Yale Global Health Review Vol. 5 No. 2

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SPRING 2018

THE YALE

VOL. 5, NO.2

GLOBAL HEALTH REVIEW

GLOBAL HEALTH SECURITY: CRACKING THE CODE TO A MORE HEALTH SECURE WORLD BY TOMEKA FRIESON Jordan Salkin, Flickr

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LETTER FROM THE EDITORS SPRING 2018 VOL. 5, NO. 2 Dear Readers, We are so incredibly excited to bring you the Spring 2018 issue of the Yale Global Health Review! This issue takes us from El Salvador to Nigeria to right back at home examining global health under President Trump’s administration. In this issue, our feature article by Tomeka Frieson focuses on global health security. Our writers have traversed the world to bring you this glimpse into some of the most pressing global health issues of our time. And as always, our mission is to use this publication as a platform to promote change and engage the Yale community in meaningful discussions about global health. None of this work would have been possible without the incredible work by the members of our Executive Board. We are humbled by the commitment our board has displayed throughout this semester, tirelessly working to publish pieces that critically examine the major issues affecting people throughout the world. But we also want to emphasize that our board is more than just our writers. We’d also like to thank our production and design team for the many late nights they pulled in order to keep this publication running. Most of all, we would like to thank you, our readers, for your interest in our work, as you are the sources of innovation that will drive global health movements in the years to come. As this is our spring issue, Nancy and I will be stepping down, and would like to welcome the new editors-in-chief, Elizabeth Qian-Wang and Sunnie Liu. We are deeply appreciative of our time as EICs, and we are sure they will continue the YGHR tradition of excellence. We wish them all the best. For more global health, visit our blog at yaleglobalhealthreview.com. Better yet, to get involved, set us an email at yaleglobalhealthreview@gmail.com. All the best, Katarina Wang and Nancy Lu OUR TEAM Erica Lin Marisa Peryer Max Ackerman Mohamed Eltoum Associate Editors-in-Chief Nathan Chang Elizabeth Qian-Wang Tomeka Frieson Krista Chen Rohan Garg Cathy Xue Publication & Design Directors Sunnie Liu Webmaster Mohammed Eltoum Cathy Xue Editors-in-Chief Katarina Wang Nancy Lu

Senior Editors Colin Hemez Krista Chen Rebecca Slutsky Sarah Spaulding Associate Editors Elizabeth Qian-Wang Erica Lin Marisa Peryer Mohammed Eltoum Nathan Chang Copy Editors Debbie Dada Dhiksha Balaji YALE GLOBAL HEALTH REVIEW

Online Editor Matthew Pettus Production & Design Team Elizabeth Qian-Wang Krista Chen Staff Writers Ben Grobman Debbie Dada Eleanor Cook Hannah Verma Indira Flores Jenesis Duran Kristi Wharton Matthew Pettus Tomeka Frieson

ABOUT US The Yale Global Health Review is the premiere undergraduate-run publication at Yale University covering topics in health. We feature original research, thoughtful commentary, and balanced reporting with a global health focus. Our goal is to bridge scholarship and practice, connect students and faculty, and bring together voices from across a spectrum of disciplines and sectors. The YGHR is a hub for discussion and engagement on all issues relevant to global health – in print and online, at Yale and beyond. SPONSORS We would like to thank the Yale Global Health Leadership Institute, Yale Global Mental Health Program, Yale China, the Yale School of Public Health Admissions Department & the Yale Undergraduate Organizations Committee for their support.

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CONTENTS EL SALVADOR

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Health Disparities in El Salvador By Jenesis Duran

GLOBAL HEALTH TODAY Flickr

VENEZUELA

U.S. The Opioid Crisis By Kristi Wharton p. 13

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p. 30

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RIDL Mosquitoes By Laura Michael

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Starvation and Sickness in the Wake of Venezuela's Economic Collapse By Ben Grobman

INTERVIEW

Young Mind, Global Scholar: A Conversation with Dr. Sten Vermund on Ways Today's Youth Can Address Global Health Issues By Tomeka Frieson

NIGERIA

The Silent Killer in Northern Nigeria: Implications & Challenges in Addressing Malnutrition By Aastha KC

HEALTHCARE

A Necessity: The Healthcare Systems Abroad and at Home By Indira Flores

U.S. Department of Defense

FEATURE ARTICLE Global Health Security: Cracking the Code to a More Health-Secure World By Tomeka Frieson p. 25

HEALTH POLICY

p. 43

HEALTH POLICY

p. 45

INTERVIEW

p. 49

Trump Must Embrace Global Health By Jude Alawa Global Health Under Trump By Sofia Braunstein

INDIA

Gendercide: Sex-Selection in India

By Debbie Dada p. 38

Flickr

Dr. Bandy Lee: The Mental Health of President Trump By Matthew Pettus


EL SALVADOR

Health Disparities in El Salvador By Jenesis Duran


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he Land of Volcanoes has had its share of difficulties. Though the smallest of seven Central American countries, El Salvador has been at the center of international attention due to its bouts with war, poverty, and violence. El Salvador gained independence from Spanish colonialism on September 15, 1821, under the national motto: Dios, Unión, Libertad, meaning "God, Union, Liberty". Its flag boasts blue and white stripes symbolizing the sky, the ocean, peace, and solidarity with the world. However, from the late 1970s to the early 1990s, a great civil war and internal conflict erupted throughout, striking a stark contrast to the idealistic establishment of a unified land. Decades of repression and military-dominated rule begat a great divide between left-wing insurgents and the U.S-backed Salvadoran Armed Forces. Political and economic turmoil ensued thereafter from the upheaval of war, resulting in the loss of more than 75,000 lives. In 1992, the United Nations mediated peace accords that strove to aid in the democratization of El Salvador.1 This objective was hampered by the onslaught of natural disasters and crime. The earthquakes of 2001 alone damaged health care facilities and roads, exacerbating pre-existing poverty. At that time, “one third of the population of 6.4 million lacked basic access to healthcare.”2 As a result, health disparities, social inequality, and gang violence (to name a few) are amongst the challenges that El Salvador faces to this day. Of particular interest is the issue of health disparities in El Salvador, which pertains to all citizens, both wealthy and destitute alike. The health care system in El Salvador is divided between the public and private sectors. This distinction is often associated with a citizen’s residence in either a rural or urban environment and their socioeconomic status. With “19% of Salvadorans living on less than $1/day and 30% of Salvadorans living below the poverty line”, a majority of citizens must depend on government funded care.3 The public sector therefore provides care for approximately eighty percent of Salvadorans, and is financed by the Ministry of Health.3 The public sector consists of several entities, including The

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Ministry of Public Health and Social Welfare (MSPAS), Salvadoran Social Security Institute (ISSS), Higher Council for Public Health (CSSP), Salvadoran Institute for the Rehabilitation of Disabled Persons (ISRI), Solidarity Fund for Health (FOSALUD), Military Health (BSM), and Teachers’ Welfare (ISBM). Meanwhile, the private sector consists of for-profit and not-for-profit organizations.4 Though seemingly abundant in resources, a “2005 MSPAS publication entitled ‘Quality Assurance of Services of Health in El Salvador’ identifies five problem areas in the public health care system.”3 These problems include preparation and resource inadequacy, shortcomings in the management of healthcare supplies, gaps in monitoring and oversight, inequitable distribution/delivery of services and resources, and the absence of a system of categorization. In addition, compared to wealthier nations, physician density in El Salvador is dangerously low, with approximately 1.6 physicians per 1,000 population. This level of physician density places El Salvador at risk of not achieving adequate coverage rates for primary health care, as defined by the Millenium Development goals.5 Primary challenges have been encountered when trying to meet the population’s needs in accordance with these goals and the new national health strategy of comprehensive primary health care. The overproduction of health workers, for instance, has led to the “financial inability of the health sector to recruit, and [an] inequitable distribution of health workers at different levels of service.”6 Disparities in working conditions, training for primary care roles, and mechanisms of coordination have also been encountered. Consequently, citizens from rural and underserved regions often seek care elsewhere, turning to traditional folk healers (curanderos) instead. According to the World Bank, clients have expressed deep dissatisfaction with the healthcare system, stating that “the facility here is useless because there is no doctor or nurse, and it is only open two days a week until noon. Waiting time is 3.5 hours average and there is a lack of medication.”2 This palpable sense of discontentment can be observed in the daily life of the average Salvadoran. Ana Iris Alvarenga de Fuentes is a housewife who lost her second child as a result of inadequate healthcare. Ana lives in Huisquil near La Union, which is located in the Eastern region of El Salvador. Her husband and his family are fishermen. She does her part in processing the fish that they catch, which the family combines

with other fish they buy to sell at the market. They depend on modest fishing boats, only making an income when they are able to catch fish. A large part of their income is supplemented with remittances from other family members who have emigrated to the United States. As a whole, they have a limited income and live in a modest home with the most basic accommodations. Situated along the water, their house location puts them at risk of mosquito-borne illnesses. For the past year, they have also lived in fear of a gang that forcefully inhabited one of their family homes. The gang leader ultimately left and was killed by the police, and the rest of the gang was arrested. Ana and her family are motivated by their strong faith. They are hopeful that God will still bless them with a child. However, the recent stroke of her father in law has added the responsibility of caring for him and working harder to supplement his income. The lack of available healthcare services has been a challenge for Ana and her family. In a coordinated interview with Ana Iris Alvarenga de Fuentes on the topic of healthcare in El Salvador, her remarks were recorded as followed: Provide an example of when you didn’t have access to medical attention. What do you do when you lack access to resources? “I want to share my experience since I went to the health unit. During my last days of pregnancy, my feet were swollen, but they told me it was normal and they didn’t offer me any medical assistance. When I got sick, and knowing that it was the time to give birth to my baby, I went to the national hospital in the city of La Union because I didn’t have the economic resources to go elsewhere.” What difficulties did you face when seeking medical assistance? “We got to the emergency room at 10:00pm, but there was no one to attend to us. After knocking several times, a sleepy nurse came out. She went to call the only doctor they had. The doctor began filling out forms and I got so despaired that he took my pressure, which was 230. They had to give me medication to control my pressure, but he had to keep filling out forms. He examined me later, and told me that my child had died, and he had to send me to the hospital in San Miguel. They called an ambulance to take me, of which they took me at 12 midnight. I got there at 12:45 a.m. They reviewed my records and then examined me. They refused to give my

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husband any information. They told him everything was fine. The next day at 2:00 pm, God helped me to have my child normally without a c-section. I was alone on a couch. There were many people praying for my life, and that of my child. But when he was born, he didn’t cry because he was not alive. [Ana has lost two babies this way]. I have lost my only two children due to lack of resources at the hospital.” What improvements do you desire to see in the healthcare system of El Salvador? “We hope that all hospitals have enough capable staff, as well as all that’s necessary to attend to the needs of the patients, like instruments and medicine, so they wouldn’t have to transfer almost all of their patients. I also wish that there were more doctors and health institutions that provided free help to the population. People don’t go to the private health facilities because they don’t have the resources.” If Ana had only had access to better widespread resources, her two children could be alive today. Countless other stories like Ana’s exist within the Salvadoran community. Another couple lost two babies, in addition to their 5 year old son, because of Pre-eclampsia. Mauricio "Cubito" Luna, a military veteran of El Salvador's civil war, currently faces bills for dialysis averaging $150 per session. Because he lost many important documents in the destruc-

has also been increasing throughout Latin America. To make matters worse, “Zika virus appeared in late 2015 and has steadily increased, peaking in the first week of 2016, when 1,142 cases were reported. From March to August 2016, 109 children were born with microcephaly.”10 These factors have devastated the Salvadoran community, crippling the lives of innocent citizens who remain hopeful for a country unified by peace and solidarity. Numerous efforts have been sanctioned to improve El Salvador’s health care system. El Salvador is currently in the initial planning phase of developing a Human Resources for Health Plan (HRH). The plan encompasses four key areas of development: “management capacity and policy; HRH planning and regulation; change in health worker quality and working conditions; and coordination of HRH education.”6 Additional initiatives include the Directorate of Development for Human Resources for Health and CISALUD intersectoral commission, El Salvador Strengthening Public Health Care System Project, U.S. Strategy for Central America, and the The Five-year Development Plan 2015-2019.11 Many of these plans have already been effective in El Salvador’s healthcare system, but there is still more work to be done, and it will take time before these methods are fully incorporated into society. In implementing health care system reform, however, we can identify key challenges and issues that the

The issue of health disparities, although divisive in nature, should thus concurrently act as a unifying force between the wealthy and destitute, drawing awareness to the quest for essential resources that plagues us all, and giving way to a path of global solidarity. tion of the war, he is not entitled to compensation. Seeing as he lost his only son due to gang violence, Cubito depends on a limited income and the support of friends in the United States to pay his medical bills. Remittances from abroad actually account for about 20% of El Salvador’s GDP, and have aided in reducing poverty.7 Through these examples, it is clear how the effects of war, violence, and health disparities have impacted the lives of Salvadorans. In recent years, El Salvador has even seized the unfortunate title of the hemisphere’s murder capital.8 The ongoing battle between “El Salvador’s two most powerful street gangs — Mara Salvatrucha and the 18th Street gang — [have caused] the death toll [to spike] to the highest levels since the country's civil war ended in 1992.”9 Sexual and gender-based violence

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global community must confront in order to advance health care systems around the world and repair health disparities. It is therefore imperative that we take the time to consider the health systems of other nations and the challenges that individuals face on a daily basis. The issue of health disparities, although divisive in nature, should thus concurrently act as a unifying force between the wealthy and destitute, drawing awareness to the quest for essential resources that plagues us all, and giving way to a path of global solidarity. www Jenesis Duran is a first year in Davenport College double-majoring in Neuroscience and the History of Science, Medicine, and Public Health.

She can be contacted at jenesis.duran@yale.edu

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Wikimedia Commons

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GLOBAL

A technique used to capture larvae of Ae. Aegypti mosquitos in Samambaia, Brazil.

RIDL Mosquitoes:

A Genetics Approach to Dengue Vector By Laura Michael 7

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ince the 2015-2016 Zika epidemic, when the Zika virus spread from Brazil to South and North America, Americans have become increasingly aware of mosquito-borne disease. Although Zika has recently received a lot of attention in the news, the Aedes Aegypti mosquito, which carries Zika, also carries other dangerous viruses that deserve equal attention. Every year, between 50 and 100 million people worldwide are infected with dengue fever, which is also carried by the Ae. Aegypti mosquito. 1 Dengue is found in urban and semi-urban areas that have tropical and sub-tropical climates.2 Infection with dengue initially causes flu-like symptoms, but if a dengue infection becomes severe, it can cause fatal blood vessel leaking. Over the past fifty years, the incidence of dengue has increased 30-fold.2 This dramatic increase can be attributed to globalization and urbanization, climate change, and the consequent expansion of the geographic range of the Ae. Aegypti mosquito.3 About half of the world’s population is now at risk for infection with dengue.2 In fact, severe dengue is the leading cause of serious illness and death among children in some Asian and Latin American countries.2 It is particularly difficult to create a dengue vaccine because there are four closely related serotypes, or strains, of dengue. Dengue exhibits Antibody-dependent enhancement, meaning that those who are immune to one of the four serotypes are more likely to develop a severe reaction if they are infected with another strain. When an individual is infected with a second strain of dengue, antibodies are able to recognize the virus as dengue and bind to it, but are not able to kill the new strain because it is shaped slightly differently. When the antibody travels to other cells to communicate with them, the dengue virus effectively “hitches a ride” with cells that it can then infect. The dengue virus particle can then detach from the antibody and infect the cell with which the antibody was attempting to communicate. Thus, the antibodies enhance the speed at which the new dengue strain can infect cells. Until scientists invent a vaccine that can protect against all four strains of dengue, vector control will be the only way to manage the spread of the disease.2 Ae. aegypti mosquitoes prefer to breed in small man-made pools of water such as those created by water-filled buckets, rain-gutters, tires, or drinking water storage containers. Although mosquito breeding can be prevented by tipping out the water in these containers or treating them with chemicals, finding and treating a high enough proportion of breeding sites is extremely difficult and impractical.4 Given the inadequacy of conventional techniques, scientists have turned to advances in mosquito genetics to find a new approach to the control of Ae. aegypti mosquitoes. For more than 50 years, scientists have used Sterile Insect Technique (SIT) as an alternative to pesticides to control and/or eliminate harmful insects such as the Mediterranean fruit fly, the screwworm fly, and the tsetse fly.5 SIT involves sterilizing male insects with radiation and then releasing them into the general population.5 Radiation generates random dominant lethal mutations that are carried by the released mosquitoes.5 When sterile males are released with wild females, they pass the dominant lethal alleles onto their offspring, which causes the offspring to die before adulthood.5 Therefore, the insect population diminishes and ultimately collapses.

About half of the world’s population is now at risk for infection with dengue.2 In fact, severe dengue is the leading cause of serious illness and death among children in some Asian and Latin American countries. VOLUME 5, NO.2

In the 1970s, a number of trials applied this technique to mosquitoes but saw little success.6,7 Irradiation of pupae damages the mosquitoes, and irradiation of adults is practically difficult.5 Moreover, mosquito populations, unlike those of most agricultural pests, are regulated by density-dependent effects.5 Density-dependent effects occur when the size of a population is limited by the amount of resources available to it. This phenomenon occurs in mosquitoes but not agricultural pests because the food for larvae and breeding sites available to mosquitoes are limited to what naturally occurs in the area, whereas agricultural pests have access to an effectively unlimited crop. The only way for SIT mosquitoes to combat this density dependent effect would be for the SIT offspring to live long enough to compete for food with their wild counterparts. This way, a larger proportion of the wild-type mosquitoes would die be

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cause lack of resources, the SIT mosquitoes would die because of their lethal gene, and the overall adult mosquito population would be reduced. However, since the offspring of SIT mosquitoes die shortly after birth, they do not compete for resources with the wild mosquitoes. In fact, mathematical models show that classical SIT can cause an increase the mosquito population when the ratio of released sterile males to wild-type females is below a critical threshold. 9 In 2007, scientists at the University of Oxford found an alternative to SIT that is more effective in mosquitoes. Their intervention, the Release of Insects Carrying a Dominant Lethal (RIDL), uses genetic engineering rather than radiation to create Ae. aegypti mosquitoes carrying a dominant lethal allele.5 RIDL mosquitoes are created by using a modified piece of bacterial DNA called a plasmid to genetically engineer mosquitoes to express a conditional lethality trait and fluorescent marker.5 The fluorescent marker makes the mosquito pupae look red instead of white and is used by scientists to identify the genetically modified (GM) mosquitoes.5 The conditional lethality trait is achieved through a recombinant DNA construct that confers late-acting lethality.5 The exact reason that the gene [LM1] is lethal is unknown, but researchers think that it inhibits transcription, a part of the process by which cells create new DNA .5 The lethal construct is called conditional because it only causes death under certain conditions; in the presence of the antibiotic tetracycline, the mosquitoes’ offspring live, allowing researchers to breed them, but without tetracycline in the wild, their offspring will not survive to adulthood.5 This conditionality is achieved through a tetracycline repressible promoter, which prevents the lethal gene from being read when tetracycline binds to it and allows the lethal gene to be read when tetracycline is not present to bind.5 After GM mosquitoes are bred in lab, in the presence of tetracycline, the males and females must be separated. Only males should be released since female mosquitoes bite and spread disease. Males and females are separated using the difference in size between male and female pupae.4 One advantage of RIDL over SIT is that the [LM2] precision of genetic engineering allows researchers to choose the stage of the mosquito life cycle in which the modified mosquitoes die.5 RIDL mechanisms are designed so that the offspring of sterilized mosquitoes die as late as possible before they reach adulthood, which is when mosquitoes can fly and spread disease. Unlike the progeny of SIT radiated mosquitoes, which die as embryos, RIDL mosquitoes do not die until the pupal stage.5

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This way, the larvae can live long enough to compete for food with their wild-type counterparts. By depleting the food available to wild-type larvae but dying before adulthood, modified mosquitoes can therefore reduce the overall mosquito population despite the density-dependent effects.5 One concern about RIDL is the potential fitness costs of genetic modification and laboratory rearing. If GM mosquitoes cannot adequately compete for mates with their wild-type counterparts, they will not be able to spread their lethal genomes. Ideally, GM mosquitoes would be able to compete equally, if not more effectively than wild type mosquitoes.10 Evidence of the fitness costs of genetic engineering from laboratory studies is mixed, and research shows that results from cage studies may be influenced by inbreeding.10 However, studies of RIDL mosquitoes in Peninsular Malaysia under semi-field conditions, which artificially simulate real life, and under field conditions in the Cayman Islands have shown that RIDL mosquitoes can compete for mates effectively with their wild type counterparts.11,12 In the semi-field study in Malaysia, a mock house was created to mimic a typical flat in Kuala Lampar.11 This environment is not only more spacious than lab cages but also closely simulates the natural mating environment for Ae. aegypti, which prefer urban environments and are attracted to humans. Ten female wild mosquitoes, ten male wild mosquitoes, and ten RIDL mosquitoes were released into the house.11 Although the low number of mosquitoes used per trial limited the amount of data that could be collected per trial, this density of mosquitoes is on the upper end of what might be found in a typical Malaysian home.11 The mosquitoes were released into the mock house for eight hours.11 A human (under a net) was present in the room to mimic the odors and situation that would be present in a real house.11 Environmental variations such as light, humidity, and temperature were not controlled.11 The realistic conditions in this experiment created some variation in the data but allowed the results to be more likely to accurately predict field performance than laboratory tests.11 Under these realistic conditions, the researchers found that RIDL mosquitoes could compete effectively: the proportion of wild type females that mated with RIDL rather than wild type males was 52% with a confidence interval of 44-60%.11 In other words, about half of female wild-type mosquitoes mated with RIDL male mosquitoes over their wild type counterparts.

A closeup image of a mosquito biting skin..

In the Cayman Island study, researchers released male mosquitoes over a 10-hectare area for four weeks.12 They monitored the mosquito population using ovitraps, devices that mimic the preferred breeding environment of Ae. Aegypti and attract female mosquitoes to lay their eggs in a trap. The trapped eggs were hatched, and their larvae were screened for fluorescence to determine whether they had RIDL or wild-type fathers.12 The estimated field competitiveness had wide confidence bounds but suggested that RIDL males could compete well for mates in the field.12 The Ma-

YALE GLOBAL HEALTH REVIEW


laysian and Cayman Island studies demonstrate that under realistic conditions, RIDL mosquitoes can compete effectively with their wild-type counterparts. Another concern about the implementation of RIDL mosquitoes is the possibility of resistance.4 In theory, both “behavioral” and genetic resistance could occur.13 “Behavioral resistance” to a hereditary gene modification happens when females who are able to identify and avoid sterile males have a fitness advantage over those who cannot do so. Such

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behavioral resistance has been shown to occur in traditional SIT insects, but few studies have investigated behavioral resistance to RIDL.14 More studies have focused on the potential for genetic resistance to RIDL. Genetic resistance involves selection for a gene that would confer an advantage in the context of an engineered lethal construct. Laboratory studies have demonstrated a 3.5% rate of survival in the progeny of RIDL males and wild females. 15 This survival rate may indicate that a small portion of RIDL offspring carry a gene that allows them to live despite possessing the

typically lethal RIDL modification. Such a gene could either develop through mutation or could be currently present in the population but undetected due to low frequency.13 If these surviving mosquitoes passed this gene to their offspring, their offspring would also be able to survive with the RIDL lethal trait. Eventually a population of RIDL-resistant mosquitoes could form and RIDL, or at least the particular dominant-lethal gene used at the time, would then become obsolete. However, while resistance to SIT insects has been observed in some species, resistance to RIDL

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has not been observed in practice.13 Researchers have used mathematical models to examine the possibility of genetic resistance to RIDL. For example, a separate team of researchers at University of Oxford used models to investigate the theoretical evolution of a RIDL-resistant allele.13 They demonstrated that there is not only a critical release ratio (ratio of released RIDL mosquitoes to wild-type population) above which the size of the population will be reduced, like previously found for SIT, but also another critical release ratio below which resistance will be prevented from spreading throughout the population.13 In other words, when researchers implement RIDL, they must achieve a release ratio that is high enough to suppress the wild-type population but low enough to avoid genetic resistance. Because there are so many different parameters that can affect the development of resistance, it may be difficult to achieve a perfect release ratio in practice.13 However, developing effective monitoring methods that allow the detection of resistance in laboratory pre-trials or at early stages of release programs will help researchers combat resistance.4 Given the large number of possible lethality mechanisms, it is also likely that new variants of RIDL mosquitoes could be developed faster than resistance would emerge.4 Moreover, if resistance remained a problem, mosquitoes with multiple lethal traits could be created to make it more difficult for resistance to develop; it would be unlikely that mosquitoes could easily generate mutations that could allow for survival in the presence of multiple lethal genes.4

RIDL also has advantages over more conventional Aedes aegypti control methods. Unlike the use of chemical insecticide fogging

Unlike the use of chemical insecticide fogging and larvicides, RIDL does not have potentially toxic effects on the environment or on humans.

RIDL has advantages not only over classical SIT but also over other new strategies for releasing modified mosquitoes. An example of another new method for modifying mosquitoes is the infection of Ae. aegypti mosquitoes with Wolbachia bacteria, which has been found to reduce their ability to carry and transmit a range of pathogens including dengue.4 Since Wolbachia are heritable, releasing mosquitoes infected with the bacteria can theoretically create a population of mosquitoes that will not carry disease.4 Unlike RIDL, the goal of Wolbachia infected mosquitoes is not to reduce the mosquito population but to replace it with a new population of mosquitoes

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that does not carry the disease. Wolbachia’s environmental prevalence is reassuring – Wolbachia strains are widespread in the environment and have no known negative effects, so they do not prompt the same safety or ethical concerns that GM mosquitoes do.4 Ironically, since Wolbachia occurs naturally (although not in mosquitoes), experiments involving the addition of the full Wolbachia genome to mosquitoes do not need to adhere to the strict regulations put in place for genetically modified organisms.4 However, because Wolbachia is not built in a lab, researchers can exert less control over how the bacteria interact with the mosquitoes.4 Moreover, the release of Wolbachia infected mosquitoes is inherently riskier than RIDL because its implementation would be difficult to reverse.4 Since the release of mosquitoes infected with Wolbachia does not reduce the mosquito population, it would be difficult to prevent the bacteria from continuing to spread through the mosquito population if anything went wrong after a release of Wolbachia infected mosquitoes. By contrast, RIDL mosquitoes are by definition autocidal, so if anything went wrong with their implementation, scientists would simply cease releases and the RIDL population would die out.13 Although Wolbachia infected mosquitoes are certainly a potential alternative to RIDL, the elevated risk of their implementation over RIDL makes RIDL a safer intervention.

and larvicides, RIDL does not have potentially toxic effects on the environment or on humans. Unlike insecticides, RIDL mosquitoes will not contaminate soil because any GM proteins will be broken down in the GI tracts of mosquitoes’ predators just as those of wild-type mosquitoes would be.16 The potential effect of RIDL mosquitoes on water quality is not as well defined, but RIDL’s impact on both natural bodies of water and water supplies is likely to be much smaller than those caused by pesticides, which are often broad spectrum and can affect non-target organisms.16 Moreover, although there has been some concern about RIDL altering food chains, this is thought to

be of low risk since there are other mosquito species on which predators can feed.16 Because RIDL is relatively new, most studies discuss its implementation alone. However, it would ultimately be ideal to implement RIDL as part of an integrated disease management program that would include vaccination.4 Even when a cheap, effective vaccine is made generally available, experts predict that vector control will still be necessary.2 An integrated disease management program would be ideal because RIDL would reduce the mosquito population, minimizing the likelihood of the spread of dengue, while vaccines would protect against severe illness. RIDL would make a good compliment to a vaccine because it would protect the portions of the population that vaccines currently cannot. For example, although children bear the brunt of dengue disease burden, Dengvaxia, the only currently licensed Dengue vaccine, has only been approved for use in patients between 9-45 years of age.17 Since the implementation of RIDL would reduce the number of dengue spreading mosquitoes, it could reduce the incidence of dengue in people of all ages in endemic areas. RIDL has the potential to be a successful long-term Ae. aegypti control method. However, there is still progress to be made. A standard monitoring strategy must be developed so that released populations can be actively observed and any resistance can be detected.13 Moreover, implementation of RIDL will require large-scale systems for mosquito production, transport, and release, which have not yet been optimized. Creating methods for widespread release is particularly important because RIDL will not be successful in the long-term unless it is implemented over a very large area. Mathematical modeling studies predict that RIDL should be focused on larger release areas rather than more intense release rates.19 Aedes aegypti do not disperse widely on their own, so they must be released over large areas of land in order for widespread mixing of GM and wild-type mosquitoes to occur.15 In order to achieve scale-up, researchers must identify standards for assessing insect quality as well as optimal procedures for mosquito breeding and release.15 Moreover, all dengue vector control, including the potential implementation of RIDL, requires collaboration between governments of neighboring countries. As shown by the failure of an efficient, well-funded, and high-compliance conventional vector control program in Singapore, countries that

YALE GLOBAL HEALTH REVIEW


A pile of used tires, which collect water and offer ideal breeding grounds for the Aedes mosquitoes that spread virus.

control Ae. aegypti are doomed to failure if neighboring countries do not prevent continued transmission.20 Singapore achieved an Ae. aegypti index as low as 2%, meaning that less than 2% of water containers in the country were infested with Ae. Aegypti lar-

“

It would ultimately be ideal to implement RIDL as part of an integrated disease management program that would include vaccination.

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vae or pupae. However, the combination of a decrease in the proportion of the population immune to dengue and an increase in imported dengue from neighboring countries made preventing dengue transmission difficult.20 If RIDL were to be successfully implemented over large areas, countries would have to agree to create joint RIDL programs. Another hurdle that will need to be overcome before RIDL can be implemented is

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public relations issues. It is difficult to convince citizens that it is safe to release male mosquitoes.15 The possibility of deliberate or accidental release of females may also adversely affect public acceptance.4 In the field performance study executed on the Cayman Islands, 0.5% of pupae were found to be female after size sorting.12 Although 0.5% is a nearly negligible number of mosquitoes when RIDL is implemented on a small scale, it would translate into a large number of females if millions of insects were released. Researchers have already begun to attempt to solve this problem by creating strains of GM mosquitoes that cause female-specific lethality. For example, researchers have created a female-specific flightless phenotype.21 Since female-specific lethality mechanisms prevent females from surviving to adulthood, they eliminate the need to separate pupae by sex and therefore allow eggs rather than adult mosquitoes to be released.21 The ability to distribute eggs has advantages; eggs are easy to store for long periods of time and do not require mosquitoes to be reared in lab, so they can be more widely distributed than live male mosquitose.21 However, the use of eggs introduces the potential issue of community involvement since eggs would most likely be distributed to communities, governments, or private citizens.21 Countries would need to

create programs to incentivize private citizens and local governments to distribute eggs and to educate people on the purpose and safety of hatching female-lethal mosquitoes. Ultimately, the successful implementation of RIDL over wide areas could drastically reduce if not effectively eliminate populations of Ae. aegypti mosquitoes from Dengue endemic areas. This would reduce the disease burden not only of Dengue, but also of other related viruses such as Zika, West Nile, and Yellow Fever and any other pathogens carried by Ae. aegypti mosquitoes. Although much research and progress must be made before large-scale RIDL programs can be implemented, RIDL has significant advantages over both conventional and mosquito modifying vector control techniques and has the potential to save millions of lives.

www

Laura Michael is a sophomore in Pierson College. Laura is an Applied Mathematics major and a Global Health Scholar. She can be contacted at laura.michae@yale.edu.

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Source Flickr

U.S.

CATEGO-

THE OPIOID CRISIS:

By Kristi Wharton

An Epidemic Without a Vaccine

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T

ommy Hill played many different roles in his life: a son, a boyfriend, a brother, a mentor. All of this ended July 10th, when he was found dead in his apartment after overdosing on heroin. For about a year, Tommy had managed to stay clean, going to meetings and even mentoring others who were also struggling with the problem of addiction — a problem he knew all too well. One of those mentees was his friend Scotty Hamblin. The two had grown up together playing as children and eventually battled heroin addiction together. Tommy became Scotty’s sponsor as Scotty made his way through a sobriety program and various counseling sessions on what could have been his road to recovery. Tommy’s death, however, caused Scotty to relapse instead, falling back into a heroin-dependent life.1 On that day in July, Tommy became one of the eighteen people who would die from overdose over the course of the following week in Cincinnati alone. Throughout America, one person dies every sixteen minutes from heroin and synthetic opiate use, which is now the leading cause of death for Americans under the age of fifty. The approach to resolving this issue, called the War on Drugs, tries to prevent addiction by interdicting drug use and reducing

In regions like these, it is not uncommon for one week to lead to 180 overdoses, 18 heroin or synthetic opiaterelated deaths, 200 newly jailed heroin users, and 15 babies born with heroinrelated medical problems.

illegal drug trade via police intervention. This method has not worked, however, because it does not approach addiction as the disease that it is.2 The opioid epidemic was finally declared a public health emergency

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by President Trump in October 2017. It will not improve until it is widely understood that people suffering from addiction need access to treatment and rehabilitation, and not incarceration. The United States has grappled with the issue of opioid abuse since way before the turn of the 20th century. During the Civil War, injured soldiers were often treated with morphine, and became addicted to the powerful opioid. In 1898, commercial heroin production began, and became infamously known as a “wonder drug” whose effects could be intensified if administered through injection. During this time period, people knew that these drugs were effective painkillers and innocuously utilized them as such, remaining unaware of their addictive nature until the 1920s. Soon after these findings were made, doctors refrained from using these forms of treatment, and heroin was declared illegal in 1924.3 By the 1970s, doctors hyper-aware of such past history were wary of prescribing highly addictive opiates to patients. But all of this changed when articles were published, with the argument that opiates could safely be prescribed to those suffering from chronic pain as long as the patient did not have a history of addiction. By the 1990s, people were less concerned about a repeat of the 1970s heroin epidemic, an attitude that led to a newfound emphasis on pain management.3 One of the doctors who argued that there was minimal risk of addiction from opiate use explained that he was trying to make primary care physicians feel more comfortable about opioids. But, in the process of de-stigmatization, these advocates often overlooked clear-cut evidence. This doctor said on the matter, “Clearly if I had an inkling of what I know now then, I wouldn’t have spoken in the way that I spoke. It was clearly the wrong thing to do.”3 Opioid addiction rates have continued to grow over the years, and as a result, the number of overdoses has also increased. The CDC Director, Tim Frieden, wrote in the New England Journal of Medicine, “We know of no other medication routinely used for a nonfatal condition that kills patients so frequently.” He also explained that recent studies have shown that one out of every 550 patients who started using opioids actually died of opioid-related causes an average of 2.6 years after their first prescription.3 These numbers only apply to those who were formally prescribed opioids, but

there are also users who are abusing heroin and other non-prescribed synthetic opiates, and remain outside of these statistics. When heroin or other opiates are injected into the body, they travel through the bloodstream up to the brain. Opiates are converted into morphine by enzymes in the body before finding opiate specific receptors in the brain to bind to. This binding decreases pain perception and increases dopamine levels, which can trigger sen-

Ten days later, Stephanie was found dead from a heroin overdose.

sations of euphoria. Dopamine levels can rise to almost ten times their normal levels when heroin is in the body. There are also endogenous opioids produced by the body, such as endorphins, that bind to the opiate receptors, but the sensations from heroin are greatly amplified compared to those of naturally occurring endorphins.6 After regular exposure to opioids as well as sustained and elevated dopamine levels, the body may begin to build tolerance to these drugs. Pain signaling sensitivity is intensified, and pain thresholds are decreased. These changes can take effect as quickly as after just one single use. The increased sensitivity of the pain signaling pathways causes these pathways to become overactive. As a result, users feel as though they need the drug to feel normal.6 In places like Huntington, West Virginia and Cincinnati, Ohio, the epidemic impacts everyone, from users to first responders and even to newborns. In regions like these, it is not uncommon for one week to lead to 180 overdoses, 18 heroin or synthetic opiate-related deaths, 200 newly jailed heroin users, and 15 babies born with heroin-related medical problems. Parents are losing children, and children are losing parents.1 Patsy Uebel works as a nurse at the Cincinnati Children’s Hospital Medical Center, treating babies suffering from neonatal abstinence syndrome. This condition occurs when an infant’s mother suffers addiction to heroin or uses heroin while pregnant. Symptoms can include seizures, tremors,

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or other common withdrawal symptoms in the infant. Patsy once worked with an infant named Elliana. When asked about Elliana’s development, Elliana’s mother, Stephanie, would proudly explain how Elliana picks things up, throws them on the ground, and then looks at them and laughs. Stephanie had used heroin and other opiates for years, but quit when she found out she was pregnant because she wanted to have a normal life with her daughter. During a visit when Elliana was 8 months old, Patsy told Stephanie that Elliana was growing up healthily, and asked to see them back in a few months. Ten days later, Stephanie was found dead from a heroin overdose.1 First responders in many parts of the US encounter overdoses like these everyday. If found quickly enough, people can sometimes be saved by a drug called Naloxone, even after their hearts stop. Naloxone is able to reverse the effects opiates by binding to opiate receptors and reversing the effects of the drug. Naloxone can be injected or administered through a nasal spray, making it easy for first responders or even the public to utilize. Naloxone prevalence reduces the number of deaths from overdose.4

responders in her county have Naloxone supplies on them at all times. Some people believe that Naloxone enables addicts, and that there is less consequence associated with overdose if it can be reversed. Rader explains that this is not the case: Naloxone isn’t an enabling substance, because it actually induces withdrawal symptoms. She says that people oftentimes become angry after receiving a treatment of Naloxone because they feel “dope sick.” She goes on to explain, “The only qualification for getting into the long term recovery is you have to be alive. I don’t care if I save somebody 50 times. That’s 50 chances to get into long term recovery. People do go into long term recovery and they do become productive citizens, tax paying citizens.” Additionally, people who have been through the recovery process often go on to mentor others who are also going through similar experiences.4

Jan Rader, the Deputy Chief of the Huntington Fire Department, firmly believes all first responders should have Naloxone on them at all times in the case of an overdose. Rader works hard to ensure that all first

These long-term recovery programs are the alternative to the War on Drugs. While the War on Drugs often sends addicts going to jail, these long-term recovery programs offer help and support for those trying their

While some people maintain the opinion that policemen are not doctors and should not carry Naloxone, many officers have taken on this new role in their communities. They help individuals suffering from addiction to receive the treatment they need, and also administer the opioid reversal drug when necessary. One day, in Ohio’s Piatt Park, a bike cop saw a man passed out on a bench. He called for paramedics, then administered a dose of Naloxone he had with him. Upon arrival, the paramedics administered another dose of Naloxone, which successfully reversed the effects of the drug that the man had overdosed on. While this is an example of the benefit of equipping cops with Naloxone, it was unfortunately not the beginning of this particular man’s road to recovery. Although encouraged to go to the hospital, the man rose from the bench and walked away, ignoring the advice. Although this is not the desired response to the incident, as Jan Rader had explained, saving any life is worth it. Even if they have to do it again, each save is simply one more chance for this man to go into recovery.4

People do go into long term recovery and they do become productive citizens, tax paying citizens.

The life saving drug now being carried by many first responders known as Naloxone. The drug is able to reverse the effects of opioids, helping those who have overdosed.

opiatesupportgroup.com

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best to reform.

Currently, Attorney General Jeff Sessions is advocating to cut treatment funding, which would ultimately revive the War on Drugs. What little funding there currently is goes towards addressing the consequences of untreated addiction, rather than towards treatment and prevention, which would directly fight the problem at the source. Putting people in prison increases and prison population and hikes up criminal justice and health care costs, therefore failing to address the disease. Additionally, a stigma has arisen around the issue, creating yet another barrier to face when trying to handle this problem. Despite these repercussions of the War on Drugs, Sessions stated, “We have to create a cultural climate that is hostile to drug abuse” at the July 2017 30th Annual DARE training conference.2, 5 President Trump made promises to aid communities who are afflicted by this epidemic. He proposed to provide those suffering from addiction with treatment rather than jail time. This is novel because Trump

YALE GLOBAL HEALTH REVIEW


Wikimedia Commons

whitehouse.gov

President Trump and the First Lady on October 30, 2017, announcing that the opioid epidemic has become a national crisis.

had previously invested much of his time and energy into attempting to dismantle the ACA and Medicaid, programs that previously provided millions of addicts with proper addiction care and health care services. He also has spent time on a “tough on crime approach,” regardless of the fact that more people are dying from overdoses than from homicide.2

In the hardest-hit regions, members of the community are coming up with ways to help however they can. In Covington, a town near Cincinnati, a woman named Scarlett Hudson works with a non-profit called the Women of Alabaster Ministries, Inc. Their mission is to assist women who are caught in human trafficking and grappling with addiction. She drives the women to

appointments, and twice a week, performs outreach ministry, with which the women can get food, shower, a nap, clothes and see a nurse once a week. Hudson also drives around handing out bags with food, toothpaste, shampoo, and various other toiletries the women may need. Hudson is affectionately known around the area as “Momma Scarlett,” and the women know they can call her if they need help. Hudson explains that the most important part of the work she does is not judging the women for the difficulties they are facing.1

Hudson explains that the most important part of the work she does is not judging the women for the difficulties they are facing.

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The growing epidemic must be fought tactfully, first and foremost by recognizing addiction as a disease and actually treating it as such. More funding must be invested in addiction prevention and treatment

strategies. The goal should be not to break down health resources, but rather, to build up a health care system that offers individuals with addiction the access to the help they require. The issue is growing, spreading, and affecting a vast population. In Cincinnati, a crowd of people gathered at the Sheriff’s office to receive pamphlets and door hangers with information about addiction and treatment. The county’s judge official asked them if they had been affected by the heroin crisis. To those who didn’t raise their hands he said, “You are touched by it. You just don’t know it yet.”1, 2

www

Kristi Wharton is a sophomore in Branford. She is majoring in History of Science, Medicine & Public Health. She can be contacted at kristi.wharton@yale.edu

16


VENEZUELA

By Eleanor Cook

A protestor waves a Venezuelan flag in front of a military blockade.

Starvation and Sickness in the Wake of Venezuela's Economic Collapse By Ben Grobman 17

YALE GLOBAL HEALTH REVIEW


ibly charismatic, and inspired deep loyalty from the Venezuelan masses. Chavez was further aided by a global oil boom in the early 2000s which bolstered Venezuela’s economy due to Venezuela’s massive oil reserves. Chavez then invested much of the resulting influx of capital in social programs. As a result, Chavez was politically successful, remaining in power until 2013, when he died from cancer at the age of 58.2 After Chavez’s death, his chosen successor, Nicolas Maduro, was narrowly elected in a special election.3 Maduro is known for imitating Chavez’s charisma and mannerisms, going as far as to call himself ‘The Son of Chavez.’2,3 However, Maduro lacks both Chavez’s charm and his economic good fortune. Chavez was able to invest so much money in social programs because he spent very little money on building infrastructure and creating a sustainable economy in Venezuela, instead relying on imports to supply basic goods and uphold Venezuela’s economy.4

O

n Wednesday, January 24, 2018, Marcos Carvajal, a former pitcher for the Colorado Rockies and Miami Marlins of Major League Baseball, died in Ciudad Bolivar, Venezuela. The cause of death was pneumonia, a common disease which is easily curable by simple antibiotics. However, due to dire shortages of medicine in Venezuela, the former elite athlete succumbed to his illness at the age of 34.1 In 2014, tanking oil prices pushed the once wealthy nation of Venezuela into

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a downward economic spiral. This economic crisis has caused massive inflation, as well as shortages in food and medicine, leaving everyday Venezuelans destitute, sick, and starving. Throughout the crisis, the government of President Nicolas Maduro has been highly ineffective, increasingly displaying authoritarian tendencies. In 1999, Hugo Chavez was elected president of Venezuela. A socialist from a humble background, Chavez was incred-

In 2014 the oil boom which bolstered Chavez throughout his tenure came to a sudden halt. As oil prices crashed, so did the fragile Venezuelan economy, sending Venezuela into an economic spiral which “[makes] the Great Depression seem like a mild recession.”2,5 During this time, Venezuela has experienced extreme hyperinflation, which has gotten so bad that the Venezuelan Central Bank stopped reporting inflation data after 2016.6 However, the International Monetary Fund has projected that Venezuela will experience inflation of 13,000 percent during 2018.5 As a result of this extreme inflation, money in Venezuela has become near worthless. In early 2018, president Maduro raised the minimum wage in Venezuela by 40%, with the stated intent of protecting Venezuelan workers. While this 40% increase brings the monthly minimum wage to near 800,000 bolivars each month, this is only worth $7, or 23 cents per day. Economists have also predicted that this raise in the minimum wage will only cause even more rapid inflation, offsetting any meager benefits. Due to this economic crisis, the Venezuelan economy is projected to shrink by an additional 15 percent in 2018. This projection would bring Venezuela to a 50% overall reduction in GDP just since 2013.7 In early 2017 thousands of Venezuelans took to the streets to engage in daily protests against president Maduro’s expanding power, as well as the dire state of the Venezuelan economy.8 During these protests, which lasted from April to July

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Police cars burn during a 2014 protest against the government of Venezuelan President Nicolas Maduro.

of 2017, over a hundred protesters were killed.9 However, as protests died down, what remained was a broken state, in which the once stable and relatively prosperous Venezuela had devolved into extreme poverty for the vast majority of its inhabitants. Meanwhile, president Maduro has become an increasingly authoritarian, out of touch, and unpopular leader. Throughout the crisis, he has refused foreign aid to Venezuela, blaming outside influences such as the United States for Venezuela’s economic state.10 In a particularly notorious incident, the already plump Maduro took a bite out of an empanada during a live televised address, earning himself widespread mockery and condemnation.11 The most significant aspect of this drastic rise in poverty has been the shortage in food and medicine throughout Venezuela. Since the 2014 economic recession, access to food and basic medicines has been limited for the majority of Venezuelans. Even before the protests of 2017, the average Venezuelan was unable to afford satisfactory quantities of food. In a national survey done at the end of 2016, three-quarters of Venezuelans reported having lost an average of nineteen pounds over the previous year.4 Entering 2018, the crisis has only worsened.

While unrest remains prevalent in Venezuela, it is no longer due to the protests of middle-class political protesters. Instead it stems from impoverished Venezuelans, who, desperate for basic nutrition, have increasingly protested shortages of basic necessities. During the so-called “pork revolution� in December 2017, thousands

of Venezuelans took to the streets after the Venezuelan government failed to deliver on promises of delivering pork legs to poor Venezuelans for Christmas. President Maduro blamed Portugal, claiming that the shipments had been sabotaged. The Portuguese company responsible for delivery of the pork responded that the Venezuelan

By creating a more welcoming environment, health facilities are able to attract and care for more young people.

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YALE GLOBAL HEALTH REVIEW


government was 40 million euros behind on payments for the shipment of pork legs from the previous year.12 In acts of desperation, starving Venezuelans have increasingly taken to looting in order to obtain food. In the first half of January 2018 alone, over a hundred incidents of looting were recorded.13 In early 2018, reports emerged of mobs of people raiding farms, and videos were taken showing cows being stoned to death before being ripped apart and carried off in pieces.14 Many other formerly well-off Venezuelans routinely scavenge through garbage dumps at night, hoping to find food in the garbage that restaurants and supermarkets throw out after closing.10 A 2016 report noted that in Venezuela, formerly the country with the highest per capita income in all of South America, 90% of households were food insecure.4,10 Not only are individuals

Three-quarters of Venezuelans reported having lost an average of nineteen pounds over the previous year.

unable to afford food, many supermarkets lack money to stock their shelves, leading to aisles completely barren of goods.10 Venezuela’s lack of access to food has most powerfully affected Venezuelan children and as the crisis has continued, there has been a sharp increase in deaths due to malnutrition. Between 2012 and 2015, the mortality rate for children under 4 weeks old increased by a factor of 100, with newer statistics showing even further increases in child mortality.10 As food has become increasingly scarce, hospitals have started to see daily cases of children with severe malnutrition. In a late 2017 report by the New York Times, doctors in 9 hospitals reported nearly 400 deaths due to malnutrition in one year.10 Many hospitals have become so overwhelmed with patients that they are forced to turn severely malnourished children away. Hospitals themselves are severely lacking in basic supplies, often unable to provide the children they accept with lifesaving baby formula and other needed treatments.10 Just as everyday Venezuelans are unable to afford basic living necessities, Venezuelan hospitals are unable to afford needed medicines, leaving the Venezuelan medical system on the verge of collapse. Venezuelan hospitals only possess 5% of the med-

VOLUME 5, NO.2

Impoverished Guatemalan girls are often married offed to support the rest of the family.

icines they require to function normally, meaning that patients who are admitted to the hospital are rarely able to receive the medicines they need. Additionally, hospitals only have 25% of the beds needed for a country of Venezuela’s size. As a result, footage has emerged of pregnant women delivering babies on waiting room floors and patients being treated on the floors of emergency rooms.15 Lack of health infrastructure has also led to the reemergence of previously controlled diseases, with sharp increases in reports of diphtheria and ma-

Many hospitals have become so overwhelmed with patients that they are forced to turn severely malnourished children away.

laria.15 To make matters worse, as wages have plummeted, even skilled workers such as doctors have found themselves unable to maintain a basic standard of living. Even with their extensive training, doctors make just over $100 a month, causing over 13,000 doctors to leave Venezuela during the crisis.16 Others have turned to prostitution, enabling them to make $25 an hour.17 As a result of the collapse of the healthcare system, everyday Venezuelans have been forced to turn to the black market in order to obtain the medicines they need. Everyday market sellers routinely sell medicines which have been smuggled from nearby countries such as Colombia.

While these sellers may possess necessary medicines, the medicine has often been improperly kept or is expired, making it unsafe for consumption. Despite this, in their desperation, many Venezuelans purchase and consume this contraband medicine. However, even when presented with access to medicines which they are unable to find through legal avenues, due to their meager wages many Venezuelans are unable to afford even this black market medicine.18 So what’s next for Venezuela? In January the Venezuelan government announced that a presidential election will be held in April. The Maduro government has previously rigged local elections, and the fairness of the upcoming election is dubious, with multiple opposition parties already being banned.19, 20 In a particularly cruel twist, the I.D.s used for voter registration are the same as those used to register for food subsidies, and rumours have spread of subsidies being denied to those who vote for the opposition.19 Despite this, Maduro is so unpopular that it may be possible for him to lose even an unfair election.20 Regardless of political developments, the outlook for Venezuela is bleak. Even with proper management, it will be many years before the country that was once the richest in South America can undo the damage of its current economic collapse.21 www Ben Grobman is a first-year in Saybrook College and a prospective Ecology and Evolutionary Biology Major. He can be contacted at benjamin.grobman@yale. edu.

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Public Domain

INTERVIEW

YOUNG MIND, GLOBAL HEALTH: A Conversation with Dr. Sten Vermund on Ways Today's Youth Can Address Global Health Issues

By Tomeka Frieson

C

urrently serving as the Dean of the Yale School of Public Health, Sten H. Vermund (MD, PhD) is a pediatrician and infectious disease epidemiologist focused on diseases of low and middle income countries. His work on HIV-HPV interactions among women in Bronx methadone programs motivated a change in the 1993 Centers for Disease Control and Prevention (CDC) AIDS case surveillance definition and inspired cervical cancer screening programs launched within HIV/AIDS programs around the world. The thrust of his research has focused on health care access, adolescent sexual and reproductive health and rights, and prevention of HIV transmission among general and key populations, including mother-to-child.1 The Yale Global Health Review had an opportunity to sit down with Dr. Vermund and discuss his views on three top global health issues of our time—HIV/ AIDS, prescription drug overdose, and cancer—and his take on the roles that younger generations play in addressing global health and applying global health knowledge and research to our daily lives.

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Doctor Sten H. Vermund, Dean and Anna M.R. Lauder Professor of Public Health

YALE GLOBAL HEALTH REVIEW


ation is more used to universal condom use than the older generation because they grew up in the AIDS era. [A modern-day adolescent or young adult might think] “of course I’m going to use a condom when I have sex. I don’t want to get HIV or an STD,” whereas the older generation was more loosey-goosey; we didn’t have a lethal STD lurking. That might be a good thing. ON PRESCRIPTION DRUG OVERDOSE In 2016, there were an estimated 64,000 drug overdose deaths in the US alone, and most of these deaths were attributed to the abuse of prescription opioids.4 Why do you think the prescription drug overdose epidemic is a big problem in our society? Well, when I was in medical school, which was the 1970s in New York City, there were an estimated 400,000 opioid addicts in the United States. Most of them were heroin addicts, some of them were prescription. 200,000 of them were in New York City, and 200,000 were in the rest of the country, mostly big cities. Today, that estimated number is 2.4 million, 6 times [the previous statistic], and we still have about 200,000 in New York City. That is, then, 2 million excess opioid addicts, and it’s no longer restricted to the big cities. Appalachia, New England, parts of the Deep South, and parts of California [have all been affected by the epidemic], and [the effects are] very rural, as well as urban. It’s an objective fact that we have a bigger epidemic. It’s not “do you think we have a bigger epidemic?” We do. Much of that, if not most of it, was fueled by the prescription patterns that became prevalent in the early 21st century. In the 1980s/1990s, there was an increased awareness that doctors were undertreating pain, and they even started talking about pain as the fifth vital sign. The vital signs are heart rate, respiratory rate, blood pressure, [and body temperature]..., and you were supposed to measure pain just like you’d measure vital signs. This incentivized people to use more pain medication. The problem is that pain is a subjective report, whereas vital signs are objective reports, and it’s difficult to manipulate... objective [data]. [You could] go under a heat lamp, and get a fever [or] you can take a drug to increase your blood pressure, but people don’t generally do that. Pain is subjective. Look at birthing [“in various societies around the world”]. [In] some societies, women are completely silent when they deliver a baby, [and when asked about the pain after birth,] say it was moderate. [In other societies], people are screaming bloody

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murder in the delivery room, and they [say] it was the worst pain they’ve ever had in their lives. Well, guess what? The pain was identical for the two women. The birthing process is identical, but it was culturally modulated. There were cultural features, where in one society a woman was encouraged or expected to express herself and express her pain and release it that way, and [in the other] one, the woman is expected to be stoic and not release it. [There] is a lot of subjectivity.

pain relief became addicted.

Now, we’re doing a better job turning off the spigot of legal access to opioids, but what does an addict do? Well, an addict is an addict, and unless they’re in a treatment program—and we don’t have enough treatment programs—they will look for an alternative supply, and that’s heroin. You would do well to read a book, written by Sam Quinones called Dreamland…. It tells [the story of] how we got into such as mess, and it also articulates how the Mexican black tar My son went to get his wisdom teeth tak- heroin filled in where the Mafia and other en out maybe ten years ago, and his dentist drug dealers were not operating and created gave him a two-month supply of oxycodone. new models. You could order your heroin My son took zero of those pills because the way you ordered pizza by calling his father recommended that someone up and having them You he try something non-opioid deliver to your home. [This could order and see if it worked, and it was] a whole different worked. We didn’t need model of heroin delivery your heroin the any of those…. If he that was more suitable way you ordered had taken two months for rural areas and more of these pills, he would suitable for areas that pizza by calling have become addicted. were more stigmatized someone up and So there was the dentist for heroin use—not the who didn’t have a clue. big cities.... They didn’t having them deliver concentrate on New York, There are many doctors to your home who haven’t had a clue, Miami, Chicago, and L.A. and in their misguided efforts They were looking for smaller to reduce pain, they inadvertentmarkets. ly addicted a lot of patients. They were Another reason [opioid users] switched helped to do this by the pharmaceutical companies. The pharmaceutical companies to heroin was because it was cheaper. An had very big campaigns to try to increase oxycodone tablet might go for $20, [but] you sells of their products, and there was a lot of could get the equivalent of 20 oxycodone misrepresentation: [imitating pharmaceuti- tablets for that amount in heroin.... Now, cal companies] “Oh, you can’t get addicted we have people injecting [frequently]. Well, with our products. Our products will help guess what comes with injection? Hepatitis control the pain, but they’re not going to C virus, Hepatitis B virus, and HIV. Have simulate addiction because you’ll use them you heard about... Scott County, Indiana? in moderation.” That was simply wrong. [This HIV breakout involved] a whole bunch Many people got addicted. So [there was] of white people—not your stereotypic urban ignorance on the part of the medical profes- poor, who were the old-fashioned heroin sional, [as well as] some criminal activity on addicts—the new era heroin addicts, many of whom were middle-class, many of whom the part of the medical professional. were poor. It was a 200-person-plus HIV epThere were doctors and nurses who set idemic from sharing needles…. There’s a lot up pill mills near freeways, who didn’t take of evidence of the upsurge of HCV, and the any insurance. Cash—$200—in the barrel, upsurge of HIV is inevitable unless we roll ten minute interview, and standard ques- out enough drug treatment slots to help peotions. The addicts knew what the responses ple stop sticking a needle in their arm. were, so they could fill it out, and it’d seem like a legitimate request. However, the doc- What would you say is the most important tors and nurses knew it wasn’t legitimate. aspect to address in order to ameliorate this They were just making millions of dollars epidemic? a year by prescribing this stuff. There were Well, right now, the horse is out of the well-meaning doctors who did the wrong barn. 2.4 million Americans are addicted, thing—overprescribing—and then there were criminal doctors and nurses—a much and we have to offer them opioid substitusmaller number—who criminally pre- tion therapy. We have to get them on methscribed…. Then a whole raft of patients who adone and/or buprenorphine so [that] they started out often with a legitimate need for can get back to functioning as parents, as citizens, [and] as breadwinners because an ac

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tive heroin addict is not functioning in those three spaces…. If they’re on methadone or buprenorphine, they can avoid withdrawal, but they can also go to work and... take care of their kids. [We need to have] enough alternative treatment programs—opioid substitution therapy in drug treatment programs—for these 2.4 million people to get off of prescription drug addiction, off of heroin addiction, and transfer that into a manageable long-term-care environment, [possibly] state-of-the-art addiction services—same thing that rich people get. Everyone needs to get that. We do need much better monitoring of physician prescription patterns, and high prescribers need re-education as to the alternative approaches because we don’t need to be addicting a new generation either. We need a lot in the way of job training because one of the reasons somebody might start using an excess of opioids [is because] they got injured on the job, or they had a sports injury. There’s something that led them to need pain medicines. It’s a vicious cycle: if you are disabled from an injury, and now you’ve become an addict, how are you going to do your job? You need to be stabilized so you can function and you need to get some job retraining so that needs of Appalachia, needs of rural New England can be met by people who are working in spaces where there are opportunities. That doesn’t mean to reopen the coal mines because nobody wants to buy the coal. There isn’t much demand for coal these days.... Those coal-mining regions need to be re-tooled into call centers, technology centers, or tourism centers. There needs to be complete revitalization of these swaths of impoverished rural America [in order] to think through what is possible to do there, how we [can] lure manufacturing there, and how we [can] lure alternative industries there, [an action] which neither Democrat nor Republican has done a good job of. For the younger generation, what would you say we could do to address this drug overdose epidemic? Well, we’ve had overdoses here in the city of New Haven. There are drug treatment centers that are desperate for additional assistance. Volunteering in such a center, working with the outreach workers to lure addicts into the center… [by] mak[ing treatment] appealing to them and mak[ing treatment] worth their while, educat[ing] them as to the benefits of these centers [would all be beneficial activities]. I think there’s a huge primary prevention agenda. Imagine somebody as yourself, a Yale freshman, going in

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to talk to eighth graders in public schools [in New Haven,] Bridgeport, Hartford, or anywhere for that matter, about the opioid epidemic in New England and making it real for people. You could probably partner with a mother or father who has lost their adult… or adolescent child from this epidemic who would be happy to be in a speakers’ bureau with you. There are organizations of such parents who are eager to do this public outreach. We often talk about treatment of the addict as a high priority, and I fully believe that as a clinician and as a public health professional; it’s absolutely essential. But we don’t talk as much about primary prevention: going into the middle schools, the high schools, and educating [students] about opioid addiction. What do they know about prescription opioids? What do they know about unscrupulous pharmaceutical practices? What do they know about what it really means to be an addict, how easy it is to become an addict, and how intractable heroin addiction is? Heroin addiction actually changes brain chemistry patterns, and the more experienced you are with heroin addicts and opioid addicts, the more convinced you are that long-term opioid substitution therapy is a much better option than detox. Detox has a 95 to 98 percent [regression] rate, which just doesn’t work. We don’t fully understand why it doesn’t work, but it’s very ineffectual. ON CANCER One in every eight deaths worldwide is caused by cancer.5 With an estimated 23.6 million new cases of cancer expected to arise each year until 2030, research into the causes of and treatments for the numerous types of cancer is widespread.6 Why do you think cancer research, or just finding a cure for cancer, is still a big concern even when this has been an issue for so long? I’m not fond of the term “finding a cure for cancer” because cancer is many different diseases. The etiology of cancer differs. The pathology and pathophysiology of different cancers differ immensely, and pathways of the origins of cancer differ immensely. There are many, many different cancers. The only thing they have in common is the overgrowth of cells, and to think of “a cancer cure,” I think, is very naïve. Now, I hope some future Nobel Prize winner your age proves me wrong, and there’s some fundamental, underlying, common denominator of all cancers, and if we fix that, we fix all cancers, but I doubt it. I doubt it very much. In my parents’ generation, if you had acute

lymphocytic leukemia as a child, [there was a] 95 percent death rate. Today, [there is a] 5 to 10 percent death rate, so there are some cancers [where] we can cure almost everybody. [Acute lymphocytic leukemia] was a death sentence; now it’s almost curable. We’ve made a lot of progress, and cancer [death] rates in the US have dropped. They haven’t increased in recent years…. Having said that, five-year survival for pancreatic cancer twenty years ago [was] about one percent. Five-year survival for pancreatic cancer today [is only] about two or three percent, so there are cancers where we’ve made almost no progress. [With] something like pancreatic cancer, we’re going to need fundamental, basic science insights because current therapies don’t work. We also need early diagnostics because the pancreas is retroperitoneal; it’s behind the peritoneum, which is the sac that holds our insides and our abdomen, so you cannot palpate the pancreas.... [You can only use] imaging, [but] you can’t have a rare cancer and then go image everybody. We found out about pancreatic cancers kind of late, which also hurts us, but what if there were blood tests, and [they] revealed pancreatic cancer? We could screen people. What if we had fundamental insights about the etiology of pancreatic cancer so we could have immunotherapies like what’s working well for melanoma? [With] melanoma, we’ve had breakthroughs with immunotherapy, and lethal melanomas can sometimes be treated. I think people have to realize that there are many types of cancers which have completely different etiologies, and they are probably going to need completely different insights on the basic science side that could translate to... [the] diagnostic [and] therapeutic side. Would you say that the fundamental, basic science insights would be the “remedy” in the near future for addressing cancer? For our incurable cancers, the ones [with which] where we’re doing a very bad job, we have to have basic science insights because our clinical insights are not getting us anywhere. Then, we’re going to need to understand the environmental and molecular mechanisms of cancers, what causes them, and what the molecular mechanism [is] that leads to the disorder: the proteomics, the genomics, the metabolomics.... For the more curable cancers, there’s still a lot of progress that is being made in the clinical environment. There are a lot of cancers where tweaking existing drugs can make a big difference by reducing side effects, by improving efficacy. Drugs like Levac that have come

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on in my professional lifetime are extraordinary drugs that have transformed oncology. I don’t know that Levac came from more fundamental understandings of the etiology of cancer. That [was just] pharmacologic innovation for which there was some reason to believe that it would be an anti-cancer drug, [but] it turned out that they were right. Some of these drugs that reduce angiogenesis are similar. We know that an almost universal feature of cancer is that the cancer stimulates blood vessel proliferation to feed these new cancer cells. If you can inhibit new blood vessel proliferation, you could starve the cancer cells. That’s just a kind of generalizable observation. I don’t know if that comes from basic science; it comes more from translational science and then generated hypotheses around pharmacological approaches, which panned out. People like Judah Folkman up at Harvard [are] pioneers in this area. Then [there is] the diagnostic side. There are people working on blood tests for cancer, and the University of California, Irvine, has had some news lately with some great, substantial insights from some of their investigations. To me, it’s a broad panoply of activity. It is on the basic side, it’s on the translational side, it’s on the drug developmental side, [and] it’s on the clinical side. The whole field of radiation therapy, or radiation oncology, has been benefited by physicists and engineers who have developed more targeted X-ray fields so that you reduce the side effects of radiation therapy. You focus [the X-rays] on the cancer cells, and you have better cancer-killing effects. That didn’t come from basic science unless it came from certain physics basic science or optics. That came from engineering innovation. You can be doing almost anything in the cancer field and be making contributions. We need contributions across the board. Some people don’t do well with their cancer because they don’t have health insurance or they live too far or they’re subject to the stigma of cancer, and they abandon their cancer care. They [could also] live in a developing country where, if you live in the capital city [healthcare professionals will] help you, but if you live in any rural part of Africa or Asia, [healthcare professionals] can’t help you. There’s a whole public health side to cancer that’s also valid. What would you say the younger generation could do to better address the innovative side of cancers that we know more about or start delving into the basic science to explore more of the [unknown cancers]? We’re always happy when a young per-

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son wants to embrace science at any level because the needs are tremendous, and we have to replace the older generation, such as myself. We’re very pleased to see people entering at any level: basic science, translational science, clinical science, public health science…. I think a young person needs to think about what excites them. One person is going to say “It is a disgrace that 6,000 women a year die of cervical cancer, a completely preventable cancer.” They may go into adolescent HPV biovaccine advocacy. They may go into immigrant or refugee health. They may go into health of Native American or Native Alaskan people. They may go into health disparities and disparities between the rich and the poor. Somebody else may say that it’s a disgrace that pancreatic cancer is a death sentence. “I had an uncle die of pancreatic cancer,” they might say, “and I wouldn’t want a dog to die the way that person died, and I want to do something about it.” That person may want to go into basic science. That may be the only place we’re going to make a breakthrough on pancreatic cancer. There are plenty of health disparities that we can address, and we can reduce cancer by earlier screening, more effective therapy, more effective assistance for people who need to adhere to their therapies, and that’s on the clinical/public health side. There are plenty of horizons on the basic science [side]; that’s the most promising area. So I would [advise] a young person [to match] their interests and passions with their profession, and that [makes for a] happy person. [This is] similar to what you do on the personal side: if you find a partner, you want to find a partner with whom you share common values, common life aspirations, mutual respect, all that stuff. You match professionally just the way you try to match personally, and that [makes for] a happy person. ON THE YOUNGER GENERATIONS We, the youth, are the future, and global health issues are not going to fix themselves. At the end of the conversation, Dr. Vermund was asked about specific roles that younger generations could play in ameliorating global health issues. In addressing all of these global health issues, how do you think the younger generations can collaborate to ameliorate global health on a large scale? There are youth movements in [the arena of global health]: The Consortium of Universities for Global Health; the American Public Health Association International Health Section; AMSA, the American Medical

Student Association; the National Medical Student Association…. There are advocacy organizations [as well]. The ONE Campaign that Bono... founded [is] aching for student volunteers. Right here in town we have the Unite for Sight organization, and [in addition to running the big conference in April,] they do lots of volunteer work all over the world. A Yale graduate founded the Global Health Corps, which sends young people to international service for a year at a time…. Did you know that the international headquarters of Save the Children is here in Connecticut, a 25 minute drive from [the Yale School of Public Health]? There are an abundance of international agencies and advocacy organizations that would welcome student engagement. On the other hand, how do you recommend that members of the younger generations on an individual level address public and global health issues within their community, city, state, or even country? I would recommend they don’t try to do it on an individual level. I think joining forces with like-minded people is the only way to get [change] done. I think sometimes you can be old or you could be young, and you can be a little bit grandiose. I’ve known people to go into global health because they want to save the world, and that’s great motive, but it’s not a very good organizing principle because when they find out they’re going to have trouble saving the world, then they get demoralized and [change professions]. I feel like it’s good to understand that you need context in which to make a real difference, and you need the communities in which you’re partnering to engage. It may be that [linking with] community-based organizations, advocacy organizations, political organizations, and public health organizations is going to be far more effective. Paul Farmer didn’t do anything by himself. He created Partners in Health, and he did it with thousands of people. He gets credit, but he’ll tell you he didn’t do it alone. [He] had colleagues from the very beginning; [it was a] group effort from the very beginning. I think linking to an organization that is making a difference, that inspires you and [in which] you can find a volunteer niche or an employee niche someday, would be the way [to address public and global health issues within your community]. www Tomeka Frieson is a first-year in Berkeley College with the prospective major of the History of Science, Medicine, and Public Health. Contact her at tomeka.frieson@yale.edu.

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FEATURE ARTICLE

GLOBAL HEALTH SECURITY: Cracking the Code to a More Health-Secure World BY TOMEKA FRIESON

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VOLUME 5, NO.2

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reaking news flashes across your phone screen. A new drug-resistant superbug, with symptoms such as fever, extreme fatigue, diarrhea, and searing muscle pain, has taken hold in a small Ethiopian town. So far, only one individual has died, but scientists are working as fast as they can to respond to the sudden and unidentified outbreak. This news is quite concerning, but given your location in the US, you refrain from preoccupying yourself with the details of the case. A month later, breaking news flashes across your phone that this infectious bacteria has managed to spread throughout all of Ethiopia. While scientists are beginning to identify the cause as a pathogen that individuals acquire through constant travel from South Asian to African countries, 200 individuals have died within the month, and hundreds of planes have taken flight from Ethiopia to all regions of the world. The pathogen is on the loose. Within the next month, cases of this drug-resistant superbug have been identified in France, India, Cuba, and now even the US. Death tolls are rising at a frightening rate, and still no solution has been made to combat the contagiousness of—or even the symptoms associated with—this virus. More and more individuals are scared to leave their houses, news outlets are panicking, and governments the world-around are scrambling to find an answer to this epidemic. Such is the possible pathway of an infectious disease, and such is the target of global health security. The summer of 2018 is expected to come with its plethora of health challenges. Drug-resistant strains of bacteria are becoming more prominent and powerful, major complacency has set in regarding the AIDS epidemic, and concrete policy regarding reproductive health rights and services remains unestablished globally.1 In addition, many recent global health challenges have brought great devastation: 2003 saw the severe acute respiratory syndrome (SARS) virus, costing countries a collective 30 billion dollars in economic output in four months; 2009, the H1N1 flu pandemic, killing 284,000 individuals in its first year; 2014, the largest Ebola outbreak in history, infecting over 28,000 people and killing over 11,000; and 2015, a sudden outbreak of the Zika virus, leading to 61 US deaths.2,3,4 Looking at the current trajectory of global health issues, it remains uncertain as to whether future outbreaks can truly be prevented. According to the US Centers for Disease Control and Prevention, global health se-

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curity is defined as the preparedness of a country to detect and respond to disease threats, whose prevalence is not only measured by the emanation and propagation of new microbes, but also rising drug resistance; the ability of laboratories to induce and release dangerous microbes, whether intentionally or not; and increased globalization of both travel and commerce.5 On February 13, 2014, countries from all regions and economic statuses gathered in Washington, D.C., with the intention of launching the Global Health Security Agenda in order to unite on an issue that is not only key for international diplomacy, but also national policy, territorial wellbeing, and personal health.3 If this issue is not soon addressed in an international manner, it could pose serious repercussions for future societies and public health infrastructure. As a result of some nations’ preoccupations with the danger of an immense infectious disease threat that could effectively eradicate an entire nation, the five-year Global Health Security Agenda (GHSA) was established and signed by over sixty countries with the common goal of limiting the spread of infectious disease outbreaks, optimizing human wellbeing and minimizing loss of life, and reducing the economic burden placed upon countries by sudden outbreaks. 3,6 In order to achieve these goals, numerous GHSA-member countries have created roadmaps by which they plan to address the specific issues of global health security in their respective nations. Moreover, every country may choose to specialize in addressing one of the three objectives of global health security: prevention, detection, and response. The prevention component contains four subcategories: antimicrobial resistance, zoonotic disease, biosafety and biosecurity, and immunization. The detection component contains an additional four subcategories: national laboratory system, real-time surveillance, reporting, and workforce development. Finally, the response objective contains three subcategories: emergency operations centers, the multisectoral rapid response of law to public health, and medical countermeasures. In addition to addressing the overall objectives of global health security, every country must also track their progress over time in reaching and surpassing these goals, the measure of which will be the central subject of this investigative piece. 7 Global health security aims to address major biological, political, and social issues that can have serious ramifications in the

long-run. For one, in our incessantly globalizing world, travel and trade between and within various countries is constant. This connects us, but also renders the threat of disease more prominent. With constant travel comes constant contact with others, and with constant contact with others comes consistent exposure to microbes that, if acquired at the opportune place and time, could give rise to an epidemic. This is why global health security is invaluable. Without any specific measures to ensure protection from threats of infectious disease, all countries are vulnerable to the onset of epidemics. Moreover, with unanticipated epidemics come unanticipated financial burdens, arising from healthcare costs, as well as debilitation of the workforce due to sickness.3 Yet, with proper procedures in place, countries can be prepared to respond more actively to any perceived threat of infection. In a study assessing the degree of compliance to the 2005 International Health Regulations issued by the World Health Organization, researchers found that seventy percent of countries failed to comply with guidelines, consequently rendering any method to effectively address the regulation of international health nonexistent. 3,8 This lack of an international map of clear gaps to address global health administration and security, combined with different countries’ varying prioritizations of global health security in their national political agendas, elucidates stark disparities in international health that could, if unaddressed, proliferate into an outbreak of epidemic proportions. 3 In fact, Dr. Jordan W. Tappero, senior advisor to the Centers for Disease Control and Prevention’s Center for Global Health insisted that “in less than 36 hours, an outbreak that begins in a remote village can reach major cities on any continent and become a global crisis.”2 The purpose of this article, therefore, is to examine the progress made by three disparate countries in achieving the goals established in the 2014 Global Health Security Agenda, as well as similar and distinct measures each country is taking to ensure global health security. More specifically, the progress of countries in achieving goals of the GHSA will be analyzed with regards to infectious disease, defined by the World Health Organization as any disease spread directly or indirectly from person to person due to the presence of a virus, parasite, bacteria, or fungi. 9 In order to best compare the progress made by varying countries in regions around the world, three countries—Ethiopia, Bangladesh, and the United States—

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Ethiopian mothers and their children lined up for vaccinations during an outbreak

were chosen as the countries of investigation and assessment. Using these three countries of differing geographic locations, economic standings, and degrees of progress in achieving their GHSA goals, a diversity of country profiles can be examined. Furthermore, the definitions for economic divisions for each country were defined by the World Bank and describe low-income countries as those with a gross national income (GNI) per capita of $1,005 or less in 2016; middle-income countries as those with a GNI per capita between $1,006 and $12,235; and high-income countries as those with a GNI per capita of $12,236 or more.10 Ethiopia, defined as a low-income country, has taken great leaps to achieve its GHSA goals, but still has much work to be done in order to most effectively prevent the initiation and dissemination of an infectious disease. 10 With a population of 102.3 million individuals and a fertility rate of 4.5, Ethiopia is a country with many citizens but few financial resources. It is for this reason that tuberculosis, although decreasing in prevalence, still remains the fourth leading cause of Ethiopian deaths and has risen to the third leading cause of premature deaths.11 In terms of Ethiopia’s capacity for addressing its healthcare needs, Ethiopia’s government performed a Joint External Evaluation (JEE) that assessed the strengths and weaknesses of the country’s Public Health Emergency Management (PHEM) system, which was severely tested during the 2014 Ebola epi-

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demic. Primary findings of this assessment included the need to take action on multisectorial engagement, increased surveillance of the spread of human and animal diseases, and increased laboratory resources. More specifically, the fundamental obstacles Ethiopia must overcome to further advance its achievement of the GHSA outcomes are threefold. The solutions require an augmented incorporation and cooperation of the various organizations that influence the health security of humans, animals, and food in order to encourage collaboration on systematic policy; a necessity for greater disease surveillance to more clearly track when and to where diseases within Ethiopia are spreading; and an assurance of ample laboratory resources and technicians.12 Flickr

Like Ethiopia, the government of Bangladesh, a middle-income country of 161.9 million residents and a fertility rate of 1.9, has identified areas that both promote and inhibit GHSA goal progress.13 Some of the main obstacles identified by the JEE, however, were those of a lack of coordination both among and within Bangladeshi ministries, a segregation of the ways by which various JEE factors are addressed, and a lack of documentation as a vector to record Bangladesh’s plans to better global health security. 14 While very adequately and efficiently improving the country’s global health security measures, clarity and cooperation of various organizations’ roles, as well as the creation of accurate documentation, would greatly augment Bangladesh’s

global health security preparedness. In addition, the United States, with a population of 322.9 million individuals and a fertility rate of 1.9, is not only a major contributor to the GHSA, but is also the driving force behind its world-wide implementation, initiating partnerships with 31 countries and the Caribbean territories; working collaboratively with 17 nations to produce 5-year roadmaps to assess milestones, gaps, and next steps in achieving GHSA aims; and providing one billion dollars in assistance to the fortification of global health security in low-income countries. 15,16,17 While found by the JEE to be very steadily and effectively implementing strategies to address GHSA progress in general, advances can still be made in the collaboration practiced among the federal and state governments in addressing global health security issues, as well as in augmenting the quantity of biosafety regulations and well-trained technicians in the laboratory. 18 Regardless of the socioeconomic statuses of these three countries, common ground in progressing with the GHSA goals can still be identified. One similarity among these three countries, for instance, is the need for greater cooperation amongst various health security sectors, organizations, and/ or governmental entities. This recurrent necessity among various countries not only elucidates a core gap in addressing security measures, but also points towards a fundamental way by which global health security

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can be improved. Lack of cohesiveness and collaboration within and amongst the organizations addressing the GHSA aims leads to unfulfilled objectives and, if taking place within multiple countries, the stagnation of GHSA progress. How, then, in societies where every organization is focused on achieving its own goals, can a strategy for global health security prevention be implemented that not only actively involves various organizational sectors, but also effectively and periodically assesses progress toward GHSA goals? In other words, how can we as a global society unite under the banner of global health security to ensure a more health-secure world? The solution to this conundrum seems to rely heavily on national efforts, and the issue for many countries—especially all three of the countries assessed within this investigation—is not an outright lack of effort in addressing GHSA aims, but a lack of institutional cohesiveness that leaves objectives uncompleted. This is due to too few organizations addressing everything that needs to be done or too many organizations addressing the same sub-aspects of the aims and neglecting to address other equally important goals. The solution to this issue, then, seems to be the presence of a centralized regulator of progress within each country. Such an institutional entity could be, as in the United States’ case with its Office of Global Affairs, a governmental entity that delineates the roles of various sectors in addressing public health issues. However, it is important to note that the lack of cohesiveness exhibited does not necessarily have to be attributed to an outright absence of cooperation. Rather, as is the case with Bangladesh, lack of documentation to evidence the division of tasks or resources could serve just as equally as a barrier to the success of future inter- and intraorganizational collaboration. If health security institutions stand together nationally, however, the positive ramifications will be felt internationally. Because the success of the GHSA is so highly dependent on the success of its moving parts—the countries at hand—a widespread and collective augmentation of cooperation on territorial and national levels could drastically affect the big picture. In the case of the GHSA, the whole is greater than the sum of its parts, so addressing a common and recurrent theme such as lack of organizational collaboration within these smaller parts can significantly change the GHSA for the better. In addition to this similarity in the work needed to be done to better address the

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GHSA aims of various countries, differences of objectives also exist that emphasize the fundamental disparaging factors of each country. The United States’ issue, for instance, lies not in its ability to access resources or technology to augment laboratorial work, but rather how and the extent to which Americans regulate laboratory work. The laboratorial creation of biological microbes, whether intentionally or not, is considered a significant part of what encompasses a global health security threat. When a country, then, has the potential to create biological weapons and, in the past, has done so, an international body of regulators needs to carefully scrutinize the microbe engineering initiatives of that country. To best address this obstacle, a review of the United States’ inventory of potentially hazardous chemicals may be necessary. In doing this, the government and scientists may better understand how varying chemicals, in concert, could produce harmful effects. Combined with the possible distribution of an informational memorandum on the dangers of microbe creation, the US may more effectively limit this threat and increase global health security. In the case of Ethiopia, however, the issue at hand is much more fundamental. In order to accurately gauge the progress of global health security measures, it is essential to establish a robust bio-surveillance network to gauge the current spread of infectious disease within a country. This lack of disease tracking could be due to a variety of factors, such as: too many people migrating to too many places within the country to accurately record data; too few human, financial, or other resources to afford the recording of data; or simply lack of governmental cooperation to organize the recording of data. As a consequence, differing solutions could be proposed. Ethiopia, for instance, could institute disease data recorders within each city to record the presence and spread of infection at various times. While this could be an ideal response to the lack of disease tracking, a key hindrance may be the lack of human resources necessary to carry out this action. Without adequate resources, disease tracking may be particularly difficult to implement, no matter the cause. Given these obstacles to the attainment of GHSA goals, then, what factors would help a country reach maximum effectiveness in achieving its aims? As the US Centers for Disease Control and Prevention points out, the implementation and observation of global health security measures relies heavily on four facets: a well-trained public health workforce, an effective way by which disease dissemination within a

country can be measured, the utilization of quality tools and technicians in laboratory settings, and an efficient emergency preparedness system to address an unexpected outbreak. 19 As a consequence of simply augmenting every country’s capacity to most effectively and efficiently achieve these four aspects of global health security, global leaders could immediately ensure a more health-secure world for future generations. However, the steps necessary to bring various countries to this level vary from one to another. While countries such as the US have practically already achieved these four aspects and could solely manage to improve internally in terms of the specifics of the varying facets, countries such as Bangladesh lack the documentation to put their spoken action into policy and establish a concrete basis for future development. Moreover, some countries like Ethiopia may lack the fundamental resources to address the problems at hand, let alone increase or reallocate resources to account for an improvement in these four aspects. For cases such as these, it may be necessary to establish a global health security fund from which countries could borrow to aid in the more immediate implementation of the GHSA outcomes to achieve the agenda within the five-year time frame. The goal is to stop an outbreak at its source. However, this goal can scarcely be achieved without the cooperation of health, defense, animal, agriculture, and developmental sectors in various societies.16 Although the history of global health is a long and complex one, the recent emergence of global health security as a primary issue to address in the coming years exhibits our global commitment to addressing current roadblocks that may inhibit future prosperity. The core theme of global health security is interconnectedness. Without this, any efforts a country makes internally to address global health may not be beneficial to the whole. Moreover, without great collaboration, policies such as the comprehensive GHSA would not have been possible. If we as a global community desire to address and prevent future and possibly fatal epidemics, we must take the current necessary steps in order to do so. Through prevention, treatment, and response, by efficiently using bio-surveillance, biochemistry, and biogeography we can collectively work to create a more health-secure world.

www Tomeka Frieson is a first-year in Berkeley College with the prospective major of the History of Science, Medicine, and Public Health. She can be contacted at tomeka.frieson@yale. edu.

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NIGERIA

The Silent Killer in Northern Nigeria: Implications & Challenges in Addressing Malnutrition By Aastha KC


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INTRODUCTION

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magine a child whose survival is challenged even before it is born. Imagine a child whose mother was shot in the chest while escaping a terrorizer from Boko Haram and has ended up at the hospital, not because of her gunshot wounds, but because her child is malnourished. Such is the story of Kasawey, a young mother in the the Borno state in northern Nigeria, whose life has been torn apart as insurgents have taken down schools, military establishments, villages and health clinics.1 Worse, these violent actions have limited transactions for agricultural activities as well as destroyed crops and fields, leaving Kasawey and 5 million Nigerians vulnerable to an inevitable famine in northern Nigeria.1 Furthermore, over 2.5 million of the 13 million children in Nigeria who are stunted live in the Borno state. The International Rescue Committee, a relief-aid humanitarian organization, estimates that more than 205 of them will die if proper actions are not taken.1 Furthermore, the health sector in the Borno state and in northern Nigeria have been severely damaged. Insurgents have destroyed over 700 health facilities, killed over 48 health care workers and injured another 250.1 Due to the instability of the region, health care worker attrition has dropped to 35% and access to health care resources have been limited.1 Boko Haram’s insurgency has sent shockwaves of political, social and health instability not just in the northern regions but throughout Nigeria leading Mr.Yakubu Dogara, the speaker of the House of Representatives to declare a state of emergency “on the menace of malnutrition in Nigeria, especially the north-east,” in October of 2017.5 Malnutrition is a public health emergency that requires severe attention from the federal government, as Nigeria is one of the countries with the highest malnutrition rates in the world.3, 11 To understand the challenges faced by children under five suffering from malnutrition, it is important to explore the underlying political and social instabilities in Nigeria, especially in the rise of extremists groups such as Boko Haram.11 Tensions between Boko Haram and the Nigerian Armed Forces have displaced over 3.3 million Nigerians from their land and severely limited their access to food and health services.9, 11

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Despite the rise in political uncertainty and health instability, Nigeria should aim to meet the targets and goals set forth by the Sustainable Development Goal 2, which seeks to “end hunger, achieve food security, improve nutrition and promote sustainable agriculture.2 Specifically, target 2.2 which aims to “end all forms of malnutrition”, including achieving by 2025 the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women. These goals will be explored in this paper.2 In the context of the goals put forth by SDG 2, malnutrition in children under five in Nigeria is a multifaceted challenge that can be approached by exploring the underlying causes and implications of malnutrition while aiming to provide soundful recommendations based on existing intervention programs and strategies. CAUSALITY ANALYSIS: FACTORS LEADING TO MALNUTRITION Labeled as a “silent killer” because it often goes unnoticed, malnutrition, which refers to the improper uptake of nutrients in children, has negative health effects for children especially during the first 1,000 days of life.4 The World Health Organization recognizes this as an important “window of opportunity” to ensure the livelihood of the child into his or her adult life.4 Being malnourished in the first 1,000 days of life can result in poor brain and body development, weaken the immune system and increase chances for infectious diseases such as diarrhoea and pneumonia.4,8,11 For Nigeria, data from the United Nations Population predicts that over a half-million children die every year due to malnutrition.3 Although by definition, malnutrition is caused by a lack of nutrients, the underlying causes build on social, economic and structural inequalities.7 Poverty combined with a lack of economic and social mobility is the leading cause of malnutrition in Nigeria. Due to politicians receiving kickbacks from giant oil companies such as Shell and Eni, wealth has not been directed to public programs and has resulted in an increase in the number of people living in extreme poverty.6 Extreme poverty as defined by those living on less than $1.90 per day has actually increased in Nigeria from 51 million in 1990 to 86 million in 2013, leaving more individuals vulnerable to food and

housing insecurity, low economic mobility and decreased access to education and health services.4,11 Extreme poverty has a multitude of negative effects for children. A child in a poor family is 3.5 times as likely of being underweight than a child in a higher income household.3 Poorer households may not have enough money to buy sufficient nutritious food and may have trouble sustaining a continued supply of food.4 Lower income households are more sensitive to economic changes and are affected by inflation rates more intensely than higher income households due to spending the greatest proportion of their income on buying staple foods.8 In 47% of surveyed households in Daura, a town of the Kistina state in northern Nigeria, agriculture production was found to account for less than 25% of the total household food consumption.8 The remainder of the households diet comes largely from buying food in local markets and food received for work. Poorer families also own fewer livestock and survive through a combination of smallholder agriculture, casual labour and petty trade.8 Overall, agriculture in Nigeria has remained on a small-scale subsistence level and is largely inefficient due to crop seasonality, inadequate storage technology and inadequate transportation systems. The spatial and seasonal variation in food production and availability further is exacerbated by a lack of proper knowledge about basic preservation techniques at the household level.9 Even before the rise of Boko Haram, the northern regions were a victim to the effects of climate change and desertification, which resulted in sporadic droughts and food shortages. Now, violent acts of Boko Haram such as seizure of livestock and food supplies, impoundment of farms and closure of markets, have resulted in the a warning from the Early Famine Warning system in Nigeria from USAID.9 KEY INDICATOR OF MALNUTRITION: STUNTING Stunting is a global indicator of malnutrition defined by the World Health Organization as the “impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation."4 Stunting is measured by the child’s weight

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and height, which are then compared to an accepted set of values. Those who fall below their accepted age groups values are said to be stunted. Stunting can be especially harmful to the developmental function of the child, often harming cognitive and education performance and has long term risks such as low adult wages and lost economic productivity. In fact, stunted children have on average 13 fewer IQ points, are more likely to start school later, perform more poorly on cognitive functioning tests, and are more likely to dropout of school.4 Adults who were stunted as children earn 20% less than non-stunted adults and are 33% more likely to live in poverty.4 Reports from UNICEF also concludes that malnutrition can reduce GDP in some countries in Asia and Africa by as much as 2% to 11% each year.4 While stunting is a key factor in delineating those who are at risk for malnutrition, it’s important to recognize that stunting disproportionately affects those in low income and rural households. The stunting prevalence for children in Nigeria under five in a rural group is 43% while those living in urban areas is 26%.8 Those living in a rural area are less likely to have access to fresh markets, be near trading ports, and have access to transportation.

Undernutrition in Children in Nigeria It is estimated that over 30 percent of children in Nigeria under 5 and over 20 percent of pregnant women are Vitamin A deficient.11 Moreover, 76 percent of preschool-aged children and 67 percent of pregnant women are anemic.11 Reason for this include inadequate dietary intake of iron, and exposure to infections and parasites. Furthermore, one in five households do not consume adequate iodized salt, thereby predisposing these children to IQ losses of up to 13 points, increasing the risk of stillbirths, and wasted pregnancies.11 The World Bank predicts that Nigeria loses over US$1.5 billion in GDP annually to vitamin and mineral deficiencies alone. Therefore, it is important to address the nutrition not simply as a health issue but also as a development and economic issue.11

. . . it is important to address the nutrition not simply as a health issue but also as a development and economic issue

Moreover, children under five in a lower income bracket are 50% more likely to be stunted than those from a higher income household.8 The poorest children are also 3.2 times likely to be wasted, as defined as having low weight for height. Even obesity, an emerging public health problem affects children in poorer households at a higher rate ( 4.9%, as compared to 3.2%) than children from the richest households.9 This may be due to the uptake of insufficient nutrients or not being able to afford healthy alternatives.8 It’s also important to note the existence of “intra-urban” inequalities in Nigeria. Urbanization has increased the urban population from 29.7 percent in 1990 to 47.8 percent in 2015.8 By 2050, over 67.1 percent of Nigerians are estimated to live in urban areas.8 Rapid urbanization brings increased slum areas and slum populations that might not have proper access to water and sanitation programs, making them highly vulnerable to developing infectious diseases. These inequities in urbanization are further exacerbated in the context of con-

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flict where many households and families become a double victim to their situations. For example, Boko Haram’s violent acts occur in the northern rural regions of Nigeria where 72 percent of the population lives in poverty. The northern region is already less likely to have access to health care, hospitals, clinics and pharmacies, making the region extremely susceptible to the challenges brought by conflict.9

GENDER INEQUALITY AND THE ROLE OF WOMEN A child’s chances of facing malnutrition and being stunted can depend on the mother's health. Women who are stunted are more likely to give birth to children who are stunted and underweight. The age at which women gives birth is also linked to her socio-economic and location status.4,8 In Northern Nigeria, adolescent girls (aged 15-19) give birth at a younger age than those living in the southern regions.4 Furthermore, 1 in six teenagers in Nigeria is a mother and 34% of adolescents mothers are from poor households.4 Since adolescent mothers have not finished growing up yet, the baby and the mother might compete for nutrients, therefore increasing the chance that the baby will be underweight and more likely to be stunted.4,11 It’s important to note that these differences between the north and the south are a result of cultural and religious differences. Generally, women are less likely to be educated than men, and have less control

over resources and decision making in the household, which leaves women with lower access to food, water and other necessary resources. Similarly, due to natural sex differences, socio-cultural traditions and household patterns, women are more likely to suffer from nutritional deficiencies. A women’s disempowerment cause set the scene for maternal undernutrition and can weaken a woman's ability to survive childbirth, increase vulnerability towards infections, increase her chances of having lowweight children.9,11 EXISTENING GOVERNMENT RESPONSE: THE FOOD AND NUTRITION POLICY OF NIGERA To combat malnutrition in children under five, Nigeria has laid out a multi-sectoral framework that aims to “attain nutritional status for all Nigerians by the year 2025”.8 The framework lays out several targets such as to “improve food security at the national, community and household levels involving various sectors such as health, agriculture, science and technology, education and economy.8 The National Food and Nutrition Policy also aims to delineate undernutrition among infants and children and increase the knowledge of nutrition among the population.8 One of the targets laid out by the Food and Nutrition policy of Nigeria is to increase exclusive breastfeeding rate from a rate of 17% in 2013 to 65% by 2025. It aims to do so by supporting early initiation of breastfeeding within thirty minutes of delivery, and by promoting exclusive breastfeeding through the first six to twenty four months of life. Exclusive breastfeeding, which prohibits other liquids such as water and solids from being administered to children, allows children to achieve optimal growth and development (WHO). In Nigeria, the National Demographic and Health survey found that only 10 percent of children 6-23 months were fed in accordance with infant and young child feeding recommendations. This gap in understanding shows us that treating malnutrition requires an educational approach, one where teaching mothers and communities about proper nutrients uptake can be a cost effective way to reduce malnutrition in children, and therefore reduce childhood mortality. NUTRITION IN CONFLICT AREAS: SHORT-TERM INTERVENTIONS For children suffering from malnutrition, especially in conflict areas, access to immediate relief is an one of the most important priorities. One such intervention that has been implemented is a Communi-

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ty-based Management of Acute Malnutrition in Nigeria which has treated over 2 million children at a cost of US$160 per child.12 For eight weeks, the mother brings her children to a healthcare facility once a week to seek information about malnutrition as well as receive Ready-To-use-Therapeutic Food, a peanut-based paste that contains milk powder, sugar and multiple micronutrients.12 However, this intervention can be difficult to address in areas such as Northern Nigeria, where access to health clinics has been destroyed. While rebuilding health clinics rebuilding is a long term goal, distribution of Ready-To-use-Therapeutic Food is viable short term intervention, which can be implemented via local community actors such as churches, mosques and schools. A holistic partnership can be taken by including the Lagos-based Nigerian company, DABS, which received an international certification to produce RUTF for the treatment of malnutrition. Working with local business to create RUTF will no longer make the government dependent on imports, which means that the intervention will be cheaper and more effective to transport and distribute.11 Participation from the local community to address and raise awareness about vitamin supplements and deworming tablets in schools can prove to be an effective way to

study has shown that the introduction of three new cassava varieties to over 50,000 farmers has a likelihood of covering 25% daily need of Vitamin A and reach over 2 million people. Fortifying food can be possible with a collaboration from the private sectors such as HarvestPlus and local farmers. Another way to promote multi-sectoral collaboration is to promote the research of agricultural techniques by increasing funding to local and national universities. Addressing the inequalities and inequities caused by poverty is key to decreasing the malnutrition rate in Nigeria. Access to education, especially in the northern region is an important investment in providing educational opportunities for the future of Nigeria.11 LONG-TERM SOLUTIONS: ADDRESSING BOKO HARAM Implementing interventions in significantly more challenging in Northern Nigeria due to the lack of infrastructure, lack of healthcare workers and a displaced population who are in need of basic supplies. In order to implement short and long terms interventions in an aim to fight malnutrition in northern Nigeria, Boko Haram must be challenged and addressed by not just the government of Nigeria but by the international community as well. The Nigerian

To recognize the underlying causes of malnutrition is to understand the intersectionality that addresses malnutrition as a food, environmental, economic, hygiene, and women’s and children’s issue.

relay information as it relies on existing infrastructure to address the problems. LONG-TERM SOLUTIONS: ADOPTING A MULTI-SECTORAL APPROACH Approaching malnutrition as a multi-sectoral solution will not only relieve short term concerns, but lay the foundation for long-term benefits. Evaluating the social determinants of health to address the access to food, hygiene, housing are key to addressing malnutrition in Northern Nigeria. On a larger scale, addressing poverty and women’s status in society is also important to improving the decision making around malnutrition. From an agricultural perceptive, Nigeria biofortified cassava, one of the staple foods along with rice, maize and wheat to address vitamin A deficiency. A World Bank

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government with collaboration from the United Nations, European Union and the United States should investigate and hold the leaders of Boko Haram accountable. The international community can also publicly denounce the attacks on schools and other infrastructure by the military and the Nigerian Government. PARTNERS IN FUNDING AND ACCOUNTABILITY: LOCAL AND INTERNATIONAL ACTORS Outside charities such as the Childrens Investment Fund Foundation (CIFF) have also provided US$60 million and challenged the leaders in northern Nigeria to raise funds in the hopes of matching donations. Other multi-sectoral partners can possibly include international aid groups such as UNICEF, DFID, Helen Keller In-

ternational (HKI), Micronutrient Initiative, Save the Children UK, Global Alliance for Improved Nutrition (GAIN), Action Against Hunger, Valid International and Food Basket International. Collaboration between the international organization, the Nigerian government and local communities is vital to implementing interventions and monitoring growth and progress. This can be done by implementing a multi-step budget approval from key stakeholders, including private and community and local actors. To keep track of progress, data for maternal mortality, child mortality, average income, growth of the population should be transparent to all stakeholders. CONCLUSION: WHY ADDRESSING MALNUTRITION IS KEY TO NIGERIA'S FUTURE By 2050, Nigeria’s population will reach over 398 million, and becomes the third largest country in the world. Over 40% of this population will be under 20, which represents an incredible opportunity for Nigeria to address and ensure that its future leaders can reach their full potential (10). Funding in nutrition is not only just a imperative health issue but also an economic one. The Ministry of Health notes that investing in nutrition provides high yield returns for the economy. Every dollar invested in interventions targeting stunting would yield an estimate of 10 dollars.11 Similarly, every dollar invested in anemia prevention can yield up to 5 dollars.11 When issues such as malnutrition will be addressed, the potential of Nigeria’s next generation will be unleashed. To recognize the underlying causes of malnutrition is to understand the intersectionality that addresses malnutrition as a food, environmental, economic, hygiene, and women’s and children’s issue. If Nigeria aims to reduce malnutrition, it must implement a multi-sectoral approach that addresses underlying factors such as poverty, lack of education, lack of economic opportunity and female empowerment. Furthermore, taking a human rights approach and aiming to build structures that are more equitable to marginalized populations will ensure that all individuals are given the opportunity to live a healthy life. Addressing malnutrition in northern Nigeria will take a step towards fighting for a peaceful, stable and health future, that all generations of Nigerians deserve. www

Aastha Kc is a sophomore in Pauli Murray College. Aatha is an Anthropology major from Georgia.

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HEALTHCARE

A NECESSITY:

The Healthcare Systems Abroad and at Home By Indira Flores

O

n January 30, 2018, Trump delivered his first State of the Union Address. Prior to the speech, 82% of registered voters in one poll stated that improving the healthcare system was important for the president to discuss — it was, in fact, their most highly prioritized topic.1 To the disappointment of these many Americans, this very topic regarding the future of healthcare was noticeably absent from Trump’s Address; he only ever mentioned the term two times in passing throughout the duration of his ninety-minute-long speech.2 Perhaps Americans were hoping that Trump would address the healthcare situation because they are unhappy with the current system, or possibly because the details of the current system are unclear and confusing to them. The American healthcare system has in fact left many people, including those outside of the United States, puzzled — because it is quite different from many healthcare systems of comparable Western nations. The Organization for Economic Cooperation and Development (OECD) is a group of 35 international governments who collaborate with the intent of “promot[ing] policies that will improve the economic and social well-being of people around the world.”3 Membership includes such countries as Australia, Japan, Sweden, Israel, Germany, Mexico, Turkey, and the United States.4 Of the 35 member countries, 32 have introduced systems of universal healthcare, but the US is not one of them.5 Universal health coverage is generally defined as a system that pro-

vides everyone with equal access to quality healthcare services and ensures that people are also protected against extreme financial risk when utilizing these services. One of the earliest adopters of some form of national health coverage was Germany. The nation’s healthcare system has evolved from a late-1800s law intended for industrial workers, to a framework covering all fields of work and social sectors.6 Today, the German state establishes both standard conditions of medical care, as well as legally designated self-governing bodies within the healthcare system. The most notable body is the Federal Joint Committee, which determines the specifics of individual medical services — from setup, to financing, to organization. All German citizens are required to have statutory health insurance if gross income is below a certain threshold. If above this level, they can elect to have private health insurance instead. Funding for individuals’ healthcare plans originates from a combination of employee salaries, employer payments, and surplus tax revenue. The amount German individuals must pay for health insurance coverage is also dependent on income — the wealthy pay higher premiums than the poor.7 Though its beginnings do not extend as far back as Germany’s, the Swedish form of universal healthcare is arguably the most comprehensive of any other contemporary nation. There, health coverage is “universal and automatic.”7 In 2013, 84% of all health expenditures in Sweden were publicly financed, and private health insurance accounted for less than one percent of

Of the 35 [OECD] member countries, 32 have introduced systems of universal healthcare; the US is not one of them.

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Trump State of the Union

all expenditures.7 To finance these services, municipalities and county councils tax their constituents proportionally to income. Sweden’s public health coverage does not have defined parameters; everything from primary care, prescription drugs, emergency services, and mental health care is covered by the system. This widespread access to healthcare has likely contributed to Sweden’s high life expectancy of 82.10 years, one of the highest in the world.8 Wealthier Western nations are not the only ones transitioning to universal healthcare. Many low and middle-income countries, including India, Mexico, and Turkey, are also on the path toward universal health coverage.4 The United States, however, has

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not joined that bandwagon, and seventy percent of all health insurance holders in the US are covered by private insurers. In 2010, the US began taking steps toward making healthcare more accessible by instituting the Affordable Care Act, commonly called Obamacare. Under this system, all Americans were required to have health insurance or else face a fine, and subsidies were available to help citizens afford the insurance. The legislation also required that businesses offer health insurance if they had more than fifty full-time employees, banned insurance companies from discriminating against people with pre-existing conditions when allotting coverage, and expanded the range of people eligible for Med-

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icaid, the government-run health coverage program. This legislation, which remains mostly intact as of the beginning of 2018, appears to be an excellent way to lower the percentage of Americans without coverage from the current 15% estimate, and slowly decreasing the US rate of healthcare spending, which is the highest in the world.10 These steps towards universal healthcare in the United States have not been universally popular. Republicans and conservatives have generally been opposed to the Affordable Care Act from its inception, due in part to both party loyalty and the Act’s increased constraints placed upon businesses. The Affordable Care Act has also led to an increase in the average cost of insurance

premiums by approximately 25% in 2017.10 This was predicted by even the Democrats, and results from mandates that require health insurance companies to provide coverage to any American, including those with pre-existing conditions. These pre-existing conditions are common throughout the population and can include anything from chronic back pain, to asthma, to cancer.11 These individuals may require more financial assistance for medical services than do healthy individuals, but health insurance companies do not want to lose their profits. Instead, they push the additional cost of insuring these individuals onto the general population of insurance holders, forcing them to collectively shoulder the

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difference. Similar events, such as dramatic increases in drug prices (such as in the Daraprim case), can also lead to higher insurance premiums, a strategy insurance companies implement to avoid losing profits.12 Since the beginning of his presidential campaign, Trump has spoken of plans to completely repeal the Affordable Care Act. Coming up with a better healthcare plan, however, must have proven to be more complicated than he had anticipated, and he has yet to take any major action. Republicans in Congress have made several attempts at new healthcare legislation throughout the past year, including the American Health Care Act and Better Care Reconciliation Act, but all of these failed.13 The primary changes proposed by these plans include allowing states to waive out of current protections for individuals with pre-existing conditions, blocking funding for Planned Parenthood for at least one year, ending subsidies made available

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by the government that had helped make health insurance premiums and deductibles more affordable, and eliminating penalties for being uninsured. This changes would effectively repeal the mandate. Although no new healthcare bills have been passed in the United States, Trump and the Republicans did find another, more subtle way to alter the healthcare system. One of the two instances in which Trump mentioned healthcare during his Address was to say, “[w]e repealed the core of disastrous Obamacare.”2 Here, he was referring to the elimination of that individual health insurance mandate. The Republican tax bill that was recently passed in December of 2017 sparked discussion for many reasons, most of which related to tax cuts for the rich. One aspect of the tax bill that many Americans are unaware of, however, is that the individual mandate will end in 2019.14 Without a replacement plan in place, this is actually expected to cause

another rise in health insurance premiums. But this time, it is because insurance companies are losing customers and thus want to make up the profit by again pushing additional costs onto the remaining insurance holders. Republicans have expressed their desires to make more changes to the healthcare system before this occurs in 2019, but this seems unlikely to happen. Trump did spend more time elaborating on the price of prescription drugs during his Address. He proudly stated that the “FDA approved more new and generic drugs and medical devices than ever before in our history” and that his administration will work on lowering the price of prescription drugs which are overpriced as compared to the same drugs in other countries.2 If this succeeds, it could decrease the cost of health insurance because insurers would not have to pay as much for holders to purchase these drugs, which in turn lessens the burden on the general holder population. Again, these things are easier said than done. Trump may have difficulty passing legislation that regulates the way pharmaceutical companies set their pricing because his fellow Republicans are often opposed to such governmental regulation of business. Many Americans are unhappy with the current state of the healthcare system. The best type of system is likely some form of universal healthcare, which is very common throughout Europe as well as in several transitioning developing countries. Unfortunately, the necessary legislation to enact such a system is difficult to pass in the United States. Party loyalty and the fear of socialism often get in the way of moving towards universal health coverage. It is therefore important that the government continue pressing forward with small actions that will shape the healthcare system, but in ways that are likely to decrease the cost of insurance and make it more accessible to all, rather than to increase these costs again and again.

www

Indira Flores is a first-year in Grace Hopper College interested in healthcare and medicine with a potential major in Molecular, Cellular, and Developmental Biology. She can be contacted at indira.flores@yale.edu.

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INDIA

Gendercide: Sex-Selection in India By Debbie Dada


INTRODUCTION

A

n estimated 40 million females are missing from classrooms, boardrooms, and political offices due to actions stemming from son-preference in India alone.1 Within the past thirty years, the frequency of sex-selective abortions against females has increased rapidly. This practice is most often cited in Asian countries, and India has one of the highest incidences with approximately 1,369 selective abortions occurring each day.1, 2 Given the increasingly alarming number of unborn females denied entry to the world simply based on their sex, it is important to understand which specific beliefs and traditions allow it to flourish. I intend to investigate how specific elements of India’s economic and social system inform the prevalence of son-preference and lead to sex-selective abortions. My investigation will be framed around Pierre Bourdieu’s theory of practice with specific reference to economic and cultural capital, to analyze how these culture-specific factors directly bring about son-preference and sex-selection. My application of this theory demonstrates that the specified elements of the Indian culture provide causation for son-preference and sex-selection and not just correlation. The discussion of sex-selective abortion in this country will be theoretically developed through a diachronic perspective, which focuses specifically on the way cultural practices have developed over time. This theoretical perspective is appropriate because of its relevance to the discussion of changes through history in the justification for and feasibility of partaking in sex-selection. In conducting an anthropological analysis, it is always key to consider issues of cultural relativism, which is defined as “a methodological principle that emphasizes the importance of searching for meaning within the local context.”4 However, this does not mean there is no place for constructive analysis of a demonstrated harmful practice, as such a notion would detract from the critical commitments of the field of anthropology. COLLECTED EVIDENCE There are three well-documented types of sex-selection practiced within Indian society, differentiated by the stages at which they occur: pre-implantation, post-implantation and post-natal. Pre-implantation methods are very expensive and there-

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fore are mainly reserved to cases in which the birth of a child of a specified gender will result in diseases (e.g. genetic conditions like hydrocephalus).2 The post-natal sex-selection technique is known as female infanticide and is highly uncommon in modern Indian society because of evident moral and legal repercussions for the family. Though female infanticide is rare, the amount of household resources allocated to the healthcare (including vaccinations) and general welfare of daughters is often lower.5 In 2013, females one to 59 months old “in every region in India have higher death rates than boys.”5 These practices are a result of son-preference and the most common method for sex selection is sex-selective abortion, and this will be discussed in the most depth. Sex ratio (the amount of males per one hundred females) at birth is a very useful metric in studying sex-selective abortion. Because of the prevalence of poorly documented at-home births as well as the recognized, though small, population of unwanted and abandoned babies, this makes the statistics collected on sex ratio at birth unreliable. Instead, in India, the metric usually cited is the ratio of children under 6 years old (ROC), which is collected from census data.1 It is of note that the natural sex ratio at birth is not 1:1 but rather “105-107 [male] births for every 100 female births” based on a large longitudinal study that found the ratio to be 105.9.1 In India this ratio rose from 104 in 1981 to 106 in 1991 to 108 in 2001. This national average hides the drastic variations from region to region, which will be detailed later.1, 2 This “proxy measure” as well as population sex ratio are the metrics most often referenced in literature on this subject. Besides sex ratio at birth, population sex ratio is affected by differential mortality rates as well as the effect of immigration and emigration.1 Population sex ratio naturally favors females as can be seen in that of Africa being 99.8 and North America being 96.8, but in Asia it is 104.8 and in India specifically it is 107.2 as of 2005.1 CULTURAL FACTORS SEX-SELECTION

AFFECTING

The motivation of couples that opt for sex-selective abortions is a result of the intersection of the economic system and social organization present in Indian society. Indian acceptance of sex-selective abortion is seen to be culturally-linked. The amount taking place in nearby countries such as Bangladesh and Pakistan has decreased

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VOLUME 5, NO. 2

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since 1990 as health care and general conditions for women have increased, but this is not the case in India.1 The reasons Indian parents prefer sons are best understood when evaluated in terms of capitals theorized by Bourdieu. Cultural capital is the sum of social assets that allow for social mobility, such as: knowledge, skills, and clothing.4 Economic capital is defined as a financial asset that affects one’s power and social status in society.4 Individuals as well as groups aim to accrue as much capital as possible in order to be more respected and powerful in societies. ECONOMIC FACTORS Indian society has a long history of son preference and many anecdotal examples date back to the nineteenth century. Examples include a city in the Eastern Uttar Pradesh region with no daughters and another region in India that was found to have a population sex ratio of 106 men to 100 women.2, 6 Such dated examples lend themselves to being explained away by the prevalence of primary sector jobs at this point in history and the therefore logical necessity of males for doing the hard labor needed to run a farm. This meant that having sons gave families greater potential for gaining economic capital, as they would be able to properly manage larger farms, which was often the only form of family income. So, the increased economic capital associated with having more sons, incentivized couples to have and raise boys in order to improve their social status and family welfare. However, this practice’s sustained prevalence in post-industrial India demonstrates that there are other factors that contribute to son-preference and show that the conditions supporting the practice have evolved over time. Having male children continues to be financially advantageous. A study carried out on 25,000 households found that having a son as your first-born child “increases annual per capita household income on average by 6.9 percent across India” and “decreases the probability that a household is in poverty by 0.7 percentage points.”3 This is mainly due to dowry, the patrilineal inheritance system, and differential wage-earning potential. Dowry is the widely practiced tradition wherein the family of the bride provides the groom’s family (not the couple) with a gift of great financial worth as a part of normal marriage proceedings.1, 3, 5, 6 Because of this practice, the parents of a female forgo some of their economic capital in order to have their daughter married. Avoiding marriage altogether (eliminating the financial stress of paying dowry) is rare for two reasons.

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First, Indian tradition states that young people get married and have families of their own. Second, getting married is often viewed in Indian society as an opportunity to improve the bride’s family’s social status by way of marrying into a family of higher status.7 This practice, known as hypergyny, exacerbates the economic problem for the bride’s family presented by dowry, as more affluent groom families expect even greater dowries, thereby putting more strain on the parents of a female. Ultrasound clinics have been known to exploit this well-known element of Indian marriages with one displaying a sign, in reference to sex-selection, that read: “invest only 500 rupees [$7.78] now and save your precious 500,000 rupees [$7,780] later.”5 From this it can be seen that the tradition of dowry contributes to the decreased economic capital of families that have daughters thereby encouraging couples to select against them. In addition, India is a patriarchal society with patrilineal inheritance and patrilocal residence. The culturally ingrained system of patrilineal inheritance (element of patrilineal descent) dictates that the family assets after the parents are deceased are passed through the male line or at least in a manner that is “highly discriminatory towards women.”1, 5, 6 Examples have been detailed where assets go to uncles or male cousins before female heirs.5 This means that if parents do not have any sons, all of the economic capital accrued in their lifetime will not be able to stay in their family line and benefit their descendants. This idea is supported by the fact that sex ratio gets more and more skewed with higher birth order: “for second births with one preceding girl the ratio is 132, and for third births with two previous girls the ratio is 139.”1 Therefore it is clear that due to the effect that having at least one son has on retaining the family’s economic capital, patri-

2009 on family incomes in New Delhi, most families had two breadwinners but of those that only had one, it was almost always the husband.8 This means that males will likely spend a greater proportion of their life in the workforce accumulating wealth, some of which can go towards their parents. Also, parents are more likely to pay for furthering the education of their sons than daughters, and since education level is highly correlated with higher paying white-collar jobs, this means that males are more likely to have the cultural capital of education needed to attain jobs in the generally higher-paying tertiary sector. With this greater cultural capital they will have more opportunities to expand their network to include relationships that will benefit them both socially (superiors and colleagues of higher socio-economic status) and economically (connections leading to higher paying jobs). Here, we see the close connections between cultural and economic capital with regards to working because increasing cultural capital greatly affects employability, which in turn affects economic capital. In addition, the work that men do is paid more than the work that females do. As detailed by anthropologist Reena Patel, when more women join a specific line of work, the social status of workers and the pay they receive reduces. An example of this phenomenon, known as “feminization of labor,” can be seen in the call-center industry at the turn of the century.9 SOCIAL FACTORS Socially, the level of gender equality and the castes of families in a region are important factors known to affect how widespread sex-selection is. In areas with less gender equality; where the “health and social status of women continue to be poor,” sex-selection is more likely to occur.5 This is the case in the state of Haryana, which has a

Socially, the level of gender equality and the castes of families in a region are important factors known to affect how widespread sex-selection is.

lineal inheritance presents a very potent incentive to select against females. Furthermore, males in Indian society, as well as all patriarchal societies, have greater earning potential than females for many reasons including: their increased likelihood of working, greater access to tertiary sector jobs, and higher pay of jobs associated with their sex. Men are more likely to work than stay home and take care of the family. For example, in a study done in

higher than average ROC, and where there are high levels of violence against women (relative to the rest of India) and “neglect of female children continues to be the cultural norm,”5 This aspect of Indian society limits the social mobility of every female from birth as they start at a lower social status. This means that all daughters automatically have less cultural capital and potential for the gain of power within society simply due to them being female. Furthermore,

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the social mobility of a family is more than just the amalgamation of each individual’s social mobility but rather a result of the interplay between higher and lower statuses meaning having one person of a high status will by proxy increase everyone else’s status and vice versa. Therefore, having a daughter is more likely to have negative effects on the family’s social mobility than having a son, which supports son-preference. Additionally, within the state of Haryana, a study was carried out in 1998 that showed upper caste families had a ROC of 127 while lower caste families had a ROC of 102.7 The fact that this study took place in the 1990s means it is possible that the ROCs differ between the two populations simply based on the high cost of the sex-selection procedures at this point in history, as they would be more affordable to members of the higher caste because they are more likely to be of greater socio-economic status. However, if this were the case it would be logical to see a level above the national average in both populations, but instead we see the lower caste population ROC was below the national average by 6 points. Even

in sex-selective abortion. The regions are divided based on their geographic area and history. North and northwestern areas of India have high levels of sex-selection whereas in the south there is no evidence of this practice taking place. A study on several hospitals in Punjab, a state in northern India, shows an ROC increase from 105 in 1983 to 119 in 1988.7 Furthermore, from 1991 to 2001 Punjab saw an increase from 114 to 127, Haryana (north) from 114 to 122 and Gujarat (north-west) from 108 to 114; however several states in the south, such as Kerala and Andhar Padesh have ROCs of 105 and have remained fairly constant.1, 10 A study was conducted on the basis of north versus south India analyzing the social status of women using the following metrics: “1) the extent of women's exposure to the outside world, 2) the extent of women's interaction with this non-familial world, and 3) the extent of female autonomy in decision making.”11 This study found that across all three indicators north Indian women had a lower social status. In this way we see that because of greater intensity of gender inequality within northern Indian culture’s social organization, women have less cul-

The many ways the life of a female child intersects with the economic livelihood and social mobility of the family can cause daughters to be viewed more as a burden than a blessing.

after accounting for lower caste people not affording safe and reliable methods of sex-selective abortion, if they had a desire to, there would be at least some evidence in the form of a higher or more uneven ROC. The reduced ROC suggests that there is no motivation for the lower caste population to take part in sex-selection and this is understandable after considering that the practice of exchanging large and financially debilitating dowries is less common among lower-caste marriages, as is the practice of hypergyny. This means that in lower castes having a daughter would have less of an effect on the future of a family’s economic capital than it would in a higher caste. APPLICATION OF FACTORS AFFECTING SEX-SELECTION In order to demonstrate the potency of these characteristics of social organization and the economic system in bringing about son-preference in terms of capitals, I will evaluate regions in which these characteristics look different in order to see the effect on the chances of families partaking

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tural capital and are more devalued. This is directly linked to an increase in son-preference. Furthermore, in northern and northwestern populations there is “a positive linkage between abnormal sex ratio and better socio-economic status and literacy.”5 These data reveal how economic capital differentially affects populations, depending on how deeply ingrained the practice of sex-selective abortion is. In areas with high son-preference, more wealthy and educated families have more economic capital that they would be in danger of losing if they have no male heir and can more easily afford the 300 to 500 rupees required for sex determination and the subsequent abortion leading to an increase in ROC abnormality. An example of this can be seen in Haryana (in Northern India), which, as of 2012, had the highest income per capita of any Indian state and a higher than national ROC of 117.9 male to 100 female children.5 The history of a region is also known to have great effect on the prevalence of sex-selection. The most noteworthy example of this can be seen in the territory now known as Kerala in southern India. This area used

to be home to a caste organized by a matrilineal social structure and inheritance system known as “Marumakkathayam.”6 Although this system was officially abolished in 1975 and the state was made to follow India’s more prevalent patrilineal system, this elevated status of women still has effects on the society today. With a ROC lower than that of the national average, this region has virtually no sex-selective abortions. It also boasts the highest female literacy rate (as of 2009), a large amount of professionally qualified women, and numerous exemplary practices that promote gender equality.1, 6 Due to the high social status of women in this region, the difference in the cultural capital of females and males is less. This means that having a female child has less of a negative effect on the social mobility of the family and therefore removes a possible incentive for preferring sons to daughters. CONCLUSION From evaluating the many different economic and social elements of Indian culture contributing to son-preference, we can now better appreciate the rationalization of a practice as difficult as sex-selective abortion in India. The many ways the life of a female child intersects with the economic livelihood and social mobility of the family can cause daughters to be viewed more as a burden than a blessing. Throughout their life they will have lower wage-earning capabilities, their inevitable marriage will necessitate the paying of dowry, and after their parents pass away they will not be able to secure the family’s wealth. These contribute to the decreased economic capital of both the female herself as well as her whole family. Simply by function of being female, women have decreased cultural capital in Indian society because of its patriarchal nature structured to keep them at a lower social status. Thus, it is clear that high frequency of sex-selection in India is due to the way in which the economic system deprives women of economic capital and how social organization deprives them of cultural capital.

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Debbie Dada is a first-year from Toronto, Canada. She can be contacted at debbie.dada@yale.edu.

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HEALTH POLICY

Trump Must Embrace Global Health By Jude Alawa

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I

n his 2018 budget, President Donald Trump called for a 24 percent reduction in spending on foreign assistance for global health. 1 Though some of the greatest achievements in U.S. foreign policy history proceeded from global health investments- namely the President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. response to the 2014 Ebola outbreak- Trump has blatantly ignored humanitarian pleas for continued U.S. leadership in global health. He insists instead that these cuts “free up funding for critical priorities here at home and put America first.” Trump is making a grave mistake: global health must be considered a matter of national security—instead of solely a humanitarian issue. This concern should compel Trump to reconsider his foreign policy agenda. Putting America first and protecting Americans at home requires foreign policy that prioritizes the strengthening of health systems across the world—something U.S. leadership has sought to do for the past two decades.2 Prioritizing global health protects Americans from the growing dangers of emerging infectious diseases, bolsters our economic productivity, and defends our security interests abroad. Investments in global health have consistently captured bipartisan support, producing tangible economic, security, and humanitarian benefits across the globe. 3 The United States has long been an advocate for global health, and in 2008, even Vice President Mike Pence demanded, “The United States has a moral obligation to lead the world in confronting the pandemic of HIV/AIDS.” 4 Largely due to United States involvement in global health, the past 15 years have witnessed the decline of global mortality rates from malaria and tuberculosis by 48 percent and 47 percent, respectively. 5 The number of annual child deaths has been cut by more than one half, and more than 18.2 million people are now receiving life-saving antiretroviral treatment for HIV/AIDS through PEPFAR.6,7 There is no question that the United States has increased standards of living across the world and decreased human suffering through its investments in global health. However, since these achievements do not convince Trump, maybe the following factors will.

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JEE Alliance

68th World Health Assembly, Global Health Securtiy Agenda

The exponential growth of the global population, warming surface temperatures, urbanization, and the development of technology have made it easier to for people and diseases to travel across the world. Diseases don’t abide by borders. Scientists have tracked drug-resistant tuberculosis originating in eastern Europe, Asia, and Africa and their sudden appearance in patients in Western Europe and North America. Consider the devastation of the recent Ebola and Zika outbreaks that were due to a lack of international preparedness to effectively address pandemics.6,8 Americans are at risk. Consistent and timely global support ensure that national health systems can effectively administer disease surveillance, medical treatment, and outbreak response, especially considering growing antimicrobial resistance.9 As they have in the past, infectious diseases will ravage Americans once they have crossed our borders and endanger U.S. citizens abroad, especially those in our armed forces. To truly fulfill his “America First” pledge, Trump must commit to global health investments to prevent deadly threats from spreading. Although the primary goal of global health has traditionally been to alleviate human suffering, investing in health systems and epidemic prevention has substantial economic returns. For instance, if the U.S. simply maintains its current commitment to the Global Fund, it could spur at least $96.7 billion in global economic gains.10 In doing so, not only does the U.S. strengthen its allies and trading partners but also incentivizes them to take ownership of their disease programs and health system. In the past two decades, U.S. exports to developing countries have grown by

more than 400 percent, and today, they total more than $600 billion annually.11 Population health status has consistently been linked to economic growth in every country. To bolster our economy, Trump should have a direct interest in strengthening health systems to combat disease. Finally, and arguably most importantly, global health protects our security interests. In the same way that we bolster some regimes and tear down others, health has the power to improve or diminish governance and peacekeeping. Just as the HIV/AIDS epidemic in sub-Saharan Africa affected the most influential members of society, poor health can destroy leadership and discourage participation in civil society. 12 With the positive socioeconomic benefits of good health, civilians are unlikely to become radicalized and will have less of a reason to evaluate the merits of violence. As Trump attempts to continue our battle against terror, he must consider the consequences of poor health—desperation, diminished economic productivity, and the erosion of social cohesion—as root causes of extremism that global health reform has the potential to address. Following in the footsteps of pioneers of U.S. leadership in global health, Trump need not forget that U.S. investments in global health are not only some of the greatest humanitarian achievements of our time but also some of the best strategic ventures for American protection and prosperity. www Jude Alawa is a junior and Syrian-American from Florida. He hopes to study global health policy in developing regions. He can be contacted at jude.alawa@yale.edu.

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HEALTH POLICY

Global Health Under Trump

BY SOFIA BRAUNSTEIN

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n July 2014, the US Centers for Disease Control and Prevention (CDC) activated the Emergency Operations Center (EOC) in response to the Ebola outbreak in Liberia. Over the course of a year and a half, it deployed 3,700 staff members and all 58 of its Epidemic Intelligence Service Officers.1 In the aftermath of the outbreak, many criticized the international community for taking too long to mobilize the necessary health infrastructure needed to combat the large-scale impact of the disease. Although the CDC operates on a global scale,

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it remains a US agency that depends on domestic funding and staffing to maintain its role as a first-responder in global health. Without the CDC at its current capacity, Ebola would have undoubtedly ballooned into a far more widespread, uncontainable threat than it did. Now, less than four years after the initial onset of the pandemic, the Trump administration’s agenda attempts to reduce this critical capacity and that of other essential federal global health institutions through budget reductions and conservative policies such as the Mexico

City Policy, a US government policy which prohibits non-governmental organizations that provide abortion counseling or services from receiving US federal funding. The effect of funding cuts and shifted priorities may have profoundly harmful effects on the current and future state of human health across the globe. The US Global Health Agenda As the largest donor to global health efforts in the world, the United States

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The US possesses extensive and complex health infrastructure that is predominantly controlled through the executive branch.

possesses extensive infrastructure for the cause. Developing nations depend on the US for funding and technical expertise, ranging from emergency response to health system strengthening. These bilateral and multilateral efforts reflect the ideology of development spending as a vehicle through which to ensure national security. Three main governmental bodies support the multifaceted, billion-dollar global health efforts of the nation: the US Agency for International Development (USAID), the Department of State, and the Department of Health and Human Services. Through these organizations, the US government funds global health research, programming, disaster response, and partnerships. Programming ranges from disease-specific to population-specific programs and includes broad efforts to reduce the threat of emerging infectious diseases to our national security. The principal actors that execute the US global health agenda include the CDC, which operates in 150 countries around the world; the President’s Emergency Fund for AIDS Relief (PEPFAR); the President’s Malaria Initiative (PMI); and the Biomedical Advanced Research and Development Authority (BARDA). The main focal points of the US global health agenda are commonly referred to as the “Big Three”: HIV/AIDS, malaria, and tuberculosis. However, in the last decade,

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the focus has expanded to include neglected tropical diseases (Chagas, African sleeping sickness, and schistosomiasis), women’s health, polio eradication, and health diplomacy.2 Although seemingly humanitarian in nature, US involvement in global health historically derives from strategic foreign policy interests rather than sheer altruism; investment in health infrastructure in developing nations promotes political stability and democracy, thereby protecting US diplomatic interests. This concept can have varied and far-reaching international effects. Every presidency crafts its own mark on foreign policy, development aid, and, by extension, global health. As the largest contributor to global health funding, the United States can shape both national and global discourse on health priorities. Under the Bush and Obama presidencies, global health funding has steadily increased over the last 15 years. Periodic threats to global health security, such as SARS and Ebola, underscored the need for robust health financing and infrastructure domestically and abroad. During his two-term tenure, President George W. Bush increased global health funding and started three critical global health initiatives: the President’s Emergency Fund for AIDS Relief (PEPFAR), the President’s Malaria Initiative (PMI), and the

Global Fund to Fight AIDS, Tuberculosis, and Malaria (The Global Fund). While the origins of these initiatives may have been paternalistic – Bush reportedly referred to PEPFAR, the largest global program to fight a single disease, as a “work of mercy beyond all current international efforts to help the people of Africa” – they do not discount the impact the programs have had, particularly in sub-Saharan Africa.3 President Bush’s legacy in part lies with the mobilization of the international community toward global health and the emergence of the United States as the leader of the movement. Since the launch of the three programs 15 years ago, 100 billion dollars have been directed to fight HIV, tuberculosis, and malaria.4 US efforts to combat malaria, particularly in sub-Saharan Africa, have been remarkably successful, marked by a 48 percent reduction in malaria mortality across all “focus countries.”5 In Zambia, the national death rate declined by 80 percent from 2010 to 2017 as a result of a national anti-malaria campaign, which received the bulk of its funding through USAID.6 Despite the proven efficacy of the enterprise, the current global budget for anti-malaria programming totals 2.7 billion dollars, less than half the funding needed to meet the 2020 prevalence target.6

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Under President Obama, the US continued to prioritize health. After steadily increasing since fiscal year 2006, the US global health funding totaled 10.7 billion dollars at the end of the Obama presidency in FY 2017.7 Obama’s contributions to global health stem largely from a response to the Ebola outbreak in 2014. In the aftermath of the epidemic, Congress approved a one-time, five-year 582-million-dollar supplemental package to build up health systems’ capacities in hot-spots for epidemics.8 By way of a November 2016 executive order, the US spearheaded the creation of a Global Health Security Agenda (GHSA) to prioritize epidemic prevention through multilateral partnerships with 55 countries and non-governmental stakeholders.9 The GHSA promotes global health security through disease surveillance initiatives, augmenting emergency capacity, and funding improved laboratory systems.10 Trump’s Vision Despite President Donald Trump’s declaration that “we cannot have prosperity if we are not healthy” at the 2017 United Nations General Assembly meeting with

African leaders, the policies and FY 2019 budget suggest otherwise.11 Statistical analysis from the Brookings Institute predicts that if the currently proposed budget is realized, total global development assistance for human health would drop from 39.2 to 28.8 billion dollars.2 The US contribution alone would drop from 13.6 to 10 billion dollars, according to the 2015 dollar value. This reduction would represent the lowest American investment in global health-related causes in the last decade, potentially resulting in political and economic instability abroad.2 Trump’s proposed budget details a 24 percent reduction in spending on foreign assistance in global health. For the CDC in particular, the FY 2019 budget reduces funding for global health activities by from 7.2 billion to 5.7 billion dollars, the majority of which detracts from the Global HIV/ AIDS program that funds PEPFAR.12 The proposal claims that “the reduction reflects the administration’s intent to further focus funds on countries, populations, and programs where resources will have the greatest public health impact; optimize staffing and technical resources to address high-

est-priority global HIV needs; and ensure that ongoing activities are consistent with overall PEPFAR priorities and are lean, efficient, and effective.”12 Clinically-validated health metrics refute these claims. A case analysis published in the Annals of Internal Medicine predicts that the scaleback strategies will result in an increase in HIV transmissions from 0.5 to 19.4 percent and HIV/AIDS-related deaths from 0.6 to 39.1 percent within the next 10 years.13 The global health and economic impact of these budgets cuts far exceeds the savings; budget cuts would exacerbate the increasing organizational disarray resulting from vacancies in foreign policy positions that play a crucial role in the proper execution of global health programming. To further complicate the issue, the one-time, five-year emergency package approved by the US Congress in the wake of the 2014 Ebola epidemic in East Africa will run out by September 2019. In preparation, the CDC began downsizing efforts in early January. Scale-backs of eradication efforts will occur in 39 out of the 49 countries where the CDC has developed programming to train front-line workers in outbreak

Trump’s administration has the power to influence health beyond the US due to budget cuts and foreign policy measures that impact critical programming for disease control and reproductive health.

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The CDC operates on a global scale nd is a crucial actor in responses to outbreaks that have the potential to become pandemics.

detection and strengthened laboratory and emergency response systems in high risk areas.14 Starting in October 2019, the CDC will maintain operations in only 10 priority countries across several continents. Highly vulnerable countries such as China, Pakistan, Haiti, Rwanda, and Congo will be left with only rudimentary infrastructure. Moreover, Tim Ziemer, the White House senior director for global health security acknowledges that “the world remains under-prepared to prevent, detect, and respond to infectious disease outbreaks, whether naturally occurring, accidental, or deliberately released.”14 At the end of January, several global health coalitions authored a letter in response to the impending US budget cuts. Current instability in these high-risk areas will only worsen in light of these budget cuts, potentially resulting in more widespread and costly outbreaks. The Ebola outbreak, for example cost US taxpayers 5.4 billion dollars in emergency supplemental funding.14 Trump’s impact on global health extends beyond US-led initiatives. On his fourth day in office, Trump reinstated the Mexico City Policy through an executive order. The policy, colloquially referred to as the “global gag rule,” emerged during the Reagan era during the International Conference on Population in August of 1984. The Policy prohibits the disbursement of federal funds to non-governmental organizations

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and agencies that provide, promote, make referrals to, or give information about abortion services.15 Historically, the viability of the policy follows bipartisan lines. For instance, President Bill Clinton rescinded it in 1993, President George W. Bush reinstated it in 2002, and President Obama rescinded it in 2009. Now, President Trump’s executive order expands the impact of the policy to all NGOs that receive US global health funding, whereas the order had previously only applied to funds disbursed through the State Department and USAID.15 According to the Guttmacher Institute, the US provides 607.5 million dollars in foreign assistance for family planning and provides services for 25 million women globally.17 Since January 2017, clinics have been forced to shut down, unsafe abortion rates have increased, and families are losing crucial access to medical services around the globe. Additionally, the Trump administration announced that it would cut the 32.5-million-dollar contribution to the United Nations Population Fund (UNFPA).16 The “global gag rule” has far-reaching implications. The International Planned Parenthood Federation and Marie Stopes International, two major organizations involved in family planning and contraceptive services, estimate that the policy will result in 7.5 million unwanted pregnancies and 2.5 million unsafe abortions in the next year.17 This policy represents one of many harmful political actions taken by the Trump admin-

istration that drastically impact the lives of millions around the world. The National Academies of Sciences, Engineering, and Medicine released a report on “Global Health and the Future Role of the United States,” calling on the Trump administration to sustain the US’s legacy as a global health leader, partner, and innovator through fourteen key recommendations that prioritize global health security; women and children; chronic diseases such as cardiovascular disease and cancer; and HIV, malaria, and tuberculosis.18 Whether the Trump administration will heed these suggestions remains to be seen. In an increasingly interconnected world, countries must embrace cross-border collaboration and information transparency to prevent the emergence of pandemics and address the current burden of disease in developing nations. Trump’s efforts to put “America First” threaten the health of the globe and, unsurprisingly, that of the US as well. Isolationist tactics fail to account for the ultimately intertwined nature of global health. Alas, epidemics do not require a passport to cross borders. www Sophia Braunstein is a senior in Pierson College studying Global Affairs. She can be reached at sofia.braunstein@yale.edu.

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INTER-

DR. BANDY LEE: The Mental Health of President Trump By Matthew Pettus

Dr. Lee is a distinguished psychiatrist and expert on violence who has written books and led conferences on the mental health and stability of President Trump. Her actions throughout 2017 have garnered opposition from political and psychiatric professionals regarding the proper interpretation of the Goldwater Rule, a section of the American Psychiatric Association’s Principles of Medical Ethics that states it is unethical for psychiatrists to give professional opinions about public figures whom they have not closely analyzed in person. Despite this opposition, Dr. Lee has significantly progressed the movement highlighting President Trump’s mental instability by citing the dangers that a mentally unstable world leader could generate. Moreover, this engenders an important conversation regarding the perception of mental health in politics and society as well as mental health as an epidemiological and global health issue. Dr. Lee clarifies that she speaks for herself and not for her division, department, or Yale School of Medicine. How has your academic and intellectual experience contributed to your work today? To give you some of my background, I am a forensic psychiatrist—a psychiatrist who works at the interface of psychiatry and the law—and a specialist in violence prevention. I started by treating violent offenders in jails and prisons, then designing violence prevention programs for them, and finally I was involved in prison reform and advising policy for several state governments. I also consulted with the World Health Organization’s Violence and Injury Prevention department, and for the last seven years have been leading a project group on violence prevention for researchers and implementers or policymakers. My work was largely global, and I had been teaching Immigration Legal Services at the Law School and Global Health at Yale College, and so I was never very interested in domestic partisan politics

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before. What woke me up was my phone ringing off the hook, and emails flooding in, beginning at 8 o’clock the morning after the election of 2016: civil society organizations, patient advocacy groups, students, lawyers, activists, documentary filmmakers, and staff from state governments were contacting me—all from fear of the violence that was to come—and they were right. I had to consider, if I have devoted my entire career to studying, predicting, and preventing violence, do I stop before the greatest risk of violence the human species could face? The answer was obvious to me. I never thought that I would become so central or that it would take so long, but I somehow had the right background for it: assessing risk, understanding violence, applying public health principles, working around the Goldwater rule—I had to consider this as a forensic psychiatrist who is frequently asked to diagnose minor public figures in court, for example, and

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I always kept with the rule—and serving as an expert consultant to Congress members. Forensic psychiatrists are trained to maintain boundaries, to comment only on areas of their expertise, and not to get involved in legal or political decision-making; these boundaries are what make it possible to serve as expert “witnesses” presenting objective evidence for cases that involve adversarial disagreement. What do you believe the role of mental health is in global and public health, specifically in terms of politics? Certainly, mental health has a greater role to play than it has. Psychiatry has traditionally been very focused on the individual, and I value person-centered care and the intimate meeting of humans as its unique strengths. However, knowledge gained about human beings in these ways could contribute greatly to a larger social, cultural, and society-level conversation, and I have written about this far before the current situation. Now, however, the need has become urgent, and there is an enormous amount of educating to do, since there is little awareness about the influence of psychological dynamics in society, or even that mental health issues are real. The political realm should not be immune, since there is no rule that says mental health problems stop at the office of the president, or whomever. Rather, the stakes are increased multifold if the same issues affect someone with great influence and

Bandy X. Lee, MD, MDiv, Assistant Clinical Professor at the Yale School of Medicine.

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power, now to mention the sole authority to launch weapons that are capable of destroying the world many times over. Like the rest of medicine, mental health has at its core the mission to prevent deaths and to save lives, and to improve the lives it saves. Like the rest of m e d i cine, it has a duty to individual patients as well as to society, to extend care as well as to improve conditions in ways that prevent illness and suffering.

able mental illness. Rather, I often use violence rates as a measure of the public mental health of a society, a social “mental disorder,” if you will. We know, for example, that the election of an impaired leader is not unrelated to the generally poor state of public mental health, w h i c h made such a leader attractive. How did this state come about? Through poor distribution of mental healthcare, education, and material resources—all of which affects the psychological health of the population. We have empirical data for this: structural violence, or inequality, is the strongest predictor of violent death rates, which again I consider to be a measure of a society’s health. This means that changes to public mental health, and prevention of disease, are best made through policy. By not addressing policy as a health issue, we have allowed governments to continue to institute policies that harm public health, until we have arrived at this critical state.

Nevertheless, the president, who has the ultimate responsibility for the use of the most dangerous weapons in the history of the world, and who has the sole capability to murder millions of people in an instant, should undergo a proper evaluation.

Global health and global psychiatry have definitely brought awareness. For example, core mental disorders remain consistent throughout a wide range of societies, but attempting to describe them through the lens of white, middle-class North American and European cohorts, however, leaves 80 percent of the world’s population with an “atypical” presentation. Without cultural knowledge and interchange among society, we would miss all these. We have seen the isolation that comes from dubbing “posttraumatic stress disorder” an individual problem in the context of wars, conflict, and migration. Without understanding it as a societal problem, the way many cultures do, we could miss the opportunity to be helpful. Worldwide, as mental disorders have become the leading cause of disability, we could not meet the growing demand for psychiatry without addressing the problem with cultural sensitivity and at population levels, using public health methods. I personally have applied knowledge of mental health to policy-making rather than politics. There is a lot one can do in terms of preventing violence, for example. Now, violence has nothing to do with mental illness, even though mental health professionals deal with both. It is important to note that mentally ill individuals are no more violent than the general population and are more likely to be victims than perpetrators of violence, while most violent individuals do not have a diagnos-

In your opinion, how does President Trump's position in society pose a public health risk? As you know, the Bulletin of the Atomic Scientists moved the hands of their “Doomsday Clock” closer to midnight.1 The clock is now the closest to the symbolic hour of apocalypse as in 1953, at the height of the Cold War. The direct reasons that the Bulletin’s president cites are: “reckless language in the nuclear realm [heating] up already dangerous situations [and] minimizing evidence-based assessments regarding climate.” Additionally, the Bulletin’s statement notes: “This is a dangerous time, but the danger is of our own making.” We can speak of the various ways in which Mr. Trump in the office of the presidency poses a public health risk: the unprecedented spike in hate crimes that continue to this day, the widespread schoolyard bullying that is done in his name, the escalating rates of gun deaths since his campaign,

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whitehouse.gov CDC Global

If he were not President, would Trump still be considered an exception to the Goldwater Rule, as you have previously called him? I actually do not consider that we are making an exception. We are calling him dangerous, which is more a description of the situation than a diagnosis of the person. Therefore, yes, it certain that he would be far less dangerous in a different situation of not in charge of the nuclear codes. We are not making an exception to the Goldwater Rule, as it is still possible to warn the public without making a diagnosis. However, you are right in that we generally break confidentiality and consent to respond to emergencies, as when an individual poses a threat to others or the public: health professionals are legally authorized, if not mandated, to report, to warn, and to take steps to protect potential victims, and to assume this as first priority in the interest of safety. We also may not choose whom to take or not take as a patient in an emergency. By parallel, we should also be permitted to break the Goldwater rule when the health and safety of the public were at stake. In fact, this exception is written into the rule by virtue of the principle it falls under. How would you reconcile the Goldwater Rule with the political idea, “duty to warn”, and the medical contract, the Hippocratic Oath? I believe it is important to keep with the Goldwater rule other than in an emergency, and even so, to keep focus on the public figure’s personal mental health to a minimum. In this way, I am a strong proponent of the rule. In this instance, I am mainly concerned about going against even the principle of the rule to silence a profession.

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Not so distant history tells us about how tragic that can be. In early twentieth-century Germany, sociologist Max Weber argued in a paper, “Politics as a Vocation,” that intellectuals should not utter any political opinions or say anything that could remotely be regarded as partisan. This became a precursor Goldwater rule for all intellectuals. As we know, under Nazism, not only psychiatrists but most German clergymen, professors, lawyers, doctors, and other leading thinkers became passive enablers of some of the worst atrocities under a dangerous political leader who led their country into the worst disaster in its history. The World Medical Association issued its Declaration of Geneva after the recognition that either silence or active collusion with a destructive regime run contrary to the humanitarian goals of medicine. These goals echo the principles underlying the APA code of ethics, the ethical code of American Medical Association, and the Hippocratic oath. How would you evaluate the American Psychiatric Association’s (APA) statement that psychiatry should not be used as a political tool? I absolutely agree and call on the APA to comply by it! The dangers of turning a reasonable rule into a silencing mechanism, without members’ input and against their protest, and in ways that run counter to medical ethics should be obvious: in this case, it even contradicts the ethical principle it falls under. Many believe its actions are politically-driven in unethical and possibly illegal ways, and dozens of members have resigned, now including high-ranking officers of the APA. Basically, on March 16, 2017, two months into this administration, the APA issued a three-page reinter-

pretation of the Goldwater rule in unprecedented ways, without scientific or ethical basis.2 In fact, the science goes in the opposite direction, and before this administration, the APA treated the rule consistently with scholarship: as an obscure rule on its way out. All of a sudden, its new interpretation required that we counter the principle the rule falls under, and even the rule itself as it is written in the code. Basically, we are not just prohibited from diagnosing or giving a full professional opinion without all the information, but commenting in any way on any aspect of a public figure’s plainly expressed emotion, speech, or behavior, including in an emergency. I resigned from the APA over a decade ago because of its growing ties with the pharmaceutical industry. Much corruption has resulted from this, undermining the profession’s reputation as well as its science and actual treatment efficacy. I was initially surprised that the APA would take the stance that it did with this administration and I assume in response to the influence of our book, The Dangerous Case of Donald Trump,which we wrote as a public service, donating all royalties to public health, and which became an instant bestseller—I believe as a result of the thirst on the part of the public. But I guess it is in line with the reasons for which I resigned. It also receives federal funding, which some insiders have cited to me as a reason. I am still very disappointed, since I take ethics seriously, and the APA is supposed to be setting guidelines for the entire profession, not just APA members. I believe that membership protest and the profession’s correction of its own guild is a healthy sign, necessary to pre

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vent corruption and the use of psychiatry as a political tool. The American Psychological Association, during the Iraq War, went against members’ protests to modify its own ethical guidelines under political pressure, allowing for psychologists to design and participate in torture—and see what scandals have resulted.

Applying psychiatric knowledge to the political realm, on the other hand, can be done responsibly and should be done in public service, according to our ethical guidelines. In legal settings, forensic mental health professionals are frequently employed as expert “witnesses”, as I said earlier, and our findings are considered as evidence. The same can apply to branches of the government. Rather than medicine or psychiatry becoming politicized by entering the political realm, the influence can and should be the other way around: medicine or psychiatry, as scientific fields describing natural phenomena, have the ability to serve as a neutralizing ground for politics. Experts speak about medical matters only and do not venture into areas outside their expertise, such as in political decision-making. Politics itself should modernize to become more evidence-based, focusing on problems and effective solutions that have been proven, rather than following power or partisan struggles, and experts can help with this. Ethical guidelines actually instruct that we be of public service in this way, by consulting with the various branches of government. Unfortunately, there has been a conflation of this with the politicization of psychiatry, when the field itself makes a clear distinction—due to what I can only describe as a misinformation campaign by a past president of the APA, who should have been denounced as ignorant but was instead backed by the APA itself.

ation and a capacity evaluation. The first regards Mr. Trump’s mental health condition and is his private affair, which he can choose to reveal or not. The second assesses his ability to function mentally in his office and is a different evaluation than that which is done for diagnosis and treatment. Usually the latter is the domain of forensic mental health professionals and should not be carried out by the treating physician. Psychiatrists or psychologists would do a standard evaluation of capacity fitted to the function or job, and then turn over the results to a legal, or in this case political, body, since issues such as incompetence or disability are legal decisions, not medical ones. However, the mental health expert’s role is important, as the legal, or political, bodies recognize that it is an area that requires the input of an “expert” and for the most part cannot be decided upon by non-professionals’ impressions alone. Of course, this is an available resource, which we strongly recommend, but not a required one, and even after experts have done the evaluation and made their recommendations, whether or not to make use of the results is entirely up to them. Hence, it may have no effect at all.

I believe it is important to keep with the Goldwater rule other than in an emergency, and even so, to keep focus on the public figure's personal mental health to a minimum.

If President Trump were to undergo a mental health exam, what implications would the results of that examination have for the political world? First, there are two exams we have been recommending: a neuropsychiatric evalu-

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Nevertheless, the president, who has the ultimate responsibility for the use of the most dangerous weapons in the history of the world, and who has the sole capability to murder millions of people in an instant, should undergo a proper evaluation. A 10-minute cognitive screen is not a comprehensive exam, and nor was it even necessary for a 71-year-old who has demonstrated multiple psychological, cognitive, and neurological signs of serious impairment. What was in order was a comprehensive neuropsychiatric examination, scans of the brain, and a capacity evaluation. The Department of Defense has established reasonable procedures and precautions since 1993 to ensure that personnel who handle nuclear weapons are evaluated and monitored on a continuing basis. It seems reasonable at least to apply the same standards to the com-

mander-in-chief who orders them. Lastly, how do you think the role of mental health should be incorporated into the definitions or disciplines of global health and policy? This is something I have been working on informally since the very moment I joined as a consultant to the World Health Organization, with its launch of The World Report on Violence and Health in 2002. Now as a leader of a project group for their Violence Prevention Alliance, I work in collaboration with many different disciplines, service sectors, and government officials to illustrate how mental health plays a role in nearly all domains of human affairs. I outline some of this in my upcoming textbook with Wiley-Blackwell, Violence: An Interdisciplinary Approach to Causes, Consequences, and Cures. We are discovering, even in areas such as political science and economics, that we cannot simplify human beings into rational actors, for example. Some sections of these fields have indeed dramatically changed their position from excluding any psychological aspects from their equation to giving them great importance. When I outline effective prison programs or the effects of social and economic policies on violent death rates in a society, a lot will be missed without applying the principles of mental health under the ecological model—and the reverse is true, of course. Recognizing the role, large or small, of psychological dynamics in all human affairs will allow us to deal with it better, rather than minimizing or denying its existence. This also applies to the domains of global health and policy. How to do it? For now, by including mental health professionals, just as we do epidemiologists, sociologists, anthropologists, economists, and political scientists, into the discussion—and mental health professionals should not be shy about sharing their special knowledge, either.

www

Matthew Pettus is a sophomore in Saybrook College majoring in Psychology. He can be contacted at matthew.pettus@yale. edu

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2. Pace, L. (2017, May 30). Why global health investments are key to 'Making America Great'. Retrieved from http://thehill.com/blogs/pundits-blog/economy-budget/335323-why-global-health-investments-are-key-making-america-great 3. Aizenman, N. (2017, May 25). Trump's Proposed Budget Would Cut $2.2 Billion From Global Health Spending. Retrieved from https://www.npr.org/sections/ goatsandsoda/2017/05/25/529873431/trumps-proposed-budget-would-cut-2-2-billionfrom-global-health-spending 4. Collins, C. (2017, January 06). Global health is good business - Trump should get in the prosperity. Retrieved from http://thehill.com/blogs/pundits-blog/healthcare/312923-the-business-case-for-global-health-in-the-trump-administration 5. B., & Topolski, T. (2017, October 06). Trump's plan to slash U.S. global health funding would be huge setback. Retrieved from https://japantoday.com/category/ features/opinions/trump's-plan-to-slash-u.s.-global-health-funding-would-be-hugesetback 6. Excerpt: Why Health Is Important to U.S. Foreign Policy. (n.d.). Retrieved from https://www.cfr.org/excerpt-why-health-important-us-foreign-policy 7. The United States President's Emergency Plan for AIDS Relief. (n.d.). Retrieved from https://www.pepfar.gov/press/2017annualreport/index.htm 8. Garrett, L. (2015, October 08). Can the Global Public Health System Learn From Its Ebola Mistakes? Retrieved from http://foreignpolicy.com/2015/10/08/global-publichealth-system-learn-from-ebola-mistakes-who/ 9. Antibiotic resistance. (n.d.). Retrieved from http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en/ 10. Private Sector Steps Up Leadership for Successful Global Fund Replenishment. (2017, March 28). Retrieved from https://www.theglobalfight.org/private-sector-steps-up-for-replenishment/ 11. The White House and the World: Practical Proposals on Global Development for the Next US President. (2015, July 20). Retrieved from https://www.cgdev.org/ publication/ft/white-house-and-world 12. Fox, D. M., & Kassalow, J. S. (2001, October). Making Health a Priority of US Foreign Policy. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1446822/

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YALE GLOBAL HEALTH REVIEW


YALE-CHINA

ASSOCIATION

health | education | arts

关系

guān∙xi means “relationship.” In China, building long-term relationships is the key to a significant impact. Since 1901, Yale-China Programs have forged relationships that build knowledge and capacity in healthcare, education, and arts in China, while developing crosscultural understanding for both our U.S. and China participants.

It’s All About Relationships

VOLUME 5, NO.2

Health and Education Fellows from China

To learn more about Yale-China programs in Health, Education, and the Arts, go to www.yalechina.org 442 Temple Street • PO Box 208223 • New Haven, CT 06520-8223 • (203) 432-0884 • fax (203) 432-7246 • www.yalechina.org

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