This publication is supported by funding from the Princeton University Global Health Program and Center for Health and Wellbeing.
The Princeton University Public Health High School Essay contest was conducted in partnership with the Program in Teacher Preparation at Princeton University
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Editor’s Note In a time that has seen unprecedented development in science, technology, and medicine, we are privileged to have the opportunity to share the most compelling innovations and stories from recent years. With every year of publication, the growing volume of literature on global health, research, and policy is truly breathtaking. The equally growing need to sufficiently communicate this information to the Princeton University community and beyond is a pressing goal that Princeton Public Health Review has continuously strived for since 2010. From using UV light to cure diseases to the health disparities experienced by refugees, we hope to bring light to such important topics to catalyze discussion on what we, as a global community, have both miraculously accomplished and continue to work towards. A broadly encompassing theme of our 2019 publication is the idea of consequences. Every action that we do, as individuals or as a society, has consequences. Edward Jenner’s discovery of vaccines has had such positive consequences on mankind that it has entirely changed the way we combat infectious diseases since. In yet other ways, the recently growing neglect of such vaccines has also had consequences, leading to resurgences of diseases thought long gone in the Western hemisphere. Furthermore, while the advancements of CRISPR facilitated new understanding of gene editing and patient therapies, it has also raised ethical questions of unbridled genome engineering as seen with the recent birth of gene-edited twins. With every advancement, therefore, is a set of complex consequences that we as a society must embrace or overcome. By including these stories in our publication, we raise the need to assess the way we understand and anticipate such consequences at the interface of the scientific and the sociopolitical, especially when consequences can instead become ramifications. As part of our dedication to informing the community about key health-related topics, we have continued our 2nd annual high school essay contest in conjunction with Princeton high school and the Program in Teacher Preparation at Princeton University. By offering the unique platform of being featured in our publication, we hope to engage the next generation of students and challenge them to think critically about the health, science, and policy topics that excite them. Finally, we encourage you, the reader, to discover what lies within these pages so that you may not only inform yourself, but also share your knowledge with others to bring about greater social awareness of current public health issues. As we have emphasized in every edition before, participation in discussion is the first step towards large-scale changes in a world filled with emergent challenges and enduring hopes. Joyce Lee & Janie Kim Editors-in-Chief
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TABLE OF CONTENTS
ARTICLES FROM THE WRITERS OF PPHR
Dealing with the first genetically-edited Birth....................................................6 THE RESURGENCE OF MEASLES IN THE U.S.: CAUSES, CONSEQUENCES, AND FUTURE DIRECTIONS....................................................................................................................................................8 HUMAN TRAFFICKING AND HEALTHCARE: USING A PUBLIC HEALTH APPROACH TO COMBAT AND PREVENT HUMAN TRAFFICKING........................................................................10 LIFE EXPECTANCY: DISCREPANCIES, OUTCOMES, AND FUTURE DIRECTIONS................12 THE INJURY YOU CANNOT SEE: THE EFFECTS OF THE REFUGEE CRISIS ON ROHINGYA CHILDREN...............................................................................................................................................14 UV LIGHT: A NEW TOOL FOR DISEASE PREVENTION................................................................16 REVIEW: EFFECT OF CLIMATE CHANGE ON INFECTIOUS DISEASES....................................19 REPORT ON DISPLACED CHILDREN WITH CANCER IN LEBANON.......................................22 HEALTH CARE REFORM: LEARNING FROM OTHER MAJOR SYSTEMS..................................24
HIGH SCHOOL ESSAY CONTEST WINNER
DESTIGMATIZING MENTAL ILLNESS - HELPING THOSE WHO HURT..................................26
STAFF: EDITORS IN-CHIEF: JANIE KIM ‘21 & JOYCE LEE ‘19 TREASURER: ROSHINI BALASUBRAMANIAN ‘22 DESIGN TEAM: MANSI TOTWANI ‘22 & DANIEL SOMWARU ‘22 EDITORS: LILY ZHANG ‘22, DEVORAH SAFFERN ‘20 & APURVA NIDGUNDI ‘21 COVER ART: JAEHEE AHN, UC BERKELEY ‘19
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By Shaffin Siddiqui On November 25 of 2018, Chinese scientist He Jiankui announced one of most seminal and controversial moments in the history of genetics: the birth of the first genetically-edited babies. According to an early report by the MIT Technology Review, the two twins, “Lulu and Nana, came crying into the world as healthy as any other babies.” Their birth, not only a biological landmark, has become the center of tremendous ethical debate. Dr. He’s experimental clinical trial set out to edit the gene CCR5, which codes for the protein that allows HIV to infect human cells. With the objective of
disabling this gene using CRISPR geneediting technology in order to create HIV resistant babies, Dr. He recruited couples with an HIV partner to in vitro fertilize their sperm and eggs. He then genetically altered the resulting embryo, an act that is still illegal in many countries today, and re-implanted the edited embryo into the mother’s womb. Lulu and Nana were the first to be born of in these trials, with a third baby expected to be born this year. Dr. He’s is facing the ire of the scientific community. While he has submitted his research for publication in scientific journals (who have yet to approve of his work), his experiments were clandestinely conducted without the “permission” of
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the global scientific community. Since his announcement, the university where he conducted his work fired him for unethical behavior. On the 28th of November at a gene-editing summit in Hong Kong, Dr. He elaborated on the details of his experiment before numerous geneticists, many of whom reproached Dr. He for his actions. By editing the embryo (a form of germline gene-editing), Dr. He changed the genes in every cell of the resulting fetus. These alterations will be inherited by the children’s progeny, thereby changing the entire human gene pool permanently – an act that many consider to be far too early. Moreover, CRISPR technology may inadvertently cause altering of genes besides the target ones, intensifying the stakes of Dr. He’s experiment and the reputation of genetic editing as a whole even more. The risks involved with such an alteration are far too great and outweigh the benefits for a disease like HIV which can be treated effectively other ways. CRISPR co-inventor Jennifer Doudna reproached Hes, stating “this work reinforces
the urgent need to confine the use of gene editing in human embryos to settings where a clear unmet medical need exists, and where no other medical approach is a viable option, as recommended by the National Academy of Sciences.” As to whether or not Dr. He’s experiments proved successful in modifying the CCR5 and creating HIV resistant individuals, no physical evidence has been produced and may not be for years. Nevertheless, one thing is for certain: Dr. He has pushed the field of genetics into long uncharted territory in which many of the scientific community have been hesitant to wander. Whether those concerns will materialize remains to be seen.
This article and its references can be found on pphr.princeton.edu Graphic art designed by Andrew White 8
THE RESURGENCE OF MEASLES IN THE U.S.: CAUSES, CONSEQUENCES, AND FUTURE DIRECTIONS By Madeleine Winter Within the past decade, there has been a significant resurgence of measles outbreaks in the United States. Between January 1 and March 14 of 2019, the CDC reported 268 individual cases of measles in 15 states. In 2018, the CDC reported a total of 372 cases of measles and in 2014, a record number of 667 cases in 27 states. Measles was declared as eliminated from the United States in 2000, which makes these recent statistics particularly concerning.
ages of 4 and 6.
Infants too young to receive the measles vaccine are particularly vulnerable to measles and its fatal complications, which makes them reliant on herd immunity — when at least 95% of the community receives both doses of the vaccine — to limit the spread of disease. However, herd immunity has been increasingly challenged by unvaccinated communities and vaccine hesitancy. In 2017, only 91.1 percent of children in the United States between the ages of 19 and 35 months received Measles is a highly contagious viral the MMR vaccine, while at least 95% of illness which may cause fever, cough, the community needs to be vaccinated conjunctivitis, an extensive bodily rash, to preserve herd immunity. The concept nasal congestion, but can result in more of herd immunity indicates how vaccine serious complications such as pneumonia, hesitancy and undervaccination poses encephalitis and death. According to the a threat not only to the individual, but CDC, on average 1 or 2 children out of also to the greater community and its 1,000 children with measles die from immunocompromised populations. complications. The measles vaccine, commonly administered as the MMR Vaccine hesitancy and the anti-vaccination vaccine (a combination of vaccines movement poses a global public health for Mumps, Measles and Rubella), is threat. While some of the concerns about 93% effective with only one dose surrounding vaccines arise out of cultural and 97% effective with two doses. It is practices and misunderstanding of science, recommended that individuals receive skepticism of vaccines was heightened these immunizations first between the ages by the British doctor Andrew Wakefield’s of 12 and 15 months and then between the study published in The Lancetin 1998 that 9
claimed there was a correlation between the MMR vaccine and autism. While the study was proven to be highly inaccurate and based on insufficient data and was later redacted by The Lancet, it helped fuel the rise in vaccine hesitancy. The increase in measles outbreaks is also heavily associated with the persistence of unvaccinated communities. According to a 2017 study in JAMA Pediatrics, parents’ decisions to resist vaccination for their children “are often influenced by misinformation, false claims regarding vaccine safety, and a low perceived risk of infectious diseases among other factors.� While many public school systems have instituted certain vaccination requirements for children to attend, exemptions for personal belief and other nonmedical purposes have been increasingly used by parents to circumvent these requirements and enables populations of children to remain unvaccinated. The JAMA Pediatrics study further demonstrated the severe consequences of vaccine hesitancy surrounding the MMR vaccine, as it claimed a 5% decrease in MMR vaccine coverage in the United States would lead to a threefold increase in measles among children between the ages of 2 and 11 each year and would consequently result in $2.1 million dollars in public sector costs. The consequences of under-vaccination were especially evident in a 2017 outbreak of measles among Somali immigrants in Minneapolis, Minnesota. Due to fears that the MMR vaccine caused autism, many Somali parents refused vaccination of their children and between 2004 and 2010, MMR 10
vaccine administration among Somali children dropped from 91% to 54%. This thus contributed to an outbreak of measles in the Minneapolis-St. Paul Metropolitan area, where 64 out of the 79 reported cases of measles were under-vaccinated Somali Americans. Similar to the outbreaks in Somali refugee communities, many of the 17 measles outbreaks documented in the United States in 2018 were linked to Orthodox Jewish communities, where significant amounts of the population are undervaccinated.Foreign travel has particularly facilitated these outbreaks. The outbreaks in the Orthodox Jewish communities were associated with travelers who had contracted measles in Israel and brought it back to the United States. Similarly, the massive measles outbreak at Disneyland in California, which evolved into a 147 case, multi state outbreak, was most likely initiated by an infected individual from overseas who visited the amusement park and subsequently exposed hundreds of other customers. The rise in measles outbreaks and the continuation of vaccine refusal and hesitancy among some sectors of the populations constitutes a major public health threat. Extensive educational reform, vaccination programs and engagement of policy makers are necessary to combat anti-vaccination sentiments, preserve herd immunity and ultimately, protect public health nationwide. This article and its references can be found on pphr. princeton.edu
HUMAN TRAFFICKING AND HEALTHCARE: USING A PUBLIC HEALTH APPROACH TO COMBAT AND PREVENT HUMAN TRAFFICKING By Nathnael Mengistie
human trafficking and passed additional laws, such as the Abolish Human Trafficking Act, which increases the prosecution of According to the International Labor Organization, human trafficking is the act traffickers. Although these efforts are certainly commendable, American law of controlling or exploiting a person for sex, labor, or other services through fraud, regarding human trafficking still focuses force, or coercion. This grave human rights on prosecution and fails to recognize the violation affected an estimated 20.9 million importance of a victim-centered approach or more individuals worldwide in 2016. In to end this heinous crime. In fact, the recent years, however, numerous countries, Bureau of Justice Statistics stated that there was a 41% increase in the number of including the United States, have passed different laws to combat this issue. In fact, prosecutions for human trafficking offenses from 2011 to 2015, which illustrates the on January 9th 2019, President Donald Trump signed into law the reauthorization government’s focus on the criminal justice aspect of human trafficking. Although it is of the Trafficking Victims Protection Act (TVPA), a law that aims to prevent human important to prosecute traffickers, members of the anti-trafficking movement should trafficking, protect victims, and punish also focus on identifying human trafficking offenders not only in the US, but also victims and providing long term support abroad. This legislation was first passed to human trafficking survivors. One of the in 2000 and has since been expanded reasons why this is not the case is because it and reauthorized numerous times. This is challenging to identify trafficking victims landmark anti-trafficking law formed the Office to Monitor and Combat Trafficking due to the obscure nature of the crime. Nevertheless, framing human trafficking in Persons, which publishes a yearly as a public health issue and increasing the Trafficking in Persons Report (TIP), and it also established the T-visa, which allows involvement of healthcare professionals trafficking victims who came from outside will not only allow us to identify trafficking victims and empower survivors, but the US to become permanent residents. also help us address the socio-economic Furthermore, the current administration determinants that facilitate human has also authorized $430 million to fight
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trafficking by working with policy makers, clinical professionals, law enforcement, and educators because human trafficking is a multifaceted problem. By using a public health approach to combat human trafficking and collaborating with different professionals, we are increasing our scope and our reach because public health is concerned with the well-being of entire populations and not just specific individuals. According to a 2014 study doneby the Beazley Institute for Health Law and Policy, nearly 90% of trafficking survivors come in contact with a healthcare professional at some point during their time of being trafficked. When trafficking victims, who are in the process of being trafficked, go to a hospital or a clinic to seek medical care, they are more willing to share their problems and concerns because they are facing a medical crisis, in comparison to when spoken to outside of a medical context. Numerous studieshave proven that trafficking victims are less likely to give personal information to authority figures such as police officers or lawyers, but they will talk to clinicians and other medical professionals because they know that they will not get medical help if they stay silent. Thus, healthcare providers have a unique opportunity to provide a space of trust and safety, but they must be trained to respond quickly should they encounter a situation they believe may be related to human trafficking. Unfortunately, only a few states like Massachusetts, New Jersey, and Michigan have adopted mandatory education programs on trafficking for health care 12
providers. New Jersey’s Human Trafficking Prevention, Protection, and Treatment Act,which requires the Health Department to “develop, approve, and provide for a onetime training course on the handling and response procedures of suspected human trafficking activities for employees of every licensed health care facility,” is serving as a baseline model for other state legislatures. This approach has been quite successful because incidents of human trafficking have been steadily decreasing in New Jersey. Healthcare professionals not only play an important role as first responders, but they are also crucial in the longterm rehabilitation process of trafficking survivors. The physical and psychological health consequences of human trafficking are severe, which is why trafficking survivors may need counseling and therapy until they fully recover. Furthermore, a public health approach to human trafficking will effectively engage trafficking survivors to eradicate the socio-economic causes and consequences of human trafficking, which is vital to the development of a more sustainable solution to human trafficking. For instance, LGBT youth are far more likely to be victims of human trafficking because they are disproportionately runaway or homeless. A public health approach will try to reduce the risk of homelessness of LGBT youth by engaging policy makers, social workers, educators, and most importantly, trafficking survivors. It is important to note that survivors play a key role in this process because they understand the different dimensions of human trafficking and can give advice on what steps to take to improve the current situation. This article and its references can be found on pphr. princeton.edu. Image edit by Andrew White
LIFE EXPECTANCY: DISCREPANCIES, OUTCOMES, AND FUTURE DIRECTIONS By Ava Torjani A recent study demonstrated a significant improvement in life expectancy among the least-expected countries, including Niger, Nicaragua, Ethiopia, Gambia, Nepal, and Peru. These are low-income countries with relatively low access to and quality of healthcare. On the other hand, people in several high-income countries, including parts of the US, Greenland, and Russia are not living as long as expected. This article will explore the data presented by several studies, as well as the proposed reasons behind their findings. Life expectancy refers to the average number of years that an individual is expected to live at a particular age if the same mortality conditions persisted throughout the rest of his or her life. The most prevalent predictors of higher life expectancy include greater wealth, fewer number of children, and a higher level of education. Overall, life expectancy has improved across the world, increasing from 65.3 years in 1990 to 71.5 years in 2013. Additionally, life expectancy at birth for females and males has increased by 6.6 and 5.8 years, respectively. These improvements are primarily due to more effective and accessible treatments against cancers and cardiovascular diseases in high-income countries, which extend life expectancy at age 65 and older, and against rotavirusbased diarrhea, neonatal disorders, and lower respiratory infections in low-income
countries, which increases life expectancy at birth. Despite these improvements, life expectancy is generally shorter in lowincome than high-income countries due to discrepancies in resources, income, and access to healthcare. BBC’s illustration of population pyramids organized by a country’s socioeconomic status. The left pyramid describes low-income countries wherein birth and mortality rates are high. The right pyramid describes high-income countries where birth and mortality rates are low. Interestingly, the greatest improvement in life expectancy was seen among developing countries to an unprecedented extent. For example, Niger and Nicaragua demonstrated an outstanding 7.8-year increase in lifespan. Christopher Murray, a health economist at University of Washington, suggests that this may be thanks to greater access to healthcare in rural and remote areas, more comprehensive child care, and effective treatments against HIV and AIDS. However, further research on public policies and healthcare practice needs to be conducted to establish concrete reasons for this improvement in life expectancy. Not only will this provide insight into effective measures to prevent greater death tolls, but it could also serve as a model for health improvement among other low- and middle-income countries who currently 13 struggle to establish effective healthcare strategies.
On the other hand, high-income countries, in life expectancy at birth in low-income including Greenland and Russia, and countries. American states such as Mississippi have shown a far less promising increase in For example, in high-income countries, life expectancy. In fact, America saw its understanding the effects of stress and other LIFE EXPECTANCY: DISfirst decline in life expectancy since 1993, socioeconomic factors on physical and CREPANCIES, OUTCOMES, dropping from 78.9 years in 2014, AND to 78.8 psychological health will prove critical to FUTURE DIRECTIONS in 2015, and only slightly increasing to 79 developing interventions to prevent their years in 2017 for both sexes combined. deleterious impacts. On the other hand, in Two health economists at Princeton, Anne low-income countries, many people still Case and Angus Deaton, believed that this die from treatable diseases such as diarrhea was a result of diseases of despair, which and respiratory infections. Hence, greater encompasses suicide, drug overdose, and research and support should be offered addiction, as well as an increase incidences to catalyze the process of discovering, of obesity and diabetes—issues that are providing, and improving the efficacy ‘affordable’ to those living in high-income and effectiveness of treatments for these countries. diseases. Taking into account all these matters, it is evident that although we have Additionally, the lack of substantial increase succeeded in improving the average lifespan for life expectancy may be due to economic of an individual, there is still a long way to inequality, insufficient attention to issues go. in early stages of child development, and a discrepancies in healthcare access and quality. Alternatively, the increased life expectancy over the decades may have induced the cumulative effect of diseases that burden the aging population, including Alzheimer’s disease which saw an increase from 25.4 to 29.4 deaths per 100,000 people. Nevertheless, these issues highlight the need to develop accessible and effective care for diseases beyond physiological pathology, as well as to adjust research focus to accommodate the aging population. Overall, these studies demonstrate an optimistic outlook on life expectancy worldwide thanks to advances in medical research, public health policy, and healthcare. However, it is important to consider ways to improve life expectancy at 65 years in high-income countries, and life expectancy at birth in low-income countries. Therefore, it is beneficial to address factors that contribute to noninfectious causes of death within highincome countries, while concurrently examining reasons behind discrepancies 14
BBC’s illustration of population pyramids organized by a country’s socioeconomic status. The left pyramid describes low-income countries wherein birth and mortality rates are high. The right pyramid describes high-income countries where birth and mortality rates are low.
This article and its references can be found on pphr. princeton.edu
Report on Research on Displaced Children With Cancer In Lebanon By Andrew Wu One of the greatest current humanitarian catastrophes is the worsening refugee crisis caused by the conflict in Syria, which has many unfortunate implications in public health, especially pediatric care. According to the United Nations High Commissioner for Refugees (UNHCR), there are around 554,288 displaced Syrians under the age of 18 in Lebanon (this is an underestimate due to a halt on refugee registration). Assuming the annual incidence of pediatric cancer is 17 in 100,000 children; there are 90 new cases each year. Lebanon, which borders Syria on the north and the east, is bearing some of the burdens of an increasing population of displaced peoples. All Lebanese citizens have some form of healthcare coverage, with almost two-thirds of its citizens relying on a national healthcare plan. However, these government plans do not offer optimal treatments to conditions that may require long-term care, such as cancer. Thus, an influx of displaced refugees can further exacerbate the country’s public health system. Besides the limited aid from various nongovernmental organizations, displaced patients with pediatric cancer lack sufficient finances for treatment and can expect little support from the government or other third-party entities. A research article published by Saab et al. explores these issues, analyzing the mounting challenge of untreated pediatric cancer and possible solutions.
In order to study the scope of the problem, the researchers collected a variety of data on patients enrolled in programs offered by the Children’s Cancer Institute (CCI) at the American University of Beirut Medical Center. Areas of interest included demographics, clinical information, treatments provided, initial responses, and outcomes (i.e. remission). Enrolled patients were entitled to functionpreserving procedures (e.g. limb-salvage surgeries), radiation therapy, and medical examinations. Researchers also analyzed data regarding the types of treatment provided, with their respective costs, and the number of patients referred or declined to make future projections about budget allocation. The data-crunching yielded the following statistics. From 2011 to 2017, 311 nonLebanese patients received partial to full treatments with 264 patients only receiving consultations due to a lack of eligibility and sufficient funds. One important trend is that the percentage of non-Lebanese patients accepted for treatments increased from 18% to 55-60% in the span of the aforementioned 6 years, which corroborates the UNHCR’s report on the escalation of incoming refugees. A majority of those patients (86%) were treated within the last four years. There is, however, some discrepancy between the acceptance rates of the CCI based on country of origin. For example, a little more than half of the presenting non-Lebanese patients were given treatment overall, while almost three quarters of native citizens were accepted. Furthermore, 56% of Syrian patients and 15
against this problem, stating that current American practices waste a similar amount of money covering the uninsured. Another practical concern is the government response to crisis. In the case of a precarious national emergency, such as war or a health crisis, funding for health services may decline as public revenue decreases, exacerbating the financial burden inherent in a large influx of patients. Such a situation would require careful allocation of emergency funding before the crisis. The Bismarck insurance model
Model:
social
health
Examples: Germany, Belgium, Japan, Switzerland Relevance to the US: similar to employerbased health care plans and some aspects of Medicaid A more decentralized form of healthcare, the Bismarck model was created near the end of the 19th century by Otto von Bismarck. Employers and employees fund health insurance in this model – those who are employed have access to “sickness funds� created by compulsory payroll dedications. In addition, private insurance plans cover every employed person, regardless of preexisting conditions. Health providers are generally private institutions, though the Social Health Insurance funds are considered public. In some countries, there is a single insurer (France, Korea); other countries may have multiple, competing insurers (Germany, Czech Republic) or multiple, noncompeting insurers (Japan). Regardless of the number of insurers, the government tightly controls prices while insurers do not make a profit. These measures allow for the government to exercise a similar amount of control over prices for health services seen in the Beveridge model. 16
The requirement of employment for health insurance provides benefits and causes problems. These measures ensure that employed people will have the healthcare needed to continue working and ensure a productive workforce. Because it was not initially established to provide universal health coverage, the Bismarck model focuses resources on those who can contribute financially. With a shift in mindset from health as a privilege for employed citizens to a right for all citizens, the model faces a number of concerns, such as how to care for those unable to work or those who may not be able to afford contributions. More immediate practical concerns include how to contend with aging populations, with an uneven number of retired citizens compared to employed citizens, and how to stay competitive in attracting international companies that may prefer locations without these required payroll dedications. The National Health Insurance Model: single-payer national health insurance Examples: Canada, Taiwan, South Korea Relevance to the US: similar to Medicare The National Health Insurance model incorporates aspects of both the Bismarck and Beveridge models. Like the Beveridge model, the government acts as the single payer for medical procedures, and like the Bismarck model, providers are private. The universal insurance does not make a profit or deny claims. There has been a tendency in recent years for countries with Beveridge-type health care systems to incorporate Bismarck characteristics or vice versa, leading to the health care policies in a number of countries like Hungary and Germany to trend towards the mixed model. In some countries like Canada, private insurance contracting is permitted for those who would prefer them. The balance between public insurance and private practice allows hospitals to maintain
52% of Palestinian patients were accepted, as opposed to the 62% of Iraqi patients who only received a consultation. Patients that were not accepted for treatment could still be enrolled in disease-specific programs, which were an offshoot of the CCI and were additionally funded by St. Jude Children’s Research Hospital and the American Lebanese Syrian Associated Charities (ALSAC). Thus, those programs covered similar treatments as the CCI (e.g. diagnosis, local control surgery, and radiation therapy). On the other hand, chemotherapy was administered elsewhere at other Lebanon hospitals. Syrian and Palestinian patients requiring chemotherapy were supported by smaller NGOs besides CCI, but there were virtually no auxiliary funds available to Iraqi patients. While some of the costs were covered by the CCI, those families needed to pay out of pocket at the other hospitals. Nevertheless, patient nationality did not affect treatment planning or consultations. Overall, approximately half of the patients admitted had intermediate-risk diseases, with the remaining percentage split between 29% developing high-risk disease and 22% having low-risk disease. In a follow-up report, a majority of the patients were in remission (58%), 20% were continuing treatment, 13% were in relapse, 8% left before finishing treatment (most of these cases were patients relocating to continue treatment in another country), and 1% died of toxicity.
Such statistics demonstrate that the ongoing conflict in the Middle East will continue to exacerbate public health burdens. The UNHCR is currently unable to cover chronic conditions due to insufficient foreign aid. While the CCI does vital work, it is only able to treat 30% of new pediatric cancer cases in the country due to financial restraints. In addition, displaced families often live in communities without oncology specialists, and so patients end up concentrated in CCI under the care of already overburdened medical staff. Already a quarter of the population in Lebanon were refugees by the middle of 2014, and the fact that more than 2000 Syrian children are born annually will only put more pressure on the country’s resources. Partnerships between different charities such as St. Jude, the Children’s Cancer Center of Lebanon, and the ALSAC, have demonstrated the importance of an organized and committed approach from both public and private sectors to addressing this issue. There is no doubt that the United Nations has the moral responsibility of continuing to resolve the crisis. Hopefully, the CCI can raise ample funding in order to expand its outreach. Considering the power of modern medicine and the treatability of pediatric cancers, we ought to provide the best care for these children and build them a better future.
This article and its references can be found on pphr. princeton.edu
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Health Care Reform: Learning from Other Major Systems By Mimi Chung With the United States Senate recently dismissing modified plans for health care in the US, different health care systems in other countries have gained considerable public interest. Health care in the United States can vary dramatically depending on an individual’s personal circumstances. Factors like employment, military service, and age can change what kind of insurance – if any – someone is able to obtain. Exploring the strengths and weakness of each may illuminate different options for modifying US healthcare policy. There are four major models for health care systems: the Beveridge Model, the Bismarck model, the National Health Insurance model, and the out-of-pocket model. While in theory these categories have distinct policy separations, in reality most countries have a blend of these approaches, though they generally have a single health care system that is uniform for most citizens. These distinctions are effective at differentiating schools of thought on health care policy, but the policies of each country should be analyzed when determining potential improvements.
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Relevance to the US: similar to the Veterans Health Administration The Beveridge Model was first developed by Sir William Beveridge in 1948. Established in the United Kingdom and spreading throughout many areas of Northern Europe and the world, this system is often centralized through the establishment of a national health service. The government acts as the singlepayer, eliminating competition in the market and generally keeping prices low. Funding health care through income taxes allows for health care to be free at the point of service – after an appointment or operation, the patient does not have to pay any out-of-pocket fees because of their contribution through taxes. Under this system, a large majority of health staff is composed of government employees. A central tenant of this model is health as a human right. Thus, universal coverage is guaranteed by the government and anyone who is a citizen has the same access to care.
With the government as the sole payer in this healthcare system, costs can be kept low and benefits are standardized across the country. However, a common criticism of this system is the tendency toward long waiting lists. Because everyone is guaranteed access to health services, over-utilization of the system may lead to increasing costs. The Beveridge Model: single-payer national There are fears that adoption of a single-payer health service national health service in the US would lead to an increase in demand for all procedures, Examples: the United Kingdom, Spain, New even medically unnecessary ones because Zealand, Cuba citizens would not pay upfront costs for these services. However, other analysts argue
independence while also reducing internal complications with insurance policies. Financial barriers to treatment are generally low, and patients usually are able to choose their healthcare providers. Like the Beveridge model, this system covers most procedures regardless of income level. The model also may reduce the costs involved with administration of health insurance, as the government processes all claims and reduces the amount of duplication of services. Perhaps the largest complaint is that these systems can suffer from long waiting lists for treatment. Waitlists are not limited to elective surgeries or other nonemergency procedures, as patients waiting to be seen in some fields like neurosurgery often may face long delays until they can see a physician. In a study by Viberg et al. from 2013, a majority of countries, including Australia, Canada, and Italy, consider waiting times a serious health policy issue. Waiting times in Canada for hip replacements can be from 42 to 178 days, depending on the province. Aging population demographics and overutilization of health resources in non-urgent situation are also problems for the long-term stability of this model. The Out-of-Pocket Model: market-driven health care Examples: rural areas in India, China, Africa, South America Relevance to the US: similar to treatment for uninsured or underinsured In less developed areas with too few resources to create mass medical care, patients must pay for their procedures outof-pocket. Without enough money, the poor are unable to afford appropriate health care. Unfortunately, this situation is common in most countries since only the wealthiest countries have robust health care systems. Disparities in wealth lead to disparities in health outcomes in these areas.
In the United States, many aspects of health care are driven by income-level. Adults in the US are less likely to see a regular physician and are more likely to have untreated conditions than adults in Canada, while at the same time rating their care as either extremely high or low in quality more often than Canadians, who are more moderate in their responses. Disparities in care due to socioeconomic status and ethnicity are found in all countries, but tend to be more pronounced in the United States than in areas like Canada. The percent uninsured ranges for different states, from as low as 3.6% in Massachusetts to as high as 20.6% in Texas. As of 2015, the percent of uninsured persons is 13.0% in the United States. The debate over increasing coverage and minimizing costs still rages in Congress – any developments may drastically change these numbers. Each country faces different concerns when attempting to construct a system for health care delivery. No health care system is completely alike, and none are completely free of problems; a method that works for one country is not likely to be completely transferrable to another due to different health concerns, priorities, and mindsets. Though complicated, considering the implications of various models is essential to implementing an American health care system that is fair and just to all citizens, not just the wealthiest. Its construction should emerge from the collaboration between policy experts, health providers, politicians, and other stakeholders to attempt to address the many complicated aspects of the health insurance market.
This article and its references can be found on pphr. princeton.edu 19
The Injury You Ca Effects of the Refug Rohingya C By MaryAnn Placheril
continue to compound on the violence they’ve already experienced. This crisis, stemmed from hatred and violence, led to a Bordering India and China, Myanmar is health crisis, particularly for children. The a mainly Buddhist country with a sizable Muslim minority, the Rohingya. However, U.N. estimates that 60 percent of the refugees are children, and over a thousand of those the government of Myanmar does not recognize the Rohingya as citizens, leaving children are not travelling with their parents. them stateless. For decades, Buddhists have These kids, and all refugees, are subject to many health risks. They endure physical systematically oppressed the Rohingya, violence, lack of safe food and water, and but this oppression has recently been especially lack of shelter. Recent floods in taken to the extreme. The Rohingya are Bangladesh have only exacerbated this issue. now being forcibly removed from the country and killed, while their property is But perhaps more crippling is the mental seized and villages burned. The UN High Commissioner for Human Rights has even and emotional trauma they endure. Young called the situation a “textbook example of children are witnessing terrible acts of violence, watching their homes be destroyed, ethnic cleansing.� and facing an ever-changing environment. There is no stability in their lives. Moreover, many of these children have experienced The Rohingya who escape prosecution the trauma of being separated from their are fleeing to neighboring countries like families, or watching family members Bangladesh. But the refugees face many be hurt. UNICEF is trying to provide troubles during their journey, which 20
annot See: The gee Crisis on the Children psychological therapy for these children, but it may not be enough. At these refugee sites, organizations will focus on treating the physical health of a patient first and many times their mental health will not receive the attention it needs, if it even receives any. Ultimately, although there will more resources for these children than there would have been in the past, this issue is not receiving enough attention, and not enough of these children will receive sufficient medical care. Many of these children will not receive treatment for their mental health. There will be instead an emphasis on treating physical health because it is tangible and Photo by Tommy Trenchard / Carnitas can be cured, while mental health may take https://www.npr.org/sections/goatsandsoda/2017/09/15/551217209/photos-childrenmany resources and a prolonged treatment caught-in-the-crossfire-of-rohingya-crisis to improve. The lasting impact of this crisis will, thus, be a generation of Rohingya people dealing with the aftereffects for the This article and its references can be found on pphr. rest of their lives. They will be the invisibly princeton.edu wounded. 21
W E N A E S : A T E H S G I I D L R V O U F N L O O I O T T N E V E PR
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UV Light: A New Tool for Disease Prevention By Devorah Saffern Ultraviolet (UV) light kills cells by causing thymine bases in the cell’s DNA to interact and form dimers, which are then removed by the DNA’s own correction mechanisms. Increased exposure to UV light increases the chances of these mechanisms incorrectly replacing the dimer or not replacing it at all, which changes the way the entire DNA sequence is read by its polymerase. This impairs the DNA and therefore the cellular functions, which can result in cell death or cause the cell to become carcinogenic (develop into a cancerous cell). Increased exposure to UV light, therefore, can cause cancer, most commonly skin cancers due to direct exposure from UV rays in the sun. Ultraviolet germicidal irradiation (UVGI) utilizes these destructive properties of UV light to target pathogens. It uses short range UVC light via air or water to kill bacteria and viruses through the DNA interfering cell death mechanism. UVGI is frequently used for air and food purification, and has been used for water treatment since 1955. In 1903 Niels Finsen won the Nobel Prize for Medicine for using UVGI to target tuberculosis of the skin called lupus vulgaris. Since then, researchers have explored the use of UV light in treating disease. In a study published in June 2016 by Buonanno, M., et al., researchers performed the first in vivo test on mammalian skin using UV light to kill virus and bacterial cells at surgical infection sites, which was not
harmful to regular skin cells. The researchers tested UVC/UVGI of 207-nm wavelength on hairless mice skin emitted by an excimer laser, a type of UV laser commonly used for eye laser surgery and in microelectronic devices. 254-nm UVG was used as a control, as well as a negative control of “sham” UV radiation. The 254-nm radiation had premutagenic DNA lesions of the skin, skin inflammation, and epidermal hyperplasia, which is an increase in organic tissue due to cell proliferation, while the 207-nm and sham UV radiated cells showed no significant changes. Cross-sectional images of the cells showed the presence of two types of dimer DNA mutations found only in the 254-nm UV samples. Premutagenic skin lesions of CPD (cyclobutane pyrimidine dimers, which is typical DNA damage due to UV light) demonstrated that the 254-nm longer wavelength UV exposed was cytotoxic while 207-nm was not. In addition, other images showed keratinocyte cells (skin cells producing keratin, found in the most outer layer of the skin) containing another type of dimer called 6-4PP dimers, found in significant amounts only in the 254nm UV exposed cells. The results essentially showed that excimer-emitted far-UVC could potentially be used as an antimicrobial agent without posing a threat to the skin’s healthy cells. Future research could perhaps include testing the effects of the radiation beyond the surface of the skin to ensure there are no unknown other potential hazards. Another Buonanno, M., et al. study, that was published in February 2017, extended 23 their previous experiment by testing 222-nm
light in addition to the 207-nm in killing methicillin-resistant Staphylococcus aureus (MRSA) in vitro. The same CPD and 6-4PP dimers were found as before but this time the experiment was done on a 3D human skin tissue model instead of mice skin, a more insightful test. The 222-nm UV light effectively destroys the MRSA and as opposed to the 254-nm UV light, produces hardly any pre-mutagenic DNA lesions, due to its lower wavelength. This inspired more recent work in the area. A research article by Welch, et al., that was preprinted last December, involved a team at Columbia University Medical Center who looked into the potentials of UV light in preventing microbial diseases. The study used far-UVC light of 222-nm to effectively kill an airborne H1N1 influenza virus in an aerosol UV irradiation chamber, which emitted droplets in the air similar to those produced by humans from coughing and breathing. The study cited the June 2016 article by Buonanno, M., et al. to prove that the light is non-cytotoxic, as well as the Buonanno, M., et al. February 2017 study. The article, which is pending review, concluded that using small quantities of farUVC light in indoor public spaces would be a safe and economical tool to target airborne microbial viruses. Infectious diseases can have harmful effects on large portions of the population and some forms, including lower respiratory infections, are even a leading cause of death. Viral and bacterial infections are often contracted from the air – they travel from an ill person through a cough or a 24
sneeze to a healthy individual and enter the person’s mouth or nose. Public spaces such as transit systems and stores are common places where disease can easily spread to many people. Prevention of the spread of viral and bacterial cells in public spaces could therefore significantly reduce the number of illnesses due to infectious diseases among the population. UV lights that target these pathogens are economical, easily implementable, and could be highly impactful in reducing the spread of disease.
Fig 4. from (Buonanno et al., 2016)
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Review: Effect of Climate Change on Infectious Diseases
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Review: Effect of Climate Change on Infectious Diseases By Andrew Wu Climate change has many implications for public health, particularly on the transmission of infectious diseases. Changes in humidity can lead to an increased risk of illnesses that spread through bodily fluids. Vectors such as mosquitoes can become more abundant and affect larger regions. Natural disasters can destroy healthcare infrastructure, alter the immunity of a population, and increase exposure to water-borne diseases. Although there are many factors that modulate infectious disease dynamics, it is crucial that researchers pinpoint associations between the spread of maladies and environmental changes, as they become more drastic and prominent in our lifetimes. A better understanding can lead to more precise models, which can enhance the accuracy of predictions and lead to more effective healthcare. Recently, Professor Metcalf of the Ecology and Evolutionary Biology and Public Affairs departments published a review paper that thoroughly analyzes techniques that investigate the links between climate change and infectious diseases. There is a multitude of challenges in identifying associations between climate factors and infectious disease dynamics. One of the main issues is the lack of useful data. For example, the information for many pathogens focuses on the incidence of human cases instead of the prevalence of infected vectors and hosts 26
with mild to no symptoms. While both types of data are equally important, more information is needed from the latter for the bigger picture. The latter also requires biological knowledge, which may only be obtained through experimentation. This presents another challenge, since there are few diseases with effective animal models or vectors that can be easily studied. Data is also rarely collected over a sufficiently long timespan in order to reflect shifts in climate, and sometimes the information gathered is only available over a large time interval (e.g. monthly, annual), which will not account for details such as a spike in transmission caused by one day of strong rainfall or a natural disaster. In general, it is important to identify the short-term effects of seasonal events and the long-term effects of climate change. Other factors must be considered as well, including drug resistance and human behavior (e.g. population growth, mobility, public health efforts), which can obscure climate influences on disease transmission. Ultimately, researchers must distinguish between coinciding and corresponding phenomena in order to establish a clear association between climate change and infectious disease dynamics. Researchers have used techniques in order to build better predictive models for the transmission of various diseases and have a more thorough understanding of the foundational mechanisms. There are two main types of models: time series methods and spatial methods. The former involves two approaches. On
one hand, there are traditional methods that utilize statistics more heavily (e.g. generalized linear models, autoregressive integrated moving average (ARIMA) models). Essentially, ARIMA models use the weighted sum of past values in order to estimate future values. They offer more reliable forecasts for shorter time intervals and have been used to predict areas of high risk to dengue due to climate characteristics in Sri Lanka. In addition, statistical approaches were used to observe seasonal variability and Streptococcus pyogenes infections in Iceland from 1975 to 2010. On the other hand, dynamic models focus more on mechanisms and offer more flexibility to account for the long-term changes and variables in climate. They are used to examine various diseases, including the relationship between the onset of influenza and humidity in the United States; the association between rainfall and cholera in Haiti; and the connection between temperature, mosquito population, and dengue in Madeira, Portugal. Spatial methods involve static versus dynamic risk maps, which depict the risk of infection on a regional, national, or global scale by generating a map based on data points from specific locations. Global risk maps were used to pinpoint the role of the 2015 El NiĂąo climate phenomenon with the spread of Zika virus in South America. Previous models have been successful in predicting the spread of certain illnesses, but there is much work to be done moving forward. As mentioned above, different types of models have their own shortcomings. Statistical do not offer the same long-term reliability of dynamic, mechanistic models. However, the latter does not always provide the short-term accuracy of traditional methods. In addition, dynamic models need to be integrated with disease incidence data, so that they can be honed in order to reflect the observed reality. There continue to be gaps in the information available, which
can be remedied using experimental studies. Furthermore, climate and disease models must be combined in order to verify that they hold true. Regardless, it is without a doubt that researchers will have to continue to adjust their models. Despite the challenges that lay ahead, this effort has already had many successes. Models have been used to observe that warmer locations are spreading dengue in Southeast Asia, give accurate real-time predictions for influenza in US cities, and suggest possible malaria spread in the future under climate change. These examples show that better models can provide governments and public health institutions with more precise warnings in order to bolster preparation, which will lead to a healthier society in an everchanging climate.
This article and its references can be found on pphr. princeton.edu
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Destigmatizing Mental Illness By Samantha Staub Criminality is not always driven by a criminal mind. Rather, it is often a symptom of the larger, often hidden societal problem of mental illness. Mental illness bears a greater prevalence than many people might realize. Approximately 20% of adults and 13% of children in the U.S. experiences mental illness in a given year. Unfortunately, not everyone sees mental illness as a true illness. In 1961, psychiatrist Dr. Thomas Szasz published “The Myth of Mental Illness” in which he criticized the idea that mental illnesses are similar to physical illnesses. Szasz claimed that “diseases are malfunctions of the human body, of the heart, the liver, the kidney, the brain” and “no behavior or misbehavior is a disease or can be a disease. That’s not what diseases are.”. Unfortunately, there are many who, almost 60 years later, still subscribe to this idea. Contrary to Szasz’s belief, mental illnesses are not solely behavioral or psychological. 28
Helping Those Who Hurt Mental illnesses can be caused by a biological reaction to environmental stresses, genetic factors, biochemical imbalances, or a combination of these factors. Although there is a spectrum of “normality” and it is sometimes hard to make a distinction between abnormal and normal behavior, there are many who suffer needlessly from true mental illness and need pharmaceutical and psychological help. We need to help remove stigma and start talking openly and honestly about mental illness. By doing that, more people will get the help they need and society will be better off. Those suffering from mental illnesses face discrimination every day, whether it be through interactions within their communities or stereotyping and negative representations of mental illness in the media. It seems individuals with mental illnesses are looked down upon or seen as weak. Afterall, doesn’t everyone get sad and doesn’t everyone get anxious? What people sometimes fail to realize is that
sadness is not the same as clinical depression and general anxiousness is not the same as dealing with an anxiety disorder. Providing education and raising awareness of mental health issues will help lessen the stigma surrounding these illnesses and allow more people to seek help. The suffering of the mentally ill can often be ameliorated though psychiatric and psychosocial treatments. However, many people who could benefit from treatment either never start or fail to fully adhere to prescribed interventions. On average, almost half of people on antipsychotic medication fail to fully comply with treatment. Why does this happen? This is a complex question with no simple answer. One of the numerous mental illnesses often left untreated is Antisocial Personality Disorder (ASPD). Untreated, ASPD can lead to avoidable tragedies, affecting both the individuals with the disorder and their communities. Antisocial Personality Disorder is a condition in which a person pathologically disregards conventional morality. People with ASPD tend to manipulate or treat others harshly and show no remorse. They may lie, behave violently or impulsively, and have problems with drugs and alcohol. People with ASPD are disproportionately represented in prison populations. Although ASPD affects about 3% of men and 1% of women, some studies have shown that nearly 50% of incarcerated men and 20% of incarcerated women showed symptoms of ASPD. People with this disorder typically cannot fulfill family, school, and work obligations and often find themselves in poor or abusive relationships.
This can often lead to or be intertwined with low economic status, financial difficulties, homelessness, gang participation, or premature death, usually resulting from violence, risky behaviors, or suicide. About 25% also suffer from clinical depression. The exact cause of ASPD is unknown, but scientists believe that it is a combination of genetic predisposition and environmental triggers. There are an increasing number of effective pharmaceutical and cognitive behavioral therapies that can stabilize mood, lesson depressive symptoms, and help with the irrational irritability, aggression, and impulsiveness often found in ASPD. Unfortunately, even with advances in treatment, ASPD remains difficult to treat. This may discourage friends from intervening and sufferers from seeking or continuing treatment. One promising area of research shows that Identifying and treating children with ASPD as early as possible might help lessen the social problems it causes. The onset of ASPD typically occurs before the age of 15, with most sufferers demonstrating deviant behavior by the age of 5. Our schools are becoming increasingly adept at identifying physical illnesses. It is time to remove the stigma surrounding mental illness. Educating those who interact with children on how to identify and refer at risk students could save countless lives. Early training in behavior modification and social and problem-solving skills, as well as parent training, family therapy, and psychotherapy may help reduce the chance that at-risk children go on to become adults with ASPD. The stigma surrounding mental
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illnesses minimizes early interventions and Works Cited discourages the mentally ill from seeking help or finding relief themselves. Ultimately, American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: the lack of intervention results in preventable DSM-5. Arlington, VA: American Psychiatric Association, 2013. “Antisocial Personality Disorder (ASPD) - Mental Health Disorders.” tragedies. Education and open discussions Merck Manuals on mental illness can spark real change as Professional Edition, www.merckmanuals.com/home/mental-health-disorders/personalipeople begin to see mental illnesses as true ty-disorders/antisocial-p illnesses and sufferers as people in need of ersonality-disorder-aspd. “Antisocial Personality Disorder.” Mayo Clinic, Mayo Foundation for help. Medical Education and It is difficult to determine the precise financial cost of ASPD to society, but experts agree it is significant. The prevalence of ASPD leads to a financial burden on law enforcement, security, and prisons. In addition to healthcare costs associated with the individuals with ASPD, there is the cost of treating the mental and physical health of the victims of their crimes. We need to raise awareness of mental illnesses and do what we can to remove the stigma. Only by doing this can we give people the tools needed to help friends and family feel comfortable in seeking the help they need. When mentally ill individuals gain access to psychiatric treatment and have the support necessary to remain compliant with treatment, they are better able to be a contributing member of their community. This will reduce suffering and, by extension, improve the quality of life for all.
Research, 4 Aug. 2017, www.mayoclinic.org/diseases-conditions/antisocial-personality-disorder/symptoms-causes /syc-20353928. Black, Donald W., and Nancy C. Andreasen. Introductory Textbook of Psychiatry. American Psychiatric Publ., 2014. “Figure 2f from: Irimia R, Gottschling M (2016) Taxonomic Revision of Rochefortia Sw. (Ehretiaceae, Boraginales). Biodiversity Data Journal 4: e7720. Https://Doi.org/10.3897/BDJ.4.e7720.” doi:10.3897/bdj.4.e7720. figure2f. “Life Consequences of Antisocial Personality Disorder | Everyday Health.” Stroke Center EverydayHealth.com, Ziff Davis, LLC, 18 July 2018, www.everydayhealth.com/antisocial-personality-disorder/life-consequences/. “Life Consequences of Antisocial Personality Disorder | Everyday Health.” Stroke Center EverydayHealth.com, Ziff Davis, LLC, 18 July 2018, www.everydayhealth.com/antisocial-personality-disorder/life-consequences/. “NAMI.” NAMI: National Alliance on Mental Illness, www.nami.org/learn-more/mental-health-by-the-numbers. National Collaborating Centre for Mental Health (UK). “ANTISOCIAL PERSONALITY DISORDER.” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, 1 Jan. 1970, www.ncbi.nlm.nih.gov/books/NBK55333/. Szasz, Thomas, 1920-2012. The Myth of Mental Illness : Foundations of a Theory of Personal Conduct. New York :Harper & Row, 1974. Print.
Image found on https://newroadstreatment.org/treat-your-mentalillness/
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