Vol. 15, Issue 1 by Frontiers: Washington University Review of Health

FRONTIERS • TABLE OF CONTENTS

URGENCY Frontiers Magazine: WU Review of Health focuses on health as it relates to the entire Washington University community. We strive to make health – including physical and life sciences, engineering, public health, health policy, economics, the humanities, the social sciences and medicine – more understandable and relevant to people’s lives. Not only does Frontiers provide an opportunity for undergraduates to publish opinions and analyses of issues related to health, but it also allows the WUSTL community to engage in current events in the health field and explore the many intersections of health. Regardless of major or interest, Frontiers is open for all to engage. As Frontiers Executive Board, we would like to thank all our contributors, our writers editors, and illustrators as well as WashU faculty and Student Union for making this magazine possible.

Executive Board Daniel Berkovich, Keshav Kailash, Shubhanjali “Shub” Minhas Executive Directors

Anhthi Luong, Soyi Sarkar, Ryan Chang, Frank Lin Editors-in-Chief

Isaac Mordukhovich, Alexandra Dram Managing Editor

Lucy Chen, Eugenia Yoh, Victoria Xu, Haley Pak Directors of Design

Casey Connelly, Jennifer Broza Co-Directors of Public Relations

Alyssa Hyman Director of Finances

Writers

Ayda Oktem, Alicia Yang Directors of Outreach

Aidan Raikar, Alexandra Dram, Audrey Bochi-Layec, Chris Byron, Daleep Grewal, Gina Wiste, Haleigh Pine, Jacob Oscherwitz, Jason Zhang, Kimberly Hwang, Lily Coll, Lily Luu, Maya Kovacevic, Pooja Shah, Rehan Mehta, Ricky Illindala, Shanthi Deivanayagam, Shubhanjali Minhas

Amaan Qazi, Neha Adari, Haleigh Pine

Editors

Please email us or visit our website.

Akshay Govindan, Alexandra Dram, Annie Feng, Caelan Miller, Frank Lin, Grace Halupnik, Haleigh Pine, Julia Bulova, Lily Luu, Nick Rogers, Ryan Chang, Shamika Bhandarkar, Sophia Xiao

Illustrators

Digital Editors

Want to get involved? Website

frontiersmag.wustl.edu

Writers and Editors

eic.frontiersmag@gmail.com

Alexandra Laufer, Angela Chen, Clair Huang, Eugenia Yoh, Haley Pak, Jennifer Broza, Lucy Chen, Neha Adari, Noor Ghanam, Shanthi Deivanayagam, Shubhanjali Minhas

Illustrators

Cover Illustration by Haley Pak

Exec Board

design.frontiersmag@gmail.com

frontiersmag@gmail.com

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Letter from the Editors Frank Lin, Ryan Chang

Trust the Process Writer: Shubhanjali Minhas Editor: Ryan Chang Illustrator: Clair Huang

ENVIRONMENT

Seasonal Affective Disorder (SAD): How has COVID-19 made SAD worse? Writer: Shanthi Deivanayagam Editor: Nick Rogers Illustrator: Jennifer Broza

GLOBAL

Rural Inequities in Care: Reducing Stigma and Providing Access for All Writer: Chris Byron Editor: Nick Rogers Illustrator: Eugenia Yoh

POLICY

A Crucial Call for Change from the Coronavirus: Revamping the American Healthcare System to Address the Gaping Holes Exposed by COVID-19 Writer: Daleep Grewal Editor: Sophia Xiao Illustrator: Shubhanjali Minhas

11 From the Cockpit to the Operating Room: Combating Medical Error Through Crew Resource Management Writer: Jason Zhang Editor: Haleigh Pine Illustrator: Haley Pak

PUBLIC HEALTH

15 Where the US Healthcare System Went Wrong Writer: Kimberly Hwang Editor: Haleigh Pine

16 The (Not So) ‘Great Equalizer’: COVID-19’s Gendered Effects and Future Leadership Recommendations Writer: Maya Kovacevic Editor: Annie Feng Illustrator: Alexandra Laufer

19 Sweden’s Herd Immunity: Success or Failure? Writer: Gina Wiste Editor: Shamika Bhandarkar Illustrator: Noor Ghanam

21 Slow Websites and Stalled Phone Lines: The Hurdles for Older Adults Getting a COVID Vaccine Writer: Aidan Raikar Editor: Frank Lin Illustrator: Alexandra Laufer

22 To Mammogram or Not To Mammogram?: COVID-19 and Reassessing Preventative Care Writer: Lily Coll Editor: Julia Bulova Illustrator: Noor Ghanam

24 COVID-19’s mRNA Vaccines: How They Work and How They are Modernizing the Field of Vaccine Research Writer: Audrey Bochi-Layec Editor: Caelan Miller Illustrator: Neha Adari

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FRONTIERS • TABLE OF CONTENTS

RESEARCH

26 The Role of ZFHX4 in Regulating the Cancer Stem Cell State Writer: Ricky Illindala Editor: Akshay Govindan Illustrator: Angela Chen

27 A Race Between COVID 19 Variants and Vaccines: How the Mutating Virus has Impacted Vaccination Efforts and Effectiveness Writer: Pooja Shah Editor: Caelan Miller Illustrator: Neha Adari

29 Breakthrough Wound Therapy: Magic? No, Maggots. Writer: Haleigh Pine Editor: Lily Luu Illustrator: Eugenia Yoh

31 The Golden Future of Cancer and Nanotechnology Writer: Rehan Mehta Editor: Alexandra Dram Illustrator: Shanthi Deivanayagam

33 AI: Cutting Edge Technology Entering Healthcare? Writer: Jacob Oscherwitz Editor: Alexandra Dram Illustrator: Angela Chen

SOCIOCULTURAL

35 The Negative Effects of Gender Bias in Health Care Writer: Lily Luu Editor: Sophia Xiao Illustrator: Haley Pak

37 COVID-19 Impact on Children and Adolescents Writer: Alexandra Dram Editor: Haleigh Pine Illustrator: Lucy Chen

38 References

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Dear Reader, As the global pandemic continues to define this year and new information becomes available at breathtaking speeds, staying informed and engaged is more important than ever. In this ever-changing world, we hope this message finds you healthy and well. As a student-led interdisciplinary health magazine, Frontiers is dedicated to educate, inform and relay information to the public, while upholding the integrity of medical journalism. At our core, we are a group of passionate undergraduate students working to express our love for science, medicine, healthcare and more. Our goal is to provide medical journalism that offers new insight into the ever-changing landscape of healthcare while also illuminating the connections between medicine and the WashU community. For this issue, we wanted to highlight the theme of Urgency. Urgency defines many aspects of medicine, from the development of new treatments and technologies, movements to address healthcare inequities, and accelerated vaccine distribution to combat new variants of the coronavirus. Our writers, editors and illustrators have produced a magazine that sheds light upon a diverse range of topics relevant to WashU and beyond. We hope that these articles will not only inform and educate, but also spark new interests and meaningful conversations about relevant issues in medicine. Each article has been crafted by our passionate writers, critiqued with care by our attentive editors, designed by our imaginative illustrators and published behindthe-scenes by our dedicated executive members. We hope that some of these articles pique your curiosity and showcase the hard work and dedication devoted to publishing a student-run scientific magazine. If you would like to become a part of our Frontiers family, there is definitely a place for you! While our operations are currently remote, we are always excited to welcome new members, whether as a writer, an editor, an illustrator or a member of our Executive Board. We would also love to hear any of your comments, questions, suggestions, and/or concerns. Please contact us at eic.frontiersmag@gmail.com or look at our website frontiersmag.wustl.edu for more information. Please take a glimpse of what our accomplished writers, editors and illustrators have put into this issue. We are confident that you will find it relevant, informative, and engaging. “Literacy unlocks the door to learning throughout life, is essential to development and health, and opens the way for democratic participation and active citizenship.” - Kofi Annan Well wishes, Frank Lin and Ryan Chang Editors-in-Chief

FRONTIERS

Trust the Process Writer: Shubhanjali Minhas Edtor: Ryan Chang

he road to medical school is an arduous one, even when not in the middle of a pandemic. Students are focused on getting better grades, gaining clinical experience and properly setting themselves up for their “ultimate” goal of medical school all while trying to better themselves as individuals. With this mission also comes a constant sense of uncertainty, with questions like “Am I doing enough?” and “Will the things that I’m doing right now pay off in the end?” becoming guiding concerns. Being a premed student myself, these questions are often at the forefront of my mind, and with COVID-19 holistically adding onto the stressors of everyday life, getting into medical school feels even more elusive. I sat down with Dr. Gregory Polites to get his thoughts on the stressors of medical students, understand his journey to becoming an Emergency Medicine Physician at Barnes-Jewish and hear his advice for pre-med students.

“A lot of students...can get caught up in the pressure of performance and excelling,” Polites said. “There are different kinds of pressures that will impact you along the way: the pressure to always excel, [the pressure that] you don’t feel like you’re doing as well as you could or you need to know more, then the pressure that you have to meet everyone’s expectations, time expectations, and then the pressure to stay the course.” Polites’ pursuit of a medical career was unique. He started as a pre-med student at WashU but soon shifted to a business major with the intent to join his father at his company. Although he soon realized that business was not as interesting to him, the pressure to stay consistent led him to graduate as a business major. It wasn’t until he had a conversation

Illlustrator: Clair Huang

with an Emergency Medicine doctor after graduation that he was inspired to pursue a post-baccalaureate degree and apply to medical school. After medical school, he later matched into radiology for residency. However, after two years, Dr. Polites considered another route.

many roadblocks and he even changed his goals multiple times. However, throughout his journey, he never let these obstacles dictate his ability to do what he wanted to do. Rather, he embraced them.

“I liked radiology a lot,” Polites said. “But I had a vision for what it is I wanted to know and do as a physician, and that’s how I gravitated towards Emergency Medicine. I never liked being in uncomfortable situations, so that’s why I gravitated towards what I was afraid of.”

“I believe that every challenge you face in life should be viewed as an opportunity – an opportunity to grow, to become stronger, more patient, more kind and more compassionate,” Polites said. “Difficult times CAN and DO make you stronger if you recognize them as opportunities for growth. ”

Polites’ journey to and through medicine was not straightforward. He hit

Polites’ unconventional journey to medicine can serve as an example for

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“I believe that every challenge you face in life should be viewed as an opportunity – an opportunity to grow, to become stronger, more patient, more kind, and more compassionate. Difficult times CAN and DO make you stronger if you recognize them as opportunities for growth. ” many students. Reflecting on what you want to do and how you want to do it can make us more sure of our decisions and more determined to pursue them, regardless of the barriers we may encounter. Additionally, it is not always the most straightforward path that leads to the greatest success or the greatest happiness. Rather, the effort and determination that we put into doing what we set our minds to is what helps us develop an appreciation for our efforts and become more confident in ourselves. “Everything [you’ve] done in the past [has] worked out,” Dr. Polites said. “So why is this going to be any different? Trust the process...if you stick with it and always come back to why you chose to do this, I think you’ll realize how fulfilling it is. At this point in my life, I can’t imagine doing anything else.” “Realize that this is a great path -- that’s something you have to keep in mind -that it’s worth it. If it was easy, everyone would do it.”

FRONTIERS • ENVIRONMENT

Seasonal Affective Disorder (SAD): How has COVID-19 made SAD worse? Writer: Shanthi Deivanayagam • Editor: Nick Rogers Content Warning: This article discusses depression and suicide.

he sky turns pitch black as snow falls on the cold, hard ground. You crave the warm blanket of sleep and cannot bring yourself to leave your bed to interact with others around you. Like a hibernating animal, all you wish to do is eat, sleep and repeat. For some, this is a feeling that spans long months every winter called Seasonal Affective Disorder. Seasonal Affective Disorder, also known as SAD, is a type of depression characterized by symptoms similar to other depressive disorders. These symptoms often begin in the late fall and disappear in the spring. This type of SAD is called winter-pattern SAD and symptoms can last around four to five months each year [6]. The symptoms of general depression include: losing interest in activities you once enjoyed, experiencing changes in appetite or weight, having trouble sleeping, feeling fatigued, hopeless or worthless, having low energy and having thoughts of death or suicide [6]. For winter-pattern SAD in particular, more specific symptoms include oversleeping, overeating—especially with a craving for carbohydrates—weight gain and social withdrawal [6]. Diagnosis for SAD involves having symptoms of major depression or winter-pattern SAD during the specific seasons for at least two years in a row, and these depressive episodes must occur more often than other general depressive episodes that a person has had during other times of the year [6]. As expected, SAD is more common in places farther north, where days are shorter and nights are longer during

winter seasons. SAD is more common in women than it is in men and is more often diagnosed in those with major depressive disorder or bipolar disorder [6]. Further, people who have SAD also tend to experience symptoms of other

For winter-pattern SAD in particular, more specific symptoms include oversleeping, overeating— especially with a craving for carbohydrates— weight gain and social withdrawal.

mental disorders like ADHD, eating disorders, anxiety disorders and panic disorders [6]. The causes of SAD are still not fully known, but research has shown that those with SAD potentially have inhibited serotonin activity, which is a neurotransmitter that is involved in regulating mood [6]. Also, research has found that sunlight may have a role in maintaining molecules that control serotonin levels, the regulation of which does not work properly in those with SAD [6]. Other research suggests that SAD-affected individuals over-produce melatonin, which is instrumental in regulating the sleep-wake cycle [6]. Since people with SAD have disrupted serotonin and melatonin levels, their normal daily rhythms are also disrupted and dysregulated. Therefore, those with SAD are not able to adjust their daily rhythms to adapt to seasonal

changes, which leads to changes in sleep, mood and behavior [6].

Additionally, a lack of vitamin D, which is normally produced when skin is exposed to sunlight, can further exacerbate these issues because vitamin D is known to promote serotonin activity [6]. In the winter, as days become shorter, the amount of time people can be exposed to sunlight decreases, which plays a role in the manifestation of winter-pattern SAD. As one might expect, in the era of COVID-19, an abundance of uncertainty and anxiety combined with the winter season compound into a manifestation of winter-pattern SAD that is more severe than ever before witnessed. The main causes of SAD—disrupted serotonin and melatonin levels, as well as the lack of vitamin D—are all worsened with the effects of a pandemic. As restrictions are put into place forcing people into their homes and away from the sunlight and other social interaction, the effects of SAD are likely to become magnified. In an article titled “Will COVID-19 Make Seasonal Affective Disorder Worse?”, Paul Desan, MD, PhD, director of the Psychiatric Consultation Service at Yale New Haven Hospital, explains how he is “... quite worried about how this winter will be for people who experience SAD. Most are already nervous about COVID19. They will be indoors, and they won’t be exposed to the same amount of bright light” [3]. According to Dr. Desan, the COVID-19 pandemic, in general, is a “major mental health event,” and many are attempting to find help to cope with anxiety and stress [3].

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was significantly decreased in subjects who had received vitamin D compared to those who underwent phototherapy treatment [1].

Illustrator: Jennifer Broza In the article, “COVID-19 and Seasonal Affective Disorder: How This Year Is Different,” by Sara Lindberg, methods to treat and manage SAD during the pandemic include engaging in social activities virtually or in a socially distant manner, self care through healthy eating and getting regular exercise, partaking in teletherapy and psychotherapy and maximizing light intake through light therapy [2]. Light therapy, or phototherapy, is essentially exposing skin to artificial sunlight. Leela R. Magavi, MD, an adolescent and child psychiatrist and regional medical director for Community Psychiatry, suggests sitting by a 10,000 lux light box for at least 30 minutes to help alleviate the negative symptoms of SAD [2]. A study titled “Effects of bright light on sleepiness, melatonin, and

...one hour of light therapy reduced depressive symptoms significantly for the 16 out of a group of 29 patients... 25-hydroxyvitamin D(3) in winter seasonal affective disorder” by Partonen, Vakkuri, Lamberg-Allardt and Lonnqvist in 1996 showed that one hour of light therapy reduced depressive symptoms significantly for the 16 out of a group of 29 patients who had SAD [5]. Another study looked at the effect vitamin D supplements had on patients with SAD. Researchers Gloth, Alam and Hollis found that depression

The pandemic has undoubtedly increased the amount of stress and anxiety that everyone is experiencing right now, and for those with SAD, this has only snowballed along with the shorter days and longer nights to make for an even more stressful and depressing winter. Desan says, “This really is a scary year. You are going to feel this generalized dread,” which is a feeling that many of us can relate to [3]. To deal with this stress, it is important to turn to healthy coping mechanisms, like exercise, eating well, mindfulness and maintaining relationships with friends and family. While life isn’t going back to the way it was before COVID-19 any time soon, there is light at the end of the tunnel—vaccinations have begun rolling out across the country and days are slowly but surely growing longer, as the cold, dark winter comes to a close. •

*If you have thoughts of death or suicide, you’re not alone. Help is available 24/7. Call the National Suicide Prevention Hotline at 800.273.8255 to speak to a professional. If you’re experiencing an emergency, call 911 [4].

FRONTIERS • GLOBAL

Rural Inequities in Care: Reducing Stigma and Providing Access for All Writer: Chris Byron • Editor: Nick Rogers

t has been over 40 years since the Alma-Ata Declaration defined the concept of primary healthcare and brought international awareness to the extreme health inequities that permeate the globe. Unfortunately, the declaration’s ambitious goal of healthcare for all by 2000 was not met as intended [3]. Nonetheless, there still exist promising implementations of primary healthcare services, particularly for mental health, which can serve as a useful model for other nations to follow. Examples discussed include a community health model from Zimbabwe and telehealth. Dr. Dixon Chibanda, a Zimbabwean physician and director of the African Mental Health Research Initiative, helped to pioneer an approach which both addresses Zimbabwe’s shortage of psychiatrists and its significant number of mental health issues. Chibanda’s program trained lay health workers, primarily local grandmothers, in a treatment approach known as problem-solving therapy (PST). The program is designed to assist those suffering from common, non-life threatening, mental disorders and aims to find solutions to problems that cause distress in a patient’s life [1]. The approach is primarily self-directed, meaning the provider facilitates the interaction and makes suggestions, but the patient ultimately develops the solutions themselves [1].

Rural hospitals have been permanently closing at higher rates in recent years.

Chibanda found great success with the initial program, and later conducted a randomized clinical trial which further demonstrated the effectiveness of the lay health workers. The majority of those suffering from the common mental disorders saw significant improvement six months after receiving just a single treatment [2]. While early results suggest the number of sessions attended is directly proportional to a better outcome, the sessions were designed to be conducted one time only due to difficulties of accessing the treatment site [1]. Furthermore, while Zimbabwe is different from the United States, there are key similarities, chief among them being the severe treatment gap in mental healthcare. That is to say, there is limited access to mental health services for many in both nations. At present, one-fifth of the United States population resides in a rural setting, and one-fifth of those individuals suffer from mental health conditions, which constitutes well over six million people [4]. These individuals are often far removed from treatment providers, which further complicates the delivery of care [4]. Nicole Summers-Gabr, an assistant professor at SIU School of Medicine, estimates that over 50% of counties do not have direct access to a psychiatrist [6]. This treatment gap is only growing larger. Rural hospitals have been permanently closing at higher rates in recent years [6]. Many patients are rightfully hesitant to drive great distances for care, and providers are often unwilling to work in rural areas, as evidenced by the frequent turnover at rural clinics [5]. Mental health services are also costly. Accessing care could potentially be financially burdensome since 14% of rural Americans live below the

poverty line and lack health insurance [5]. Additionally, seeking help for mental health is more heavily stigmatized in rural areas compared to urban areas. In smaller communities care tends to be less anonymous, which causes some to feel embarrassed or guilty when they

Accessing care could potentially be financially burdensome since 14% of rural Americans live below the poverty line and lack health insurance.

do seek help [5]. With mental health disorders and suicides on the rise, particularly during the COVID-19 crisis, it is imperative that this rural disparity is addressed. While the U.S. has traditionally been in favor of implementing mental healthcare alongside primary healthcare, the current data suggests that this is not as effective as it should be [5]. A non-traditional model based on Chibanda’s approach may prove useful if formally adopted in the United States, but it merits further research and community feedback. Implementing such an approach would involve recruiting physicians and psychologists to train trusted community members, likely elderly and/or trusted residents, on the basics of PST. The approach must be localized, and communities must have confidence in the system. Accessing PST must be promoted in the media, and community members should feel proud when taking action and seeking help.

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Another method of providing access to mental health services is through telehealth. When telehealth is properly implemented, it gives patients direct access to a clinician who can diagnose and treat virtually, and it has the potential to greatly reduce stigma. Patients would not have to fear being spotted in public, and care can easily be provided in the comfort of one’s home. However, a stable internet connection and access to computers, while often taken for granted in many urban areas, is not always available in rural areas. Various

Illustrator: Eugenia Yoh

estimates suggest that 20 million to 40 million Americans do not have stable internet [6]. Summers-Gabr also noted that while the CARES Act (a COVID relief act) provided 100 million USD for rural internet access, most estimates suggest it will take over 80 billion USD to ensure all Americans have access [6] In summary, Chibanda’s model of care could provide one alternative approach to help alleviate the current mental health crisis in the United States. However, more research is required to

determine if such a system could feasibly be applied. In addition, more funding needs to be directed towards rural mental healthcare access to bridge the gaps in care. Rural communities need expanded access to internet and telehealth services, and the United States government has a responsibility to listen to its constituents. These rural communities are speaking through their silence regarding mental health issues and will do so until something changes. •

FRONTIERS • POLICY

A Crucial Call for Change from the Coronavirus: Revamping the American Healthcare System to Address the Gaping Holes Exposed by COVID-19 Writer: Daleep Grewal • Editor: Sophia Xiao

n her five-minute video-log, Dr. Ashley Bray, a general medicine resident, records her average day in a New York City hospital overburdened by new patients who have contracted COVID-19, a virus which has infected nearly 109 million people globally and has been responsible for the death of over 485,000 people in the United States alone [6,2]. In the video, we hear repeated calls over a loudspeaker of “Team 700,” which is the code for when a patient is on the verge of death. The final shots in this video-log show the dozens of refrigerated trucks stationed outside the hospital to hold the bodies of the dead. Dr. Bray ends her video by describing the overall situation as “apocalyptic.” As America continues to lose the battle against COVID-19, it would be all too easy to assert that the effects of COVID-19 have been indiscriminately felt, and that the healthcare system is “managing” the virus. Going beyond a rudimentary analysis, it is evident that 1) specific populations, namely minority groups, are disproportionately affected by COVID-19 due in part to the healthcare system’s reactionary, late-stage approach to illness [1]; 2) an exorbitant amount of money is wasted in the healthcare system, which diverts resources away from other areas that require improvement [2]; and 3) significant legal loopholes exist that allow health insurance companies to deny people insurance, which has resulted in millions being uninsured during the pandemic [3]. Given these realities, America moving forward must create a more financially efficient and encompassing system that guarantees everyone high-quality healthcare. By adopting a single-payer healthcare model that is more standardized and

efficient, more resources would be available to readjust the public health approach from reactionary to preventative, which, in turn, would mitigate health disparities. The chaos ensuing from the COVID-19 pandemic has shed light on a system that is both inefficient and exclusionary, and this system has played a significant role in minority communities being so heavily affected by coronavirus. So, how can we create a health care system that is both efficient and accessible while allowing for a redistribution of wealth toward creating a more preventative approach to public health? A potential answer lies in adopting a single-payer healthcare model. This model is a tax-funded system operated by the government that takes responsibility for financing healthcare for all residents. Under this system, everyone in America would have health insurance under one standardized plan, and access to necessary services, including doctors, hospitals, long-term care, prescription drugs, dentists and vision care. Furthermore, individuals would still be able choose where they receive care to ensure that everyone has the opportunity to make an informed decision about their healthcare plan. The single payer model starkly contrasts with the current system, in which healthcare is mainly funded by private companies that vary in benefit structures depending on their employees’ premiums and rules for paying medical care providers. In addition, while the current system does not have an aligned plan for providing healthcare on a local, state and federal level, a single-payer system would create uniformity in healthcare delivery, which would significantly reduce inefficiencies due to administrative complexity.

...how can we create a health care system that is both efficient and accessible while allowing for a redistribution of wealth toward creating a more preventative approach to public health? Under a single-payer model, no American would needlessly suffer due to a lack of medical insurance. Given the thousands of people who were more prone to suffer from COVID-19-related issues due to a lack of an insurance backbone, in addition to the fact that an estimated 68,000 patients die annually due to lack of insurance, the system’s benefits are extremely relevant [3]. Furthermore, according to Dr. Andrea Christopher from the Harvard Medical School, a single-payer system would incentivize more to direct healthcare spending toward public health measures. For example, targeting funding towards childhood obesity prevention programs in elementary schools and daycares could reduce the rates and complications of obesity more effectively and at lower costs than paying for doctor visits to recommend healthier diets and increased physical activity. With respect to the association between government-run insurance and preventative care, there are some relevant studies that challenge this projection. One such study sought to assess the impact of Medicaid expansion on the receipt of 15 different measures of preventive care including cancer screening, cardiovascular risk reduction,

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Illustrator: Shubhanjali Minhas

FRONTIERS • PUBLIC HEALTH

...a single-payer system would incentivize more to direct healthcare spending toward public health measures. diabetes care and other primary care measures. After comparing 24 states which expanded their Medicaid and 19 states which did not, the study found that Medicaid expansion was not associated with improvements in cancer screening, cholesterol monitoring, diabetes care, or alcohol use screening [4]. Despite these findings, however, the level of relevance or applicability of a state-by-state study toward a national expansion of Medicaid/Medicare may not be as high. This is because under a single-payer system, all fifty states would be required to uphold standardized criteria of quality healthcare that includes preventative and corrective treatment. Another study illustrates how hospitals in both Maryland and Pennsylvania that replaced the feefor-service system with a Medicare/ Medicaid global budget system were able to acquire a reliable and substantial revenue source, allowing them to reinvest in community health care delivery; as such, there is a notable relationship between the revenue acquired by hospitals and the reinvestment into community-based public health [5]. Furthermore, an additional study on the effects of Medicare for All finds that rural hospitals specifically would see their revenue increase largely due to the elimination of financial burdens that uncompensated care places on hospitals. Under the implementation of a single-payer system with Medicare

expansion, the alignment of all fees to the Medicare schedule would result in a mean projected revenue of 103% for rural hospitals for the same level of service provision and, therefore, operating costs. Notably, the magnitude of the shift would be largest for hospitals serving the least affluent communities, which tend to have substantial balances for uncompensated care and receive much of their revenue from Medicaid [6]. As such, a single payer system is not only encompassing and cost-effective, but has significant revenue space to reinvest in developing a more preventative public health approach, wherein money could be invested in better public transportation systems, community-based health systems and better access to higher quality food. While the needs and challenges of revitalizing the American healthcare system can sound daunting, it is important to reiterate the scale of the problem. The ongoing COVID-19 pandemic has exposed and exacerbated pervasive systemic inequities and has already begun to reshape medical care. Despite the inevitable political and legislative pushback against top-down reform, the tragedies of the pandemic -- from hospitals being severely overburdened to millions of people being debilitated from this virus -- can provide the impetus for a powerful call for action that can serve to break down these barriers. Creating a uniform single-payer healthcare plan can legitimately save thousands of lives that would be needlessly lost to a lack of adequate healthcare. Furthermore, eliminating or even substantially reducing wasteful medical care spending could be an opportunity to fundamentally reshape our nation’s medical care system through investing in a more preventative public health

approach, thereby igniting a movement against the obesity and diabetes crises. Overall, a single-payer healthcare system can move our public health approach in a positive, more equitable direction and could thus shape a healthier, safer and prepared America. •

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From the Cockpit to the Operating Room: Combating Medical Error Through Crew Resource Management Writer: Jason Zhang • Editor: Haleigh Pine

n December 28, 1978, United Airlines Flight 173 silently glided through the night sky over the sleeping suburbs of Portland. At 6:15 PM, it struck the ground, killing 10 and severely injuring 23 passengers and crew [8]. The plane was supposed to have landed just an hour before at Portland International Airport with all 152 passengers alive [8]. In the final report, investigators state that “the probable cause of the accident was the failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crew members’ advisories regarding fuel state,” adding that “[the captain’s] inattention resulted from preoccupation with landing gear malfunction…” [8]. More specifically, United 173 was holding over Portland because the crew was troubleshooting an indication that the landing gear (wheels) was not extended for landing. The captain in particular was so consumed by the issue that he was distracted from noticing the little fuel remaining. This was in part because of “a breakdown in cockpit management and teamwork” whereby the captain took on too many tasks by troubleshooting the landing gear, blinding him from seeing the “bigger picture” regarding fuel (sometimes called “task saturation”) [8]. Moreover, this distracted him from hearing the multiple comments from other crew members regarding low fuel. The report notes that the other crew members were also not assertive enough because “the stature of a captain...may...force another crew member to yield his right to express an opinion” [8]. Thus, the other crew members likely felt intimidated by the captain’s high position and authority, resulting in a breakdown in teamwork and communication where a

minor landing gear issue evolved into a major accident. Eleven years later, on July 19, 1989, United Airlines Flight 232 barrel-rolled in a ball of flames across the runway as it made an emergency landing at Sioux Gateway Airport. About an hour prior, an engine explosion resulted in a loss of hydraulics and therefore most controls of the aircraft, leaving the engines as the only way to control the crippled jet. Although the crash killed 111 passengers and crew, it was a miracle United 232 was even able to land [7]. When placed in a flight simulator set to the same conditions that United 232 was in, many other test pilots crashed far before reaching the simulated airport. The investigation concluded that United 232 “could not have been successfully landed on a runway” [7]. Despite this conclusion, the crew of United Airlines Flight 232 was able to control the aircraft and make it to the nearest airport, saving 185 lives [7].

Why was the behavior of the crew so different in these two accidents? After reviewing audio recordings of cockpit conversations, the final report attributed the miracle of United Flight 232 to the fact that the flight crew demonstrated good teamwork in “discussion of procedures, possible solutions and courses of action” when trying to land [7]. Compared to the crew of United 173, the captain of United 232 provided leadership while encouraging communication/teamwork and

remaining open to inputs from other crew members. Additionally, other crew members were not intimidated by the captain’s authority and were active in all stages of the flight. For example, a United Airlines pilot flying as a passenger decided to help the crew and was tasked by the captain with handling the throttles [7]. By giving such an important task to another pilot, the captain showed that he trusted his crew members and valued their input in landing the plane. United 232 and United 173 demonstrated that when in the presence of individuals with differing levels of authority, proper teamwork, task management and open communication can mean the difference between crashing a perfectly flyable plane and flying a plane that should have crashed otherwise. Why was the behavior of the crew so different in these two accidents? The primary reason was because of the implementation of Crew Resource Management (CRM) in the airline industry prompted by accidents such as United 173. CRM is an umbrella term for a set of skills that emphasize teamwork and communication. More specifically, the Federal Aviation Administration (FAA) states that CRM training and practice “were derived primarily from management training approaches and stressed interpersonal teamwork while preserving a leadership chain” in response to “ uneven distribution of workload during critical situations such that one crew member, usually the captain, became overloaded while others were not effective contributors to resolution of the situation at hand” [13]. United Airlines Flight 173 exemplified the airline industry prior to CRM where the lack of teamwork, uneven workload and a perceived hierarchy

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Illustrator: Haley Pak

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that stifled communication led to many preventable accidents. These accidents prompted the development and implementation of CRM that directly addressed these problems, contributing to the success of United Airlines Flight 232 and improving airline safety up to the present day [3]. Healthcare in America and especially the field of surgery shares many characteristics with the airline industry. Helping patients requires teamwork, communication and proper leadership. Additionally, healthcare workers often have to make quick decisions, ones where small mistakes can have devastating consequences. In fact, medical errors are estimated to cause 250,000 deaths annually, making it the third leading cause of death in America according to Johns Hopkins University [5].

Researchers found that following CRM training, there was a significant drop of “adverse events” (including, for example, maternal death and birth trauma) from 305 to 187 events.

To understand what factors are behind this high rate of medical errors, it is useful to provide an example of one. In one such incident, a resident notices that a patient is presenting symptoms that could indicate a serious infection. However, when he voices his concerns

to the attending physician, the attending dismisses it as a commonplace infection and not serious, recommending that the resident discharge the patient. The resident disagrees but has to give the patient over to another resident at the end of his shift. When he comes back the next day, he learns that the patient was discharged and died from a rare, deadly form of a Varicella infection [1]. In this example, a barrier of communication between the resident and the attending physician meant that the attending physician did not adequately listen to and consider the resident’s position, recommending the discharge of a patient with a serious and fatal infection. The paper also adds that since the attending was seeing multiple patients, he wasn’t able to focus on the specific one that the resident had concerns about, instead dismissing it as a common infection and recommending patient discharge [1]. If this sounds familiar, this is because it demonstrates a breakdown in communication and teamwork that doomed United Airlines Flight 173 in the absence of CRM. Moreover, this is by no means a unique story. In a report ordered by the United States Senate, researchers from the Agency for Healthcare Research and Quality found that communication problems and inadequate information flow were among the top factors that contributed to the majority of medical errors [12]. In a separate paper focused on surgical errors in New York hospitals, researchers also found that “communication failures” and “team issues: informal norms and hierarchy” were in part to blame [2]. In observing interpersonal dynamics in operating rooms, researchers reached similar conclusions, noting that “while informants valued open communication,

they continued to operate in a hierarchical culture which...threatened safety because less powerful members had limited input in decision making, and were reluctant to speak up” [4]. Karen Mazzocco painted a clearer connection between communication/teamwork and patient outcome, finding that the lack of behaviors associated with teamwork was “significantly associated with any complication or death” in surgery [6]. Thus, issues addressed by CRM in aviation such as a lack of open communication and teamwork are not only present in the healthcare setting but are prevalent and have a major impact on patients. Therefore, CRM could prove to be a useful solution to these issues, improving patient outcome by reducing medical errors. CRM could theoretically be a solution to preventing medical errors. However, could adapting principles from aviation for use in healthcare actually work? Some have tried to answer this exact question by attempting to do just that. In 2006, nurses and physicians working in the obstetric department underwent CRM training that involved “real-life examples of topics such as: situation monitoring to maintain appropriate work load distribution and anticipate the unexpected, mutual support to provide performance feedback to team members...” among others [11]. This was followed by subsequent team meetings focused on how staff can further implement CRM. Researchers found that following CRM training, there was a significant drop of “adverse events” (including, for example, maternal death and birth trauma) from 305 to 187 events [11]. Additionally, there was a statistically significant drop in the Adverse Outcome Index that measured the severity of the measured

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adverse outcomes [11]. It appeared that CRM training and meetings could have contributed to the decline in adverse events, likely due to better communication and teamwork between staff as a result of CRM implementation. A similar study analyzed a Vermont hospital’s implementation of CRM training among staff working in the ICU. This training utilized “didactics, case-study discussions, “hands-on” team-building exercises and simulated operating room brief and debrief sessions” and continued every six to 12 months for two years [10]. Following CRM training, researchers noticed common medical errors such as “wrong site surgeries and retained foreign bodies decreased from a high of seven in 2007 to none in 2008” [10]. Although it increased to five a year after CRM training ended, the researchers point out that “malpractice expenses (payouts and legal fees) totaled $793,000 (2003–2007), but have been zero since 2008” [10]. Once again, it appears that CRM training was associated with a decrease in medical errors, although continual training might be necessary to maintain those improvements. Additionally, the benefits of CRM training go beyond just helping patients but also helping physicians and hospitals by reducing malpractice expenses. Perhaps the strongest evidence demonstrating the efficacy of CRM in a healthcare setting has been from the Veterans Health Administration (VHA). In 2006, the VHA implemented CRM training on a national level to 74 of its facilities. The training involved learning sessions and follow-up interviews that emphasized the ability to “challenge each other when they identify safety risks; conduct checklist-guided preoperative briefings and postoperative debriefings; and

implement other communication strategies such as recognizing red flags, rules of conduct for communication, stepping back to reassess a situation [etc.]” [9]. When compared to 34 other facilities that received no CRM training, the 74 facilities with CRM training “experienced a significant decrease of 18% in observed mortality” [9]. Furthermore, increasing the frequency of CRM training sessions also further decreased mortality, with researchers stating that “for every quarter of training, the mortality rate decreased 0.5 per 1000 procedure deaths” and “for every increase in degree of briefing and debriefings mortality rate was reduced by 0.6 per 1000 procedures” [9]. The reduced mortality that the VHA saw from implementing CRM supports the notion that CRM is a useful tool in preventing medical errors and improving patient outcome. Moreover, the dose-response relationship between CRM implementation and decreased mortality further strengthens the argument that CRM implementation is not only associated with but likely directly causes decreased patient mortality.

The breakdown in communication and teamwork within a hierarchical structure can sometimes jeopardize safety, putting both passengers and patients at risk.

The root causes of medical errors in healthcare stem from the same issues that plagued the airline industry. The breakdown in communication and teamwork within a hierarchical structure can sometimes jeopardize safety, putting both passengers and patients at risk. Although the use of CRM in hospitals and healthcare is relatively new and uncommon, those that have experimented with CRM have demonstrated its efficacy and utility in preventing medical errors and improving patient outcome. Thus, hospitals and other healthcare facilities should continue to introduce and implement CRM training for its staff in order to protect patients and provide the best care possible. By doing so, maybe the healthcare industry will see less stories similar to United 173 and more stories similar to United 232 – stories where proper teamwork and communication between individuals can prevent potentially deadly mistakes and save countless lives. •

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Where the US Healthcare System Went Wrong Writer: Kimberly Hwang • Editor: Haleigh Pine

“A

man who was hospitalized with COVID-19 for 62 days received a $1.1 million medical bill” at the end of his hospital stay [3]. The COVID pandemic has exposed devastating flaws in the US healthcare system. Not only is going to hospitals a risk to one’s health due to the risk of contracting COVID, but healthcare costs are also much more expensive than those of other countries. In 2019, the Congressional Budget Office estimated that of those under the age of 65 years old alone, 30 million Americans were uninsured, whereas 99.6% of the population in Taiwan has coverage [7,5]. So why are medical bills so expensive in the United States? Many of these people attribute their lack of insurance coverage to reasons like affordability, that they “live in a state that didn’t expand Medicaid, or [that they] are undocumented” immigrants [4]. Unfortunately, even for the people who have health insurance, they still have to pay a hefty amount of fees for important medical procedures and treatment, like psychotherapy sessions or “elective” surgeries [4]. The bills are so expensive that medical expenses are one of the leading causes of declaring bankruptcy in the US [1].

The US has adopted a fee-for-service attitude towards medicine, causing physicians to order large amounts of unnecessary tests. According to Dr. Harlan Krumholz, a cardiologist who works at the Yale School of Medicine, “it’s in the economic interest of the hospital, the physician, the health care system…. and the justification is that more is better” [3]. However, that is not true in every case, especially if it leaves patients with medical debts that they spend the rest of their lives trying

to pay back. Oftentimes, there is no adequate reason to run these tests [3]. Having too many tests also has other side effects, such as causing even more medical problems: in South Korea, thyroid cancers became very common due to excessive ultrasound screenings [2]. This problem has happened in the US as well, even though it is manifested in other ways. 97% of the doctors in the US have run tests that were unnecessary, “even if they know the results won’t really help them decide how to treat their patients” [6]. Because of this, the US wastes $210 billion in additional health care costs and that means less affordable care for patients as well [6].

To counter these problems, systemic change is needed. To counter these problems, systemic change is needed. For example, the US is one of the only countries in the world that relies on a “for-profit insurance system” [3]. This means that when private companies control insurance administration, most people have to “pay for it themselves, even if their employer subsidizes some of it” [3]. On the contrary, other countries consider healthcare a basic human right and utilizes the government’s resources to insure most of their population [3]. For example, in Taiwan, everybody receives healthcare insurance coverage and has created a “Medicare-for-all” system while keeping the quality high [8]. It has adopted a single-payer system, which the government’s National Health Insurance Administration runs. A single-payer system motivates companies that make

drugs and run hospitals to keep costs low, because they have nobody else to sell these services to other than the government. Although patients still have to pay extra money when seeing a doctor or receiving their medication the fees are “generally low...about $12...or less” [8]. Unfortunately, this system is not without its flaws, and the US should also be careful if it wishes to transition to this system. Because of cheap doctor visits, “the average number of physician visits per year [in Taiwan] is nearly twice that of other developed economies”[8]. These excessive visits mean that healthcare providers do not have a lot of free time and can be overextended. However, it is not worth it for the US to keep its current system, as a lot of people who need care are afraid to receive it because of the price. Perhaps, what the US needs is something in between. One thing that the US can start off with is revising its education for both physicians and consumers. In medical school, which consists of mostly STEM courses, physicians should also learn how to ethically use their medical resources and help keep medical expenses for their patients a priority along with their health. As for consumers, learning how to not overuse medical resources would be helpful as well. Maybe, the government can provide a certain amount of cashback from the amount they paid through their insurance if they use medical resources only when they need to. •

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The (Not So) ‘Great Equalizer’: COVID-19’s Gendered Effects and Future Leadership Recommendations Writer: Maya Kovacevic • Editor: Annie Feng

he COVID-19 pandemic revealed to our global society the extent of our social nature, the wide range of essential professions from cashiers to physicians, and more. Yet one lesson that’s gained momentum in the past year is the efficacy of women leaders. Particularly in the political arena, national leaders who have maintained control on COVID spread throughout the pandemic like New Zealand’s Prime Minister Jacinda Ardern and Iceland’s Prime Minister Katrín Jakobsdóttir are popular examples of how women are leading the way for success, in terms of COVID-19 and otherwise [4,8]. This trending recognition of women leaders gives insight into a critical aspect in the advancement of gender parity in leadership, not only in areas like politics but also in health [6]. On the frontlines of the delivery of health worldwide, women greatly outnumber men, accounting “for 70% of the health and social care workforce” [3]. Despite women making up the majority of those delivering care, there still exists an evident gap in gender parity in health leadership as “69% of global health organizations are headed by men, and 80% of board chairs are men” and a mere “25% [of global health organizations] had gender parity at senior management level” [3]. This persistent trend in underrepresenting women in leadership positions denies beneficiaries of these women’s skills and expertise [3]. This underrepresentation is expressly concerning in light of the COVID-19 pandemic, as its effects are gendered and the burdens are compounding. As the majority of frontline workers, women’s exposure risk is increased. Since many of them also adhere to the traditional

social norm of being the primary caretaker at home, their family members’ risks are also raised [5]. In an effort to prevent transmission to their loved ones they care for, many health workers have tried avoiding immediate family, but in many cases, this is an unfeasible and emotionally-taxing solution for the female workers who also are caretakers at home. Heightened feelings of anxiety and depression were reported by all health workers as well, especially early in the pandemic, but these feelings were intensified for women health workers who were torn between demanding professional and domestic responsibilities [7]. This was especially the case for health workers who were also single mothers or those with an unequal burden of domestic responsibilities compared to their partner, such as mothers shouldering a majority of the burden of managing their children’s now virtual education [5]. Moreover, the pandemic’s effects on childcare and education are multifaceted. From the perspective of adult women, 10 million [working women] (17% of all working women) rely on childcare and schools to keep their children safe while they work.” Building on this, the lack of access to regular education will be devastating for thousands of girls globally. In March of 2020, “UNESCO estimated that the pandemic was preventing 1.52 billion children from attending school” [1]. As The Lancet reports that a lack of education is found to increase the risk of female genital mutilation, early marriage, teenage pregnancy, sexually-transmitted diseases, and unpaid labor for girls, among other detriments [1]. A “UNFPA analysis reports [the delay due to COVID-19 in initiating prevention programs] is projected to lead to an

additional 13 million child marriages, as well as 2 million female genital mutilation cases over the next decade that otherwise would have been averted, that is, a 33% reduction in progress” [9]. Evidence such as this supports the tangible repercussions of the COVID-19 pandemic on women and girls, underscoring the importance for their needs to be appropriately and actively met.

On the frontlines of the delivery of health worldwide, women greatly outnumber men, accounting “for 70% of the health and social care workforce”

As a general population, “women and girls are disproportionately affected by armed conflict and humanitarian emergencies” [9]. Economically, the pandemic has been devastating for women. The Lancet reports “an estimated 740 million women are employed in the informal economy [1]. In developing nations, such work constitutes more than two-thirds of female employment.” Without employment, women are unable to provide for themselves or their dependents – destabilizing their ability daily lives and overall health. At the same time, in non-developing nations like the United States, “women account for about 77% of workers in occupations that require close personal contact and cannot easily be done remotely, such as food preparation, health-care support and personal service” [2]. The influence of gender on the COVID-19 pandemic’s economic impacts

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Illustrator: Alexandra Laufer

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are unlike those in previous recessions, with the Wall Street Journal reporting that “‘Every recession is a ‘mancession’ except this one’” [2]. With women being expected to assume domestic responsibilities, the Boston Consulting Group finding that “women were spending 15 hours more a week on domestic labor than men were, at 65 hours versus 50 hours, compared with a pre-Covid balance of 35 hours and 25 hours,” the ability for them to balance competing, demanding responsibilities often forces them to sacrifice their career [10]. This is especially true in cases where the higher-earning spouse is the one to keep their job, yet “about 70% of husbands in dual-income heterosexual couples earned more than their wives” in 2018 [10]. Once again, leaving women’s careers at a disadvantage, pushing them out of the professional sphere and into domesticity. Financial implications from COVID-19 also manifest themselves in the form of increased financial dependence on partners. This financial dependence, in combination with a lack of access to support services and the mandated isolation and stay-home-orders, trap victims of gender-based or domestic violence with their abusers, exacerbating this endemic violence. It’s been found that in the last year, “some 243 million women are thought to have experienced sexual or physical abuse at the hands of an intimate partner at some point” and in France one week after the first lockdowns, “domestic violence reports had surged by 30%” [1]. Though, it is likely that even these numbers are under-representative of the true magnitude as domestic violence reports often go under-reported [1]. This could be especially applicable because of the effects of the lockdowns

(i.e. isolation and constantly being with their abusers), increasing the barriers for them to seek help. The elevation in vulnerability for women, particularly during and after crises, is a persistent issue and one that must continue to be worked toward eliminating.

...financial dependence, in combination with a lack of access to support services and the mandated isolation and stayhome-orders, trap victims of gender-based or domestic violence with their abusers, exacerbating this endemic violence. At the same time, due to inadequate representation in leadership, women lack the substantial decision-making power to address their concerns. In previous health crises, such as the Ebola outbreak, “women were less likely than men to have power in decision making around the outbreak and their specific needs, resulting in their health needs being largely unmet” [9]. Furthermore, the detriments from women’s absence are intersectional as “women do not form a homogenous group; therefore, when women are excluded in decision making and policy implementation, other groups are also disadvantaged” [9]. Expanding women’s leadership is not only beneficial for the immediate future, but studies have supported that women leaders are powerful role models and thus generate a “ripple

effect” for future generations [9,6]. In fact, “experience shows that a systematic and intentional gender lens leads to more effective local, national and global responses and management of infectious disease outbreaks: women’s leadership and contributions are critical to curbing infection rates and enabling resilience and recovery” [9]. For far too long, underrepresented demographics have been forced to deal with inadequate responses both in and out of crises. Diverse representation in health leadership creates the opportunity to normalize the diversity of the global population and human experience. It also begins the process of creating programs that are effective in catering to the unique needs of the populations these leaders represent. Caring for the global population at each of its microlevels requires leaders who both recognize and understand the plethora of challenges, and multilayered complexities, of their populations. But the expansion of women leadership must be more than a title, it must have concrete impacts and center on gender-inclusive policies [3]. COVID-19 has catalyzed many shifts to our health system and an excellent time to prioritize gender-inclusivity is while the processes are still malleable. And that time is now. •

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Sweden’s Herd Immunity: Success or Failure? Writer: Gina Wiste • Editor: Shamika Bhandarkar

approach, allowing community transmission to occur relatively unchecked” [5]. While the agency did recommend limiting gatherings to 50 people or less on March 29, 2020, there were no mandatory measures taken to limit crowds on transport, in malls, schools, and other crowded places [5]. The government acknowledged the fatal risk of such a strategy; on April 3, Prime Minister Stefan Löfven said, “[Sweden] will have to count the dead in thousands. It is just as well that we prepare for it” [4]. In early May, the FHM predicted that 40% of Stockholm’s population would have gotten the disease, recovered, and have protective antibodies; but, according to the antibody studies published on Sept. 3 by the agency, based on samples collected through June, that number was only 11.4% [4]. In August, a study by the Journal of the Royal Society of Medicine stated that herd immunity was still “nowhere in sight” [7]. However, even as the death toll in the country climbed, the government reaffirmed its faith in the strategy, despite the fact that herd immunity against an infectious disease has never been achieved without the aid of a vaccine [4].

Illustrator: Noor Ghanam

s SARS-CoV-2 swept across the world in 2020, it left a wave of national lockdowns in its wake. Different countries enforced these lockdowns in different ways. Australia made good use of its status as an island, barring travel into the country except in strict instances followed by a fourteen-day quarantine. Towns in Italy and Spain set curfews and limited the number of times residents could step outside

their homes. The United States lacked a cohesive national strategy; instead, their policy was a patchwork of local restrictions and shutdowns. One country that caught the world’s eye by bucking this trend all together was Sweden. At the very beginning of the COVID19 pandemic, Sweden’s public health agency, Folkhälsomyndigheten (FHM), opted for a “de-facto herd immunity

...there were no mandatory measures taken to limit crowds on transport, in malls, schools, and other crowded places. Sweden stands in contrast to its Nordic neighbors, with COVID-19 deaths in Sweden reaching 787 deaths per

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million in December 2020, a figure which is four to five times higher than that in other Scandanavian countries [5]. Neighboring Norway, with 632 total COVID-19 deaths, attributes its low mortality rate to its aggressive testing strategy, one which enables rapid identification and isolation of those who are sick in order to control the spread [1]. Indeed, Norway has administered 663 tests per 1,000 population [8]. Meanwhile, Sweden has consistently had among the lowest test rates in Europe. Even when the country increased its testing in the fall, it still only tested about one-fourth of the people Denmark does per capita [4]. Those who do test positive in Sweden, however, face very different paths of what comes next as compared with those in other countries in Europe. Family members of those who test positive for the virus must attend school in person, unlike in other European countries, where a 14-day quarantine is mandatory if a member of a household tests positive [4]. Employees are to attend work as usual despite a positive test if they have no symptoms. FHM guidelines issued on May 15 that are still in place state that students and employees who have symptoms are to return to school and work so long as they are “seven days post-onset of symptoms and fever free for 48 hours” [4]. A curated Google map shows all the outbreaks that have been linked to Swedish schools throughout the year [6]. Sweden’s COVID-19 strategy took a toll on those needing immediate medical care of any kind. The country’s “National Board of Health and Welfare’s guidelines for intensive care in extraordinary circumstances throughout

Sweden state that priority should be given to patients based on biological, not chronological, age” [4]. This meant that regional health agencies used a Clinical Frailty scale to assess a person’s fragility and determine whether or not they should receive hospital care. Dr. Michael Broome, the chief physician at Stockholm’s Karolinska Hospital Intensive Care Unit, said he had “repeatedly been forced to say no to patients we would normally have accepted due to a lack of experienced staff, suitable facilities and equipment” [4]. In December 2020, Sweden made its first recommendation of wearing masks on public transport; prior to this, masks were only worn in healthcare settings despite strong recommendations regarding mask usage given by the World Health Organization [3]. However, there are no legal consequences if citizens do not comply; the country is relying on an “appeal to citizens’ sense of responsibility and civic duty” [3]. Meanwhile, countries such as the Netherlands, Germany and Italy imposed nationwide lockdowns. The main reason behind Sweden’s approach to COVID-19 was economic cost. FHM Director Johan Carlsson and General Counsel Bitte Bråstad wrote to the government as early as Jan. 31, 2020 about the costs associated with classifying COVID-19 as a “socially dangerous disease,” bringing up fears of loss of production and progress in society should containment measures be implemented [4]. But Sweden’s lack of containment measures did not help the economy; Sweden’s GDP fell more than any of its fellow Nordic countries, which imposed lockdowns more in line with other nations. Sweden reported

an 8.6% drop in the second quarter of the year, as compared to a 7.4% drop in Denmark and only a 3.2% drop in Finland [2]. Writing about the COVID19 response in their country, molecular biologist Andrew Ewing and activist Kelly Bjorkland wrote in their article for Time, “the Swedish way has yielded little but death and misery” [4]. •

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Slow Websites and Stalled Phone Lines: The Hurdles for Older Adults Getting a COVID Vaccine Writer: Aidan Raikar • Editor: Frank Lin

he United States started administering COVID-19 vaccines in Dec. 2020 [1]. When the vaccines became available, the country was faced with the decision of who should be vaccinated first. The Center for Disease and Control (CDC) provided guidelines of groups to be vaccinated in a specific order [2]. Per these suggestions, the people who should receive the vaccine first are healthcare personnel and long-term care facility residents (in group 1a). The next group that the CDC recommends to get vaccinated are people aged 75 years and older, as they are at the highest risk of hospitalization from COVID. Vaccinating healthcare workers happened fairly smoothly in the US, but it has been difficult for some older adults to secure a COVID vaccine. One of the problems is that it is simply hard for them to find appointments. They have to navigate buggy websites that are fairly complicated, especially to those who are not very familiar with technology. NPR featured an article with many accounts of older adults and their struggles with finding a vaccine appointment [6]. One older adult revealed that she luckily was able to get a vaccine from a town pharmacy, but she knows many others who gave up trying to look because they were frustrated. From a different news source, the story of a 78-year-old with chronic lung disease shared her

They have to navigate buggy websites that are fairly complicated, especially to those who are not very familiar with technology.

troubles of finding a COVID vaccine. She successfully navigated through a website and provided her email and phone number with no response. Then, she called the doctor’s office, which urged her to wait [3]. She did not receive any other information to secure a vaccine appointment. These are only a few examples of older adults’ struggles with finding a COVID vaccine appointment. Fortunately, there have been some grassroots movements that are helping older adults find appointments. In Albuquerque, the local fire department held a workshop with other local workers to help older adults secure vaccine appointments [5]. A software developer named Huge Ma discovered how difficult it was to find a COVID vaccine appointment when he tried to schedule one for his mother. He decided to build a free website, TurboVax, that compiles

Illustrator: Alexandra Laufer

information about appointments from multiple websites and makes it easier for people to find available COVID vaccines in New York [4]. While it was nice to see people helping out in their community, the government seemed poorly prepared for orderly vaccine distribution. Hopefully, in the future, the United States government will be more prepared to protect those most at risk without having to rely on the actions of a few individuals. •

While it was nice to see people helping out in their community, the government seemed poorly prepared for orderly vaccine distribution.

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To Mammogram or Not To Mammogram? COVID-19 and Reassessing Preventative Care Writer: Lily Coll • Editor: Julia Bulova

hroughout the pandemic, thousands of Americans have had to make difficult decisions about the value and safety of minor procedures, annual checkups and preventative care measures such as colonoscopies and mammograms. The question of whether medical appointments are worth the risk of contracting Covid-19 in a doctor’s office has created a dangerous culture in which each visit requires an impossible risk-benefit analysis [4]. Data from the Health Cost Institute demonstrated that, by mid-April of 2020, childhood immunizations were down by 59%, mammograms were down by 76% and colonoscopies were down by 88%, as compared to data from April of 2019 [4]. While many of these services have had a substantial rebound to pre-pandemic numbers in recent months, the impact of foregoing preventative care measures, specifically those related to early detection of cancer, may not be known for years to come.

Telehealth and at-home screenings are not only safer options for patients, but also protect healthcare workers by minimizing contact. According to Dr. Alon Bergman, a researcher at the Leonard Davis Institute of Health Economics, the decline in routine screening mammograms and diagnostic mammograms has led to a backlog, which will only continue to grow as people feel more comfortable going to clinics and

hospitals for the procedure [1]. Many patients who are due for preventative care procedures and checkups are not able to schedule appointments due to this backlog. Bergman’s analysis of mammogram trends showed that even patients with prior breast cancer diagnoses had a 40% reduction in screening mammograms and 30% decrease in diagnostic mammograms between March and July of 2020 [1]. Of the pool of data Bergman analysed, the percentage of missed screening mammograms translated to approximately 200-320 cases of delayed breast cancer diagnoses, of which 130-200 would be cases of invasive cancers [1]. The Breast Cancer Now charity predicted that almost 9,000 women in the UK who missed mammograms due to the pandemic are living with undetected breast cancer [2]. When discussing the health implications of the pandemic, not many people think about the impact of reduced diagnostic and preventative care measures. These statistics demonstrate the shocking and pervasive impacts of lost appointments on people’s health. However, hope is not lost. Hospitals and clinics are finding new ways to meet the shifting demands related to preventative care during the pandemic era. In a September 2020 interview, Dr. Alexander Ding described how advancements related to telemedicine have introduced several options for select preventative care measures, such as colorectal cancer screenings [5]. Patients are briefed in a virtual visit, and then a test kit is sent to their home. These at-home resources are helpful for mitigating anxiety associated with deciding whether to go for in-person appointments. Moreover, telehealth and at-home screenings are not only safer options for patients, but

also protect healthcare workers by minimizing contact. While there is certainly value in the expansion of telemedicine usage, it also presents several difficulties. In order to effectively participate in telemedicine, you must have a secure internet connection and access to a computer or device in a private location, a “luxury” that not all patients enjoy. Moreover, only 26 states require private insurers to cover healthcare services delivered through telemedicine [6]. These financial and sociological considerations illustrate how telemedicine is a service catered towards a wealthier demographic and cannot completely alleviate the growing need for routine screening.

When discussing the health implications of the pandemic, not many people think about the impact of reduced diagnostic and preventative care measures. In addition to the increased usage of telemedicine, the pandemic has uncovered other questions about the efficacy of existing health structures as they relate to preventative care. In particular, the concept of the ‘routine annual exam’ is being scrutinized. Physicians Daniel Horn and Jennifer Haas at Massachusetts General Hospital argue that the US healthcare system should embrace this moment of readjustment in the delivery of preventative care to shift from face-to-face annual exams to focusing on population health and

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community based initiatives [3]. Named strategies would include “clinical registries that readily identify all preventive services for which a patient is due; annual prevention kits for patients that facilitate widespread deployment of home-based testing, shared decision making, and self-scheduling of preventive screening tests and procedures in more convenient and approachable community settings; and robust community-based strategies involving navigators to overcome health disparities in underserved populations” [3].

Illustrator: Noor Ghanam

As we think creatively about how to increase health equity for people of all races, socioeconomic groups, gender identities and geographic locations, it is important to recognize that annual physical exams are far more common among white, wealthy populations [3]. Therefore, passively continuing to rely on annual exams as the main form of preventative care will not effectively address existing disparities in health. These are the same disparities which have been highlighted by the progression of the pandemic in which we see

Black, Indigenous and People of Color (BIPOC) being hospitalized due to Covid-19 at far greater rates than white people. Horn and Haas argue that we must shift our focus towards a population-based prevention strategy in order to both improve health outcomes as a whole as well as create a more racially and culturally competent preventative health system [3] While the impact of missed mammograms, colonoscopies and immunization appointments cannot be known for years to come, Covid-19 has presented us with a watershed moment to creatively reassess how we deliver and access preventative care in ways which will reduce health disparities and promote equity. •

FRONTIERS • PUBLIC HEALTH

COVID-19’s mRNA Vaccines: How They Work and How They are Modernizing the Field of Vaccine Research Writer: Audrey Bochi-Layec • Editor: Caelan Miller

ith its first case reported in December 2019 and over 110 million cases and 2.5 million deaths officially reported worldwide, COVID-19 is a highly contagious disease caused by the virus SARS-CoV-2 [3]. In an attempt to flatten the curve, countries have severely restricted travel, closed down businesses and schools and instituted a mask policy when in a public space. Despite all of these precautions and attempts, the number of cases, especially in the U.S., continues to skyrocket. Fortunately, two promising vaccines have recently come out by two biotechnology companies, Pfizer and Moderna. These two vaccines are both messenger RNA (mRNA) vaccines, a new form of vaccine that involves injecting mRNA that corresponds to a spike protein found on the surface of SARS-CoV-2 into the patient. This allows the patient to form an immune response and memory B and T-cells against the spike protein [2]. As such, the immune system becomes better prepared to defend the patient against an infection by the virus itself. People diagnosed with COVID-19 can report a wide range of symptoms, ranging from mild to severe symptoms that ultimately require hospitalization. Symptoms usually appear two to fourteen days after infection and include: fever, cough, shortness of breath, loss of taste or smell, body aches and chest pain. The virus is easily spread during close contact via respiratory droplets ranging from visible droplets to smaller, invisible droplets, via airborne transmission and, although less commonly, through contact with contaminated surfaces. SARS-CoV-19 is composed of an RNA genome enclosed in a viral envelope, coated with envelope (E) proteins, membrane (M) proteins and

spike (S) glycoproteins, of which the S glycoprotein specifically mediates hostcell binding and entry. Upon entering the host, the S1 sub-unit of the S protein likely binds to ACE2 receptors found on airway epithelial cells and vascular endothelial cells [2]. This initiates a

These two vaccines are both messenger RNA (mRNA) vaccines, a new form of vaccine that involves injecting mRNA... into the patient.

limited innate immune response as the virus begins to release its viral genome into the host cytoplasm and replicates. As the virus propagates, it migrates down the respiratory tract, triggering a stronger innate immune response in addition to activating the adaptive immune system. A patient’s viral load peaks during the first week of infection, declining as antibody production slowly increases as part of the adaptive immune response [2]. T-cells, a crucial component of the adaptive immune response, are critical in generating early control and eventual clearance of viral infection, yet their specific role in SARS-CoV-2 infection is still in the process of being researched. COVID-19 vaccine research is mainly centered around targeting B-cells to promote the induction of neutralizing antibodies against SARS-CoV-2. Creating a vaccine that also promotes a T-cell response, is equally as important as T-cells are critical to the production

of antibody-producing plasma cells and long-lived memory B-cells. Researchers have developed a variety of vaccine formulations for COVID-19, of which mRNA vaccines appear to be quite promising. As of December 2020, some of the first COVID-19 vaccines were authorized for use in the U.S. and mRNA vaccines represent a promising alternative to conventional vaccine approaches due to their capacity for rapid development, low manufacturing cost and high efficacy. The mRNA vaccines created by Pfizer and Moderna both contain mRNA that codes for a portion of the S protein unique to SARS-CoV-2 as well as a special coating that protects the mRNA from enzymes in the host’s body that would normally break the mRNA down. Upon injection, the mRNA enters the dendritic cells and macrophages, two types of antigen presenting cells, in the lymph node near the vaccination site. Once inside these antigen presenting cells, the cell translates the mRNA into the piece of the S protein and subsequently excretes the protein outside of the cell. The cell then breaks down the mRNA strand and disposes of them using enzymes [1]. Once the protein is displayed on the cell’s surface, the protein stimulates the patient’s innate and adaptive immune system to begin producing antibodies and activating T-cells to fight off the perceived invader. A second dose is administered between twenty-one and twenty-eight days after the first dose to help the body create more antibodies and T-cells. Since only part of the protein is made, it is antigenic but cannot harm or infect the patient with COVID-19 [1]. As such, the immune system will create memory B-cells and memory T-cells specific to the SARS-CoV-2 S protein, which will protect the patient in case of an actual COVID-19 infection.

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Even after the number of cases decreases and subsides, the COVID-19 pandemic has altered the lives of millions and has left a lasting impact on the world. The release of the revolutionary Pfizer and Moderna mRNA vaccines grants us a method of immunizing and preventing further deaths due to COVID-19. In the future, the release of these vaccines will usher in a wave of more efficient and cost-effective vaccine alternatives to conventional vaccine methods. •

Illustrator: Neha Adari

FRONTIERS • RESEARCH

The Role of ZFHX4 in Regulating the Cancer Stem Cell State Writer: Ricky Illindala • Editor: Akshay Govindan

his past summer, Americans have had to confront the pervasive racial injustice and ill-equipped public health infrastructure that underlie our daily rhythms. On the one hand, the COVID19 pandemic had a debilitating effect on the morale and mental health of us all. On the other hand, a wider reckoning with the violent history and present of the United States has reinvigorated the Black Lives Matter movement and the demands to defund the police. With so many things in tension and veiled in uncertainty, it is tempting to get lost in the rhetoric or overwhelmed by the losses. It is easy to forget that the people who suffer the most are often treated the worst. And vice versa. If we treat people better, perhaps their suffering will decrease.

With so many things in tension and veiled in uncertainty, it is tempting to get lost in the rhetoric or overwhelmed by the losses. When a situation arises and no one knows what to do, the first number people think to call is probably 9-1-1. As a result, the police handle cases ranging from mass shootings to accidental iPhone dials to mental health crises. This broad range of responsibilities is taught in 28 weeks in the St. Louis Police Academy at the Metropolitan Police Department in the city of St. Louis, Missouri. [Include interview with the police station if possible]. Police departments across the nation have become call centers for general SOS cries.

But not all calls should be treated equally. And when people struggling with mental health issues are perceived and treated as criminals, an emergency call can be deadly. The Washington Post found that since 2015, about a quarter of all people killed by police officers in America have had a diagnosed mental illness. Daniel Prude was one of many that unfortunately suffered from a mental breakdown in public. Due to misunderstanding, mistreatment, but probably both, Prude suffered from fatal injuries. In this scenario, calling the police cost a person’s life rather than protecting the wellbeing of the community. To combat the shortcomings of a system that was never meant to bear so much of the weight of caring for the community and all of its individuals, Crisis Assistance Helping Out on the Streets or CAHOOTS exists in Eugene, Oregon to provide mobile crisis intervention 24/7. They do not function as

In this scenario, calling the police cost a person’s life rather than protecting the wellbeing of the community. a substitute for the police department; rather, they work in conjunction with the police-fire ambulance department to dispatch teams of a medic and crisis worker to provide care or medical attention in mental health crises. This organization was started in 1989 when the White Bird Clinic collaborated with the city of Eugene to improve the city’s response to mental illness, substance abuse, and homelessness. Interestingly, the White Bird Clinic was formed only two decades prior to the formation of CAHOOTS. The clinic is unique in its interest in alternative and experimental approaches to addressing societal problems. At present, CAHOOTS responds to more than 65 calls every day. Demand is high, but not just in the Eugene-Springfield Metro area. More cities are beginning to implement similar mobile crisis intervention teams including Denver, Oakland, Olympia, and Portland. This integrated health care model could be a key solution in providing better crisis care for our cities’ homeless population, our neighbors, and ourselves. •

Illustrator: Angela Chen

SPRING 2021 • VOL 15 ISSUE 1

A Race Between COVID-19 Variants and Vaccines: How the Mutating Virus has Impacted Vaccination Efforts and Effectiveness Writer: Pooja Shah • Editor: Caelan Miller

he first COVID-19 case was reported over one year ago in Wuhan, China on December 31, 2019. Since then, the virus has reached every continent with over 98 million reported cases and two million deaths [6]. As cases have been rising in record time, vaccine development and clinical trials have been simultaneously progressing due to a heightened urgency to get the pandemic under control. Over a year after the first case of COVID-19, we now possess numerous vaccines that have been granted emergency use authorization by the FDA. Just as vaccine distribution has begun, three new variants of the virus have been identified in Brazil, South Africa, and the United Kingdom [4]. These variants have raised widespread concern regarding the efficacy of the current vaccines in response to the new strains potentially causing people to experience a second round of COVID-19.

How effective are the current vaccines in building immunity towards these three new variants? It may appear that we are now back to where we began due to the emergence of these new variants; however, the key difference is the arsenal of vaccines at our disposal. The discovery of the new variants of coronavirus raises an important question: How effective are the current vaccines in building immunity towards these three new variants? Clinical trials have been underway to better understand how these mutations affect the efficacy of the current

vaccines. In order to better understand the levels of immunity the vaccine provides from the new variants, it is first important to understand how the vaccine works. The Pfizer-BioNTech and Moderna vaccines utilize a recombinant spike glycoprotein generated from mRNA [6]. The CDC explains that mRNA vaccines provide instructions to our cells to make a spike protein [1]. A spike protein is found on the surface of the virus that causes COVID-19. By generating this protein upon the mRNA vaccine, our immune system is able to recognize that the protein doesn’t belong there and it starts to build an immune response by generating antibodies, simulating what happens in natural infection against SARS-CoV-2. Through the administration of this type of vaccine, the body is able to learn how to protect against future infection, without facing the risks and consequences of being naturally infected by COVID-19. With the three new variants of the virus, researchers are focusing on studying how effective the current mRNA vaccines are in preventing reinfection. In a recent study, researchers from Pfizer, BioNTech and the University of Texas Medical Branch studied how effectively blood taken from people who had received the companies’ vaccines fought off a virus that was engineered to have the main mutations found in B.1.351 (South Africa) , B.1.1.7 (United Kingdom) and P.1 (Brazil) [5]. The two vaccines developed by Pfizer-BioNTech and Moderna appeared to be very effective against the variant of the virus first detected in the UK. The study also indicated a decreased efficacy of the vaccine towards the variant first discovered in South Africa. They reported

Clinical trials have been underway to better understand how these mutations affect the efficacy of the current vaccines. a two-thirds drop in neutralization power against the variant compared to other variants of the SARS-CoV-2 coronavirus [5]. From the results alone, it is relatively difficult to extrapolate what would happen to someone who was vaccinated and potentially exposed to one of the SARS-CoV-2 variants. A limitation of the study was that it focused primarily on neutralizing antibodies, not accounting for how other branches of the immune system would react to the variants. Vaccines are capable of generating a range of different antibodies and T-cells, so it is possible that other avenues of the immune system can play a role in generating an immune response, even if the effectiveness of the neutralizing antibodies is reduced. It is likely that the virus will continue to mutate based upon the intrinsic high error rate of RNA replication, which is worrisome to researchers and vaccine providers alike. In response, Pfizer and BioNTech recently announced they were in the process of developing a booster shot or updated vaccine to address the concern these variants have created [2]. Based on the data provided by studies thus far, researchers speculate that even if the vaccines are less effective against B.1.351 or other potential variants, the shots can still protect people from severe COVID-19 symptoms and side effects.

FRONTIERS • RESEARCH

The study also indicated a decreased efficacy of the vaccine towards the variant first discovered in South Africa.

Illustrator: Neha Adari

The mutated variants have presented a new challenge and utmost urgency to limit the spread of the virus. In an interview with CNBC, Dr. Mike Ryan from the World Health Organization compared the mutating virus to entering the second half of a football game [3]. He stated that while it doesn’t “change the rules of the game, it does give the virus some new energy” [3]. Hence, limiting transmission by following

current public health guidelines is crucial to preventing the virus from rapidly mutating. While the virus mutating is inevitable, the current vaccines provide adequate immunity towards COVID-19. Equitable distributions of the current vaccine and continued clinical research is necessary to keep the new variants from proliferating, requiring equal effort and commitment from all parties involved. •

FRONTIERS • RESEARCH

SPRING 2021 • VOL 15 ISSUE 1

Breakthrough Wound Therapy: Magic? No, Maggots. Writer: Haleigh Pine • Editor: Lily Luu

ntentionally introducing disease-ridden larvae into an open wound for days at a time sounds like some sort of medieval torture. But maggot therapy, first performed in the early 20th century, has been re-emerging as a useful standard of care and an alternative to amputation. This FDA-approved procedure involves applying germ-free larvae of “medical-grade maggots” to open wounds at a dose of five to ten larvae per square centimeter of surface area and covering with a special dressing for two to three days. The maggots use digestive enzymes to dissolve dead and infected tissue, which can disinfect the wound by secreting antimicrobial molecules and actually stimulate healthy tissue growth. These specialized medicinal maggots cannot eat healthy tissue, so they want to crawl elsewhere once the wounds are clean [3]. This phenomenon was first observed by injured soldiers during World War I, noting that wounds healed faster when they had been infected with maggots. William Baer, an orthopedic surgeon, was one of the witnesses to this, and upon his return, became the first to intentionally apply maggots to a wound. Throughout the 1920s, he bred specific species of larvae to treat 98 children with osteomyelitis and soft tissue infections. Within the next five years, American, Canadian and European surgeons promoted the use of maggots, with many hospitals creating their own insectaries for a maggot supply. Yet, by the 1940s, surgical techniques improved and antibiotics became widely available, thus the types of wounds receiving maggot therapy became much less common [5]. However, at the end of the 1980s, pressure and diabetic foot ulcers were an

This phenomenon was first observed by injured soldiers during World War I, noting that wounds healed faster when they had been infected with maggots. emerging threat, along with the rise of antimicrobial resistance. With more current medical technology, previously fatal diseases have now become chronic. Diabetic foot ulcers affect 15% of the diabetic population and are the cause of at least 70,000 amputations annually [5]. In addition, the increasing prevalence of nonhealing wounds has already led to over $20 billion for annual management costs and two million workdays lost [5]. Multiple clinical studies at the end of the 20th century showed that maggot debridement therapy (MDT) can be more effective in cleaning chronic wounds than conventional treatments [3]. These include topical antimicrobial therapy, hydrogels, chemical debriding agents, saline-moistened dressings and surgical debridement [4]. The studies also demonstrated that while MDT was effective as a last resort over

Current technology includes “maggot containment dressings,” which are cage-like designs that completely surround the larvae while restricting access to the wound...

amputation, with a limb salvage rate of over 40%, it was even more successful when used at an earlier time in the course of treatment [3]. The high limb salvage rates may be attributed to increased oxygen perfusion, cellular proliferation, restructuring of the extracellular matrix and rapid spread of connective tissue [5]. Some of the problems that existed with MDT in the past were making the dressings, obtaining germ-free maggots and expenses. There have been improvements to adhesives and synthetic fabrics as well as easier methods of disinfecting and raising maggots, and the cost is now relatively inexpensive due to the escalation of many other surgical treatments [2]. Current technology includes “maggot containment dressings,” which are cage-like designs that completely surround the larvae while restricting access to the wound, minimizing patient discomfort since

There have been improvements to adhesives and synthetic fabrics as well as easier methods of disinfecting and raising maggots. the maggots can’t crawl over exposed nerves. There is a simpler technique of “maggot confinement dressings,” which give complete access to the wound but don’t provide the same benefits [5]. From the patient’s perspective, MDTassociated pain is reported in 5-30% of cases [5]. However all of these

FRONTIERS • RESEARCH

treated with secretions had lower levels of complement proteins than the control groups, which include the aforementioned standard treatments. Specifically, the researchers observed the secretions had ripped some of the proteins apart, reducing the protein levels by 19% to 55% in postoperative wounds [2]. Interestingly, the maggot secretions were just as effective after sitting on the shelf for a month and more effective after being boiled. This team is working to isolate these complement-inhibiting compounds for clinical drug development; however, a solution

Maggot secretions were just as effective after sitting on the shelf for a month and more effective after being boiled.

Illustrator: Eugenia Yoh instances also reported wound pain before receiving treatment. Pain most likely occurred within the first 24 hours as maggots increased in size and can usually be adequately controlled with analgesics [5]. Looking towards the future, there are some studies on how to isolate the wound-healing molecules without having to apply the maggots. Researchers at the Leiden University Medical Center

in the Netherlands have introduced isolated maggot secretions into blood samples and measured the production of complement proteins, which contribute to inflammatory responses. Having complement proteins in the blood usually help restore healthy tissue, but in cases of chronic wounds, they can actually cause cell death and enhance inflammation, leading to further injury and impairment of wound healing [2]. In the experiment, every blood sample

is still several years away, at least [2]. In all, this effort to create drugs from maggot secretions is likely more difficult than just combining a few chemicals. There seems to be a synergistic effect from the secreted mixture and the movement of the maggots also contributes by giving the enzymes access to deeper tissue [5]. For now, the resurgence of MDT as a standard practice will suffice. With new technology and research investments, this old 20th century treatment is still relevant, especially with concerns about antimicrobial resistance. While it has developed substantially from just letting diseased maggots loose into a wound, the principal and efficacy remain in these modern times. •

SPRING 2021 • VOL 15 ISSUE 1

The Golden Future of Cancer and Nanotechnology Writer: Rehan Mehta • Editor: Alexandra Dram

ancer is one of the leading causes of death worldwide, with the 18.1 million new cases worldwide in 2018 expected to rise to 29.5 million by 2040 [1]. Despite more knowledge about the causes of cancer and improved interventions, cancer mortality rates are still high due to delays in diagnosis and high rates of recurrence. Additionally, current cancer treatments involving chemo or radiation therapy often cause damage to surrounding healthy tissue and result in several side effects. Taking these into account, there is a high demand for the development of effective diagnostics and treatments for cancer. The field of nanotechnology has seen considerable growth in the past few years, and it is thought that nanotechnology can be utilized to overcome the limitations of conventional cancer treatments. Gold nanoparticles have been of particular interest due to many of their intrinsic properties. Their synwwthesis is relatively simple and their size and shape, which influence stability, mobility and biocompatibility, can be controlled [2]. Precious metals like gold also have a unique optical property called surface plasmon resonance, which allows their electrons to both absorb and scatter light [3]. This property tailors gold nanoparticles for cancer imaging, detection and therapy.

Taking these into account, there is a high demand for the development of effective diagnostics and treatments for cancer.

Another important property is the surface functionalization of gold nanoparticles, allowing their surface to be conjugated with a biological compound which could enhance biocompatibility, provide protection, promote specific interactions with cells and allow for targeted drug delivery. Preventing immune recognition and increasing particle circulation time can further maximize the efficiency and minimize harm of such novel treatments. The surface of gold nanoparticles can be coated with polyethylene glycol (PEG) in a process called PEGylation in order to accomplish these aims [4]. One of the various applications of gold nanoparticles is their potential as drug carriers. Traditional drug delivery of chemotherapeutic drugs results in only a fraction of the drug reaching the tumor site [5]. A targeted drug delivery would increase the effectiveness and avoid side effects caused by the drug being delivered to other parts of the body. Gold nanoparticles are able to pass through capillaries to easily reach the cell with lifesaving drugs bound to them. Such targeted delivery to the tumor site could occur either passively or actively. Passive targeting takes advantage of the unique characteristics of solid tumors, such as their leaky vasculature, which enables these nanoparticles to accumulate in the tumor [6]. This is known as the enhanced permeation and retention (EPR) effect. It is important to note that not all tumors exhibit this effect and that there are still limitations. Active targeting, on the other hand, involves the surface of the nanoparticle being conjugated with ligands of tumor specific biomarkers [5]. Methotrexate (MTX), for example, is a common drug used to treat cancer.

When bound to gold nanoparticles, MTX displays higher cytotoxicity towards tumor cells and accumulates at a higher level in tumor cells when compared to free MTX, demonstrating that anticancer drugs may be more effective when combined with gold nanoparticles [7]. The ability of gold nanoparticles to target tumor cells also makes them ideal for imaging. A variety of imaging techniques, such as MRI, positron emission tomography (PET) imaging and fluorescence imaging, have been able to detect gold nanoparticles [8]. Medical imaging utilizing gold nanoparticles has the potential to help detect tumors early and make it easier to identify where the tumor ends and where the healthy tissue begins.

Active targeting, on the other hand, involves the surface of the nanoparticle being conjugated with ligands of tumor specific biomarkers. Due to their unique optical properties, gold nanoparticles are of particular interest for the application of photothermal therapy (PTT). This kind of treatment involves the gold nanoparticles absorbing light and efficiently converting it into heat, which can then kill the tumor cells. PTT utilizes near infrared light since it is not absorbed by tissues and can treat tumors under the skin [9]. Since the gold nanoparticles would only accumulate in the tumor cells, this method would effectively kill cancer cells while leaving the healthy

FRONTIERS • RESEARCH

cells unharmed. In one study utilizing this approach, tumors were grown in 25 immune-competent mice and PEGcoated gold nanoparticles were intravenously injected. For the treatment group, which consisted of seven mice, the tumors were then exposed to near infrared light using a laser. Within 10 days, all tumors showed complete necrosis and 90 days following treatment, the mice remained healthy and tumor-free [10]. Although this treatment was performed in mice, it is still very promising and the results demonstrate that PTT utilizing gold nanoparticles is effective. Additionally, such a treatment is minimally invasive, easy to perform, and can treat tumors in regions where surgery is not feasible. As of now, this technology is still in its infancy and there are not many clinical trials being conducted. That being said, one early stage clinical trial has demonstrated remarkable results. The study used gold-silica nanoparticles and PTT for the treatment of prostate cancer. Sixteen men diagnosed with low or intermediate risk localized prostate

One cause of concern is that gold nanoparticles might have unintended side effects on human health. cancer underwent treatment [11]. The nanoparticles were infused and the tumors were exposed to a near infrared laser. Biopsies revealed that PTT was successfully achieved in fifteen of the sixteen men and no serious adverse

Illustrator: Shanthi Deivanayagam events were reported [11]. Ultimately, the trial demonstrated that photothermal therapy utilizing nanoparticles is both a safe and feasible method to destroy prostate tumors. While gold nanoparticles do show promise and potential to diagnose and treat cancer in the future, it is also important to consider their current limitations. One cause of concern is that gold nanoparticles might have unintended side effects on human health. Certain properties may cause these gold nanoparticles to be toxic, which can be influenced by factors such as size, shape, surface charge and composition [5]. One of the main challenges is that it is hard to determine the response of the biological system to nanoparticles in different cells or tissues due to their complexity and heterogeneity.

Additionally, the fate of nanoparticles and how they will be excreted from the body is also an important aspect that needs to be considered [5]. Lastly, more information on whether gold nanoparticles impact epigenetics and gene expression patterns is needed. Taking these factors into consideration, gold nanoparticles offer a unique opportunity to improve cancer diagnostics and treatments; however, more research is needed before they can be translated into clinically accepted cancer diagnostics and treatments. •

SPRING 2021 • VOL 15 ISSUE 1

AI: Cutting Edge Technology Entering Healthcare? Writer: Jacob Oscherwitz • Editor: Alexandra Dram

he healthcare sector is one of the most important markets in the United States economy. The implementation of the modern healthcare system has allowed the overall quality of life in the United States to drastically improve since the last century. For instance, the infant mortality rate has declined from 12.6 deaths per 1,000 live births down to 5.9 over the span of 1980-2016 [1]. Such strides in America’s aggregate quality of life would not have been possible without the implementation of healthcare systems. However, these systems’ hidden flaws, inefficiencies, and inequities continue to propagate yearly health concerns such as the flu, necessitating additional solutions for greater societal benefit. Alongside growing inequities are strides in innovation: a recent proliferation into research and development of artificial intelligence (AI) has spilled over into healthcare. For instance, it is projected that the healthcare-centric AI industry will grow around 42% per year into 2025 [2]. It is evident that change is coming. What is catalyzing this interest in healthcare AI? What are examples of ventures and endeavors aiming to improve healthcare through this nebulous new innovation? And most importantly, how will these endeavors have built upon these innovations impact healthcare? One area of the United States healthcare industry with concern for inefficiency on a large scale is in clinical laboratory testing, valued at $176.7 billion [3]. An example of the industry’s sheer costs and profits of the industry can be analyzed by examining the projected 700 million predicted to be living with diabetes, and thus testing for and monitoring diabetes. Like diabetes, other chronic diseases affecting large numbers of individuals are also creating an

astronomical demand on clinics, laboratories, and healthcare systems. Such demand, as concluded previously, will inevitably lead to inefficiencies and therefore misdiagnoses. According to the University of California, San Francisco, misdiagnosing illness and medical errors account for approximately 10% of all US deaths [2]. Fortunately, this harrowing statistic has not gone unnoticed by medical professionals and innovators in healthcare. New ventures, such as Buoy Health – a startup leveraging AI to help patients determine diagnoses and next steps for treatment – have utilized AI to improve diagnostic test distribution and analysis, lowering the margin of error to a far lower frequency [5]. By using algorithms & national databases and combining them with AI, Buoy has been able to develop an individualized AI chatbot. Through a series of questions, the chatbot is able to guide the user to the most probable prognosis, as well as guide the user to specialists. Innovations in diagnostic testing such as Buoy could prove extremely useful towards enforcing equal access to quality testing and lowering the rate of dangerous misdiagnoses.

It is already clear that AI is proving useful in the healthcare market. It is already clear that AI is proving useful in the healthcare market; for example, new innovations in AI have also helped make essential strides

in deciphering recent public health events, such as the COVID-19 pandemic. Recently, AI was implemented to analyze the composition and compatibility of one billion small molecules to determine their ability to bind to SARS-CoV-2 proteins [6]. It was discovered that particular drugs such as Baricitinib can weaken SARS-CoV-2 and its proteins, making it more manageable by the human immune system. Baricitinib is a Janus kinase inhibitor, which can bind to receptors on immune cells, blocking the receptor pathway to make more cytokines that cause immune system reactions. This leads to the body’s reaction from COVID-19 being milder, meaning a smaller chance lungs and components of the airway are affected and lowering the chance of intubation. The knowledge from this discovery was quickly implemented in hospitals across the country, leading to a contribution towards the effort to reduce the spread and severity of COVID-19. More importantly, such a discovery would not have been possible simply by human means or through present computer models. By utilizing the hyper-efficient recursive algorithms that comprise the AI model, billions of molecules could be analyzed in days when it would normally take years to be analyzed through other methods. Whether employed on diagnostic testing or discovering biochemical breakthroughs, AI has a place in healthcare. Its ability to execute at a higher level than humans for a longer period of time with fewer inherent biases makes it an invaluable asset. Ambitious initiatives such as contact tracing, symptom tracking and diagnosis, hospital organization, and more can now be handled with relative ease by both healthcare professionals and everyday citizens. •

FRONTIERS • SOCIOCULTURAL

Illustrator: Angela Chen

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The Negative Effects of Gender Bias in Health Care Writer: Lily Luu • Editor: Sophia Xiao

hroughout history, women have been victims to implicit bias in medical diagnosis, treatment and care. This bias has made its way into the examination room, where women are less likely to be diagnosed with a non-psychosomatic illness, have their pains treated and have their symptoms be taken seriously compared to men [8]. There exists a number of contributors to the health disparities and gender biases experienced by women today, including the controversial history of “female hysteria” and women being excluded from clinical trials until the early 1990s. Instead, the majority of medical treatments and diagnosis have been based on males, specifically a 75-kilogram white male [2]. Legal Explanation defines gender bias as the “prejudice in action or treatment against a person on the basis of their sex,” which can contribute to disparities in medical assessment, diagnosis and treatment [7]. For example, men and women are treated differently in healthcare, from their pain to medical diagnoses. One study found that in the emergency department, “women who report having acute pain are less likely to be given opioid painkillers” (the most effective type) than men [1]. Even though women report experiencing more frequent and severe pain levels, research shows that physicians prescribe fewer pain medications to women than men after surgery [5]. Through her studies, Dr. Esther Chen suspects that doctors are less likely to prescribe opioids to women present in the emergency department with abdominal pain due to the assumption that women with abdominal pain have gynaecological problems rather than acute surgical disease [1].

The tendency to connect women’s physical complaints to the female reproductive system and mental illness dates back to the phenomenon of “female hysteria.” This commonly diagnosed female “disorder” during the 18th and 19th centuries blamed the “wandering womb” or sensitive nerves for causing illnesses experienced by women and later became perceived as a psychological problem [4]. Although “female hysteria” might be controversial today, its history and attitude towards women and their physical pain still lingers through the gender bias that exists in today’s health care. Even before receiving a diagnosis, women already experience disparity in the waiting room. A study from the University of Pennsylvania found that women waited 16 minutes longer than men before receiving pain medications when they visited the emergency room [3]. Additionally, a 2014 Swedish study reported that women’s cases were classified as urgent less often [10]. This bias can be lethal and has led to numerous diagnostic errors and unnecessary deaths. Each year, an estimated 40,000 to 80,000 people die due to diagnostic errors in the United States alone [4].

This bias can be lethal and has led to numerous diagnostic errors and unnecessary deaths. Women experience having their pains dismissed and having to make multiple visits, sometimes with different doctors, before receiving a diagnosis.

The Brain Tumor Charity released a report in 2016 on the treatment of brain tumor patients in the United Kingdom and found that women were less likely than men to receive an immediate diagnosis, with many having to make over five visits before obtaining one [11]. In the same report, a 39-year-old woman shared how she was made fun of by doctors who sarcastically asked if she thought her headaches were caused by a brain tumor. She had to request a referral to neurology, and even then, had to make repeated visits just to be prescribed antidepressants, sleep charts and analgesia, none of which were helpful [4].

Women’s physical complaints have not been taken seriously and instead, are too often written off as psychiatric.

Women’s physical complaints have not been taken seriously and instead, are too often written off as psychiatric. Maya Dusenbery’s book “Doing Harm” includes personal stories from women across the United States to look at how sexism in medicine harms women today. Jackie, a woman whose story is told in “Doing Harm,” suffered from chronic kidney problems, fever fatigue and terrible menstrual and joint pain. She went to see a primary care doctor, a urologist and a pulmonologist, but in the end, was diagnosed with depression and prescribed with unhelpful antidepressants [4]. The Chronic

FRONTIERS • SOCIOCULTURAL

Pain Research Alliance’s co-founder and director, Christin Veasley, stated that “women have been more often referred to psychologists or psychiatrists, whereas men are given tests to rule out actual organic conditions” [1]. Veasely recounted women’s alarming stories of doctors’ advice, ranging from their diagnosis being caused by marital problems to having wine before sex to make things better [1]. Gender bias in health care needs to be recognized and addressed. In the modern day, closing the gender gap in health care and alleviating gender biases are crucial to assure all patients receive the right medical care and are treated with respect. Some ways to help eliminate the existing gender bias include educating clinicians to increase their awareness of their own biases, diversifying health care teams, having checklists and guidelines to standardize patient evaluations and including more women in clinical trials for a more proper representation of women in medical research [6,9]. Being able to recognize that gender bias still exists in health care today is an important first step, but there is still more that needs to be done. •

Illustrator: Haley Pak

SPRING 2021 • VOL 15 ISSUE 1

COVID-19 Impact on Children and Adolescents Writer: Alexandra Dram • Editor: Haleigh Pine

midst the COVID-19 pandemic, one of the most shared experiences has been one of isolation, quarantine, and social distancing. But how much of this experience can we truly say is shared? During an era that requires skillsets of rapid adaptation and resilience, the mental health consequences of the COVID-19 pandemic have presented a monumental challenge to current and future health systems. In particular, children are challenged by these trying times in novel ways. Evidence from previous outbreaks and environmental transitions have shown to present barriers to healthy development in youth, and there is no doubt that the current pandemic will present a myriad of new obstacles for years to come [3].

...longitudinal studies have shown that psychosocial stressors in youth... create a hyperinflammatory response that impair neurodevelopmental processes and lead to cognitive and mood disturbances. Navigating online and hybrid learning scenarios has required increased online presence, accelerating a dangerous curve of media addiction, stress and loneliness. Andrew Archer, a therapist at Minnesota Mental Health Services, says, “[The children] need to be climbing on stuff, they need to be tackling each other, they need to be in physical contact because they’re learning social

Illustrator: Lucy Chen norms. They’re learning boundaries with interacting with one another” [4]. Instead, abrupt withdrawal from school, social life and outdoor activities, in addition to increases in domestic violence and food insecurity, have created new stressors translating to higher incidences of post-traumatic stress, depression and anxiety, as per a systematic review of 63 studies featuring over 51,000 participants [5]. Furthermore, longitudinal studies have shown that psychosocial stressors in youth, such as those which have arisen over the past year, create a hyperinflammatory response that impair neurodevelopmental processes and lead to cognitive and mood disturbances [3]. As these new stressors see no resolution for at least the coming months, neither will their resulting effects which contribute to increased anxiety, changes in diets, fear or even failing to scale problems [2].

Current frameworks to support mental health needs are already in much need of repair; however, given the exacerbated effects of the pandemic, educational institutions must prioritize providing this type of support to returning students. It is crucial that schools have access to highly-skilled mental health professionals and create pathways for students to access these resources, a task which schools, communities and governments have long been grappling with how to approach [6]. Additionally, increasing screening for at-risk individuals as well as educating staff and teachers will prove to be useful measures for understanding how to best support students [1]. After all, despite its many physical, social and mental consequences, the pandemic has made clear how students, and communities, depend on schools as cornerstones of emotional well-being. •

FRONTIERS • REFERENCES

References p.4-5

p.8-10

Seasonal Affective Disorder (SAD): How has COVID-19 made SAD worse? Writer: Shanthi Deivanayagam

A Crucial Call for Change from the Coronavirus: Revamping the American Healthcare System to Address the Gaping Holes Exposed by COVID-19 Writer: Daleep Grewal

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p.6-7 Rural Inequities in Care: Reducing Stigma and Providing Access for All Writer: Chris Byron [1] Chibanda, D., Cowan, F., Verhey, R., Machando, D., Abas, M., & Lund, C. (2017). Lay health Workers’ experience of delivering a problem Solving therapy intervention for common mental disorders among people living with Hiv: A qualitative study from Zimbabwe. Community Mental Health Journal, 53(2), 143-153. doi:10.1007/s10597-0160018-2 [2] Chibanda, D., Weiss, H. A., Verhey, R., Simms, V., Munjoma, R., Rusakaniko, S., . . . Araya, R. (2016). Effect of a Primary Care–Based psychological intervention on symptoms of common mental disorders in Zimbabwe. JAMA, 316(24), 2618. doi:10.1001/jama.2016.19102 [3] Declaration of Alma-Ata. (n.d.). Retrieved February 22, 2021, from https://www.who.int/teams/social-determinants-of-health/declaration-of-alma-ata [4] Morales, D. A., Barksdale, C. L., & Beckel-Mitchener, A. C. (2020). A call to action to address rural mental health disparities. Journal of Clinical and Translational Science, 4(5), 463-467. doi:10.1017/cts.2020.42 [5] Smalley, K. B., Yancey, C. T., Warren, J. C., Naufel, K., Ryan, R., & Pugh, J. L. (2010). Rural mental health and psychological treatment: a review for practitioners. Journal of clinical psychology, 66(5), 479–489. https://doi. org/10.1002/jclp.20688 [6] Summers-Gabr, N. M. (2020). Rural–urban mental health disparities in the United States during COVID-19. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1). doi:10.1037/tra0000871

[1] Agarwal, Ankit, and Trevor J. Royce. “The Effect of Medicare for All on Rural Hospitals.” Lancet (London, England), vol. 396, no. 10260, Oct. 2020, p. 1392. EBSCOhost, doi:10.1016/S0140-6736(20)32210-8. [2] COVID-19 map. (n.d.). Retrieved February 21, 2021, from https://coronavirus.jhu.edu/map.html [3] Fitzpatrick, M. C., Singer, B. H., Foster, E. M., Parpia, A. S., & Gal- vani, A. P. (2020). Improving the prognosis of health care in the USA. The Lancet, 395(10223), P524-533. [4] Horn, C. (n.d.). COVID-19 highlights underlying racial health disparities. Retrieved February 21, 2021, from https://www.sc.edu/uofsc/posts/2020/06/covid_health_ disparities.php#.YDKT7i9h01I [5] Raifman, M. A., & Raifman, J. R. (2020). Disparities in the population at risk of severe illness from COVID-19 by race/ethnicity and income. American Journal of Preventive Medicine, 59(1), 137–139. https://doi.org/10.1016/j. amepre.2020.04.003 [6] Rothfeld, M., Sengupta, S., Goldstein, J., & Brian. (2020, March 25). 13 deaths in a day: An ‘APOCALYPTIC’ CORONAVIRUS surge at an N.Y.C. HOSPITAL. Retrieved February 21, 2021, from https://www.nytimes.com/2020/03/25/nyregion/nyc-coronavirus-hospitals.html [7] Speer, Matthew, et al. “Excess Medical Care Spending: The Categories, Magnitude, and Opportunity Costs of Wasteful Spending in the United States.” American Journal of Public Health, vol. 110, no. 12, Dec. 2020, pp. 1743–1748. EBSCOhost, doi:10.2105/AJPH.2020.305865. [8] Tummalapalli, S. L., & Keyhani, S. (2020). Changes in preventative health care after medicaid expansion. Medical Care,Publish Ahead of Print. doi:10.1097/ mlr.0000000000001307 [9] Vohra, S., Pointer, C., Fogleman, A., Albers, T., Patel, A., & Weeks, E. (2020). Designing policy solutions to build a healthier rural america. Journal of Law, Medicine & Ethics, 48(3), 491-505. doi:10.1177/1073110520958874

p.11-14 From the Cockpit to the Operating Room: Combating Medical Error Through Crew Resource Management Writer: Jason Zhang [1] Cosby, K., & Croskerry, P. (2004). Proﬁles in Patient Safety: Authority Gradients in Medical Error. Academic Emergency Medicine, 11(12), 1341-1345. doi:10.1197/j. aem.2004.07.005 [2] Faltz, L., Morley, J., Flink, E., & Dameron, P. D. (2008). The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures. Advances in Patient Safety, 1. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK43622/ [3] Fischer, J., Phillips, E., & Mather, J. (2000). Does Crew Resource Management Training Work? Air Medical Journal, 19(4), 137-139. doi:10.1016/S1067-991X(00)90006-3 [4] Gillespie, B., Gwinner, K., Chaboyer, W., & Fairweather, N. (2012). Team Communications in Surgery- Creating a Culture of Safety. Journal of Interprofessional Care, 27(5), 387-393. doi:10.3109/13561820.2013.784243

[5] Makary, M., & Daniel, M. (2016). Medical Error- the Third Leading Cause of Death in the US. The BMJ, 353. doi:10.1136/bmj.i2139 [6] Mazzocco, K., Petitti, D., Fong, K., Bonacum, D., Brookey, J., Graham, S., … Thomas, E. (2009). Surgical Team Behaviors and Patient Outcome. The American Journal of Surgery, 197(5), 678-685. doi:10.1016/j.amjsurg.2008.03.002 [7] National Transportation Safety Board. (1989). Aircraft Accident Report: United Airlines Flight 232. (NTSBAAR-90-6). Retrieved from https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR-90-06.pdf [8] National Transportation Safety Board. (1979). Aircraft Accident Report: United Airlines Inc. (NTSB-AAR-79-7). Retrieved from https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR7907.pdf [9] Neily, J., Mills, P., Young-Xu, Y., Carney, B., West, P., Berger, D., … Bagian, J. (2010). Association Between Implementation of a Medical Team Training Program and Surgical Mortality. JAMA, 304(14), 1693-1700. doi:10.1001/ jama.2010.1506 [10] Ricci, M., & Brumsted, J. (2012). Crew Resource Management: Using Aviation Techniques to Improve Operating Room Safety. Aerospace Medicine and Human Performance, 83(4), 441-444. doi:10.3357/ASEM.3149.2012 [11] Shea-Lewis, A. (2009). Teamwork: Crew Resource Management in a Community Hospital. Journal for Healthcare Quality. doi:10.1111/j.1945-1474.2009.00042.x [12] US Department of Health and Human Services, Agency for Healthcare Research and Quality. (2003). Efforts to Reduce Medical Errors: AHRQ’s Response to Senate Committee on Appropriations Questions. (Publication # 04RG005). Retrieved from https://archive.ahrq.gov/research/ findings/final-reports/pscongrpt/psini2.html [13] US Department of Transportation, Federal Aviation Administration. Crew Resource Management. Retrieved from https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/cami/library/online_libraries/aerospace_medicine/tutorial/media/II.8.5_Crew_Resource_Management.doc

p.15 Where the US Healthcare System Went Wrong Writer: Kimberly Hwang [1] Amadeo, K. (2019, November 19). Medical Bankruptcy and the Economy. Retrieved March 05, 2021, from https://www.thebalance.com/medical-bankruptcy-statistics-4154729 [2] Gan, E. (2021, February 03). Are the more expensive medical scans better, and do you really need them? Retrieved March 05, 2021, from https://cnaluxury.channelnewsasia.com/experiences/are-the-more-expensive-medical-scans-better-12946248 [3] Hohman, M. (2020, September 22). Why is Health Care So Expensive in the United States? Retrieved March 05, 2021, from https://www.today.com/tmrw/why-healthcare-so-expensive-united-states-t192119 [4] Khazan, O. (2018, June 22). The 3 Reasons the U.S. Health-Care System Is the Worst. Retrieved March 05, 2021, from https://www.theatlantic.com/health/archive/2018/06/the-3-reasons-the-us-healthcare-systemis-the-worst/563519/ [5] Leong, S. (2019, March 01). Health Care for All: The Good & Not-So-Great of Taiwan’s Universal Coverage. Retrieved March 05, 2021, from https://international.thenewslens. com/article/108032#:~:text=Liu%20is%20among%20 the%2099.6,quality%20and%20affordable%20medical%20care

SPRING 2021 • VOL 15 ISSUE 1

[6] Park, A. (2015, March 24). Your Doctor Likely Orders More Tests Than You Actually Need. Retrieved March 05, 2021, from https://time.com/3754900/doctors-unnecessary-tests/ [7] Percy, A., & Stockley, K. (2020, September 30). Who Went Without Health Insurance in 2019, and Why? Retrieved March 05, 2021, from https://www.cbo.gov/publication/56658 [8] Scott, D. (2020, January 13). Taiwan’s single-payer success story - and its lessons for America. Retrieved March 05, 2021, from https://www.vox.com/healthcare/2020/1/13/21028702/medicare-for-all-taiwanhealth-insurance

p.16-18 The (Not So) ‘Great Equalizer’: COVID-19’s Gendered Effects and Future Leadership Recommendations Writer: Maya Kovacevic [1] Burki, Talha. “The Indirect Impact of COVID-19 on Women.” The Lancet Infectious Diseases, Elsevier, 29 July 2020, www.sciencedirect.com/science/article/pii/ S1473309920305685. [2] Chaney, Sarah, and Lauren Weber. “Coronavirus Employment Shock Hits Women Harder Than Men.” The Wall Street Journal, Dow Jones & Company, 15 May 2020, www.wsj. com/articles/coronavirus-employment-shock-hits-women-harder-than-men-11589535002?mod=article_inline. [3] Delivered by women, led by men: A gender and equity analysis of the global health and social workforce. Geneva: World Health Organization; 2019 (Human Resources for Health Observer Series No. 24). License: CC BY-NC-SA 3.0 IGO. [4] Huang, Peter H., Put More Women in Charge and Other Leadership Lessons from COVID-19 (June 15, 2020). U of Colorado Law Legal Studies Research Paper No. 20-21, 15(3) Florida International University Law Review (2021), http://dx.doi.org/10.2139/ssrn.3604783 [5] Jolly, Shruti et al. “Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers.” Annals of internal medicine vol. 160,5 (2014): 344-53. doi:10.7326/M13-0974 [6] Langer, Ana, et al. “Women and Health: the Key for Sustainable Development.” The Lancet, vol. 386, no. 9999, 4 June 2015, pp. 1165–1210., doi:10.1016/s01406736(15)60497-4. [7] Li G, Miao J, Wang H, et al. “Psychological impact on women health workers involved in COVID-19 outbreak in Wuhan: a cross-sectional study.” Journal of Neurology, Neurosurgery & Psychiatry 2020;91:895-897. [8] Live, Washington Post. “Coronavirus: Leadership During Crisis with Iceland Prime Minister Katrín Jakobsdóttir.” The Washington Post, WP Company, 26 Oct. 2020, www.washingtonpost.com/washington-post-live/2020/10/20/coronavirus-leadership-during-crisis-with-iceland-prime-minister-katrn-jakobsdttir/. [9] Meagher K, Singh NS, Patel PThe role of gender inclusive leadership during the COVID-19 pandemic to support vulnerable populations in conflict settingsBMJ Global Health 2020;5:e003760. [10] Weber, Lauren. “Women’s Careers Could Take LongTerm Hit From Coronavirus Pandemic.” The Wall Street Journal, Dow Jones & Company, 15 July 2020, www.wsj. com/articles/womens-careers-could-take-long-term-hitfrom-coronavirus-pandemic-11594814403.

p.19-20 Sweden’s Herd Immunity: Success or Failure? Writer: Gina Wiste [1] Amundsen, B. (2020, October 27). Norwegian government: “The goal is to beat the coronavirus epidemic as much as possible.” Science Norway. https://sciencenorway.no/covid19-crisis-epidemic/very-low-mortality-ratefrom-coronavirus-in-norway-compared-to-other-countries/1661751 [2] Baker, S. (2020, August 14). Sweden’s GDP slumped 8.6% in Q2, more sharply than its neighbors despite its no-lockdown policy. Business Insider Nederland. https:// www.businessinsider.nl/coronavirus-sweden-gdp-falls8pc-in-q2-worse-nordic-neighbors-2020-8?international=true&r=US [3] BBC News. (2020, December 18). Covid-19 pandemic: Sweden reverses face mask guidelines for public transport. https://www.bbc.com/news/world-europe-55371102 [4] Bjorklund, K., & Ewing, A. (2020, October 14). The Swedish COVID-19 response is a Disaster. It shouldn’t be a model for the rest of the world. Time. https://time.com/5899432/ sweden-coronovirus-disaster/ [5] Claeson, M., & Hanson, S. (2021). COVID-19 and the Swedish enigma. The Lancet, 397(10271), 259–261. https://doi.org/10.1016/s0140-6736(20)32750-1 [6] Covid-19 i svenska skolor. (04/20/12/20). [Dataset]. https://www.google.com/maps/d/viewer?mid=1w7se6os3RVB716ljPmRuvwPEZsBqXd4v&ll=61.04403930711468,1 7.653563550000005&z=5 [7] Orlowski, E. J. W., & Goldsmith, D. J. A. (2020). Four months into the COVID-19 pandemic, Sweden’s prized herd immunity is nowhere in sight. Journal of the Royal Society of Medicine, 113(8), 292–298. https://doi. org/10.1177/0141076820945282 [8] Statista. (2020, December 17). Number of coronavirus tests per capita in the nordics as of december 2020. https:// www.statista.com/statistics/1108867/number-of-coronavirus-tests-per-capita-in-the-nordics/

p.21 Slow Websites and Stalled Phone Lines: The Hurdles for Older Adults Getting a COVID Vaccine Writer: Aidan Raikar [1] COVID-19: First vaccine given in US as roll-out begins. (2020, December 14). BBC News. https://www.bbc.com/ news/world-us-canada-55305720 [2] COVID-19 and your health. (2020, December 16). Centers for Disease Control and Prevention. https://www.cdc. gov/coronavirus/2019-ncov/vaccines/recommendations. html [3] Otterman, S. (2021, January 15). The maddening red tape facing older people who want the vaccine. The New York Times - Breaking News, US News, World News and Videos. https://www.nytimes.com/2021/01/14/nyregion/ covid-vaccine-older-people-senior-citizens.html [4] Ottorman, S. (2021, February 9). N.Y.’s vaccine websites Weren’t working. He built a new one for $50. The New York Times - Breaking News, US News, World News and Videos. https://www.nytimes.com/2021/02/09/nyregion/vaccine-website-appointment-nyc.html [5] Reader, G. (2021, January 30). Los Lunas fire department helps seniors register for COVID-19 vaccine. KOB 4. https://www.kob.com/albuquerque-news/los-lunas-fire-department-helps-seniors-register for-covid-19-

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p.22-23 To Mammogram or Not To Mammogram? COVID-19 and Reassessing Preventative Care Writer: Lily Coll [1] Bergmon, A. (2020, December 21). The Backlog in Mammograms During the COVID-19 Pandemic. Leonard Davis Institute of Health Economics. https://ldi. upenn.edu/healthpolicysense/backlog-mammograms-during-covid-19-pandemic [2] Broster, A. (2021, January 5). A Drop In Mammograms During Coronavirus Could Have Serious Implications In Years To Come. Forbes. https://www.forbes.com/sites/ alicebroster/2021/01/04/a-drop-in-mammograms-duringcoronavirus-could-have-serious-implications-in-years-tocome/?sh=2258ecb7b9c0 [3] Horn, D. M., & Haas, J. S. (2020). Covid-19 and the Mandate to Redefine Preventive Care. New England Journal of Medicine, 383(16), 1505–1507. https://doi.org/10.1056/ nejmp2018749 [4] Martin, K. D. K. (2021, February 12). The Impact of COVID-19 on the Use of Preventive Health Care. Health Care Cost Institute. https://healthcostinstitute.org/hcci-research/the-impact-of-covid-19-on-the-use-of-preventive-health-care [5] Smith, T. M. (2020, October 16). Preventive care: As pandemic stretches on, “no more time to wait.” American Medical Association. https://www.ama-assn.org/delivering-care/patient-support-advocacy/preventive-care-pandemic-stretches-no-more-time-wait [6] Will My Insurance Cover Telemedicine? (2020). Chiron Health. https://chironhealth.com/definitive-guide-to-telemedicine/telemedicine-info-patients/will-insurance-cover-telemedicine/

p.24-25 COVID-19’s mRNA Vaccines: How They Work and How They are Modernizing the Field of Vaccine Research Writer: Audrey Bochi-Layec [1] CDC. (2020, November 24). Understanding and explaining mRNA covid-19 vaccines. Retrieved March 06, 2021, from https://www.cdc.gov/vaccines/covid-19/hcp/mrna-vaccine-basics.html [2] Cevik, M., Kuppalli, K., Kindrachuk, J., & Peiris, M. (2020). Virology, transmission, and pathogenesis of SARSCoV-2. BMJ (Clinical research ed.), 371, m3862. https://doi. org/10.1136/bmj.m3862 [3] Johns Hopkins University. (n.d.). COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. Retrieved March 06, 2021, from https://coronavirus.jhu.edu/map.html

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p.26 The Role of ZFHX4 in Regulating the Cancer Stem Cell State Writer: Ricky Illindala [1] Hanif, F., Muzaffar, K., Perveen, K., Malhi, S. M., & Simjee, S. U. (2017). Glioblastoma Multiforme: A Review of its Epidemiology and Pathogenesis through Clinical Presentation and Treatment. Asian Pacific Journal of Cancer Prevention : APJCP, 18(1), 3–9. https://doi.org/10.22034/ APJCP.2017.18.1.3 [2] Lathia, J. D., Mack, S. C., Mulkearns-Hubert, E. E., Valentim, C. L. L., & Rich, J. N. (2015). Cancer stem cells in glioblastoma. Genes & Development, 29(12), 1203–1217. https://doi.org/10.1101/gad.261982.115 [3] Mitchell, K., Troike, K., Silver, D. J., & Lathia, J. D. (2021). The evolution of the cancer stem cell state in glioblastoma: Emerging insights into the next generation of functional interactions. Neuro-Oncology, 23(2), 199–213. https://doi. org/10.1093/neuonc/noaa259 [4] ZFHX4 Interacts with the NuRD Core Member CHD4 and Regulates the Glioblastoma Tumor-Initiating Cell State: Cell Reports. (n.d.). Retrieved February 13, 2021, from https:// www.cell.com/cell-reports/fulltext/S2211-1247(13)007900?_returnURL=https%3A%2F%2Flinkinghub.elsevier. com%2Fretrieve%2Fpii%2FS2211124713007900%3Fshowall%3Dtrue#fig4

p.27-28 A Race Between COVID 19 Variants and Vaccines: How the Mutating Virus has Impacted Vaccination Efforts and Effectiveness Writer: Pooja Shah [1] CDC. (2021, March 4). Understanding mRNA COVID-19 Vaccines. Retrieved March 9, 2021, from https://www.cdc. gov/coronavirus/2019-ncov/vaccines/different-vaccines/ mrna.html. [2] Erin Cunningham, P. (2021, February 19). Pfizer, Moderna vaccines have reduced effectiveness against South African VARIANT, studies show. Retrieved February 23, 2021, from https://www.washingtonpost.com/nation/2021/02/18/coronavirus-covid-live-updates-us/ [3] Higgins-Dunn, N. (2021, January 11). WHO warns new COVID variants are ‘highly PROBLEMATIC’ and could further STRESS HOSPITALS. Retrieved February 23, 2021, from https://www.cnbc.com/2021/01/11/who-warnscovid-variants-are-highly-problematic-could-stress-hospitals-.html [4] Jesus, E. (2021, February 22). What we know about coronavirus variants’ effect on reinfection and vaccines. Retrieved February 23, 2021, from https://www.sciencenews.org/article/covid-19-coronavirus-variants-reinfection-vaccination-efforts [5] Liu, Y., Liu, J., Xia, H., Zhang, X., Fontes-Garfias, C. R., Swanson, K. A., . . . Shi, P. (2021). Neutralizing activity of bnt162b2-elicited serum — preliminary report. New England Journal of Medicine. doi:10.1056/nejmc2102017 [6] Williams, T. C., & Burgers, W. A. (2021). Sars-cov-2 evolution and vaccines: Cause for concern? The Lancet Respiratory Medicine. doi:10.1016/s2213-2600(21)00075-8

p.29-30 Breakthrough Wound Therapy: Magic? No, Maggots. Writer: Haleigh Pine

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[3] Medical Maggots™ (maggot therapy, maggot debridement therapy, MDT, biotherapy, biosurgery, biodebridement, larval therapy) | Monarch Labs - Advanced Wound BioSurgery. (2021). Retrieved 20 February 2021, from https://www.monarchlabs.com/mdt [4] Sherman, R. (2002). Maggot versus conservative debridement therapy for the treatment of pressure ulcers. Wound Repair And Regeneration, 10(4), 208-214. doi: 10.1046/j.1524-475x.2002.10403.x [5] Sherman, R. (2009). Maggot Therapy Takes Us Back to the Future of Wound Care: New and Improved Maggot Therapy for the 21st Century. Journal Of Diabetes Science And Technology, 3(2), 336-344. doi: 10.1177/193229680900300215

p.31-32 The Golden Future of Cancer and Nanotechnology Writer: Rehan Mehta [1] National Cancer Institute. (2020). Cancer Statistics. https://www.cancer.gov/about-cancer/understanding/ statistics [2] Sztandera, K., Gorzkiewicz, M., & Klajnert-Maculewicz, B. (2019). Gold Nanoparticles in Cancer Treatment. Molecular Pharmaceutics, 16(1), 1–23. https://doi.org/10.1021/ acs.molpharmaceut.8b00810

p.33-34 AI: Cutting Edge Technology Entering Healthcare? Writer: Jacob Oscherwitz [1] Artificial Intelligence in Healthcare Market Size Report, 2019-2025. (n.d.). Retrieved March 05, 2021, from https:// www.grandviewresearch.com/industry-analysis/artificial-intelligence-ai-healthcare-market#:~:text=The%20 global%20artificial%20intelligence%20in,41.5%25%20 from%202019%20to%202025 [2] Big Data, Analytics & Artificial Intelligence The Future of Health Care is Here [PDF]. (2016). San Francisco: General Electric & University of California, San Francisco. [3] Clinical laboratory Tests market SIZE: Industry Report, 2027. (n.d.). Retrieved March 05, 2021, from https://www. grandviewresearch.com/industry-analysis/clinical-laboratory-tests-market [4] Health, B. (2021). Here’s how Buoy works. Retrieved March 05, 2021, from https://www.buoyhealth.com/howit-works

[3] Huang, X., & El-Sayed, M. A. (2010). Gold nanoparticles: Optical properties and implementations in cancer diagnosis and photothermal therapy. Journal of Advanced Research, 1(1), 13–28. https://doi.org/10.1016/j. jare.2010.02.002

[5] Olena, A. (2020, May 7). Ai is screening billions of molecules for coronavirus treatments. Retrieved March 05, 2021, from https://www.the-scientist.com/news-opinion/ai-is-screening-billions-of-molecules-for-coronavirus-treatments-67520

[4] Suk, J. S., Xu, Q., Kim, N., Hanes, J., & Ensign, L. M. (2016). PEGylation as a strategy for improving nanoparticle-based drug and gene delivery. Advanced Drug Delivery Reviews, 99(Pt A), 28–51. https://doi.org/10.1016/j. addr.2015.09.012

[6] Ramirez, M. (2019, May 09). How has the quality of the U.S. healthcare system changed over time? Retrieved March 05, 2021, from https://www.healthsystemtracker. org/chart-collection/how-has-the-quality-of-the-u-shealthcare-system-changed-over-time/#item-usquality_ the-infant-mortality-rate-has-declined

[5] Singh, P., Pandit, S., Mokkapati, V. R. S. S., Garg, A., Ravikumar, V., & Mijakovic, I. (2018). Gold Nanoparticles in Diagnostics and Therapeutics for Human Cancer. International Journal of Molecular Sciences, 19(7). https://doi. org/10.3390/ijms19071979 [6] Rosenblum, D., Joshi, N., Tao, W., Karp, J. M., & Peer, D. (2018). Progress and challenges towards targeted delivery of cancer therapeutics. Nature Communications, 9(1), 1410. https://doi.org/10.1038/s41467-018-03705-y [7] Chen, Y.-H., Tsai, C.-Y., Huang, P.-Y., Chang, M.-Y., Cheng, P.-C., Chou, C.-H., Chen, D.-H., Wang, C.-R., Shiau, A.L., & Wu, C.-L. (2007). Methotrexate Conjugated to Gold Nanoparticles Inhibits Tumor Growth in a Syngeneic Lung Tumor Model. Molecular Pharmaceutics, 4(5), 713–722. https://doi.org/10.1021/mp060132k [8] Fan, M., Han, Y., Gao, S., Yan, H., Cao, L., Li, Z., Liang, X.-J., & Zhang, J. (2020). Ultrasmall gold nanoparticles in cancer diagnosis and therapy. Theranostics, 10(11), 4944– 4957. https://doi.org/10.7150/thno.42471 [9] Guo, J., Rahme, K., He, Y., Li, L.-L., Holmes, J. D., & O’Driscoll, C. M. (2017). Gold nanoparticles enlighten the future of cancer theranostics. International Journal of Nanomedicine, 12, 6131–6152. https://doi.org/10.2147/ IJN.S140772 [10] O’Neal, D. P., Hirsch, L. R., Halas, N. J., Payne, J. D.,

p.35-36 The Negative Effects of Gender Bias in Health Care Writer: Lily Luu [1] Billock, J. (2018, May 22). Pain bias: The health inequality rarely discussed. Retrieved from https://www.bbc.com/ future/article/20180518-the-inequality-in-how-womenare-treated-for-pain [2] Cedars Sinai. (2019). Examining Gender Bias in Medical Care. Retrieved from https://www.cedars-sinai.org/research/news/cedars-science/2019/examining-gender-bias-in-medical-care.html [3] Chen, E. H., Shofer, F. S., Dean, A. J., Hollander, J. E., Baxt, W. G., Robey, J. L., Sease, K. L., Mills, A. M. (2008, May). Gender disparity in analgesic treatment of emergency department patients with acute abdominal pain. Retrieved from https://doi.org/10.1111/j.1553-2712.2008.00100.x [4] Dusenbery, M. (2018, May 29). ‘Everybody was telling me there was nothing wrong.’ Retrieved from https://www. bbc.com/future/article/20180518-the-inequality-in-howwomen-are-treated-for-pain

SPRING 2021 • VOL 15 ISSUE 1

[5] Hoffmann, D. E., Tarzian, A. J. (2003, Feb. 27). The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain. Retrieved from http://dx.doi.org/10.2139/ ssrn.383803 [6] Jefferson, T. (2019, Sept. 4). Exploring Gender Bias in Healthcare. Retrieved from https://medcitynews.com/?sponsored_content=exploring-gender-bias-in-healthcare&rf= [7] Legal-Explanations.com (2020, Feb. 12). Gender Bias. Retrieved from http://www.legal-explanations.com/definitions/gender-bias.html [8] Pagán, C. N. (2018, May 3). When Doctors Downplay Women’s Health Concerns. Retrieved from https://www. nytimes.com/2018/05/03/well/live/when-doctors-downplay-womens-health-concerns.html [9] Paulsen, E. (2020, Jan. 14). Recognizing, Addressing Unintended Gender Bias in Patient Care. Retrieved from https://physicians.dukehealth.org/articles/recognizing-addressing-unintended-gender-bias-patient-care [10] Robertson, J. (2014). Waiting Time at the Emergency Department from a Gender Equality Perspective. Retrieved from https://gupea.ub.gu.se/bitstream/2077/39196/1/gupea_2077_39196_1.pdf [11] The Brain Tumor Charity. (2016). Finding Myself in Your Hands: The Reality of Brain Tumour Treatment and Care. Retrieved from https://www.thebraintumourcharity.org/ about-us/our-publications/finding-myself/

p.37 COVID-19 Impact on Children and Adolescents Writer: Alexandra Dram [1] American Psychological Association (2020, Sept. 22). Student mental health during and after COVID-19: How can schools identify youth who need support?. Retrieved from https://www.apa.org/topics/covid-19/student-mental-health [2] Children’s Mental Health Ontario (2020). How the Pandemic Impacts Children’s Mental Health. Retrieved from https://cmho.org/how-the-pandemic-impacts-childensmental-health/ [3] de Figueiredo, C. S., Sandre, P. C., Portugal, L., Mázala-de-Oliveira, T., da Silva Chagas, L., Raony, Í., Ferreira, E. S., Giestal-de-Araujo, E., Dos Santos, A. A., Bomfim, P. O. (2021). COVID-19 pandemic impact on children and adolescents’ mental health: Biological, environmental, and social factors. Retrieved from https://doi.org/10.1016/j. pnpbp.2020.110171 [4] Grey, M. (2021, Feb. 17). How the COVID-19 pandemic has affected children’s mental health. Retrieved from https://www.msn.com/en-us/health/medical/how-thecovid-19-pandemic-has-affected-children-e2-80-99smental-health/ar-BB1dJKab [5] Loades, M. E., Chatburn, E., Higson-Sweeney, N., Reynolds, S., Shafran, R., Brigden, A., Linney, C., McManus, M. N., Borwick, C., Crawley, E. (2020). Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19. Retrieved from https://doi.org/10.1016/j. jaac.2020.05.009 [6] Walker, T. (2018, Sept. 13). Are Schools Ready to Tackle the Mental Health Crisis?. Retrieved from https://www.nea. org/advocating-for-change/new-from-nea/are-schoolsready-tackle-mental-health-crisis

Vol. 15, Issue 1

Articles inside

References

The Golden Future of Cancer and Nanotechnology

The Negative Effects of Gender Bias in Health Care

Breakthrough Wound Therapy: Magic? No, Maggots

COVID-19 Impact on Children and Adolescents

AI: Cutting Edge Technology Entering Healthcare?

A Race Between COVID 19 Variants and Vaccines: How the Mutating Virus has Impacted Vaccination Efforts and Effectiveness

The Role of ZFHX4 in Regulating the Cancer Stem Cell State