of New York City. Currently, New York City has the largest HIV problem in the United States and accounts for 16% of the nation’s overall AIDS cases.1 It is also estimated that Medicaid currently covers 72% of those living with AIDS in New York City. In addition, male representation among person living with HIV/AIDS is significant, particularly by adult African American males who “account for 10% of the of the city’s adults and adolescents [ages 13 and older], yet 34% of new HIV diagnoses and 28% of person living with HIV/AIDS.”1 Studies have also shown that African Americans and Hispanics have a shortened survival rate than Caucasians, which is the result of delayed access to care.2 Considering the relatively significant difficulties that adult males have enrolling in Medicaid as addressed above, coupled with the fact that black males “account for more [persons living with HIV/AIDS] and HIV diagnoses than any other demographic group,”1 it may be assumed that a large number of minorities are unable to access adequate treatment for their condition that they deserve. As Medicaid serves a majority (72%) of New York City’s population living with an AIDS diagnosis, it is imperative that requirements envelop those who are low-income and diagnosed as HIV-positive so as to delay progression to AIDS, benefiting both the state’s Medicaid budget, and the individual’s survival.
Not only do black men represent the largest demographic of those living with HIV/AIDS in New York City, 65.3% of black males with HIV/AIDS reside in zip codes with higher rates of poverty, and in “prevalence among black males there was 4.0 vs. 2.7% in lower-poverty zip codes.”1 Furthermore, those who are black and Hispanic and living with HIV/AIDS are more likely to be uninsured.4 Prevalence rates were also 53% higher among black males residing in New York City compared to the rest of the United States, with prevalence and diagnoses rates among this demographic three times that of the overall rates in New York City.1 This strong correlation between black males and higher-poverty zip codes coupled with their disproportionate representation among all of those living with HIV/AIDS in New York City, shows that a large portion is also of a low-income background and must rely on Medicaid. Those with an AIDS diagnosis are also more likely to have public health insurance, and not be uninsured, than those who are HIVpositive.4 Without proper health insurance coverage upon initial HIV diagnosis, this demographic faces numerous barriers in access treatment that could both improve the health of the individual, and also prevent the spread of the disease in these neighborhoods. Exclusion from Medicaid forces the disease to continue and rates of diagnosis to remain the same, or even increase. The Future of Health Care Policy in the United State: The Medicaid Expansion The implementation of the Affordable Care Act (ACA) in 2014 will substantially improve the lives of those living with HIV/AIDS in the United States. The ACA includes significant changes to Medicaid, known as the Medicaid expansion, which addresses the needs of those who currently fall outside Medicaid eligibility based on disability status. With the improvements to HAART in the last two decades, more and more people are successfully delaying the onset of AIDS through treatment. Persons living with HIV/AIDS could previously be denied coverage based on their preexisting condition, however the ACA has forbidden this practice in the future.5 Even if an HIV-positive individual received coverage from an employer, the benefits packages traditionally **!
offered would not have been comparable to the comprehensive mix of services [that Medicaid offers].”4 With a 50% increase of those living with HIV in the United States from 1996 to 2006 (Sherer 106),5 more and more people are living longer, requiring affordable health coverage for costly antiretroviral treatments.
affectively absorb a substantial number of people living with HIV into Medicaid coverage, various other factors may still prevent some from not only accessing treatment, but also maintaining an adequate quality of living.
The Medicaid expansion within the ACA effectively eliminates the disability requirement from Medicaid eligibility, by increasing the income limit form 75% to 133% of the federal poverty level. Now, all persons living below 133% of the federal poverty level will be able to qualify for Medicaid, regardless of their disability status.5 Sherer asserts “this is the most dramatic single improvement in the care of people with HIV infection that results from ACA reforms.”5 It is estimated that 54% of those uninsured prior to the implementation of the ACA will obtain coverage. Participation in the Medicaid expansion is optional for states, however.6 The federal government has agreed to pay 100% of the extra costs of the ACA for the first three years of its implementation for the states that agree to participate. After three years, the government will decrease its aid by funding 90% of the extra costs, and slowly continue to decrease over time.6 As a result of the Medicaid expansion, the needs of those living with HIV/AIDS in the United State have been successfully addressed by the ACA in two ways: by eliminating the disability requirement from Medicaid eligibility, along with insurance providers’ inability to deny coverage for an HIVpositive individual based on their pre-existing condition.
As has been continuously demonstrated throughout this paper, immediate access to Medicaid for those who have been diagnosed with HIV is critical for their survival. In addition, while dependence on Medicaid is crucial to accessing HAART, HIV patients are forced to relinquish the independence of maintaining and job in order to remain within the income limits of the program, stuck in a situation of imposed poverty. While the ACA will *"! !
Wiewel, Ellen W., David B. Hanna, Elizabeth M. Begier, and Lucia V. Torian. "High HIV Prevalence and Diagnosis Rates in New York Cit Black Men." J Community Health 36 (2010): 141-144. 2
Conover, C. J., and K. Whetten-Goldstein. "The Impact of Ancillary Services on Primary Care Use and Outcomes for HIV/AIDS Patients with Public Insurance Coverage." AIDS Care 14 (2002): S69. 3
Fact Sheet: Medicaid and HIV/AIDS – Kaiser Family Foundation, 1-9 4
Kelaher, Health Policy, 81-82.
Sherer, Sexually Transmitted Infections, 106 -107.
Brandon, J. of Health Care for the Poor and Underserved, 1361.9 Conover et al. J. AIDS Care, S60.
Contrasting HIV Prevention Across the Atlantic: The United States vs. The United Kingdom Jay C. Liu Jr. | Steinhardt 2014 ! Introduction HIV/AIDS entered the global arena of pandemics with a massive splash, striking fear across the world that a virus could strip healthy individuals of their immune systems and sentence them to a painful, gruesome death. What initially raised the alarm that an epidemic was occurring in the early 1980’s was a sharp increase in the number of rare cancers and infections in young homosexual males.i These outbreaks were appearing in clusters, and predominantly manifested with Kaposi’s sarcomas, pneumocystis pneumonia, and other opportunistic infections. ii While seemingly unrelated, these findings all had one thing in common: they indicated that young healthy individuals were suddenly falling ill as if their immune system had become non-existent. Soon it was found that the underlying causality was actually a virus, which was subsequently termed Gay Related Immunodeficiency Syndrome, until being renamed Human Immunodeficiency Virus (HIV) after the realization years later that the virus did not only affect homosexual individuals. In fact, while the epidemic initially seemed to be targeting young gay men with multiple sexual partners, it soon evolved and could be found with high prevalence in the intravenous drug user population, and eventually the population dependents on IV blood transfusions. The subsequent evolution of the epidemic and the rates of infection within different nations directly correlated to the individual countries healthcare system and infrastructure. The National Healthcare System In 1948 in response to the sudden dire need for a strong healthcare system following World War II, the United Kingdom created the National Health Service (NHS). The NHS quickly became a highly successful and beloved organization, which provided universal !
healthcare to the UK. On the other hand, healthcare in the United States operates off a system of privately owned hospitals, which all intend on profiting off the services they provide in this capitalistic type infrastructure. These two different healthcare systems inevitably handled the HIV pandemic during the early 1980’s differently. Although homophobic, racist, and political obstacles hindered early aggressive epidemiological intervention and research in both nations, the UK’s NHS quickly received large governmental funding to create programs for HIV/AIDS treatment, control and prevention. With this financing, the NHS set up HIV/AIDS designated centers, such as the Mortimer clinic. These centers subsequently developed a highly holistic model of treatment and prevention programs for its patients. A primary example of how the Mortimer clinic has responded to provide the best care for its patients as possibly was the development of a health advisor concept. These health advisors, all individuals who have been battling HIV and have been successful in continuing to prosper despite being HIV positive, serve as an anchor, which individuals being treated at the clinic can use to weather the storm. These unique professionals help to fill the role that is not filled by nurses and doctors, and greatly improve the level of care provided to the patients of the clinic. Along these lines, the Mortimer clinic also provides social support, workshops, classes, screening, and a plethora of other services for the treatment and prevention of HIV/AIDS, all of which are practically free to all citizens and even undocumented immigrants in the UK. The many services provided by the NHS for HIV/AIDS related healthcare in the UK are provided in the US in a less holistic fashion. *#!
Unfortunately due to the nature of the capitalistic model, consultation and care provided to patients in the US tend to be rushed in comparison to those of the UK. This disparity can be largely attributed to the nearly complete lack of association between healthcare and money in the UK created by socialized medicine. In addition, holistic type treatment is difficult to provide in the US, as it is more costly to maintain. While the US may be more progressive in some of its experimental programs such as the creation and administration of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), there is ample evidence that there is much that the US healthcare system can learn from the UKâ€™s NHS model of holistic treatment of HIV/AIDS. Post Exposure Prophylaxis Antiretroviral Medication Strongly endorsed by the UK, are post exposure prophylactics (PEP). In 2011 the British Association for Sexual Health and HIX, or UK-BASHH, released a protocol for PEP to standardize its administration, as well as set a concrete set of indications for PEP. The groups targeted by the protocol are healthcare professionals, infants, and individuals with suspected sexual exposure to HIV. iii Unlike PrEP, PEP is utilized in people who have been exposed, or suspect having been exposed to HIV; in PrEP prophylactic antiretrovirals are administered prior to viral exposure. PEP is prescribed in the UK based on the theory of Information-Motivation-Behavioral Skills. This model suggests that relevant prevention information, motivation to practice prevention, and behavioral skills with respect to prevention all interact to predict health outcomes.iv This type of holistic approach to HIV/AIDS prevention is rather common in the UK, where no single service is provided to individuals independent of others to ensure all
needs are satisfied. While PEP is used in the United States, the United Kingdom has made strides to make PEP a more routinely prescribed HIV prevention tool than the US has. Much like PrEP, the efficacy of PEP is difficult to measure as it is unethical to withhold treatment with antiretrovirals to an individual post exposure. As such, much of the research regarding utilization of PEP in the UK is focused on understanding why individuals who begin a PEP regiment only have a 60% completion rate of the 28-day regiment.v The UK believes so strongly in PEP that it recently conducted a study to assess the percentage of medical school students, who intend on becoming general practitioners, which are well versed at prescribing PEP; 96% of the students surveyed had received formal training in prescribing PEP. vi The fact individuals can simply pick up a starter pack at a local A&E is proof of how accessible PEP is in the UK. vii In comparison to the US, perhaps the UK has made PEP more accessible simply by providing universal healthcare to its residents. National HIV/AIDS Strategy for the United States On July 13th 2010, the Obama administration released the first National HIV/AIDS Strategy for the United States (NHAS). This publication was intended to renovate the current HIV/AIDS prevention programs and provide a concise and highly refined set of goals for the entire nation to address. These goals revolve around reducing new HIV infections, improving access to care for seropositive individuals, and to reduce health disparities. viii Approximately 21% of seropositive individuals in the United States are unaware of their status. Additionally, in 2009 approximately 28% of seroconversions took place in foreign-born
individuals, a dramatic increase from previous years. An emphasis on identifying individuals who are seropositive or at high risk for seroconversion, as well as which groups are most at risk is critical in understanding the epidemic and preventing new infections.ix From studies, several key high-risk populations have been discovered, notably men who have sex with men (MSM), injection drug users (IDU), African Americans, serodiscordant couples, and commercial sex workers. x Pre-Exposure Prophylactic Antiretroviral Medication On July 16th 2012 the FDA approved the first Pre-exposure Prophylactic Antiretroviral Medication (PrEP) for the US. PrEP has become a uniquely American prevention strategy and is not practiced in the UK. The concept behind PrEP is to place seronegative high-risk individuals onto antiretrovirals to provide the individual some level of protection from infection upon exposure. While predominantly prescribed to individuals at risk, PrEP is specifically intended for individuals who practice high-risk behaviors such as unprotected anal intercourse. xi The iPrex study found that with over 90% compliance to PrEP a 44% reduction of HIV incidence was accrued.xii While PrEP is arguably solely a biological intervention, a strong psychosocial grounding is essential, as 90% adherence to PrEP is required for it to be effective. As such, the theory of planned behavior must be applied to increase compliance. This would be done by manipulation of social norms, self-efficacy and attitude towards compliance. xiii In essence, PrEP must be applied and treated as a combination strategy. Ethical implications must also be considered when prescribing PrEP. Much like the introduction of oral contraceptive forty years ago, xiv PrEP may provide a false sense of security and actually increase the frequency of
risky sexual behavior. Due to the PrEP, the UK has yet to adopt strategies based on PrEP and focusing on providing treatments seroconversion after exposure.
infancy of prevention is instead to prevent
The efficacy of PEP based programs in the US is still questionable due to lack of evidence. Similarly, the applicability of PEP in the UK to the overall population is debatable, as the programs only a certain subset of individuals involved in healthcare or conscientious sexual exposure. While the two programs are great tools for preventing the spread of HIV/AIDS, they are only two tools in a large toolbox. Treatment as Prevention Perhaps one of the most powerful tools currently in use is the concept of treatment as prevention (TaP). In TaP, an attempt is made to reduce community level viral load by treating seropositive individuals to reduce individual viral loads, which culminates into a lower infectivity rate overall which would reduce the incidences of seroconversion. To measure the potency of this concept, the HPTN 052 trials were started in 2005, and intended to conclude in 2015. The goal of the trial is to study serodiscordant couples, some of which receive early antiretroviral therapy, and some who do not. xv Then researchers would compare the incidences of seroconversion between the two groups to measure TAPâ€™s efficacy, as well as the costs/benefits of each, as they have yet to be measured. PEP, PrEP, and TaP each have unique applications as well as roles in the prevention of HIV/AIDS. While efficacy rates and cost benefit analysis do differ among the three prevention strategies, the efforts to prevent the spread of HIV/AIDS would not be as well off without any of these strategies.
Perhaps if the US and UK made stronger efforts to share the successes each had through the different strategies and combine tactics to form a potent prevention strategy incorporating all three, the world would become safer from the virus that has terrorized our race for the past four decades. ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! i
Altman, Lawrence. "Rare Cancer Seen in 41 Homosexuals." The New York TImes [New York] 3 July 1981: n. pag. Print. ii
UNK. "Pneumocystis." UNK (1981): n. pag. Web.
Fisher,"Pneumocystis." Martin, Paul Benn, Evans, Anton UNK. UNKBarry (1981): n. pag. Web.Pozniak, Mike Jones, Suzie MacLean, Oliver Davidson, Jack iii Fisher, Martin, Paul Benn, Barry Evans, Anton Pozniak, Mike Jones, Suzie MacLean, Oliver Davidson, Jack Summerside, and David Hawkins. "UK Guideline for the Use of Post-exposure Prophylaxis for HIV following Sexual Exposure." International Journal of STD & AIDS 17.2 (2006): 81-92. Print. iv
LLewellyn, Charlie, Charles Aberham, Alec Miners, Helen Smith, Alex Pollard, Paul Benn, and Martin Fisher. "Multicentre RCT and Economic Evaluation of a Psychological Intervention Together with a Leaflet to Reduce Risk Behaviour amongst Men Who Have Sex with Men (MSM) Prescribed Post-exposure Prophylaxis for HIV following Sexual Exposure (PEPSE): A Protocol." BiomedCentral (2012): n. pag. Print. v
Van Der Maaten GC, Davies J, Nyirenda M, and Chitani A. "HIV Post-exposure Prophylaxis Programmes in the Developed and Developing World: Can We Learn from Each Other?" Journal Article; Research Support 22 (2011): n. pag. Print. vi
Stacey K, Sellers L, and Barrett S. "Education Provided to Outgoing UK Medical Elective Students regarding HIV
! ! ! ! ! ! ! ! !
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Risk and Post Exposure Prophylaxis." Royal Society of Medicine Services 23 (2012): n. pag. Print. vii Rees, Janice. "A Diary of PEP." HIV Nursing UK (2012): n. pag. Print. viii
Yehia, B., and I. Frank. "Battling AIDS in America: An Evaluation of the National HIV/AIDS Strategy." American Journal of Public Health 101.9 (2011): E4-E8. Print.
Petroll, Andrew E., Wayne DiFranceisco, Timothy L. McAuliffe, David W. Seal, Jeffrey A. Kelly, and Steven D. Pinkerton. "HIV Testing Rates, Testing Locations, and Healthcare Utilization among Urban African-American Men." Journal of Urban Health 86.1 (2009): 119-31. Print.
Petroll, Andrew E., Wayne DiFranceisco, Timothy L. McAuliffe, David W. Seal, Jeffrey A. Kelly, and Steven D. Pinkerton. "HIV Testing Rates, Testing Locations, and Healthcare Utilization among Urban African-American Men." Journal of Urban Health 86.1 (2009): 119-31. Print.
Bonn, D. "Tenofovir: A Pill to Prevent HIV?" The Lancet Infectious Diseases 5.2 (2005): 78. Print.
Hillier, Sharon. "Pre-Exposure Prophylaxis to Prevent HIV Transmission." Annual Review of Medicine 63.1 (2011): 110301100719093. Print.
Tapper, Michael L., Eric S. Daar, Peter J. Piliero, Kimberly Smith, and Corklin Steinhart. "Strategies for Initiating Combination Antiretroviral Therapy." AIDS Patient Care and STDs 19.4 (2005): 224-38. Print.
Myers, Julia E., and Kent A. Sepkowitz. "A Pill for HIV Prevention: Deja Vu All over Again?" Infectious Disease Society of America (n.d.): n. pag. Print.
Goldenberg, R., T. Taha, I. Hoffman, W. Fawzi, and A. Mwatha. "HPTN 024: Antibiotics Do Not Prevent Preterm Birth (PTB) in an HIV-infected African Population." American Journal of Obstetrics and Gynecology 193.6 (2005): S3. Print.!
ECONOMICS AND DEVELOPMENT !
The Other Half: Hong Kong’s Housing Problem Nathaniel Johnson | Global Economics Columnist College of Arts and Science 2014!
Hong Kong is a city known for its extravagance. At its most luxurious, Hong Kong rivals New York, Paris, and London. At its worst, however, the city more closely resembles the developing world. The following photos were released by the Society for Community Organization, a Hong Kong activist group that hopes to raise awareness for the city’s housing crisis. They are reminiscent of How the Other Half Lives,* exposing the harsh conditions endured by the poorest residents of a modern metropolis. With 1.2 million people in poverty, Hong Kong’s poverty rate is 17 percent. While this is high, it is nowhere near the poverty rates in some U.S. cities (New York City’s is 20%). Hong Kong’s Gini coefficient is 53.3, the 13th highest in the world between Paraguay and Thailand. The richest 10 percent of Hong Kong residents take home 40 percent of the total income — that’s more than the poorest 70 percent combined. Hong Kong has the highest level of income inequality in the developed world.! The worst, however, is in Hong Kong’s housing market. Housing prices have doubled since 2008. The average price per square foot in Hong Kong is $2.84. For comparison, the average price per square foot in New York is $1.17. Hong Kong has the 3rd most expensive real estate in the world. Meanwhile, median wages in Hong Kong have been stagnant since 2006. The explosion in Hong Kong property values has left many poor residents behind. Roughly 1 in 3 residents live in public rental housing. And another 20 percent receive subsidies for their housing. While this is much lower than it was in the 1980s, the number of people on the waiting list is now over 200,000. Oxfam Hong Kong estimated that 3/4 of them have been waiting for more than 4 years. The shortage of housing has created a market for low-cost housing. This includes subdivided flats, which are apartments that have been divided up into tiny rooms for beds. The per-square-foot rate for subdivided flats is $3.40 — residents of Manhattan’s Morningside Heights pay $3.00. Subdivided apartments are legal and the regulations governing them are rarely enforced. For many apartment owners, renting out many subdivided apartments can be more profitable than renting out the apartment as is. Many of the poorest live in stacked cages. These are essentially rooms that are filled with wooden compartments or wire cages. Some apartments contain 10 to 20 cages. Many others live illegally in abandoned factories or on rooftops, though this is becoming less common as the government has started cracking down on it. !
The Hong Kong Government requires 5.5 square meters per person. Anything over that is considered “overcrowded.” Oxfam estimates that over 60 percent of those living in inadequate housing are in overcrowded conditions. These tiny apartments are not only uncomfortable, but they are unhealthy. A reporter for the South China Morning Post attempted to live in a subdivided flat. After just a week, she discovered that her air conditioner was filled with mold and the spread of spores into her room posed a serious health risk. This was likely due to the improper plumbing and poor ventilation that is common in subdivided flats. The people living in these conditions include those who are unemployed, disabled, and recent immigrants. As home prices have skyrocketed and wages have remained stagnant, many were forced to move out of their apartments as rents were raised. While Hong Kong does offer public education, for many who lose their jobs later in life, learning more competitive skills is simply not an option. Hong Kong’s public housing does not extend to recent immigrants. Only those who have been residents for more than 7 years can qualify for public housing.
The housing crisis has attracted the attention of Hong Kong’s chief executive, Leung Chun-ying, who says he will make solving the housing problem his “top priority.” It’s a good thing too. Experts and activists are pushing for reforms that shorten the waiting time for a public rental apartment and increase subsidies for rent payments. Hong Kong residents have also not remained silent on the issue. In 2011, protesters called for the resignation of then Executive Donald Tsang. They demanded a resumption of the construction of government-subsized housing and an increase in measures to slow the rise in home prices. Tsang eventually stepped down in response to an unrelated scandal.
The economic cause of Hong Kong’s extremely high property values are unclear. One major argument is that it’s a simple supply-demand issue. Currently, only seven percent of Hong Kong’s land use is designated for residential use and the unused land is owned by the government. Some suggest that the government has restricted its sale in order to raise property values and collect more from the sale of land tracts to developers. The Wall Street Journal reports, “The government has restricted land use to keep prices high so that it can collect more revenue when it sells tracts, said Alice Poon, a former executive at a Hong Kong real estate developer … The government's ‘over-reliance on land-sale revenue for its fiscal health is the root problem of its land and housing policies’.” According to the Economist, “The biggest factor behind the rise in prices, though, is constricted supply. The government has a monopoly on land in Hong Kong, and it doles out more parcels for auction only when it deems fit. Since 2002 or so, observes C.K. Lau of Jones Lang LaSalle, a property broker, officials have maintained ‘extremely tight land supplies’. Less land at auction has inevitably resulted in fewer homes being built. In the 1990s new-home completions averaged about 23,000 a year. That figure has been only 10,00011,000 a year of late.”
The photos depict the lives of the nearly 280,000 residents of Hong Kong who cannot afford decent housing. They instead live in tiny apartments with no bathroom or kitchen. These are the faces of Hong Kong’s housing crisis. Photos can be accessed online at http://qz.com/55977. No copyright infringement intended.
Another commonly cited reason is Hong Kong’s currency peg. Currently, the Hong Kong dollar is pegged to the U.S. dollar. 43 percent of goods imported to Hong Kong come from China. This means the Chinese Yuan’s appreciation against the US dollar has caused overall price inflation in Hong Kong. The peg (combined with the U.S. Federal Reserve’s loose monetary policy) also forces interest rates in Hong Kong down. This has further pressured housing values upward as investors seek higher return in Hong Kong’s historically fast-growing property market. Recently, the government of Hong Kong is responding by instituting a number of measures to try to cool down the property market. These measures include, increasing the tax on foreign purchases of domestic property and instituting maximum loan-to-value ratios. It seems unlikely that this will be enough to alleviate the problems of Hong Kong’s lower class.
Hong Kong is considered by the Heritage Foundation to be one of the most economically free places in the world. Milton Friedman once said “If you want to see capitalism in action, go to Hong Kong.” This is not capitalism. It certainly isn’t the same capitalism that drove economic growth in the U.S. for the better part of the 20th century. Or the same capitalism that pulled Europe from the rubble of two world wars. As a nation, Hong Kong has a responsibility to her citizens. The hundreds of thousands of residents who live in slum-like conditions are infinitely more important than the revenues of foreign investors.
Doing well is the result of doing good. That’s what capitalism is all about. Ralph Waldo Emerson
Chan, K. (2013, February 7). In wealthy Hong Kong, poorest live in metal cages. The Big Story. Retrieved from http://bigstory.ap.org/article/hong-kong-poor-living-cages-and-cubicles. Accessed 6 March 2013. Chan, K. (2013, January 16). Unpopular HK leader tries to soothe housing anger. The Big Story. Retrieved from http://bigstory.ap.org/article/hks-disliked-leader-tries-sooth-housing-anger. Accessed 6 March 2013. Flor Cruz, M. (2012, December 18). Hong Kong's 'Shoebox' Apartments: Slums, But More Expensive Than New York. International Business Times. Retrieved from http://www.ibtimes.com/hong-kongs-shoeboxapartments-slums-more-expensive-new-york-photos-948926. Accessed 6 March 2013. Hong Kong property - Mid-levels they ain’t. (2012, April 28). The Economist. Retrieved from http://www.economist.com/node/21553462. Accessed 6 March 2013. Hui, P. (2011, July 20). Hong Kong Faces Renewed Pressure Over Its Housing. The Wall Street Journal. Retrieved from http://online.wsj.com/article/SB10001424052702303661904576452982242744572.html. Accessed 6 March 2013. Over 70 per cent of "N have-not" families receive no offer of public housing after extended wait of more than four years. (n.d.). Oxfam Hong Kong. Retrieved April 04, 2013, from http://www.oxfam.org.hk/en/news_2040.aspx. Accessed 6 March 2013. Pomfret, J., & Leung, A. (2013, February 22). Hong Kong unveils more property-cooling measures. Reuters. Retrieved from http://www.reuters.com/article/2013/02/22/us-hongkong-property-idUSBRE91L0D620130222. Accessed 6 March 2013. Wilson, C. (2007, May 27). Living in Morningside Heights - A Slice of Relaxed Life, Sandwiched by Parks. The New York Times. Retrieved from http://www.nytimes.com/2007/05/27/realestate/27livi.html?_r=1. Accessed 6 March 2013.
GLOBAL NETWORK UNIVERSITY Plain Packaging in Australia: A Global Role Model for Smoking Prevention Cara Bradley | Steinhardt 2014 Sydney, Australia ! March 2013 ! A photograph of a decaying lung appears below the bold phrase “Smoking causes lung cancer.” Graphic and often gruesome images like this are the norm for cigarette packages in Australia due to the recent introduction of a monumental health policy. Australia became the first country in the world to mandate plain packaging for cigarettes with the Tobacco Plain Packaging Act 2011, which officially went into effect on December 1, 2012. The policy requires all cigarettes to be sold in generic packages characterized by prominent health warnings with corresponding images in place of company logos. While this may be viewed as an aggressive policy to curtail the tobacco industry’s marketing and branding, these actions could decrease smoking and tobacco-related disease rates and ultimately improve the nation’s health. By standardizing cigarette labeling, the government hopes to reduce smoking by making health warnings more noticeable and impactful, preventing misleading packaging that leads consumers to believe a product is less harmful than another, as well as decreasing the attractiveness of cigarettes. The Preventative Health Taskforce of Australia’s Department of Health and Ageing cites evidence from research that supports these claims. 1 Even though the Australian government has been implementing broad initiatives to prevent tobacco use, Australia has one of the lowest smoking rates in the world, with 15.1% of adults over age 14 smoking daily. 2 While smoking rates remain stable but critical among the general population, indigenous Australians remain a high-risk group. The daily smoking rate among Aboriginal Australians is estimated to be 47.7% of the population. With education-focused interventions to complement these policy actions, smoking rates could decrease significantly in the coming years. 3
While the public health community has praised the new policies, the tobacco industry has vehemently protested the actions, arguing that plain packaging unlawfully acquires brand names without compensating the tobacco companies. Two countries, Honduras and the Ukraine, have also lodged complaints to the World Trade Organization (WTO) citing violation of intellectual property rights. However, Trade Minister Craig Emerson affirmed that “The measure is not antitrade; it is anti-cancer.” 4 Since plain packaging has been in effect for only a few months, further research will be necessary to determine if this policy can be successful in reducing smoking rates as well as tobacco-related disease in Australia. Despite undetermined efficacy, the plain packaging mandate acts as a critical and monumental event for international health. New Zealand recently announced plans to require plain packaging and several other countries are considering the move towards generic cigarette packaging. In Australia, public health has triumphed as the government prioritizes its nation’s safety and well-being over the corporate power of the tobacco industry. 1 “Plain packaging of tobacco products.” 15 March 2012. Department of Health and Ageing. http://www.health.gov.au/internet/main/publishing.nsf/ Content/tobacco-plain. Accessed 16 March 2013. 2 “Tobacco control.” Department of Health and Ageing. 13 March 2013. http://www.health.gov.au/internet/main/publishing.nsf/Content/tobacco. Accessed 16 March. 3 “Statistics on smoking in Australia.” Cancer Council NSW. http://www.cancercouncil.com.au/31901/reduce-risks/smoking-reducerisks/tobacco-facts/statistics-on-smoking-in-australia/?pp=31901. Accessed 16 March 2013. 4 Vasek, Lanai. “Australia’s landmark tobacco packaging laws face world trade challenge.” The Australian. 6 April 2012. http://www.theaustralian.com.au/national-affairs/australias-landmark-tobaccopackaging-laws-face-world-trade-challenge/story-fn59niix-1226320500047. Accessed 16 March 2013.
NUTRITION Food Fraud Lillian Udell | College of Nursing 2014 ! This past February, Oceana, the largest ocean conservationist NGO, released a report revealing that a significant amount of seafood sold in the U.S. is fraudulently labeled. After testing 1200 fish samples, the organization found that nearly one-third of the seafood was marketed as a different type than what it really was. Subsequently, consumers may be eating high levels of mercury without knowing it, and possibly facing other digestive risks related to eating too much of the wrong kind of fish.1
milk, organic or conventional, is manufactured in China with myriad chemicals from Australian sheep grease (75). B1, an essential ingredient in Splenda, is produced from the “brown goop” that comes from burning coal; B3 is manufactured from the waste products of nylon; and Vitamin A is often produced using acetone, a chemical we know best as nail polish remover (84-85). These synthetic ingredients are even allowed to slip into certified organic foods, often accepted by consumers as being safe and untainted (80).
The week after Oceana’s report, Oxfam International, a confederation of organizations aiming to end poverty, released “Behind the Brands,” the product of an 18 month long project measuring the performances of the ten largest food corporations including PepsiCo, Kellogg’s, Coca- Cola, and Nestlé. The report graded each company on seven main issues: small-scale farmers, farm workers, women’s rights, climate change, water, land, and transparency. Each of the ten companies received a failing score in every category.2
Additionally, ingredients are often listed as something they’re not. One example is what the food industry calls “food-stimulating starches.” These not only allow the components of frozen foods to stay thick and moist, but also allow the flavor that’s needed from fruits and vegetables to be extracted without including the actual fruit or vegetable itself. Just to add to the mystery of the finished product, the list of ingredients is lawfully allowed to include “flour,” “cornstarch,” or “blueberries,” for example, even if all of the above is modified beyond recognition (6).
These issues illuminate one of the largest problems that the American public has to face when it comes to all things food-related: the issue of transparency, or the lack thereof. In the modern day U.S., it is extremely challenging to eat healthy even if we want to; in the absence of transparency, we don’t know what is in what we’re eating, where it comes from, or even how it’s being made. The evidence is hard to ignore, with report after report exposing our food for what it really is, or, really is not.
Then there are the ingredients that do not need to be listed at all. These include food contact substances, materials added to packaging and machinery, which can come with their own dangers. In fact, in 2010, General Mills recalled 28 million boxes of cereal because of a contamination caused by methylnaphthalene, a food contact substance. Events like this are bound to happen as long as companies have enormous discretion over what to consider safe or authentic. As long as the corporation’s own hired scientists deem it innocuous, the Food & Drug Administration does little to interfere (Warner, 2013, pg. 104-109).
In one such exposé, a new book called Pandora’s Lunchbox, author Melanie Warner uncovers the real sources of the added vitamins we so often see in our ingredient lists.3 Vitamin D, for example, which goes into nearly all of our ""! !
Delving further into this issue, Pulitzer Prize winning writer Michael Moss spoke to chemists, food technicians, executives, designers, lobbyists,
and others to investigate the inner workings of the food industry for his recent book, Salt Sugar Fat.4 What he discovered paints a bleak picture of the powers that be in the food industry. “It has taken me three and a half years of prying into the food industry’s operations,” Moss wrote, “to come to terms with the full range of institutional forces that compel even the best companies to churn out foods that undermine a healthy diet. Most critical, of course, is the deep dependence the industry has on salt, sugar, and fat” (pg. 337). According to Moss, this dependence has gotten our taste buds “jacked up for big doses” of all of the above, allowing consumers to become addicted to processed food while food corporations pander to their shareholders (p. 341,pg.338). All of this information presents a bleak prospect for change. However, as Moss says, just knowing this information can be empowering; after all, what we eat and what we buy are our choices (p. 347). We can begin implementing change by holding the food industry accountable and demanding more transparency. The wheels have already been in motion for years, but there is still a long way to go. Last November, Proposition 37 was on the ballot in California, proposing the enforcement of labeling for any food containing Genetically Modified Organisms (GMOs).5 Though the measure failed, since then, several states have also moved to bring the issue to the ballot box, with Whole Foods even announcing recently that by 2018, all products with GMOs in their stores would be mandatorily labeled.6 Also earlier this year, an online petition pressured PepsiCo to remove the ingredient Bromated Vegetable Oil, commonly used as a flame retardant, from Gatorade. While PepsiCo claims the change had nothing to do with the grassroots campaign, it stated that it was done in reaction to consumer concerns.7 Pressuring corporations into changing or better labeling their ingredients is certainly necessary, but still far from ideal. It is also imperative to reform our eating habits by changing how we look at eating itself. Properly educating the public about proper portion sizes might !
significantly lower the amount of food that’s necessary to buy in the first place. Plus, spending money on food can be better emphasized as a priority. Americans spend a significantly smaller amount of their annual income on food than they did in 1950.3 Perhaps our priorities need to be reordered, and our taste for the newest technology and “toys” can be tempered a bit. The market exists on supply and demand; if consumers begin demanding fresher products, the food industry will be forced to reorder its priorities and more space will be made available to supply the consumers with what they desire. Even if we cannot reach the day when our shopping carts include more carrots than potato chips, perhaps we can start by eliminating the riskier edibles, or at least learning about what they are. Maybe then, we can eliminate the chemical azodicarbonamide, which can cause burning eyes and skin irritation when exposed to air, from our bread, or propylene gycol, a chemical used in British Petroleum’s oil dispersant, from the sugar glaze that often coats our sweet snacks (Warner, 2013, p.103, p. 99). Maybe our list of 5000 additives, 3000 of which have been added since 1980, can be made smaller (p. 105). Or maybe, one day, when we sit down for dinner, we can be certain of what kind of fish is on our plate. 1
Democracy Now. (2013, February 22). Study: 1/3 of U.S. Seafood Samples Are Mislabeled. Retrieved from http://www.democracynow.org/2013/2/22/headlines#22212 2 Democracy Now. (2013, February 27). Behind the Brands: On Food Justice, Oxfam gives Coca-Cola, Kellogg’s, Nestlé, & Pepsi failing grades. Retrieved from http://www.democracynow.org/2013/2/27/behind_the_brands_on_fo od_justice 3 Warner, M. (2013). Pandora’s Lunchbox. New York: Scribner. 4 Moss, M. (2013). Salt Sugar Fat. Toronto: McClelland & Stewart. 5 Almandrala, A. (2012, November 7). Prop 37 Defeated: California Voters Reject Mandatory GMO-Labeling. The Huffington Post. Retrieved from http://www.huffingtonpost.com/2012/11/07/prop-37defeated-californ_n_2088402.html 6 Polis, C. (2013, March 8). Whole Foods GMO Labeling to be Mandatory by 2018. The Huffington Post. Retrieved from http://www.huffingtonpost.com/2013/03/08/whole-foods-gmolabeling-2018_n_2837754.html 7 Choi, C. (2013, January 25). Gatorade To Remove Bromated Vegetable Oil After Consumer Complaints. The Huffington Post. Retrieved from http://www.huffingtonpost.com/2013/01/25/gatoradebrominated-vegetable-oil_n_2551533.html
The Societal Perception of Obesity: An Analysis of Misconception Aleena Zahra | College of Arts and Science 2011 ! The alarming rise in obesity rates, in both children and adults, has triggered a robust response from diverse sectors of society, ranging from the dire warnings of healthcare professionals and researchers, to the drive for nutritional literacy and healthy lifestyles advocated through government programs, to the voyeuristic tendencies exposed by the myriad of reality television shows that focus on the weight of participants. Current research strongly indicates not only genetic predisposition to the condition, but increasingly, the role of gut microbiota. Sufferers of obesity, many of whom have tried unsuccessfully to decrease their weight to a manageable level, may feel exonerated by this knowledge; yet societal attitudes towards the overweight and obese remain highly negative. On an individual and societal level, statements, in jest or otherwise, regarding race and gender are often deemed highly offensive, yet the same statements made about the overweight or obese rarely trigger a defensive response, or far less likely, a public outcry. Campaigns are frequently launched lauding the benefits of a nutritionally balanced diet and healthy lifestyle. The embedded message is simple: eat “right”, exercise, and a healthy, manageable weight will be yours. As the public is increasingly courted by this message, it is also likely internalized by sufferers of obesity, perhaps leading to significant drops in positive self-image and a subsequent increase in depression and feelings of decreased self-worth. Aside from the emotional toll of psychological distress, the pervasion of severe self-deprecation and clinical depression has an immense toll on worker productivity, possibly translating into economic losses for employers. The adverse effects of obesity are innumerable, ranging from an increased risk of social isolation which can lead to a detrimental psychological "$! !
impact, to critical health issues, including an increased risk for chronic conditions such as diabetes and cardiovascular disease, and severe, life-threatening health emergencies such as heart attack and stroke. Numerous studies have made the risks of obesity abundantly clear, heightening awareness, but perhaps also pervading a culture of blame. Just as diseases associated with smokers and drug addicts seldom awaken societal sympathy due to public perceptions of divine justice or merely natural selection for poor lifestyle choices, the presence of obesity often appears to the observer as a punishment for gluttony. The sufferer often internalizes this message, and believing the cause of suffering to be selfinflicted, may attempt to control the situation through extremes of self-deprivation and exercise, usually resulting in dismal long-term yield. This sense of failure and loss of agency is likely exacerbated through media highlights of "success" stories, of individuals defeating insurmountable weight, through controlled diet and exercise. Reality television shows such as "The Biggest Loser," and specials such as "True Life: I’m a Chubby Chaser" and "True Life: I’m Happy to Be Fat" perpetuate the stereotype of obesity as a choice, possible to reverse with a few months of dedication. The dangers presented by the perpetuation of these messages are twofold. Firstly, it misleads societal attitudes towards the obese, encouraging their characterization as lazy, slow and irresponsible and as lacking selfcontrol and discipline. Secondly, it places a strain on healthcare resources by the refusal of the sufferers of obesity to alter their habits, and triggers responses of severe self-deprecation or alternatively, an irrational defense of lifestyle choices. As research increasingly identifies genetic predispositions to obesity, in addition to the influence of microbial species colonizing the
gut, the solution to obesity must evolve from a simplistic "eat less, exercise more" philosophy.
and development, yet rapid progress in the field of obesity research must be acknowledged as an urgent necessity. As millions of dollars are allocated to public service outreach programs advocating for “healthy lifestyles” and to diabetes, cancer, and cardiovascular disease, the substantial contributor, obesity, must be met with a similar monetary and professional research commitment. !
Aside from preventative measures such as advocating health literacy with an emphasis on nutrition from the primary school years and onward, and surgical interventions in the form of laparoscopic gastric bypass or gastric banding surgery for advanced sufferers, and Qsymia, the recently approved FDA drug for weight loss, medicine offers few options for the obese. The identification of causes and viable treatment options often involves greater than a typical lifetime of dedicated research
Hydration Richard Hsu | Fitness & Healthy Living Columnist Steinhardt 2015! !
INTRODUCTION Depending on body size, our bodies consist from 55% - 78% of water. More specifically, our muscles, brains, bones, and blood consist of approximately 75%, 90%, 20%, and 80% of water, respectively. The Institute of Medicine of the National Academies (IOM) states in the Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate Report, “The largest single constituent of the human body, water, is essential for cellular homeostasis and life. It provides the solvent for biochemical reactions, is the medium for material transport, and has unique physical properties (high specific heat) to absorb metabolic heat. Water is essential to maintain vascular volume, to support the supply of nutrients to tissues, and to remove waste via the cardiovascular system and renal and hepatic clearance. Body water deficits challenge the ability of the body to maintain homeostasis during perturbations (e.g., sickness, physical exercise, or climatic stress) and can impact function and health. Total water intake includes drinking water, water in other beverages, and water (moisture) in food.1 ” Up until recently has there been extensive and innovative research on hydration and the role of water in our bodies. Despite controversial research on the water intake of Americans, it is needless to say that proper hydration is beneficial to the human body. In a hyperactive environment such as New York City, hydration becomes a vital element in healthy daily activity.
Research conducted by Maughan et al., demonstrates that performance of both physical and mental tasks can be adversely affected by heat and dehydration. Additionally, the heat and hydration status of the cardiovascular and thermoregulatory systems can be held accountable for fatigue and lack of mental focus.2 Exercise feels harder for students, athletes, and individuals with physically demanding occupations when the ambient temperature is high and there is a corresponding reduction in exercise performance. For instance, in an extreme perspective, marathon runners experience high rates of heat production. Thus, it is not surprising that increasing the ambient temperature results in performance impairment and a necessity for increased water intake.
RECOMMENDED ADEQUATE INTAKE The recommendation for daily total water intake for women is 2.7 L (91 fl oz) and 3.7 L (125 fl oz) for men. In the United States, the annual consumption of bottled water averages 26.1 gallons per person, 3 or about six 8 fl oz of water daily (48 fl oz). 4 However, the human body does not solely rely on the pure water intake from tap or bottled water. It should also be noted that water in food provides approximately 19% of total daily water intake. Because water intake comes from drinking water, other liquids, and food, recommendations for the adequate intake of water consider all dietary water sources that contribute to a person’s total daily water intake.5
Below is a chart that shows the extensive amount of water content that each food provides 6:
CAFFEINE Contrary to popular belief, research shows that coffee, tea, and other caffeine-containing beverages do not increase urine output or negatively affect indicators of hydration status in those who consume caffeine regularly. The Institute of Medicine and Food and Nutrition Board states that “caffeinated beverages appear to contribute to the daily total water intake similar to that contributed by noncaffeinated beverages.” Additionally, available studies on hydration found that caffeine intakes of up to 400 mg per day did not produce dehydration, even in subjects undergoing exercise testing. Studies concluded that the range of caffeine intake that appears to maximize benefit and minimize risk is 38 to 400 mg per day, equating to 1 to 8 cups of tea per day, or 0.3 to 4 cups of brewed coffee per day. 7 "&! !
ALCOHOL According to the Institute of Medicine and Food and Nutrition Board, “it appears that the effect of ethanol ingestion on increasing excretion of water appears to be transient and would not result in appreciable fluid losses over a 24-hr period.” 1 Thus, alcohol intake in moderation does not seemingly play a huge role in dehydration. Furthermore, while there is an increased need to urinate (diuresis) in the initial three-hour span following the consumption of alcohol, the effect stops temporarily (anti-diuretic effect), and the need to urinate begins again six hours after alcohol consumption. This does not mean that alcohol does not have other adverse effects; it solely means that conditions of hydration under alcohol influence are limited on a case-by-case basis. Consistent alcohol intake can take a toll on hydration status when compounded. CONCLUSION Hydration plays an important role in the human body, but a limited amount of research has focused on hydration and its effects. However, the importance of proper hydration should be noted and made aware to individuals, especially those with active lifestyles. This article serves primarily as a general guideline, but it should be noted that adequate amounts of water intake prove beneficial at moderate levels.
Institute of Medicine and Food and Nutrition Board: “Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. ”Washington, DC: National Academies Press,2004. 2
Maughan, R. J., Shirreffs, S. M., & Watson, P. (2007). Exercise, heat, hydration and the brain. Journal of the American College of Nutrition, 26 (suppl 5), 604S-612S. 3
Beverage Marketing Corporation: Bottled Water Continues As Number 2 in 2005. New York, NY: 2005. Available at http://www.bottledwater.org/public/Stats_2005.doc. 4
Bullers, AC: Bottled water: Better than the tap? Rockville, MD: FDA, 2002. Available at http://www.fda.gov/fdac/features/2002/402_h2o.html. 5
Campbell, S.M. (2007). Hydration needs throughout the lifespan. Journal of the American College of Nutrition, 26 (suppl 5), 585S-587S. 6
Campbell, S.M.: Dietary Reference Intakes: Water, potassium, sodium, chloride, and sulfate. Nutrition & the MD, 30:1–4, 2004. 7
Ruxton, C. H. S. (2008). The impact of caffeine on mood, cognitive function, performance and hydration: a review of benefits and risks. Nutrition Bulletin, 33(1), 15-25.
HEALTH AND SOCIETY
Maternal Health, Birth Models, & Midwifery: A Proposed Solution Mary Kern | College of Nursing 2015 Context What exactly is the plight facing mothers in the developing world? According to the World Health Organization’s fact sheet on maternal health (2010), approximately 800 women die each day from preventable causes related to pregnancy and childbirth. Additionally, maternal mortality is highly associated with living in rural areas and underserved communities, a reflection of lack of access to healthcare. An example of lack of access is demonstrated well in a Partners in Health publication. PIH (2012) created an infographic comparing the birth experience for American women versus women in rural Lesotho. For the women in Lesotho, they, walk an average of up to five hours to a healthcare facility. This is in comparison to the twenty minute car ride the average woman takes in the US to a healthcare facility. This type of access is all too common in the developing world, which explains why 99% of all maternal deaths occur in the developing world, with one half of them in subSaharan Africa and another one third in South Asia. But what exactly are these causes? Why does a skilled birth attendant, midwife, or physician’s presence matter so much? Eighty percent of maternal deaths are attributed to the following four causes, according to WHO (2010): hemorrhage after childbirth, infections after childbirth, high blood pressure during pregnancy (preeclampsia and eclampsia), and unsafe abortion. Thus, the need for these trained professionals is dire. For hemorrhaging after childbirth, the administration of oxytocin can make all the difference as it helps the cervix to contract and control the bleeding. Infections can be "(! !
prevented by having a trained professional properly sanitize their hands while assisting with birth along with having the appropriate supplies for a sterile environment. These professionals can also identify what an infection looks like more easily. For the matters of preeclampsia and eclampsia, these high blood pressure issues can be detected in advance with proper prenatal checkups so that measures to ensure safety of both mother and child, such as administration of magnesium sulfate or induced labor, can be taken more swiftly. Unsafe abortions can be remedied by providing facilities for safe abortions, along with family planning supplies and education for the general public. The good news is that a lot of these interventions are working. From 1990 to 2010, maternal mortality dropped almost 50% and in these improvements, there are opportunities for women to empower themselves. This provides an entirely sustainable solution. Women are becoming the OB/GYNs, midwives, and birth attendants themselves in these developing nations, and this provides them with an occupation and role within their societies. They become an asset and gain respect for the service to the community by spreading information on what is important for prenatal nutrition, along with what’s normal with antenatal care. Not to mention, these improvements in women’s living condition also provides a higher standard of health for the infant and the rest of the family’s well being. Along the lines of family planning, knowledge can be passed from woman to woman about options available to make their own decisions;
the woman’s body becomes her own, no longer an object the society makes it to be. This establishment of ownership and control over oneself is one of the greatest forms of empowerment. Beginnings of Birth Models As far as successful birth models go, Sweden is one to take note of and its integral usage of the midwife. The role of the community midwife was very much solidified in Sweden during in 19th century, according to Dr. Ulf Högberg’s article for the American Journal of Public Health entitled, “The Decline of Maternal Mortality in Sweden: The Role of Community Midwives.” Specifically, in 1819, a national midwife training program was established for all of the parishes within Sweden, requiring at least one midwife per parish. The program paid for all of the students’ expenses, and the state defined the required curriculum and training. This professionalization of the midwife in Sweden was critical, as the requirement of their role elevated their status to be complementary to physicians, rather than the typical asymmetry of power that is often felt between the two positions. Because of Sweden’s prioritization of maternal and infant care during this time period, by 1894, 94% of the country’s births were attended and the maternal mortality rate had dropped from 490 deaths per 100,000 births to 100 deaths per 100,000 births in a period of 33 years. Then, medical advances picked up in the early 20th century, improving the rates of maternal mortality in all Western nations, but Sweden’s rate was still one third of the United States’ rate. Presently, Sweden is one of the safest countries to give birth in, with a maternal mortality rate of 5 per 100,000 live births. The midwifery framework of this country’s birthing model is what makes it so efficient and good for mothers and babies— similar to the frameworks of Norway, Iceland, and The Netherlands, which are all considered some of the best countries to deliver a baby in.
It is impossible to deny the importance of the midwives’ role in achieving healthier birth outcomes. A Present Day Application & Program Idea in Ghana Every week in Ghana, 50 women die during pregnancy and childbirth. More than 400 babies also die weekly. The Ghanaian government has made strides to improve this issue by passing legislation in 2008 for free healthcare for women who are pregnant, new mothers and babies—but this measure isn’t enough. There is a huge disparity in the rural and urban populations in their access to health personnel. In the urban population, 80% of births are attended by a health professional. In the rural population, however, only 40% of births are attended by a health professional. Take Mary Issaka for example; she is one of few midwives who serves in the rural regions of Ghana. Recipient of the ‘International Midwife Champion’ prize, she is a provider for the Bolgatara, which is a northmost region of Ghana. Since 2003, she has delivered 2,240 babies and made major strides in her community. When she first arrived to Zorkor Health center, maternal deaths were very common. Many of the women in the community preferred to give birth at home, but Mary was able to create a welcoming labor ward with traditional hot bath techniques for delivery and by preparing traditional millet flour beverages for women after giving birth, amongst other things. Thus, the women in the community sought out the health center, increasing birth attendance in the region six fold. We need more Mary Issakas in rural Ghana today. The unfortunate part is that she, like 85% of current Ghanaian midwives, is over the age of 50. What is the cause of this unsettling statistic? The “brain drain,” or the emigration of highly trained/intelligent people to other countries, is what is hurting the future
of Ghanaian midwifery, along with other fields. There is no incentive for a woman to stay in Ghana and practice as a midwife because the pay is substandard, the position comes with little respect, and the training is expensive. A birth model restructuring would set out to alleviate all of these issues and benefit mothers, babies, and young women entering the field of midwifery; a brighter, healthier future allaround. Following suit of nations with exceptionally low maternal mortality and infant mortality rates (such as the Nordic countries), the project sets to establish a community midwife birth model in order to best serve all populations of Ghana. By doing so, women all across the country will have access to appropriate prenatal and postnatal care, labor assistance, and referral ability to a major facility if there is a need for extra medical attention (i.e., a Caesarean section). The critical piece for this project is the recruitment and training of high school graduates, such as students supported by the Campaign for Female Education (Camfed). By identifying a high achieving group of girls with leadership skills, they are the ideal candidates for going on to midwifery. Based on test scores, a nomination by Camfed, and an essay expressing interest in midwifery, a committee comprising of representatives from an activist organization, like the White Ribbon Alliance in Ghana, and the Ghana Health Service will determine who will qualify to attend one of sixteen midwifery schools in Ghana with all expenses paid. A key component of the training will be curriculum designated by the White Ribbon Alliance as methods and techniques for respectful maternity care, something that is lacking in many health systems today, and advocacy training for maternal health rights. After the three years, the new midwives are required to serve an assigned region under the discretion of the Ghana Health Service for three years.
With a handsome starting salary, a 5% per year increase after the three required years (similar to the pay increase by year with school teachers), and full government benefits, the program will work to keep these welltrained, strong leaders in the rural areas where their expertise is needed most. Maternal health is of the utmost importance, and this project idea is one of the most sustainable ways to ensure that progress is being made. In order to have healthy, well raised children, the mother must be alive and well to do so. Additionally, all of the rights and freedoms that are being fought for in the interest of women are for nothing if the women themselves are dying needlessly. By having healthy pregnancies and deliveries, along with general womenâ€™s health, women will be able to exercise rights to land ownership or ability to take out a microfinance loan. Women will be able to help raise nurtured children who can succeed in school if they themselves are healthy. In Ghana in particular, women do most of the farming and household work, so families are losing a huge contributing member in the family if women are ill. Right now, $15 billion in productivity is lost every year due to the deaths of mothers in developing countries, according to the United Nations Population Fund (UNFPA). The other piece of this is that the young women who are becoming midwives themselves will be empowering women in Ghana, showing the necessity and prestige that should go along with a critical role in society. These young women will be well-educated, which means later marriage and less unplanned pregnancies as they will have more knowledge about the authority they possess over their own bodies. A restructuring of the birthing model would benefit Ghana as a whole and would serve as a model for countries who wish to restructure their present birth model situation.
Bumsters and Prostitutes: Intersectionality at Work Jasmine Boutros | NYU Abu Dhabi 2014 prostitute [pros-ti-toot, tyoot] noun a woman who engages in sexual intercourse for money; whore; harlot bumster [bum-stir] noun unemployed young men who try to hassle and hustle female tourists into giving them their money in exchange for sexual intercourse
Common to the beach resort area of many developing countries, is a group of people known as bumsters. Bumsters prowl many a beachfront hotel looking for older women to prey on. They’ll attempt to become friendly with these women and offer them sex in exchange for money and/or citizenship in whatever Western country the women have traveled from. So is bumsterism not to be considered a form of prostitution? Technically, it is someone offering sex for some sort of reward. In this paper I will examine the obvious double standard surrounding bumsterism and female prostitution, and how that affects gender stereotypes in our world today. First, let us look at the how the terms by which bumsterism and prostitution differ. Bumsterism is described as a personalistic economy. A personalistic economy is the use of someone’s body as a source of income purely because that is his only point of access into the global capitalist system. Prostitution is referred to as commercial sex work, which alludes to the fact that a person is selling their body for money. What is the difference? Maybe sex work is a prostitute’s only point of access to the global capitalist system. The difference lies in gender. If a woman has sex for money, she is a prostitute. If a man does, he’s a businessman. This is a sign of the apparent gender bias in our world today. To top it off, women are often the victims of intersectionality, under which someone can be affected by multiple oppressions disadvantages at the same time.
Let’s first look at this from the viewpoint of a female prostitute. For example, let’s say that I am a black, lower class high school dropout with no way of putting myself through university except through prostitution. Society will look at me as nothing but a whore. Not only am I a prostitute, but I’m a prostitute of the wrong race and the wrong class and I’m a woman. The stigma surrounding me is not just a summation of the stigma surrounding each of these individual disadvantages - it is exponentially worse. Now let’s look at the standpoint of the white tourist in one of the coastal areas in which bumsters thrive. This white tourist is swept off her feet by this charming, exotic man and ends up financially supporting him. She is now disadvantaged by the fact that she is a woman, she is lessening her class status by giving up a sum of money for this man, not to mention the fact that she is probably quite foolish for falling for such a rouse. Again, the combination of these oppressive forces is exponentially stronger than either of the entities on their own. Finally, let’s take a look at the bumster. He is making money. He is having sex with foreign women. He’s upping his class status. For him, the experience is purely positive. I believe this is because gender is possibly the biggest disadvantage someone could be put at. When looking at the key tenets of intersectionality, we see that gender is the only oppressive force that is also classed and raced. So it doesn’t matter if a woman is participating in commercial sex work to better herself.
Because she is a woman, she is in the wrong. God forbid she be a low class, minority ethnicity woman. All in all, I do not see a difference between bumsters and prostitutes. If anything,
bumsters are morally worse off because the people paying them for sex are disadvantaged by the behavior. Unfortunately though, until gender equality is attained, such practices and double standards will remain.
Analyzing Speech Samples of New York Latino English from Assimilating Latin Americans Hugo Rodas | Steinhardt 2013 Introduction ! In American English, the New York dialect is one of the most popular regional speech, and the basis of its development was the end-result of multilayering ethnic speech through centuries. In the 19th and early 20th century, native-born Americans widely perceived immigrant groups, such as the Irish and Italians, as inferior national-origin groups. As a result, they were racially categorized. However, because these groups were nonblack, they eventually came to be seen as white (Brown & Bean, 2006). By the end of the Spanish-American War, there was a massive migration of Latin Americans to New York City. The subsequent generations of Latin American background born in the New York dialect regions were native speakers of both English and Spanish, and they were not generally seen as either White or Black---nor did they consider themselves as such, regardless of their skin color. In efforts to maintain a linguistic difference, certain features of Spanish were preserved in the English they spoke. Eventually, the bilingual speech spoken within the Five Boroughs gave origin to a form of New York dialect known as New York Latino English (NYLE). Nevertheless, in the process of assimilating to the host culture, many individual generations of immigrant families maintain ethnic markers perceivable in their own English dialect, while
others choose to consciously erase them. A brief summary of a more complex explanation confers, “Immigrants who become racially categorized are treated as disadvantaged racial or ethnic minorities and may find their pathways to economic mobility and assimilation blocked because of racial/ethnic discrimination” (Brown & Bean, 2006). Empirical research has shown that acculturation into the dominant culture and socioeconomic status are dependent factors of each other. Nevertheless, for our analytical purposes, gathered speech samples showcase NYLE speakers that may sound, either: more Black, some more White, and some more Spanish. Though it may seem otherwise, NYLE is not “Spanglish,” or “learner English” and may show the degree to which individual immigrant families adapt to their new society over generations and how their speech may stray from normative dialects during acculturation. Data Collection Familiarization with three NYLE speakers is the basis for conducting a brief study of their speech. In order to acquire a better understanding of the varying verbal aspects of NYLE and learn more about the subjects as members of the NYLE speaking population, voice recordings of the three working-class native speakers were studied.
Three Latin American male acquaintances; two that sound more Black, and one that sounds more Spanish verbally answered a short questionnaire about their lifestyle, and their recorded responses will support observations made about the main characteristics unique to their personality and their New York Latino English. At a fastfood restaurant in Manhattan, three NYLE speakers contributed individual voice samples by answering a short questionnaire about themselves, and their lifestyle. In order to develop a more interesting study about their voice, the actual voice samples obtained from each fast-food chain worker are based on autobiographical information. For the interview, the three gentlemen were invited to introduce themselves by stating their: name, age, country of origin, and age they moved to the U.S. (if applicable). From the two sources previously acknowledged, the following personal data was gathered: The assistant-manager was the first subject interviewed. Jeffrey Taveras, age twenty-one, was born and raised in Manhattan, and his ethnic background is Dominican. The second interviewee is food prep, Yamil Hernandez. The nineteen year-old is actually a Dominican native, but at age one moved with his family to the Bronx. The third interviewee is delivery driver Nelson Molina. He is a Brooklyn native, forty-five years old, and his ethnic background is Puerto Rican. The three subjects are first generation Latino Americans, and hold a full-time job position at a Domino’s Pizza restaurant located in Manhattan. Based on their current yearly income they are considered low-SES. Next, in the same questionnaire, the three males were individually asked to verbally describe an ideal day in which they had an opportunity to engage in any activities of their own liking, and they were informed about the actual content in the questionnaire one day prior to conducting the interview. The purpose of giving the subjects time to !
prepare their answers was simply to conduct the interview in a timely fashion. In the audio recordings, a description of their own perfect day was stated in a morning-to-evening order. Nonetheless, their audio recorded responses account for the bulk of their own voice sample, which will be analyzed and compared in annotations following the transcripts. 1. Jeffrey Taveras is in the first voice sample. In his discussion of a perfect day, he indirectly relates to his aspiring career as a hip-hop artist: Morning (Starting at 00:24): “My perfect day. Morning. There’s no morning--I sleep right through it. Noon (00:32): I’ll probably take a nice hour-shower. Uh, walk a little--hit the studio--stay there till the ni--till the evenin’--you know.” [Interviewer interjects] “Oh, what do I do at the s--you want me to spit, bro? [Interviewer answers] Oh, ‘aight’ nah! At the studio, you know, just record a couple hours, jus--sessions after sessions. Um, trying to make that perfect hit. Music is everything--um, probably stay there like four, or five hours--that’ll reach evening, maybe nighttime.” Evening (01:06): “The evening, go home. You know, get some if I could get some--you know (Have sex). Keepin’ it real. And.. Uhhh,.. YEAH! Have a nice dinner. Shrimp, yes! Shrimp! I want some shrimp right now, man. And that’s it, go to sleep--hard work. That’s my perfect day, I just wanna record music, and that’s it.” 2. Nineteen year-old, Yamil Hernandez, is the second subject to describe his perfect day, and it goes as follows: Morning (00:34): “Describe your perfect day--Huh! It’s hard-this is a hard one right here! Perfect day-perfect day! ..Huh! Can I think about it for a second? (Interviewer responds) Alright, no problem. In the morning,.. wake up to some.. ##!
banging ass.. platanos con salami y queso (plantains with salami and cheese).That’s first! Noon (01:00) “Fo’ da noon! ..Can I be completely honest?! Noon is the--[chuckles and giggles]--twelve o'clock blunt! (Marijuana cigarette) [chuckles/laughs] Afternoon (01:21): What’s the other one!? It was for--in the afternoon, in a perfect day--either chill with shawdy (spend time with his girlfriend). Or, spend it with da family, you know, playin’ dominoes--drinkin’. Evening (01:32): “And for the evenin’ another plate of platanos con salami y queso before going to sleep. That’s about it, man. It’s pretty simple. 3. The last male subject to talk about his perfect day is forty-five year-old, Nelson Molina. Morning (00:23): “My perfect day would be a day that I would get up, have a nice breakfast: a bacon egg and cheese with coffee. Then, uh.. check out my.. Uh,.. my web pages in the computer.” Afternoon (00:42): “Then, in the afternoon I probably would like to.. uh.. [long pause] Watch a good movie.” Evening (00:51): “And in the evening, go do the shopping. Go spend time with my friends--playing dominoes. And spend a little time with my son. Keep it simple. ..That would be a perfect day for me.”
Observations Prior to making observations about the three subjects based on their voice sample, their sex should be acknowledged. According to Kreiman & Sidtis, “An individual’s sex is one of the most important aspects of that person’s identity, and voice is an important way in which males and females identify each other” (J. Kreiman & D. Sidtis, 2011, p. 124). Moreover, by listening to the perfect day verbal responses guesses can be made about the their age, perceived emotion, and even personality. However, as a personal acquaintance to the subjects, having prior knowledge of them would ultimately yield biased results in making guesses about their personal characteristics. Therefore, a second listener, a stranger to the three subjects, was invited to participate in the study. Columbia grad student, Amanda Alfieri, twenty-seven, individually listened to the three perfect day recordings, and afterward, jotted down her observations about each subject. In guessing the age of the three subjects, her numbers are follows: Jeffrey: 25 (actual age: 21) Yamil: 21 (actual age: 19) Nelson: 40 (actual age: 45) Results and Analysis Amanda’s guesses fit with empirical research, “When listeners are asked to guess the decade of a speaker's age or to guess exact ages, they consistently underestimate the ages of older speakers and overestimate the ages of younger speakers” (J. Kreiman & D. Sidtis, 2011, p. 122). Next, she noted the main cues in the samples’ voice quality for her age guesses. She described Jeffrey’s voice as, “low in pitch, but smooth.” She noted Yamil as having a, “varied pitch range” in his voice quality. Lastly, the main cue for Nelson was, “slow and raspy.” In
perception of age from voice, according to Kreiman, and Sidtis, “Speakers with slower speaking rates were perceived as older. Hoarseness, roughness, increased breathiness, and decreases in the precision of articulation also corresponded to increases in perceived age. Voices that were perceived as old were also described as harsh, strained, tremulous, reduced in loudness, and hesitant. Listeners also consistently associate low pitch with old age, despite reported increases in F0* with age in men, suggesting the presence of vocal stereotyping” (J. Kreiman & D. Sidtis, 2011, p. 121) Amanda’s next task was to identify the main emotion expressed in each voice sample. However, her attempts at trying to pinpoint a specific emotion based the voice were almost weak in the case of Jeffrey, and Nelson. While these two individuals sounded, “composed, and neutral, Yamil broke out in laughter couple of times, which led me to believe he was excited.” Indeed, from what Amanda could tell from Yamil’s voice sample, “listeners should be rather good at distinguishing an aroused speaker - whether happy or angry, triumphant or terrified - from a calm one, but should be rather less able to determine the specific emotion being experienced. These data also suggest that listeners should rely on similar cues no matter what their linguistic or cultural background, because most emotional expression appears to derive from physiological processes that are common to all humans, and indeed to most mammals.” Lastly, Amanda gauged personality traits from the three voice samples. For this particular assessment she mostly paid close attention to the content in each response to the perfect day section, yet, still considered the vocal pitch, and speech rate. According to her notes, “Both
Jeffrey and Nelson sound easy-going.” At the same time, she sensed in Nelson’s long pauses, “uncertainty,” or, perhaps, an “unwillingness” to divulge personal information, and Jeffrey’s questioning reflected insecurity. On the other hand, she noted, “great confidence,” and, “maybe even ruthlessness,” in Yamil’s playful, but controversial responses. In support of Amanda, “Loud, boisterous voices were judged to be extroverted” (J. Kreiman & D. Sidtis, 2011, p. 345). These observations were based on Yamil’s inconsistent speaking rate, and variable F0. “Either very fast or very slow speaking rates were associated with less benevolent personalities. Increased speaking rates have also led to perceptions of a more active personality, while normal speaking rates were judged most fluent, persuasive, and empathic, and least nervous. Decreasing the speech rate had a large negative impact on these variables, and may also decrease perceived potency” (J. Kreiman & D. Sidtis, 2011, p. 351). Also, fast speaking rates are associated with more activity, dynamism, potency, extraversion, and competence, while slow talking is associated with less truthfulness, less fluency, less emphaticness, lack of seriousness and persuasiveness, and increased passivity (but also with more potency). As mentioned, Amanda also noticed Yamil’s variability in F0 during his brief moments of laughter. “The effects of F0 are more variable; higher F0 is associated with greater extraversion, assertiveness, confidence, and competence, but also with immaturity, emotionality and emotional instability, nervousness, and less truthfulness” (J. Kreiman & D. Sidtis, 2011, p. 352).
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! * F0 is short for fundamental frequency - the basic rate of vibration of the vocal folds/chords (the lowest tone of an individual's voice, perceived as pitch)
Overall, Amanda provided useful evaluations of the voice samples, which were consistent to personal assertions in my acquaintance to Jeffrey, Nelson, and Yamil. Yet it is important to emphasize that guesses made about the their age, perceived emotion, and even personality are subjective. “Because of the many limitations inherent in these studies, the data do not allow us to fairly conclude whether the impressions listeners form reflect actual differences in personality, or whether they are the product of vocal stereotypes only tenuously tied to fact” (J. Kreiman & D. Sidtis, 2011, p. 352). Discussion and Conclusion At the main focus of the study, NYLE has unique characteristics, and social implications that are worth pointing out. In a societal context, the three subjects, and the larger Latin American community belong to a minority group, and generally are affected as NYLE speakers since, “Cultural effects on the perception of personality from voice are also apparent in studies examining how speaker’s accents affect the way in which they are perceived” (J. Kreiman & D. Sidtis, 2011, p. 354). Indeed. For example, a Los Angeles native working part-time in Manhattan may find NYLE strange, yet, fascinating to listen to, in relation to American Standard English, and LA’s Chicano English. In support of this observation, “General American appears to enhance a speaker’s credibility, while social attractiveness is enhanced somewhat by accent, foreign or regional. Research confirms these accent-related decreases in credibility; however, these data suggest such effects are due to the fact that non-native speech is more difficult to understand than native speech, rather than to social prejudices” (J. Kreiman & D. Sidtis, 2011, p. 354).
In efforts to learn more about the linguistic aspect of NYLE, “there have not been sufficient studies made on the subject” (Gordon, 2004). However, Labov clarifies, "It appears that these geographic labels are in fact labels for perceived social class differences" (Labov, 2005). Nevertheless, NYLE can be summarized, "as a varying mix of the traditional New York accent, African American Vernacular English (AAVE)," and features of Spanish origin, to make what are called an, "ethnolect" (Gordon, 2004). A second approach to learning more about NYLE is by comparing the acquired voice samples to the root dialect: the New York dialect (NYD). Though the origins of NYD are diverse, Labov has pointed out that the most noticeable trademarks of the accent, the loss of the "R," (non-rhothic), as well as the short-A split mainly derives from the high-class London, and that through time, moved down the social latter (Labov, 2005). Examples of non-rothic are the most common, and heard in the words: car, card, and york, and of the short-A split can be found in the words: plan, class, and bad. When a New York native pronounces the same set of words, "the /æ/ is raised and tensed to an in-gliding diphthong of the type [e!!] or even ["!!]" (Gordon, 2004). Unfortunately, in the three voice samples there were no identifiable sentence phrases, or even words, that stood out as clear examples of NYLE. Even Yamil’s platano con salami y queso, did not serve evidence of NYLE. According to Newman, “NYLE is not ‘Spanglish’. It is not ‘code switching,’ meaning changing backing and forth from Spanish to English. Some NYLE speakers cannot even speak Spanish (Newman, 2004, p. 4).”
In further attempts at trying to learn more about NYLE, research conducted by Newman points out: “NYLE is not ‘learner English,’ in other words English learned as an adult or adolescent that is not native. A NYLE speaker does not have a ‘foreign accent’ or speak with errors that come from incomplete learning of the language. It is a native variety of English, although it is what is called a ‘contact variety.’ It has been influenced by contact with another language, much in the way that Irish English contains features traceable to Irish (Gaelic)” (Newman, 2004, p. 5). Indeed, Jeffrey’s and Yamil’s speech may stand out from Nelson in the sense that their NYLE leans more toward African American Vernacular English. In support of my observations, “NYLE is characterized by a mix of African American English and local European American English with features from Spanish.” The study on the three NYLE speakers focused on observations made about their age, perceived emotion, and even personality. The fourth participant, Amanda Alfieri, who had no prior knowledge of subjects listened to the voice samples and made assumptions about the three gentlemen--based on vocal stereotyping. Afterward, attention was shifted to the study of the NYLE speech. Future Steps Historical research points to its origins after the mass migration of Latin Americans throughout the twentieth century, but very little linguistic research has been conducted on the subject. Regardless, comparisons between NYLE and NYD were made using the voice samples, and the strongest link to NYLE in the voice samples is the subjects’ speech containing Spanish, and African American Vernacular English influences. Also, the socioeconomic status of individual immigrant families may determine the levels of proficiency in both English and Spanish. From an assimilation !
perspective, the higher the social class of one's parents the more likely the parents and children are integrated into American mainstream, and therefore the greater the likelihood that the children will speak only Standard American English. Lastly, fluent bilingualism is not within the reach of all immigrants, but is a function of social class. Lutz suggests that immigrant parents with high socioeconomic status have the resources available to be able to maintain high levels of English proficiency while resisting the societal pressure to shift to English completely (Lutz, 2006). Further study should explore the extent to which NYLE is reflective of the socioeconomic status and education of Latino immigrants.
___________________________ Gordon, Matthew (2004) "New York, Philadelphia and other Northern Cities" in Kortmann, Bernd & Schneider, Edgar W. (Eds.) A Handbook of Varieties of English: Volume 1: Phonology Walter de Gruyter Labov, William Ash, Sharon Boberg, Charles, (2005). Atlas of North American English : Phonetics, Phonology and Sound Change. 1st ed. Berlin: Walter de Gruyter . Michael Newman (2005). The New York Latino English Project Page. [ONLINE] Available at: http://www.microsoft.com. [Last Accessed April 28th, 2012]. J. Kreiman & D. Sidtis, (2011). Foundations of Voice Studies. 1st ed. United Kingdom: Wiley-Blackwell. Lutz, A. (2006). Spanish Maintenance Among English-Speaking Latino Youth: The Role of Individual and Social Characteristics. Social Forces, 84(3), 1417-1433. doi: 10.1353/sof.2006.0057 Migration Information Source - Assimilation Models, Old and New: Explaining a Long-Term Process. (2006, October). The Migration Information Source. Retrieved March 16, 2013, from http://www.migrationinformation.org/Feature/display.cfm?ID=442
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