Yale Global Health Review Vol 3 No 3

SPRING 2016

THE YALE

VOL. 3, NO. 3

GLOBAL HEALTH REVIEW

ZIKA

WHAT HISTORY CAN TELL US ABOUT THE CURRENT EPIDEMIC

BY ELI RAMI Wikimedia

P. 25

LETTER FROM THE EDITORS SPRING 2016

VOL. 3, NO. 3

Dear Readers, We’re excited to close the year with this issue of the Yale Global Health Review! This year has witnessed major developments in the field of global health, from the battle against the Ebola virus to the groundbreaking adoption of the Sustainable Development Goals for 2030. In this issue, we are excited to feature unique perspectives and insights on recent health challenges such as the tie between microencephaly and the Zika virus as well as the Syrian refugee crisis. Another particularly relevant piece for this election year discusses healthcare for Mexican immigrants, especially considering that nearly ⅓ of the 30 million uninsured Americans are immigrants.

The articles presented in this issue highlight the interdisciplinary nature of global health, touching on the political, social, and economic determinants of health. We are proud to publish this extremely diverse and thoughtful issue that encompasses unique student perspectives on contemporary health issues. Creative thinking by Yale students instills hope in us that change is possible and innovation can improve lives. Personally, we learned an incredible amount reading through this issue’s pieces, and hope that these articles spark interest in lesser-discussed topics as well as deepen discussions of more well-known, health-related issues today.

We would like to thank our amazing team who worked so hard to put together this publication. We’re also thrilled to feature articles written by mostly first-time YGHR writers, as we are always looking to expand the network of students involved. We are sure that many members of our diverse and talented team will go on to become leaders in global health or whatever field they choose to pursue. It has been incredibly exciting to witness and contribute to the growth of this relatively new publication on campus. YGHR has come a long way and we can’t wait to see how it continues to flourish next year.

Sincerely,

Amber Tang & Sophia Kecskes OUR TEAM Editors-in-Chief Amber Tang Sophia Kecskes Senior Editors Hannah Krystal Kai DeBus Lauren McNeel Rachel Arnesen Associate Editors Cassandra Lignelli Claire Chang Jessica Schmerler Ohvia Muraleetharan Production & Design Team Holly Zhou Jessica Schmerler Maheen Zakaria Xindi Chen Web/Social Media Director Sarah Barreto Ornellas

Senior Online Editor Elizabeth Kitt Online Editors Al Nurani Carlin Sheridan Caroline Tangoren Staff Writers Akhil Upneja, Anabel Starosta, Holly Robinson, Rebecca Slutsky, Sarah Spaulding Business Team Erica Kocher Harland Dahl Mary Chandler Gwin Paul Won Copy Editors Dhikshitha Balaji Hannah Krystal Katerra Logan Neha Anand

YALE GLOBAL HEALTH REVIEW: VOLUME 3, NO. 3

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.

CONTENTS OPINION

FEATURE ARTICLE

FIELD WORK

INCLUSION, NOT EXCLUSION 6

ZIKA 25 What History Can Tell Us About the Current Epidemic

Expanding Healthcare Access to Undocumented Immigrants in California

by Eli Rami

by Jade Harvey

INTERVIEW

HIV/AIDS 38 The Limits of Moral Ideology

JOANNA RADIN 20

A Historical Approach to Global Health

by Jude Alawa

AUTISM 45 Experiences in the Pediatric Emergency Department

by Ava Hunt

by Akielly Hu

by Anabel Starosa Katja Schulz

BRAZIL 30

RESEARCH & INNOVATION CANCER 35 Risks Associated with Red and Processed Meats

by Harland Dahl

by Rebecca Slutsky

PHOTOGRAPHY

ECOLOGY

EBOLA & MARBURG An Evolutionary 9 Perspective on Viruses

by Rachel Arnesen

BURMA 51

by Kira Tebbe

BLUE GOLD 17 The Global Cost of Water Privatization Brian Smithson

SYRIA The Plight of Refugees in Turkey 3

by Frances Fagan

FECAL MICROBIOTA TRANSPLANTATION: The Future of Feces 48

by Mckenna Tennant Wikimedia

ADVERTISEMENT Wikimedia

HEALTH POLICY

SOUTHEAST ASIA 13

Where Being Gay is a Risk Factor

by Sarah Householder

CHINA 23

Saying Goodbye to the Aging Population and One Child Policy

by Victoria Loo

ADDRESSING URBAN VIOLENCE 41

Program in Judaic Studies Yale University 451 College St., Rm. 301 New Haven, CT 06511

The Cure Violence Public Health Approach

by Sophia Kecskes

TURNING A BLIND EYE

A Look at Unjust Health Outcomes among the Deaf, Blind and Physically Disabled 55

by Holly Robinson

Visit our website at www.judaicstudies.yale.edu

SYRIA:

FIELD WORK

The Plight of Refugees in Turkey

By Jude Alawa

Trocaire

I

magine your hometown in chaos. Airstrikes every day. The grocery store down the street is suddenly destroyed, your friends are fleeing, and you watch a family of seven be reduced to just two. Each day, a red truck arrives in the morning, just to drag away the piles of dead bodies. You can barely walk, and you require medical assistance but can’t find any.

During January of 2016, I traveled to Turkey with a group of students from the Yale International Relations Association. In Istanbul, we met with a family of Syrian refugees who escaped from Aleppo, a city under siege for the past few years. I had the opportunity to spend some time chatting with the grandmother of the family, and she explained why they had fled: the violence, the scarce resources, and the lack of medical treatment for those who needed it. She required medical assistance to treat her failing legs, and she arrived in Turkey with the hope of finding adequate healthcare only to discover that the system was much more convoluted than it had appeared.

Today, Turkey bears the burden of caring for over 2.62 million refugees from Syria.1 A

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large part of this responsibility entails providing some form of healthcare to non-citizens who desperately need it. Although several policies have been put forth, issues of implementation, demographics, communication, and institutional gridlock still create instability within Turkey and prevent Syrian refugees from accessing sufficient healthcare. On January 18th, 2013, two years after the start of the Syrian Civil War, the Turkish government issued its first policy addressing healthcare. It stated that all Syrians refugees, registered or not, in the eleven provinces along the Turkish-Syrian border would be authorized to receive the same health services as Turkish citizens but at no cost.2 According to this new policy, the Turkish government had committed to provide free healthcare to a large sum of refugees. That is, they could, in theory, walk into any public hospital to see a physician and receive medical treatment.

Despite the decree, medical teams in many of the bordering regions did not uniformly apply the policy. For instance, a think tank our group met with mentioned that in the province of Hatay, teams of physicians were told that unregistered urban Syrian

refugees, who comprise the majority of the refugee population, were experiencing difficulties accessing services, especially tertiary medical care. Although hospitals have been reported to be consistent in providing emergency healthcare to almost all refugees, follow-up visits have not been covered, largely because the visits are free for refugees, and doctors are not necessarily compensated for their work.3 About a year after the initial decree, the Turkish government introduced a new protection policy to extend health coverage to all 81 provinces in Turkey.4 In addition to issuing this policy, Turkey also introduced identification cards for Syrian refugees. Refugees require ID cards to access healthcare, education, and similar civil services.5 The purpose of introducing these ID cards was to promote the registration of refugees: if refugees knew they required ID cards to access services, they would be more inclined to register.6 However, in spite of the ID cards and the extension of coverage in all provinces of Turkey, the implementation of the health system remains problematic.

Most of Turkey’s troubles with refugees are derived from the assumption that the Syrian Crisis would be transient.7 Four years

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Freedom House

ago, when refugees first started to flee to Turkey, the Turkish government did not expect the conflict to last, and as a result they only planned for temporary accommodations. However, the persistence of the crisis and the nearly exponential influx in refugees has made the problem increasingly complicated and difficult to manage. Furthermore, it has become clear that refugees are unable to return home anytime soon, especially given the deadly circumstances in modern Syria. Every government official with whom we met in Turkey, including President Erdogan’s Chief of Staff, Ibrahim Kalin, mentioned that the likelihood of permanent residence among refugees has complicated policy issues and questions of integration, which largely include access to healthcare services.

In refugee camps, the challenge of providing health services has largely been met thus far. For instance, primary healthcare and vaccinations are provided to refugees and are completely funded by the Turkish government. In spite of this, however, the Turkish Medical Association has reported several inefficiencies in the system, which include a lack of access to more specialized services such as advanced procedures and medications.8 The healthcare situation is vastly different outside of the refugee camps (i.e., urban areas). Today, over 80% of all refugees reside in urban areas outside of the camps.9 Although the Turkish government has made all of its public hospitals accessible to refugees and has provided funding to staff the hospitals, urban refugees are encountering many difficulties in gaining access to hospitals and health services. These difficulties are a result of the sheer number of refugees and the lack of awareness among health workers of the governmental policies extending health coverage to all Syrian refugees with an ID card. In addition, it has been widely reported that doctors are refusing to treat chronically sick refugees who have been diagnosed with conditions such as diabetes or cancer. Because refugees with such chronic conditions require follow-ups or continuous treatment, they have encountered major shortages in treatment. In some provinces, hospital administrators have even refused to recognize the recent government decree and have demanded that refugees pay to cover their healthcare costs.10

Children playing in a camp for Syrian refugees.

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In addition, since Syrian refugees are concentrated in many of the provinces along the Turkish-Syrian border, overcrowding has overwhelmed the health system and thrust

it into chaos. Hospital workers have complained of being overworked and exhausted due to the increased number of patients.

Many doctors have requested transfers out of the area, which has led to grave concerns regarding a shortage of qualified medical personnel in the border areas. As a result, many refugees requiring medical care have not been able to see a physician. Beyond the refugees, Cengiz Candar, a famous Turkish journalist, and many other figures have mentioned that the Turkish people and staff in these areas are upset because they claim that the havoc has prevented them, as Turkish citizens, from receiving the services they pay for and to which they are entitled. For instance, one commonly cited example during meetings was Kilis, a city situated near the border. Today, Kilis is home to more than 200,000 Syrian refugees, and the number of refugees exceeds the number of actual Turkish residents. With such numbers, the central public hospital within Kilis has been unable to respond to the needs of both refugees and local patients, creating distress in the region and a point of conflict between the refugees and locals.11

“

Today, Kilis is home to more than 200,000 Syrian refugees, and the number of refugees exceeds the number of actual Turkish residents.

�

By far one of the most troubling obstacles preventing refugees from accessing services is the language barrier.12 Syrians typically speak Arabic, not Turkish. The inability of Syrian refugees to communicate with locals was increasingly apparent during my visits to local markets, Syrian schools, and meetings. Not only has the language barrier complicated matters of simple communication and understanding, it has also prevented Syrian refugees from voicing their needs and rights as specified by the government.

The Turkish government recognizes this problem, and the Directorate General of the Ministry of Migration mentioned that they intend to put forth programs for adults to learn Turkish and for students to gradually acquire the language throughout primary and secondary school.

As the Turkish healthcare system is definitely strained, the Turkish government has allowed international non-governmental or-

4

ganizations (NGOs) to provide specialized health services for Syrian refugees within Turkey. Although these efforts are not without their complications, they have added another level of temporary protection for refugees. NGOs are beginning to provide health services to non-registered and noncamp refugees but are unable to meet all of their needs. Some of the international NGOs have been able to partner with local NGOs to operate fully-functional health clinics with the help of funding from international relief organizations and support from Médecins Sans Frontières (Doctors Without Borders).

For instance, the American Society of Addiction Medicine has worked closely with the International Medical Corps to build a major health center for refugees in Istanbul.3 A representative from the International Strategic Research Organization (USAK), a think tank based in Turkey, mentioned that a similar center will be developed in Gaziantep soon.

Many of these organizations are vying for the Turkish government to ease registration restrictions for international NGOs seeking to work inside Turkey, especially for those trying to expand assistance programs to non-camp refugees in need. Similarly, public sentiment in support of these donors has encouraged the government to promote collaboration between local and international NGOs. One of the biggest worries of the international healthcare community and the Turkish Ministry of Health is the emergence of communicable diseases. Many of the refugees moving across the border potentially act as vectors of disease, which translates into a public health threat for the Turkish population. To make matters worse, the World Health Organization announced that the incidence of polio among Syrian children has risen considerably in recent months.

In response, the Turkish government has launched a campaign to vaccinate refugees in the camps and in provinces along the border. The problem, however, is that many so-called “vectors” have already arrived in urban areas, making them very hard to track down. Turkish health officials are worried that a substantial percentage of children inside and outside of the camps have yet to be vaccinated for polio, putting the people around them at a much higher risk for disease contraction.13 The most alarming news relating to health services in Turkey is a new policy on pharmacies and medical expenses, implemented by the Disaster and Emergency Management Presidency.14 According to this policy, all pharmacies within Turkey can only provide

5

Mehmet Bilgin

Syrian refugee children face severe challenges due to trauma, displacement, and poor provision of healthcare.

medicine to Syrians if the prescription is given by a hospital in the same district. Previously, Syrian refugees could get medicines at any pharmacy within Turkey. This new rule has not only decreased the number of pharmacies where refugees can get medicines but has also changed the attitude of pharmacies toward Syrian refugees. For example, some pharmacies are reluctant to supply medicine to Syrian refugees due to delays in receiving reimbursements from the Turkish government. In fact, over 5,000 pharmacies in Turkey have refused to provide medicine to Syrians, claiming that the government owes each pharmacy, on average, 25,000 to 40,000 Turkish liras, which translates to roughly $28,000 to $44,000 (USD). In meetings, I was told that only five pharmacies within all of Turkey still provide medications to Syrian refugees, even if they have a prescription.15 Only five.

Throughout my trip, it was evident that the public, the government, and, to a large extent, the published research support policies that encourage integration, especially with respect to healthcare. The system has problems, and the international community faces a great challenge ahead, but the Turkish government’s efforts are commendable.

Based on a report from USAK, the Turkish government has reported that 63 Syrian doctors and 18 Syrian pharmacists have accepted positions at Temporary Protection Centers with the approval of the Ministry of Health. In conjunction with the United Nations Higher Commission on Refugees (UNHCR), the UN’s refugee agency, and the European Union, Turkey also plans to open 10 fully equipped hospitals and 12 mobile health units with the sole purpose of increasing Syrians’ access to healthcare services.

Similarly, the UNHCR has undertaken the construction of fully staffed health facilities; five near the camps by the border and two in urban areas.10 Resolving this crisis requires a lot more effort, but hopefully, these new developments will be beneficial and effective in addressing the healthcare needs of Syrian refugees.

The Turkish people, the government officials, and Ahmet Icduygu, a Professor at Koc University, with whom I met cited Turkey’s history as the main inspiration behind maintaining an open-door policy and encouraging integration. Dating back to the times of the Ottoman Empire, World War I, World War II, and the Armenian genocide, Turkey has historically provided refuge for those fleeing civil conflict, and the Turks we met with were proud of their history of having preserved such hospitality. Despite this historical precedent, Turkey faces what could be one of the worst migrant crises of our time, with challenges of integration, implementation of services, and providing a future for multiple generations of Syrians. In spite of all of this, this inspiration demonstrates patience and benevolence.

As a Syrian-American student, I am deeply saddened by the healthcare problems Syrians face in Turkey today. Nevertheless, I am hopeful for a resolution to the Syrian crisis and a prosperous future for all those suffering from the terror of war. www Jude Alawa is a freshman 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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Wikimedia

OPINION

INCLUSION, NOT EXCLUSION:

By Jade Harvey

Expanding Healthcare Access to Undocumented Immigrants in California

W

ith 2.55 million of the nation’s 11.2 million undocumented immigrants living in California, the Golden State is host to the nation’s largest percentage of undocumented immigrants in the country. While undocumented immigrants make up approximately 6.8 percent of the state’s residents, they also represent an overwhelming 24 percent of the uninsured population.1 As debates in immigration and healthcare continue to lead current political discourse, the connection between the two topics is commonly either overlooked or misunderstood. Despite the fact that undocumented immigrants hold high employment rates—typically working more hours than the average documented non-immigrant to sustain vital industries such as farming, construction and maintenance—undocumented workers often find themselves between a rock and a hard place, not guaranteed employment-based health coverage, but also unable to afford private insurance. As of now, the Affordable Care Act (ACA) excludes undocumented immigrants from the expanded federal Medicaid coverage. Furthermore, although this measure would bear no additional cost to the government, the ACA also does not allow for undocumented immigrants to purchase insurance through the Marketplaces, even without subsidies, despite the clear financial and social consequences of denying coverage. California legislature should expand undocumented immigrants’ access to primary and preventive care to cut rates of avoidable acute care expenditures in the long term, improve the standard of life for residents contributing tirelessly to the state’s economy, and provide a more sustainable model of healthcare for the greater population.

Conservative political ideology often blames undocumented immigrants for high healthcare costs, claiming that undocumented residents over-consume healthcare, specifically in the form of emergency department and hospital services, leaving documented citi-

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zens to pick up the check. Additional conservative channels claim that undocumented immigrants travel to the United States specifically to receive free healthcare. Such myths could not be more false.

In the current hostile political climate that seeks to capitalize on xenophobic fears to win conservative votes, vulnerable populations like undocumented immigrants tend to become victim to hateful propaganda and racially-driven, pseudo-economic policy backed by few facts.

Research shows that “most undocumented immigration occurs because of the search for higher wages by unskilled workers or for family reunification”—not because of the search for healthcare.1 Furthermore, immigrants in the United States typically, to the detriment of their own health, under-consume services and face a variety of unique difficulties when trying to obtain healthcare services from an already limited pool of options. One study finds that undocumented immigrants in California, both insured and uninsured, have “lower rates of hospitalization for non-childbirth-related reasons, fewer visits to physicians, lower likelihood of receiving blood pressure and cholesterol checks, and lower overall healthcare expenditures compared to US citizens and other immigrant groups.”

1 This goes to show that conservative accusations of undocumented immigrants abusing healthcare services are simply unfounded.

Further, this study affirms that “undocumented immigrants have lower healthcare spending, estimated in one study at $15.4 billion in annual average spending compared to $1 trillion for US-born individuals.”1 Thus, the rumor that undocumented immigrants have high healthcare costs proves to be false.

Evidence of undocumented residents’ limited use of healthcare services can also be seen in the contrast of access between undocumented versus documented immigrants. According to a Journal of

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Immigrant and Minority Health study, undocumented immigrants from Mexico are “27% less likely to have a doctor visit in the previous year” and “35% less likely to have a usual source of care compared to documented Mexican immigrants.”2 Considering that undocumented immigrants from Mexico represent 57 percent of the majority of all undocumented immigrants in the United States, these findings have a significant application to the overall study of the disparity in healthcare access even between documented and undocumented immigrants.2 Though understanding the current underconsumption of medical resources by undocumented immigrants is necessary to debunk myths on immigration and healthcare, the fact that so many undocumented, working residents in California receive little to no healthcare services is surely not a topic to applaud. Despite lower healthcare expenditures, undocumented immigrants are in no way less prone to illness or less in need of medical attention than the rest of the population, but instead face significant, sometimes prohibiting barriers to accessing care when needed.

When it comes to public coverage options for undocumented adults that do choose to seek out medical attention, Medicaid funds are limited to strictly emergency, condition-specific situations. For an undocumented adult to receive Medicaid coverage in California, the law requires an “emergency medical condition,” which must be “severe, acute, and life-threatening or lead to disability.”1 Under current law, Medicaid is restricted to low-income, documented residents within targeted high-need groups as well as all adults less than 65 years old with incomes up to 138% of the Federal Poverty Level.3 In one study, researchers found that undocumented workers' households are around “half as likely to use Medicaid as documented households.”4 In other words, the only public healthcare coverage option available to undocumented adults, i.e. emergency Medicaid, is also drastically underused. There are many factors that contribute to this stark underuse of healthcare services by undocumented immigrants, ranging from demographic factors, to English proficiency, to the number of years lived in the United States—all of which affect the health maintenance and well-being of community members.

Due to the high cost of healthcare services for uninsured individuals in the United States and the limited service options for undocumented residents, poverty significantly affects access to care for immigrants. Cali-

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fornia Latino DREAMers—young undocumented immigrants who, through qualification for the Deferred Action for Childhood Arrivals (DACA), program are eligible for temporary legal status, but excluded from the Affordable Care Act's Medicaid expansion and Health Insurance Exchanges—cite cost as a significant barrier to care access.5 When already faced with the tremendous challenges of making a life in a new country as a low-wage worker without English proficiency or financial support, young undocumented youth struggle to pay for daily necessities, let alone high fees for uninsured doctor visits. In the case of DREAMers, having insurance did not always eliminate the cost burden of seeking care. One youth explains, “I had insurance from my dad growing up. But, even then, you still had to pay five bucks… I tried avoiding going to the doctor or getting medicine because it's so expensive.”5 Whereas lack of insurance can also be an obvious barrier for many undocumented immigrants, poverty’s impact on access to care is also significant.

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California legislature should expand undocumented immigrants’ access to primary and preventive care.

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The time it takes for undocumented immigrants to seek medical help also factors into care costs. In a 2013 case study on undocumented women, many participants reported high wait times as a deterrent from accessing health services.6 When individuals and families are struggling to make ends meet, there sometimes simply is not enough time to wait at overcrowded community clinics. Many safety-net healthcare systems are overburdened with patients seeing as for many uninsured, undocumented families, they are one of the only sources of help.

Many low-wage, undocumented, working families do not have the leeway to take work off and see a doctor, thus not only the price of healthcare services, but also the opportunity-cost remains too high for many.

Along with financial difficulty, other factors such as immigration status, language, lack of familiarity with the healthcare system, and mistrust of providers due to fear of discrimination and deportation

also prove to be critical barriers to care access for many immigrants. In a study titled “Fear of Discovery Among Latino Immigrants Presenting to the Emergency Department,” researchers show that one in eight of undocumented Latino immigrants seeking care in Emergency Departments in California express fear of discovery and consequent deportation.7 This fear comes in part from existing discrimination by medical providers—a widely expressed sentiment throughout many studies. One study shows that among the state’s uninsured, immigrants have higher odds of perceiving discrimination than non-immigrant populations and tend to postpone emergency room trips at higher rates.8 The “DREAMers” study quotes a youth on discrimination: “I think it's related to like how we're brown, and we're undocumented, and we're low income…They're going to treat you differently.”5 The discussion continues: “because the majority of DACA-eligible young adults lack a regular provider, they have few opportunities to develop trusting relationships that might increase their comfort level.”5 In addition to the commonly overlooked factor of lacking the comfort and support of a regular doctor, undocumented immigrants’ fears of discrimination may additionally stem from the current hostile, anti-immigration political climate, the country’s history of xenophobia and racism or lingering fear from previous anti-immigrant legislation, such as the notorious Proposition 187 that sought to restrict undocumented residents’ access to resources.

In 1994, California passed the controversial Proposition 187, which aimed to discourage undocumented immigration into California by denying education, health, and social services to people without legal immigrant status. The Proposition passed, but ultimately was never implemented; nevertheless, it still had notable effects on the undocumented immigrant population in the state. Community healthcare providers in California at the time “reported declines in visits from [undocumented Latino immigrants], despite the proposition never having taken effect.”7 Lasting fear and misunderstanding of the state’s current non-reporting practices discourages many undocumented immigrants from seeking care.

This lack of familiarity with the current functioning of healthcare options for undocumented immigrants spreads beyond fear of being deported, but also includes a general healthcare illiteracy amongst many non-English speaking immigrants.

All of the aforementioned limited health

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opportunities for undocumented immigrants do not go without repercussions.

Due to the fact that healthcare access is not a statistically significant factor for immigration to the United States, “including undocumented immigrants in the exchanges without subsidies is likely to have little effect on the size of the undocumented population, but denial of coverage may have important financial and social consequences.”1 Financially, since California does not provide ample options for primary or preventative care for undocumented immigrants, the state ends up having to deal with sicker, more-expensive-to-treat patients. When it comes to public health, studies show that appropriate preventative care saves money. One study found that “if 90 percent of the population had access to tobacco cessation services, alcohol abuse screening, daily aspirin intake... and colorectal cancer screening, each of those four interventions alone would result in more than 100,000 years of life saved… if preventive care had been widely delivered in prior years, all without an increase in net cost."9 Underutilization of medical services is associated with “poorer health outcomes such as longer stays in hospitals, more acute health crises, and higher mortality rates.”1 When undocumented immigrants exhaust all options to avoid the perceived risks of seeking help in emergency departments, by the time that families do chose to seek help, individuals’ conditions tend to be more severe and costly. Increasing primary care options can reduce emergency department and acute-care costs while reducing the burden on safety-net providers.

The social consequences to inadequate access to health services vary with certain undocumented immigrant demographic groups. Among working poor families, “immigrant children experience increased poverty and uninsurance and decreased access to care which may jeopardize their health and future productivity.”8 The American Academy of Pediatrics recommends a minimum of one annual physician visit for children. The lack of check-ups and continuity of care puts immigrant children at increased risk for missing vital preventive care opportunities, which is especially concerning given the increased health risks of living in poverty.8 In addition to dealing with the trauma and stress of their immigration, coming of age in a foreign country as an undocumented immigrant often results in significant mental health concerns that go largely unmet.5 Some pregnant women may receive government-sponsored insurance since care is often provided “to ensure the health of future U.S. citizen babies,”

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Flickr

Immigrants speak in favor of the dream act at a forum in Los Angeles.

but even this conditional support raises the question of whether it is morally permissible to only support the health of an undocumented woman if she is raising a “future citizen” and calls into question why the health of an unborn American citizen in the womb is more worthy of protection than a working woman contributing to American society on her own.10 Seeing as increasing access to preventative services can improve the health of undocumented immigrant populations with little to no cost and failing to do so has serious social consequences, the points against expanding healthcare access pale in comparison to pro-expansion arguments.

The process of extending healthcare access to more undocumented immigrants could manifest in the form of both insurance and noninsurance solutions. One insurance solution could be to allow undocumented immigrants to find healthcare without subsidies in the new Marketplaces. Though less financially feasible, expanding Medicaid to allow for the inclusion of necessary preventive care beyond just emergency services for undocumented immigrants would also have tremendous positive effects. Non-insurance solutions include increasing language and culturally-competent staff, developing mutual-aid organizations, employing undocumented immigrant health promoters and mandating signage in public hospitals that reminds undocumented immigrants of California hospitals’ non-reporting policies to diminish fear of seeking help when needed.

One study brightly suggests that “non-employer-based options for coverage could be sponsored or negotiated through unions, farm bureaus, churches or other immigrant organizations.”8 Politically, California can work to strengthen the enforcement of labor laws to improve conditions, raise wages and provide incentives for employers that use undocumented labor to provide work-

ers with health insurance. These solutions, among many more, would have measurable success in improving community health standards while also decreasing acute healthcare costs.

Despite the proliferation of misinformation on the high costs of undocumented immigrants in the healthcare system, researchers continue to publish study after study dismantling such detrimental myths in favor of expanding access to health services in California. In all, there are a diversity of cost-effective options in addressing the issue of limited healthcare access for undocumented immigrants in California that will not only benefit marginalized communities, but also subsequently raise the health and well-being of the state as a whole. Although certain right-wing politicians continue to make inflammatory cries on the supposed burden that undocumented immigrants place on the national economy, the facts backing these hateful statements are simply not there. Instead of pushing policies to deny undocumented residents crucial services, the American public should recognize the value in investing in human capital and protecting the health of all residents. In a state whose economy and general function relies so much on the tireless work of undocumented immigrants in many lowwage industries, policy makers have a responsibility to recognize the legitimacy of undocumented immigrant health concerns to create a more healthy, productive and equal working population in a more economically-sensible healthcare model. www Jade is a junior in Ezra Stiles College majoring in Ethnicity, Race, and Migration.

She can be reached at jade.harvey@yale.edu.

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CDC

ECOLOGY

By Rachel Arnesen

EBOLA & MARBURG: An Evolutionary Perspective on Viruses

T

“Ebola in the air? A nightmare that could happen.”

“Ebola: World Goes on Red Alert.”

“Ebola: ‘The ISIS of Biological Agents.’”

hese headlines, taken from real CNN and BBC articles, capture all too well the fear mongering that occurred during the most recent outbreak of Ebola in West Africa.

From 1996 to 2009, 53% of emerging global infectious diseases had their roots in Africa, the continent that lags furthest behind in disease detection and warning.1 Ebola is an example of a zoonotic virus, or a virus that has “spilled over” from animals to humans. Zoonotic viruses, the most frequently emerging human pathogens, constitute over 65% of all pathogens discovered in humans since 1980.1 Despite the predictions of prominent virologists Macfarlane Burnet and David O. White in the 1970s that the “most likely forecast about the future of infectious disease is that it will be very dull,” the emergence of zoonotic diseases such as HIV/AIDS, Ebola, and SARS demonstrates that the field of infectious disease remains far from boring.2 The continued emergence of such zoonoses is rooted in an evolutionary past and has the potential for devastating public health outcomes.

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The headlines mentioned previously, though alarmist, raise important questions about the danger of these zoonoses, why they emerge, and what we can do to control them.

In 1976, the Ebola virus was identified in what is now the Democratic Republic of the Congo (DRC).3 Since then, subsequent outbreaks of this filovirus have occurred throughout central and western Africa, with the largest outbreak ending only recently in West Africa. As of mid-July 2015, this outbreak had caused over 27,000 cases and 11,000 deaths in Guinea, Liberia, Nigeria, and Sierra Leone.4 Marburg virus, the only other pathogen in the filovirus family, was discovered in 1967 when several laboratory workers in Marburg, Germany, fell severely ill. Scientists traced the outbreak back to the researchers’ study subjects: African green monkeys from Uganda. During that outbreak, a total of 31 cases of Marburg were detected, with seven fatalities.5 Large natural outbreaks of Marburg have occurred since, including an outbreak in the Democratic Republic of Congo in 1998, which resulted in 149 cases and 123 deaths (83% fatality rate), and a 2004 Angola epidemic that led to 252 cases and 227 deaths (90% fatality rate).5 In 2012, a novel coronavirus

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emerged in the Middle East, which soon earned the name Middle East respiratory syndrome (MERS). Since September 2012, the disease has caused 1,611 confirmed cases of MERS and 575 deaths across 26 countries.6 Ebola, Marburg, and MERS represent just three examples of diseases that spread from animals into humans, and then among humans as well.

Of 335 emerging infectious disease (EID) events cataloged between 1940 and 2004, 60.3% were classified as zoonoses, with 71.8% of those zoonotic events caused by pathogens of “wildlife origin.” 7 Over the course of those 65 years, pathogens originating in wild animals caused 43% of all EID.7 However, from 1990-2000, the proportion of EID caused by zoonotic pathogens originating in wild animals jumped to 52%, a large statistical increase.7 This rise begs an important question: what is driving the increase in spillover events in recent years? The accelerated emergence of zoonotic diseases calls into focus a need to understand the evolutionary processes behind spillover virulence, the phenomenon in which a disease moves from an animal host into the human population and causes illness.

What are the driving forces behind these spillover events? More specifically, how have human actions increased the likelihood of zoonoses?

Filoviruses such as Ebola move from one live host to another, thus they must balance an increase in virulence, defined as the pathogen’s ability to cause disease, against transmission ability. This tradeoff between the length of time the host survives after a pathogenic invasion and the rate at which it is transmitted to others is known as the virulence-transmission tradeoff. Bats are the long-term host for filoviruses, thus filovirus infection in bats is asymptomatic and non-lethal. One rea-

53% of emerging global infectious diseases have their roots in Africa

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son this host-pathogen relationship may have evolved is because the metabolism and core temperature of bats increases greatly during flight.7 Since the inhospitable environment of the bat acts as a selective force on pathogens, such viruses would have to evolve to weather those changes. Given that tradeoffs are central to evolution, such an adaptation would have to be accompanied by another change: in this case, decreased pathogen virulence in the bat host. Bats and filoviruses have coevolved so that the high bat body temperature during flight does not kill the filoviruses, and conversely, the presence of filoviruses does not harm the bats. However, when the filovirus encounters a naïve host with less hostile conditions, such as the human body with its lower temperatures, the virulence level skyrockets. Within a naïve host, such as a human, the parasite proliferates as increased virulence is selected for.8 When a filovirus outbreak ends, the disease goes back into “hiding” in its natural reservoir.

Since the pathogen is practically harmless to its natural host, it is near impossible to predict the next episode of spillover virulence. This difficulty of detection begs the question: what determines whether or not a disease will spill over into the human population?

Because Ebola and Marburg viruses have equilibrated to the bat immune system, they can withstand large fluctuations in body temperature, rendering the typical human fever response relatively ineffective. An individual parasite does not “think” on an evolutionary time scale, so this ability did not result from conscious decision-making. Rather, once the virus enters a naïve host, it can proliferate and grow unhindered. However, such rapid growth is not conducive to a sustained epidemic or outbreak. Diseases such as Ebola and Marburg tend to kill their hosts

more quickly than they infect new ones, preventing the diseases from becoming established in the new host population.

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The continued emergence of such zoonoses is rooted in an evolutionary past and has the potential for devastating public health outcomes.

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In addition to the individual, biological characteristics of viruses that predispose them to spillover events, human actions have increased the rates and risks of zoonotic events. Human behaviors affect animal-environment interactions, human-environment interactions, and animal-human interactions. These non-biological drivers fall into two different categories: proximate drivers and ultimate drivers. Proximate drivers occur on a relatively local level, and include population movement and migration, habitat changes, and alterations in food and water usage.9 Ultimate drivers occur on a broad temporal and geographic scale, and they shape the proximate drivers. Examples of ultimate drivers include climate change and variability, changes in land use, and changes in animal interactions.9

The proximate drivers of movement/ migration and habitat change primarily affect zoonosis emergence by expanding the human-wildlife interface. When habitat destruction, flooding, drought, etc., displace animals from their natural habitats, they may be forced to move to new areas, frequently located closer to

65%

71.8%

of all pathogens discovered in humans are zoonotic viruses

of zoonotic events are caused by pathogens of "wildlife origin"

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Wikimedia Commons

Countries affected by the 2014-2015 Ebola outbreak in West Africa.

human population than before.10 This convergence provides more opportunity for human-wildlife interactions and more opportunity for a disease harbored by a wild animal to jump into the human population. The same process can happen in reverse when humans migrate to new locations.10 Though a less direct mechanism than the drivers described above, climate change also drives zoonoses, affecting the rate of spillover events through four different mechanisms. First, climate change induces a “range shift” in human or animal populations, thus increasing the number of interactions between the host and the vector. Second, it changes the population density of the host or vector, shifting the frequency of interactions between the two. Third, it augments the infection prevalence, which could change how often humans come into contact with an infected animal. Lastly, climate change alters the pathogen load through “changes in rates of pathogen reproduction, replication, or development,” thus affecting the ability of the pathogen to infect a human even if contact is established.11 Ecological niche models predict the location of potential filovirus outbreaks to mainly concentrate in sub-Saharan Africa, with Ebola outbreaks occurring in the “humid rain forests of central and western Africa,” and Marburg outbreaks occurring in “the drier and more

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open areas of central and eastern Africa.”12 By affecting these ranges, climate change could render our current modeling techniques inaccurate and increase the risk of spillover events in previously unaffected or lightly affected areas.

Growing land use on large scales, another ultimate driver of spillover events, has likely contributed significantly to the increased rate of zoonoses in recent years.

Such changes include deforestation, pasture to cropland conversions, crop intensification, and urbanization.9 These alterations expand the human-wildlife interface in ways similar to those of the proximate drivers mentioned above. As humans expand further into previously uninhabited territory, they augment the risks of new or increased contact with species that previously lived separately from them.9 The widely seen practices of deforestation and agricultural intensification encroach on land previously prowled only by wildlife.

Cutting down forests where, for example, bat species live, forces the bats to find a new habitat. Since less and less land remains unexplored by the human species, these bats will now frequently share their habitat with human populations, increasing the risk of zoonotic events.

Changes in animal management and food sources can be viewed as both proximate and ultimate drivers of zoonotic dis-

ease emergence. When dealing with zoonotic diseases originating in wildlife, not domesticated animals, the hunting, trade, and consumption of bush meat play crucial roles. Any meat obtained from wild animals, a frequent source of food in many of the regions that have experienced filovirus outbreaks, is considered bush meat.13 A study conducted in 2002 in the Congo basin, a hot zone for Ebola, estimated that over 282.3 grams of bush meat is eaten per person per day, with a total of 4.5 million tons of bush meat extracted annually.13 Many zoonotic diseases, including Ebola and Marburg, can pass to human hosts when people eat or even handle infected meat. Increased demand for bush meat is likely associated with the increased incidence of zoonotic diseases.

No single “most important” factor drives filovirus spillover events. These events occur when the bat-human-environment interactions line up in a way that facilitates virulence spillover and subsequent propagation throughout a human population. This leads to an important question: What does the future zoonotic disease landscape look like for the human population?

A massive, prolonged filovirus event does not seem to be a major risk to the human population. Although the most recent outbreak of Ebola in West Afri-

YALE GLOBAL HEALTH REVIEW

ca is certainly worrisome, the epidemic appears to have ended approximately two years after it began ravaging the region. While the 27,000+ cases and 11,000+ deaths it caused make the epidemic by far the largest outbreak of Ebola in human history 4, this zoonotic event still does not even come close to the annual impact of pneumonia and influenza (3.5 million deaths in 2000) or tuberculosis (1.5 million deaths), diseases that have established themselves in human populations by optimizing their virulence level in human hosts.14 Just because the risk of filovirus adaptation to the human species is currently minimal, however, does not mean we should ignore the potential threat. As our ecological landscape changes due to a wide range of phenomena such as climate change and deforestation, which effectively expand the human-wildlife interface, the currently increasing frequency of zoonotic events is likely to continue and possibly even accelerate. As of this moment, we lack the tools to predict seemingly erratic Ebola and Marburg outbreaks. Most people agree that the most important defense against zoonoses is effective surveillance.9 Yet, as illustrated by the West African Ebola outbreak, the regions most at risk of these zoonotic events also lack effective public health surveillance.

tion today, an outbreak concerns regions beyond those in which it occurs. Viruses such as Ebola transmit rapidly, and have the potential to infect individuals around the globe within a few days or weeks. Significant attention has been given to the idea of an Ebola vaccine, with only limited success. Less attention has been paid to the importance of surveillance methods. Zoonotic diseases are particularly difficult to deal with from a public health perspective as they can retreat into their animal hosts until conditions line up that again facilitate spillover. Without comprehensive surveillance and contact tracing resources available in at-risk areas, we run the risk of seeing more frequent zoonotic events reminiscent of the 20142015 West Africa Ebola outbreak.

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Since the pathogen is practically harmless to its natural host, it is near impossible to predict the next episode of spillover virulence.

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That is not to say, however, that virus hunting poses the solution. As noted by Professor Andrew P. Dobson of Princeton University, “Undiscovered viruses are abundant everywhere …and we need to think more about the dynamics of emergence than the romance of fishing for viruses with computer Color-enhanced electron micrograph of Ebola virus particles. chips.”15 I would take that statement a step further: not only should we focus on the dynamics of emergence, but we also need to create infrastructural improvements that can improve the quality of daily life and strengthen disease response efforts in the event of an outbreak.

One of the main problems with the West African Ebola epidemic response that many overlook is the fact that large numbers of cases occurred in communities with poor transportation and communication networks.16 Much of the focus in stopping Ebola centered around the creation of a vaccine, but what good can Thomas W. Geisbert a vaccine do if the affected For decades, diseases common to sub-Saharan Africa and Southeast Asia were known as “tropical diseases;” in other words, diseases that did not typically affect those living in North America or Europe. But given the level of globaliza-

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region lacks the infrastructure to distribute that vaccine to those in need? Similarly, how can we expect to survey “hotspot” regions when inadequate road and communication networks prevent at-risk communities from receiving the support that they need? What happens when an infected individual travels multiple days to a larger village or city to seek treatment and infects those he or she comes in contact with along the way? Discovering an outbreak represents an important first step. Developing a vaccine for filoviruses would be another major breakthrough.

But adequate infrastructure to make the distribution of treatment and information possible, a factor all too frequently overlooked, must precede the implementation of any sort of surveillance system or vaccine distribution.

Zoonoses constitute a major public health risk already, and threaten to grow even more dangerous over the coming decades. There is no simple way to explain the phenomenon of spillover virulence without delving into the evolution of the virus and its hosts, as well as the intersection of humans, wildlife, and the environment. At this intersection, the human-wildlife-environment interface, the dreaded “species jump” occurs. But we must recognize that this species jump represents only the first step; the biology of the host and pathogen play an equally important role in determining how the virus will interact with its new target population. Filoviruses provide ample opportunity for research, particularly with regards to the role of bats as the natural reservoir of these pathogens. Spillover events are an inevitable consequence of living in a world where humans, wildlife, and pathogens all constantly evolve.

We can, however, potentially slow the increase in frequency of spillover events and minimize the devastation they cause to the populations in which they emerge.

Yet unfortunately that is not the future we are heading towards if we continue on our current trajectory. www

Rachel Arnesen is a junior in Branford College.

Rachel is a Global Affairs major in the 5-year BA/MPH program.

Contact her at rachel.arnesen@yale.edu.

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Source Gay RVA News

HEALTH POLICY CATEGORY

SOUTHEAST ASIA:

By Sarah Householder

Where Being Gay is a Risk Factor

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O

n June 27th, 2015, hundreds of Americans waiting outside the Supreme Court building erupted into cheers as it was announced that the Supreme Court had officially ruled that “same-sex marriage is a legal right”. 1 Celebrations across the nation broke out and couples rushed to courthouses to legalize longstanding relationships.

On such a historic day, it is easy to forget that the progress made in the West is not reflected in other parts of the world. With this motion, the US joined the ranks of 21 other countries in Western Europe and the Americas who have legalized same sex marriage.2 However homosexuality is still punishable by death in 5 countries in the world, and by incarceration in 72 others—a legal indication of the scope of intolerance. 3 Beyond the well-documented burden of HIV/AIDS in the lesbian, gay, bisexual, and transgender (LGBT) community, the health effects of living in such a stigmatized community as a queer individual are unknown and largely unaddressed.

By combining statistics from a region of the world with extreme discrimination, such as Southeast Asia, with data from studies on health consequences within more tolerant countries, a more accurate understanding can be achieved of how, in parts of the world, one’s sexual orientation affects health, and what interventions need to be taken.

Many Southeast Asian countries, including Brunei, Burma, Indonesia, Malaysia, the Philippines, Singapore and Thailand, share several key features, including geographical proximity, agricultural economies and highly religious societies. Though the countries differ in their religious composition, most have a dominant religion of Islam, Buddhism or Christianity, with a significant minority religious group. 4 While most countries in the region have HIV/AIDS intervention for the 4-5 million infected men who have sex with men, the true number of LGBT individuals and their specific health outcomes is unknown.5 Research suggests that there are deep psychological and physiological effects of discrimination, which, in these countries, extend from a lack of legal recognition and protection to discrimination in social services, and societal backlash—the latter of which being the least quantifiable, yet the most damaging form of discrimination. Due to a lack of government initiatives and activist organizations for LGBT issues in Southeast Asia, most accounts of dis-

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crimination are anecdotal and difficult to generalize. To gain a reliable picture, the US State Department conducted a worldwide survey on Human Rights that helped shed light on the true situation of LGBT rights in the region.

Intolerance is easiest to measure when codified in the law. Queer activities are illegal in 5 of the 7 countries in the region, with consequences ranging from 14 days in jail for cross-dressing in Malaysia to 10 years of imprisonment for men who have sex with men in Brunei.

In Indonesia, same gender relationships are not strictly illegal, but homosexual sex is processed under the same law that criminalizes prostitution, and transgender individuals are treated as sex workers in the eyes of the law. Additionally, the lack of protective laws in most countries makes it difficult to prosecute crimes against LGBT persons. Though countries such as Indonesia, Malaysia and the Philippines have anti-discrimination laws, they are silent in regards to violence against LGBT individuals. In Burma and Thailand, law enforcement is often the source of violence, and protection comes at the price of steep bribery.6 It is one thing for individuals to be intolerant; it is quite another to have a legal system invalidate and criminalize someone’s identity, making it dangerous for him/her to access the justice system for fear of facing charges him/herself.

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It is one thing for individuals to be intolerant; it is quite another to have a legal system invalidate and criminalize someone's identity.

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In countries without the threat of incarceration, LGBT individuals are more open, and it is possible to gauge institutionalized discrimination from other sources. In the Philippines and Thailand, where non-heterosexuality is not legally punishable, the US State Department was able to collect more accurate data on discrimination in business and finance.

Non-heterosexual respondents reported widespread discrimination in employ-

ment, education, access to healthcare and housing, which impaired them socially and fiscally. In Singapore, even undercover LGBT couples are unable to live together, as the government does not allow single individuals to share housing until the age of 35, meaning couples are not only unable to legalize their partnership, but are unable to even live together. 6 Institutionalized discrimination does not solely stem from law enforcement, and, for LGBT persons, sexual orientation complicates all aspects of public life.

But in every country surveyed, the deepest stigma came from communities and families. Most countries in Southeast Asia are primarily agricultural, with tight-knit communities entrenched in tradition and resistant to change. Many perceived benefits of a close community become antagonistic when one breaks tradition, especially in a way that is seen culturally as madness, depravity or sin.

In this environment, it is nearly impossible for LGBT individuals to find a supportive community among their peers or elders. In Burma, bullying against LGBT youth often turns violent, occasionally requiring hospitalization. And, due to increased Islamic radicalization in Burma, Malaysia and the Philippines, many areas have become less tolerant in the last five years, with increased violence towards and ostracism of LGBT persons.6 Though judgment from one’s community is challenging, it is easier to manage pressures healthily when supported by close family. The vast majority of LGBT persons in Southeast Asia lack this support. In Indonesia, it is common practice for families of non-heterosexual children to institutionalize them for therapy, confine them to homes, or pressure them to marry early. In Brunei, 89% of LGBT individuals reported experiences of violence within their family.6 What is perhaps the most disturbing is how incomplete, yet horrifying, the glimpses we catch are: without more data, we are left to assume that the forms of societal discrimination in one part of this region are not specific, and are experienced throughout Southeast Asia.

When people are discriminated against on the basis of differences in gender, race, religion or nationality, the impact on health and mortality can be quantified from hospital records. Simple statistical analyses show that life expectancies in racially stratified neighborhoods in Baltimore differ as much as 20 years from the richest to the poor-

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est area.7 Queer identities are different: LGBT people are able to conceal their sexuality or gender preference, making it difficult to identify what their health challenges are. Instead, we must rely on Western studies on the effects of stigmatization and assume the documented effects translate across the world to far worse environments.

The root of health consequences from stigmatization is elevated, constant stress. Despite what Yalies say, no one dies from short-term stress, which can actually have positive effects on cardiovascular and psychological health. Longterm stress, however, can have severe chronic health consequences on immune function and mental health. Uncontrollable, unpredictable stress from multiple sources is more dangerous than routine aggression. When someone is able to predict stressful episodes, his/her stress response heightens in preparation for the attack, but quickly returns to baseline, minimizing long-term effects. But without a consistent pattern of discrimination, LGBT persons maintain an elevated level of awareness in preparation for random acts of violence. This heightened stress response causes extreme psychological and physiological consequences.8 The psychological consequences are more comprehensive and also more understood. In 2015, the CDC compared the mental health of LGBT youth in the US who have supportive families to that of youth who feel that their family is either indifferent or actively opposes their sexuality. Youth without familial support were six times more likely to report high levels of depression and

eight times more likely to have attempted suicide than youth with supportive families.9 A UCLA study showed the effects went beyond the obvious mental health consequences and also affected personality and emotional intelligence.

Experiences of sustained discrimination affected queer individuals’ acquisition of social and personal resources, including a sense of personal mastery, self-esteem and social support—skills necessary for healthy management of daily stressors.10 Without resources to handle mental health issues, psychological effects of discrimination can have a major debilitating effect on the quality of one’s life.

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diabetes prevention, leading to increased prevalence of such issues.8 Partially due to stigma and familial pressures, queer individuals are also less likely to form stable monogamous relationships, leading to an increased risk of STIs.9 Bear in mind that all of the data above was collected on queer-identifying US citizens; though their lives have certainly not been free from stigma, most have access to ever increasing social, religious and legal support. At the very least, in the US there are organizations dedicated to helping LGBT persons with identity, bullying, and social issues. We can only imagine how the above health responses might be magnified in a population that is stigmatized in a more universal, violent and permanent way.

One of the most pressing demands in this situation is the need to mobilize domestic LGBT voices.

Long-term experiences of stigmatization also have physiological consequences. Longterm intensified stress responses in LGBT individuals have been linked to decreased immune function, higher rates of hypertension and breast cancer, and more drastic cardiovascular responses to stressful situations. 8 Additionally, stigmatized individuals are less likely to have healthy habits: LGBT persons without a support system are three times more likely to use illegal drugs and four times more likely to have risky sex. 9 LGBT individuals in the US have higher rates of obesity and higher blood pressure than their heterosexual counterparts. Additionally, stigmatized people are less likely to prioritize preventative health and have fewer resources to spend on measures such as cancer screenings and

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Being gay isn’t a risk factor for poor health.

Rather, it is low social capital, discrimination, and the threat of violence that causes LGBT individuals to have different health outcomes than straight persons.

Actions to combat these health consequences naturally align with human rights efforts and need to involve multiple players with different approaches in order to increase surveillance, decriminalize status, improve social services, and elevate voices in the region.

First and foremost, more data must be acquired and homosexuality must be decriminalized. More information is needed to inform aid organizations on what the scope of the problem is, where it is

QUICK FACTS 89% of LGBT individuals in Brunei report experiences of violence within their families

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Queer activities are illegal in 5 of the 7 countries studied in Southeast Asia

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Nearly countries around the world have decriminalized homosexuality in the last 20 years

4-5 million

men who have sex with men were infected with HIV/AIDS in Southeast Asia as of 2010 YALE GLOBAL HEALTH REVIEW

Wikimedia Commons

Thousands gather for the fifth annual Pink Dot LGBT rights rally event in 2013 in Singapore.

concentrated, and where they should intervene. Without this knowledge, it is nearly impossible to be effective. As a first step towards better intelligence and assurance of basic human rights, legislation in these countries needs to evolve to not only decriminalize LGBT persons, but also protect them against acts of violence. When prejudices are institutionalized, societal hatred is legitimized and efforts to reduce stigma and violence become much more difficult.

On a different level, civil services need to be made more inclusive and accessible. With today’s conditions, queer people in need of civil services are reluctant to utilize resources due to fear of being reported or receiving discriminate treatment. This is especially true within law enforcement, where officials often become sources of violence towards the victims they are called to support. 11 Law enforcement officials need to be trained on how to approach and protect LGBT individuals, and oversight is needed to dissuade abuse. Additionally, many health professionals still view homosexuality as a disease and are ignorant of health concerns specific to transgender patients. In some countries, health professionals are required to report the sexuality of their patients to federal officials, breaching their obligation of confi-

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dentiality. 12 Changes need to be made to education and policies to ensure that patients can access appropriate care without reluctance to express their sexuality.

But one of the most pressing demands in this situation is the need to mobilize domestic LGBT voices. If local civil society groups were formed, LGBT persons would be able to reach out to at-risk members, advocate for political change, and direct international aid to be more effective. 13 International, governmental, and not-for-profit organizations need to encourage these organizations as a necessary way to unite and support LGBT individuals and distribute resources. In order to effectively initiate change, people experiencing conditions firsthand need to be a part of the conversation.

Naturally, the demands above are extremely linked and reliant on each other. That’s part of the challenge: efforts have to be coordinated in several arenas, despite not knowing the true demand.

Without reliable data, government support, or country-based organizations, it is extremely difficult to gain momentum and affect change. All that we can assume is that discrimination in intolerant parts of the world, such as Southeast Asia, is causing real psychological and physiological health effects that demand our at-

tention. However, challenges are not indicative of hopelessness, nor grounds for a lack of effort. Change is not impossible: in the last 20 years, nearly 30 countries have decriminalized homosexuality.12 But it is not possible without specifically directing funds and energies to improve the quality of life of LGBT individuals.

In global health efforts, most resources go toward ‘low hanging fruit’—interventions that cost less, yet have large potential return. Yet root causes are often still there, causing other complications that majorly affect the quality of life. In order to truly improve the health of this marginalized group, health efforts need to start at the human rights level and work up. It is only by tackling the challenge head on that, someday, the expression of one’s sexuality might be a celebration, instead of a sentence to a harder and unhealthier life. www

Sarah Householder is a sophomore in Berkely College. Sarah is a Modern Middle Eastern Studies major and a Global Health Fellow.

Contact her at sarah.householder@yale.edu.

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Public Domain

ECOLOGY

By Frances Fagan

BLUE GOLD

The Global Cost of Water Privatization

M

ajor shifts in the availability and purity of water have already begun to affect the health of the Earth’s water cycle and water-dependent ecosystems. Through carbon emissions and other unregulated business practices, we spew large quantities of harmful pollutants into the atmosphere that leech into our soil and limited groundwater reservoirs. This contamination increasingly threatens the potable water supply of our planet, creating a growing ecological concern that requires more effective and sustainable water management practices.

drinking water.8 As our populations increase and water-dependent industries (such as fracking) expand, the 1% of water on Earth that is currently safe for consumption will become increasingly scarce – and all the more valuable. The production of water bottles, the environmentally damaging bulk transport of water from origin to market, and the effect of unsustainable water management practices will only increase global health concerns. Due to privatization or pollution, access to, as the World Bank now terms it, “Blue Gold,” may well become a luxury during our lifetime.

As the lead contaminated drinking water of Flint Michigan illustrates, governments and corporations have historically failed to limit pollution or to orchestrate the balanced distribution of essential resources to those most in need. As a global population faced with unreliable organizations, we must become informed advocates of sustainable water management and consumption practices. Citizen advocacy is often the most successful method for ensuring continued access to drinkable water, a singularly precious resource.

Increasingly, global corporations including Nestlé and Coca-Cola, as well as more powerful agencies such as the World Bank, have already begun the slow march towards the global privatization of water resources. Looking into any grocery store or recycling bin you will see that bottled water is big business. Bottled water is one of the fastest growing industries in the world. In 2008, in the United States alone, companies dealing in water made a profit of 77.6 billion dollars.2 We can safely assume that through marketing and consumer demand these numbers have only increased.

Interestingly, the highest demand for bottled water stems not from developing countries with limited access to safe drinking water, but from developed nations whose water supplies are likely to be

The World Health Organization estimates that, by 2025, more than one half of the global population will not have access to safe

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YALE GLOBAL HEALTH REVIEW

of similar quality to the bottled water they purchase. A quick Google search will show that bottled water quality tests consistently reveal, ironically, in regards to bacterial contamination and chemical content, that the quality of bottled water often falls below that of local state-mandated tap water standards.

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al was set to move forward until it met with protests from environmental stewardship advocates such as First Nations representatives and the Department of Environment and Labor of Newfoundland and Labrador. Those resistant to the bottling plant

as efficiently (and therefore profitably) as commercial firms. Those who support the idea of private ownership suggest that if we treated water like a commodity, competition would incentivize efficiency and benefit both producer and consumer. We cannot ignore the fact that the global supply of drinkable water is shrinking even as the global population expands. Water management practices, therefore, must improve, and may benefit from competitive management strategies. Any shifts in the status of water as a free resource available to all citizens, to a privately owned yet necessary product, must consider the likelihood of sustainable feared that large-scale water removal and and ethical water management practices transport would have far-reaching effects under profit-based businesses, which often on both aquatic and terrestrial ecosystems, operate beyond state control. especially since the sheer amount of water removed would exceed the rate at which These abstract arguments may suggest the basin could naturally replenish itself that, aside from the presence of bottled each year.4 The local economy would again water in our stores, issues of water privatfind itself without a sustainable industry, ization remain geographically distant conhowever positive the temporary economic cerns. This is untrue. After being rejected benefits, as McCurdy Enterprises would ul- by several other communities in Califortimately drain the basin dry. nia and Oregon, Nestlé Corporation, the world’s largest food and beverage manEnvironmental advocacy groups also ufacturer, has been worked diligently to feared that the precedent of turning wa- set up a large-scale water bottling plant in ter into globally traded commodity could the town of Cascade Locks, less than 100 interfere with the rights of local govern- miles from Portland, Oregon. Located in ments to control access to necessary water the Columbia Gorge, the town of Cascade resources. This fear was quickly justified. Locks is economically struggling. Much During the same timespan as the protests like the small town in Newfoundland, its against McCurdy Enterprises, Snowcap traditional industry has evaporated and Water Ltd., a Canadian company that had the creation of water bottling jobs could paired with the investment group Sun Belt, provide economic stability. Nestlé’s prisued the Federal Government of Canada mary argument for its new plant is the 53 when they were denied permission to go jobs it would provide to local residents. forward with their own large-scale water In 2011, researchers Kristen Sheeran and bottling and export project. The legal basis Feng Zhou examined the Nestlé proposal for their lawsuit centered on Chapter 11 in depth.7 They found that, in return for of the NAFTA trade agreement, which the these 53 jobs, primarily in construction and Canadian government had signed in 1992. maintenance, Nestlé would gain private Sun Belt argued that according to the NAF- ownership over Oregon water rights and TA agreement, water could be considered a the ability to drain nearly 200 million galcommodity rather than a public property, lons of water per year from Oregon’s watherefore the Canadian government had tershed and groundwater reserves.7 This no legal right to block investors from their almost incomprehensible amount would projected profits.4 The case, which is still result in the loss of 225 gallons of water, pending, indicates the sheer political power per minute, of currently public water supof these multi-national for-profit agencies plies. who seek to benefit from human thirst.

The annual loss of 200 million gallons of Despite these dramatic examples of water would affect both biotic and abiotic clashing environmental and business in- aspects of Oregon’s habitats. The plant’s terests, valid arguments for the privatiza- detrimental operations would strain Ortion of water management exist as well. egon’s already shrinking groundwater Public utilities, because they lack compe- supply. The most recent report by the U.S. tition, may be less motivated to function Geological Survey Groundwater Resource

The World Health Organization estimates that, by 2025, more than one half of the global population will not have access to safe drinking water.

Experts have proven that pollutants created by water bottling operations are detrimental to global health. The process of packaging and transporting water is tremendously resource-intensive. Some research indicates that current production methods require three liters of water to produce one liter of bottled water.7 Estimates calculate that the fossil fuel required not only for the production of the plastic bottles, but also for global transport to distribution centers, with the ultimate destination of our stores and cafeterias, reaches more than 17 million barrels of oil a year.3 The United States alone produces almost 29 billion disposable water bottles annually.

Statistics have shown that only 15% of water bottles are recycled globally, meaning that 85% of water bottles end up, at best, in landfills. Many are simply incinerated, releasing more toxic chemicals into the air.3 Considering that those with access to safe tap water consume the lion’s share of bottled water, this mostly unnecessary environmental cost is staggering.

Beyond the environmental consequences of water bottling and distribution, the legal precedents for turning public water rights over to for-profit agencies have historically caused damage to local communities and governments. Canada has clearly demonstrated the dangers of treating water as a business commodity. University of Toronto researchers Keith Hipel, Obeidi Amer, Fang Liping and Mark Kilgaur examine the multi-faceted aspects of water privatization in their article on the politics of Canadian water management.4 In 1995, McCurdy Enterprises proposed a large-scale water export project at Gilbourne Lake, a water basin located in a wilderness area on the coast of Newfoundland. The company stated that it would pump a maximum of 80 million gallons of water each week from the lake, shipping this “blue gold” to foreign markets in China and the Middle East.4 The organization appealed to local agencies by claiming that their operation would benefit the local economy, which had lost its traditional fishing industry and was suffering from an economic recession. The bottling plant propos-

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Program measured changes in groundwater levels from 1984-2009. The report found that groundwater levels had declined in 85% of all wells, with levels decreasing by 25 feet in 30% of wells in the region.6 The Nestlé plant would draw a portion of its annual 200 million gallons from these already declining wells. The bottling plant would also drain water from terrestrial and aquatic habitats that rely upon the regular flow of water to thrive.

Public Domain

According to Nestlé’s proposal, the majority of water bottled by the company would come from freshwater streams, some of which feed Oregon hatcheries currently supporting endangered fish species.

Responding to protests about the reallocation of water from fish to bottle, Nestlé proposed shipping in water taken from local wells to supply the hatchery.7 Nestlé argues that this solution works, and that its research has found that the fish are unaffected. Because Nestlé itself oversaw the study, the validity of the food giant’s findings are questionable at best. In a public hearing with the Oregon Department of

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Fish and Wildlife (a surprising supporter of the Nestlé plant), many protested the inaccuracy of the findings. A key critique lay in the narrow scope of the study. Although a majority of fish in the hatchery, such as the endangered steelhead and salmon, live in both fresh and saltwater during their life cycle, the test only looked at freshwater rainbow trout. These trout may better adapt to the warmer temperature and the increased sediment levels found in well water.5 Water management studies in the U.K. have concluded that any valid effort to maintain the health of a local population, specifically that of fish, must be “approached by applying the standards of the most sensitive.”1 In order to accurately determine the success of their water-replacement strategy, Nestlé would need to test their hypothesis on the actual fish residing in the hatcheries.

The Nestlé bottling plant would adversely affect the economic health of Oregon’s Columbia Gorge. Peak production would require 200 semi-trucks daily to transport water and supplies up Oregon’s interstate I-84.7 In addition to releasing CO2 into the atmosphere, this heavy traffic would negatively affect a tourist economy reliant on the scenic view of the Columbia Gorge. Dave Palais, a representative for Nestlé, has publicly stated that the company will not reimburse the state for the additional road wear this convoy of semitrucks will cause, resulting in increased road maintenance costs falling to local taxpayers.7 Water privatization would therefore not only draw water from Oregon’s natural habitats, but would also divert local tax dollars from other public services.

When one considers the increased state costs of maintaining Oregon’s transportation infrastructure, as well as the individual cost of buying back formerly public water resources, possibly under the name

of “Arrowhead,” the arrangement clearly falls short. Nestlé’s efforts to tap into Oregon’s resources represent only one of many of such global water privatization efforts. In many ways Oregonians are fortunate. Environmental watchdog groups and private citizens in many nations have far less ability to challenge governments and corporations seeking to profit from public resources.

Some water bottling companies, aware that consumers may question water-bottling practices, have actually begun to use decreasing access to clean drinking water as a marketing strategy. Volvic, a water brand that claims to donate some proceeds from water sales to water-focused charities, implies that your purchase helps poor African communities gain access to clean water.2 This sales pitch, an example of a popular form of environmental marketing referred to as “green-washing,” suggests that the consumer actually contributes to global health with their purchase. Whatever the emotional outcome, this marketing strategy does not diminish the waste produced by the water-bottling process.

While local organizations may actively monitor the activities of corporate entities like Nestlé, as well as the actions of elected officials and wildlife agencies, they mainly rely on volunteer effort. We, the public, must remain active advocates of public water rights. Only continued public engagement can maintain the health of our watersheds and legal rights to our own public resources. Two ways you can get involved in successful stewardship include contacting state representative and remaining informed of how our resources are managed. Another effective tool, our power as conscientious consumers, is even easier to wield. Global water shortages indicate a significant need for sustainable water management and consumption practices. How strongly we advocate for accessible water and environmental accountability will determine the health of this precious resource, and therefore the health of all living species. www

Frances Fagan is a sophomore in Silliman College double majoring in Ethnicity, Race, and Migration (ER&M)/Film and Media Studies.

Frances is particularly interested in the development and maintenance of technically efficient and culturally supportive spaces for refugee populations.

She can be contacted at frances.fagan@yale.edu.

YALE GLOBAL HEALTH REVIEW

CDC Global

INTERVIEW

JOANNA RADIN: A Historical Approach to Global Health

By Anabel Starosa

Professor Joanna Radin is an Assistant Professor of History of Medicine and History, and currently teaches a course called Historical Perspectives on Global Health. Today, the term global health describes a crucial, widespread framework that brings together public health workers, philanthropists, economists, politicians, activists, and students worldwide. But global health did not simply spring up out of nowhere. Historical legacies, both good and bad, dictate our current notions and practices of global health. So, how did we get here? I sat down with Professor Radin to find out.

First, how did you become interested in the history of medicine, and specifically, the history of global health?

The short answer is that I’ve always been interested in ideas about risk – relations of risk of public health and how people who have expertise about science and medicine share that expertise with the people who are affected. Before getting my PhD, I worked for a consultancy that helped the CDC to do media relations. My job, essentially, was to make scientific information legible to people who weren’t epidemiologists or might not be inclined to think in terms of statistics. This type of work made me realize that there was potential in learning about the history of the entire apparatus that enables us to [understand] health and disease. I actually didn’t plan to become a professor, I just wanted to be able to do the type of work I had been doing, but more effectively. But, then, I went to graduate school for History and Sociology of Science and I fell in love with ideas and with teaching... and here I am.

What did you focus on while you were in graduate school?

I wrote my dissertation about blood samples; I got really interested in the kinds of invisible infrastructures that make it pos-

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sible for scientists to learn about health, identity and disease. I realized that there were massive collections of blood samples, and was interested in the way that knowledge, risk, and power accrued through science by looking at this resource that isn’t a specific disease or a particular place. Anyone who has worked in a biomedical lab has dealt with some sort of biospecimen—a tissue that originally came from a person or non-human animal—and I wanted to think about what it meant to collect such material and preserve it for the future and what kinds of problems and opportunities that created.

Did you learn anything interesting from the blood samples?

In doing this research, I was looking at the WHO’s involvement in creating the infrastructure for maintaining the collections of blood as early as the 1950s so that they could go back to these blood samples if a new disease emerged and try to understand it.

They maintained collections for both known and unknown purposes – people knew that there would be unpredictable problems in the future, so they wanted to have a system that would let them be responsive.

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I’m not interested so much in giving students dates and places but in helping them appreciate how they can use history to cultivate a sensibility – a way of asking the question ‘what does it mean to help’ and examining their own motivations for wanting to help.

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How did you get involved with global health?

I got interested in global health in doing this work and looking at the WHO’s involvement because I started to appreciate how the creation of this type of infrastructure enabled an international body that was created after WWII to be responsible for detecting and curtailing

Professor Joanna Radin, Assistant Professor of History of Medicine and History.

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epidemics whose impacts would transcend national borders.

and start realizing that maybe New Haven is the global to them.

What led you to teach your Historical Perspectives on Global Health course?

What are some historical moments that have influenced global health?

Colonialism isn’t a moment, but it’s not possible to understand global health without having an appreciation for colonialism and for missionary medicine, both of which continue today. The inter-war period after World War I, which saw the creation of the League of Nations and its health office, set a precedent for the WHO, which was created after WWII. The rise of pharmaceuticals, of ideas of modernization following the Cold War, and the realization that chronic diseases, not just infectious disease, can be massive problems are all important.

When I came to Yale, I knew there was enormous student interest in global health on campus and I knew the classes that were being offered were really trying to help the students become practitioners of global health; how to hit the ground running. I thought that one thing I could provide as a historian of science and medicine was a class that could put those experiences into context and give students a way to think about ‘what is global health, why do we have it, where did it come from, and what does it mean to engage with it?’

What do you hope that students will gain from studying the history of global health?

I’m trying to give students critical tools for making sense of their own experiences. I’m not interested so much in giving students dates and places but in helping them appreciate how they can use history to cultivate a sensibility – a way of asking the question ‘what does it mean to help’ and examining their own motivations for wanting to help.

Why might people be driven toward global health?

Part of the appeal of global health is in the recognition that there are problems that are very severe and need to be conceived of on a global scale. I think most people feel compelled to help but it’s hard to know what to do and how to evaluate the various ways you can do it. That’s why [in class] we try to think about things like humanitarianism as a historical concept, about what the nation-state is, and colonialism, and how each of these has facilitated some of the uneven relations in global health today.

What outcomes do you hope will result from this class?

It’s my hope that students who take this class or look at the history of global health think differently about what it means to participate in global health and maybe even gain insight that helps them think differently about other enterprises they’re engaged with. For example, maybe they’ll think differently about New Haven. Maybe they were attracted to some of the exotic dimensions of health overseas but they can use these lessons

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It's important for us to examine our motivations and think: Do we want to go far away to help people that we don't even know so that we can say we went far away to help people we don't know or are we willing to commit to people who live in our own community?

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What kinds of organizations have shaped global health?

The World Health Organization and its different investments at different times in primary healthcare versus vertical disease eradication campaigns have shaped global health’s trajectory. The Rockefeller Foundation’s role in the early 20th century is the first example of the kind of philanthropy that people like Bill Gates build and model their own approaches off of today. The creation of World Bank and the financialization of health is also important. The creation of large-scale international bodies that control and redirect funds and political

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CDC Global

authority really shapes experiences of global health.

Are these large-scale controlling bodies beneficial or detrimental to global health?

It’s not really possible to answer that question in that way. We always can benefit from multiple different registers of intervention and any one person or organization with too much power is something that I, personally, think should be regarded critically.

What is an instance in which we should be critical?

Philanthropy is incredibly important, but we should be careful before we celebrate someone’s generosity – we should ask what is motivating how his or her money is being distributed. For example, Bill Gates has as much power, if not more, in the WHO as some individual nations. It is an incredible phenomenon that he has dedicated his wealth to these health, but also worth noting that his original reason for getting involved with

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global health had to do with interests in population control, which is not often recognized.

Why has Gates been criticized in the media?

Critics of someone like Gates have dealt with his focus on technology – technology can be good, but sometimes it’s not enough. I think Gates is starting to become attentive to this; he’s starting to read history! He’s also starting to realize that these problems are not as simple to solve as he thought they would be.

Even if there is no definite “good” or “bad” in regards to health, what should we be wary of?

I don’t think there’s a set good and bad, but what I do think is bad is when people set out to help but they’re really trying to help themselves. It’s important for us to examine our motivations and think: Do we want to go far away to help people that we don’t even know so that we can say we went far away to help people we don’t know or are we willing to commit

to people who live in our own community? Are we willing to start there? I hope this class helps people figure out how to confront what it means and has meant to help others. www

Anabel Starosta is a junior in Morse College majoring in History of Science, Medicine and Public Health. She hopes to be a doctor and also work at the intersection of medicine and public health. She is from South Florida and her parents are from Mexico and Venezuela, making her specifically interested in health inequities in Latin America. In her free time, she likes to paint, dance, and travel.

She can be contacted at anabel.starosta@yale. edu

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CHINA:

HEALTH POLICY

By Victoria Loo

Saying Goodbye to the Aging Population and One Child Policy

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ver the past decade, the demographic of the world population has always been unbalanced with young children outnumbering elderly people. However, the proportion of the world’s population over 60 years of age is rapidly growing, and between 2015 and 2050 it will reach a new high of nearly 714 million of the world population compared to 601 million today.1 It is expected that by the year 2020, people aged 60 years and older will surpass the proportion of children younger than 5 years by 2.5 times.2 Currently, China contains a large portion of the world population over the age of 60 years. The issue of aging in China within the next years will soon escalate, and with its previous One Child Policy, China does not have a large population of youth.

As a result, China has recently officially eliminated their onechild policy that has been known as their “Great Wall of family planning” for the past 35 years.3 The elimination of this policy is thought to be a response to China’s aging population, and an attempt to balance the proportion of the population. By the year 2050, 24% of China’s population is expected to be aged 65 or above, which is approximately 331 million people.2 However, due to the previous one child policy, China’s population of individuals aged 20-34 is projected to be 16% of the population.4 This will create a

worrisome problem, as China’s elderly population will soon be dependent on the working population. In addition, China may struggle to support the burden of healthcare and social services required by this large percentage of their population.

China’s decision to change the policy indicates a growing worry about its new demographic crisis. By 2030, China will be the world’s most aged society.3 With a rapidly aging population comes the need for a long-term economic plan. As a result of the past 20year one child policy, China’s labor force has increasingly shrunk due to the small percentage of a younger population.5 This shortage of labor can cause a drop in production, which in turn could possibly lead to an increase in the average wage level. In doing so, China’s competitiveness in the labor-intensive industries could fall.

The consequences of China’s aging population can lead to huge implications on their global status and overall national progress.

The challenge China must now overcome is to keep its colossal aging population healthy, active, productive, and working in order to ensure the productivity of their population.

Healthcare systems must be equipped to provide the necessary health services when populations age and take on different health

Lindsay Maizland

The elderly represent a large proportion of China’s population, which will prove a significant challenge in years to come.

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conditions and diseases. A population with more people over the age of 60 years can also mean more people experiencing a decrease in physical and mental capacity as a part of the process of aging.6 The risk of disease and poor health statuses among the population becomes greater as the elderly are more susceptible to common conditions such as body pains, chronic diseases, diabetes, depression, and dementia. Additionally, many elderly fall into indiscrete disease health states called geriatric syndromes that are a result of factors such as frailty, urinary incontinence, falls, delirium and pressure ulcers. Many nations struggle to ensure that their healthcare systems can sustain and treat their new aging population.

By 2030, China will be the world's most aged society

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One crucial step needed to meet the growing healthcare needs of an elderly population is the implementation of better systems of long-term care. This can be done by establishing the foundations necessary for a system of long-term care, maintaining a sustainable and appropriately trained healthcare workforce, and ensuring the quality of long-term care. A major obstacle that China may face is a lack of resources and a sustainable healthcare system framework to respond to geriatric diseases. These diseases, if left untreated, can have significant social and economic implications on China, including additional medical costs if new treatments should develop, social costs of unproductivity, and later costs of informal care.

An area in which China can focus its attention is the current pension fund that was put in place in 1997. Currently this pension plan requires employers to contribute 20 percent of each worker’s wages to social security, while workers must contribute 8 percent of their wages to an individual retirement account. Despite these requirements, the pension reserve level is too low to support the aging population because it only accounts for 2 percent of China’s

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annual GDP. Therefore, only about onethird of China’s elderly population receives monthly payments from the pension.5 In addition, the benefit level for social services and facilities geared toward the elderly are low and rare. Without government aid to help provide care for the elderly, a large portion of China’s population will be left to find care on its own. Nearly 23 percent of China’s elderly currently cannot fully take care of themselves and require various health services in order to maintain their functionality.5 Therefore, China’s government must acknowledge the growing issue they have at hand. Improvement for social services and programs for the elderly need to be prioritized to ensure that care is given to a large, and soon vulnerable, portion of their population.

One way that China can reduce the increase of their shrinking labor force is to encourage their older population to continue to be active, productive workers in society.

In fact there have been many occurrences when the older population has provided tremendous benefits and sacrifices to help the younger population. The benefits that come with a growing older population can be beneficial. Older people can still provide significant contributions to their families and societies. For example, in many families the main caretakers of children are the oldest members of the family. The elderly can also take part in activities or services that may require time that working individuals may not be able to do. If opportunities are provided for older generations to continue to contribute to society’s progress, then perhaps China can lessen the burden of their disproportionate population.

For this reason, one step in the right direction can be to support and embrace older workers. This may require the development of training programs and learning opportunities to see what skills are often overlooked among older citizens, but can still positively impact society. If older people are found to be in poor health or marginalized from participation in society, then their contributions can be greatly undermined.7 Diminishing health among the elderly too often leads to loss of independence and productivity, which can later create an unnecessary burden on individuals, families, and society. The right to the best possible healthcare should not diminish as we age, just as access to the best healthcare should not be prevented from the elderly as a result of misconceptions and discrimination towards aging.

As China works toward addressing their aging population, it must keep in mind that in order to continue to benefit from the contributions provided by their older citizens, those elderly need to remain in good health. Therefore quality healthcare must be provided along with available social services. Since life expectancy will continue to increase over generations, more sustainable long-term systems of care should be maintained to ensure care is continuously provided throughout an individual’s lifetime. In doing so, a source of productivity among the elderly can continue to help China’s society and economy thrive.

China has already taken the first step toward addressing their aging population by eliminating the one child policy. Now China must direct its attention to maintaining the productivity of their current population composed of a large portion of senior citizens until their disproportionate demographic straightens out. It will take many years before the size of the younger generation catches up to the size of the older generation. Until then, China’s elderly will play a large role in shaping the country’s coming years, and will influence China’s status within the global context. While the youth may be commonly referred to as the “future,” the elderly will shape what this future will look like in the coming decade.

However, social stigma regarding the elderly often acts as an impediment to the continued involvement of older individuals in society. Many stereotypes wrongfully characterize the elderly, which can lead to harmful marginalization within societies.

One example is enforced retirements, and viewing the elderly as less valuable contributions to the workforce and society. A term for these negative attitudes toward elders can be described as “ageism”, which can lead to discrimination against individuals or groups because of their age. The formulation of these attitudes that devalues the worth of the elderly creates a social divider between the young and the old. As a www result, many elderly may find themselves prevented from fully participating in social, Victoria Loo is a sophomore in Morse majoring political, economic, cultural, spiritual, civic, in Political Science and Economics. and other activities to which they can bring value and knowledge.

She can be contacted at victoria.loo@yale.edu.

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ZIKA:

FEATURE ARTICLE

WHAT HISTORY CAN TELL US ABOUT THE CURRENT EPIDEMIC Learning from the Rubella Epidemic in the 1960s

BY ELI RAMI

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26 Wikimedia

Wikimedia Commons

Aedes aegypti, the mosquito that carries the Zika virus.

Z

IKV, more commonly known as the Zika virus, has quickly evolved from a little-researched virus into a global public health threat. Virologists first discovered the pathogen during the late 1940s in a species of monkey that inhabits Uganda’s Zika forest. For decades, scientists believed that ZIKV was a mosquito-borne virus that could only be transmitted to monkeys and mice.1 Even after that theory was disproven, prior to 2007, a total of only fourteen cases of ZIKV in humans had been documented.2 As a result of Zika’s low infection rates in humans, research on the virus remained virtually nonexistent for decades.

Today, with a ZIKV epidemic raging in the Americas, over 1.5 million cases have occurred in Brazil alone. The virus most likely arrived in the Americas during the 2014 World Cup, carried by a visitor from a region such as Africa or the South Pacific, in which the virus is endemic.3 Zika had never before traveled to the Americas, so individuals in the region had not acquired immunity to the disease. Their vulnerability to the virus has allowed it to spread rapidly. For most individuals, ZIKV infection leads to relatively harmless symptoms: a slight fever, a headache, and muscle pain, all of which last for a few days and easily go away with rest. Only one in five individuals infected with the virus become symptomatic. For women, however, the disease has transformed the normally exciting process of pregnancy into a dangerous guessing game—one that can quickly transform into a nightmare. The Zika virus has

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been determined to cause microcephaly, a disorder in which infants are born with abnormally small heads. Microcephaly reduces life expectancy and causes severe intellectual disability, difficulties with movement and balance, hearing loss, vision problems, and speech problems. The microcephaly epidemic has developed alongside the ZIKV one, with 2,782 cases of microcephaly in 2015 compared to only 147 in 2014.1 The birth defects of children born to Zika-infected mothers have inspired several Latin American governments and public health agencies, most notably those of El Salvador, Colombia and Jamaica, to advise women to delay childbirth for two to three years.

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For women, Zika has transformed the normally exciting process of pregnancy into a dangerous guessing game—one that can quickly transform into a nightmare.

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While Zika may have found itself a new home in the Americas, the history of one long-forgotten epidemic, which occurred over fifty years ago in the United States, could inform

YALE GLOBAL HEALTH REVIEW

our way of thinking about the virus terrorizing Latin America today. Rubella, an airborne disease that has been all but eradicated in the Americas, once devastated our country. Between 1964 and 1965 alone, over 12.5 million cases of rubella emerged across the United States.

Like Zika, rubella’s primary symptoms are quite mild in the general population.

Most symptomatic individuals develop a mild fever, respiratory problems, and a red-colored rash that begins on the face and spreads downward over the body. The most dangerous effect of rubella, however, attacks the very population that is devastated by the Zika virus: pregnant women. These women experience a condition known as Congenital Rubella Syndrome (CRS), in which the rubella rubivirus passes from mother to fetus. When a woman contracts rubella early on in her pregnancy, the likelihood of infecting her fetus rises to 90%.4

Between 1964 and 1965 alone, over 12.5 million cases of rubella emerged across the United States.

In the devastating rubella rampage of the 1960s, one that can now be called “the forgotten epidemic,” over twenty thousand children were born with birth defects such as blindness, deafness, and heart deformities. During the epidemic, the majority of infected newborns displayed signs of mental retardation.

Many infants affected with CRS were stillborn or died shortly after birth.

During the height of the epidemic, images of children with deformed bodies circulated throughout print and television media. The American public learned to recognize images of spotted infants with “blueberry muffin rash,” dark greyish spots under the skin that appear as a result of CRS. Infected children also held the risk of propagating the virus, often to their own or other mothers. Most infected women acquired the virus from affected children with whom they interacted. Children became both the victims and the threat. While infected children posed significant danger to women during the epidemic, they simply could not be avoided. With women mainly employed as school teachers, retail clerks, and nurses—those professions deemed

“suitable” for them at the time—interacting with children often represented a significant aspect of daily life.

During the rubella epidemic, children born with disabilities such as blindness, deafness and mental retardation faced severe social stigma, so women often chose to not bring their babies into the world. Many women infected with rubella were encouraged to abort their children due to the incredibly high risk of birth defects. During the height of the epidemic, over eleven thousand abortions occurred, many of them performed after women were informed of the risks regarding rubella exposure during pregnancy. 2 Miscarriages also occurred spontaneously as a result of maternal rubella infection. State governments strongly encouraged parents to place their disabled, CRS infected children in special, state-run institutions. Not only did the disabled children face dire living conditions within these institutions, but they also struggled later in life. Reports of abuse and unsanitary conditions circulated freely within the American public by the end of the decade.

In the devastating rubella rampage of the 1960s, one that can now be called “the forgotten epidemic,” over twenty thousand children were born with birth defects such as blindness, deafness, and heart deformities.

Wikimedia Commons

Mosquito eradication in Votuporanga, São Paulo, Brazil.

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Wikimedia Commons

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The rubella epidemic of the mid-sixties shaped reproductive laws in the United States. Prior to the epidemic, the public viewed abortion as a crime committed by the Mafia, prostitutes, illegal drug users, and gamblers.5 Furthermore, popular accounts of abortion in magazine and newspaper stories emphasized the risk of women dying. Women who did seek abortions despite legal restrictions discussed their decision only with close family and friends. The rubella epidemic, however, dramatically changed the national discourse on abortion. Physicians faced with the alarming rise of children born with birth defects accepted maternal rubella as a justification for legal therapeutic abortion, as standard medical textbooks at the time endorsed abortion if parents did not want to “… assume the obvious risks…” of having a child born with CRS.6 The epidemic also provoked public mainstream media to discuss the decision to have an abortion, and determine that it belonged to the individual women threatened by the epidemic.

rican American women infected with maternal rubella in the 1960s struggled to access therapeutic abortions. Black women lived in a society that regarded them and their race as negative, criminal and deceitful. While white middle-class suburban women stood at the forefront of the epidemic, medical textbooks at the time did not recognize rubella infection in nonwhite individuals, with one leading pediatric textbook stating, “its identification in Negroes is almost impossible.”6 Women of color were also far less likely to have a doctor who had established relationships with the physicians and hospitals that provided therapeutic abortions—let alone health insurance. As a result, very few nonwhite women were ever deemed “qualified” for a therapeutic abortion; they could not gain the trust of the medical establishment because the medical community questioned their respectability as mothers. 7

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El Salvador and Venezuela) have high rates of poverty among their overall populations. In El Salvador and Honduras, close to forty or sixty percent of the population, respectively, lives below the international poverty line of less than $1.25 per day.8 In El Salvador, where the government has advised women to delay childbirth for two to three years, laws governing abortion are the strictest in the world. Since 1998, the government has restricted abortion in all circumstances, even in cases where pregnancy poses a risk to the life of the mother.9 In many Zika-affected countries, birth control poses a financial burden so significant as to be effectively insurmountable for much of the population. These barriers to healthcare leave many women in Latin America defenseless against the greatest danger of the epidemic: severe birth defects in their children.

In both the rubella epidemic of the 1960s and the ZIKV epidemic of today, children, the most severely affected victims, represent the dangers and unknowns of new diseases. Microcephaly-infected infants, with their clearly visible shrunken heads, have become the face of the current ZIKV epidemic. They grace the news in a manner reminiscent of “blueberry muffin rash.” Both epidemics raise questions of reproductive rights, the social effects of disability, and the long-term treatment of disabled children in larger society. In both epidemics, the burden of disease falls primarily on women and their unborn children. The inequalities of the past strongly echo the issues of the present; many women still lack access to proper reproductive care. Many barriers to necessary healthcare could be reduced through reforms in public health policy and legislation. While ZIKV may be a new and mysterious disease, we must remember that this situation has manifested within our society before, and ensure that the disabled children of the present are not marginalized like those of the past.

The inequalities of the past strongly echo the issues of the present; many women still lack access to proper reproductive care.

This discourse, however, was not universal. Rubella overwhelmingly affected white, suburban, middle class women. These women presented abortion as a woman’s decision, one to be made in consultation with her doctor and her husband. They received respectful attention from the media, which glorified their motherhood and the plight of their rubella-infected children. At the same time, Black and Latina mothers were demonized—blamed for crime, poverty, and overpopulation during the time of a serious epidemic.6 Women infected with maternal rubella advocated for their right to decide whether or not to abort their rubella-infected fetuses, despite the hoops they had to jump through, mostly instituted by men, before obtaining a safe, legal medical abortion. During the 1960s, many hospitals housed special ethics committees that decided whether or not abortions were medically necessary on a case-by-case basis. 6 While therapeutic abortions in the case of maternal rubella passed through the committees with relative ease, not all cases were given equal treatment. Access to therapeutic abortion during the epidemic, almost a decade before the decriminalization of abortion in the Roe vs. Wade decision in 1973, proved exceptionally difficult for the majority of women of color. Af-

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Today, children born with Zika-induced microcephaly face several difficulties. Despite medical advances, many of the complications brought on by microcephaly have no cure or treatment.

Before the advent of Zika, microcephaly was an extremely rare condition. As a result, current medical literature on the disorder leaves much to be desired.

Children born with microcephaly today face severe intellectual disability, neurological defects and seizure disorders.

For example, the face of a child with microcephaly develops a receding forehead because it continues to grow at a normal rate while the head retains its shrunken size. In addition, microcephaly often causes low body weight and dwarfism.

Another product of microcephaly, reduced motor skills, can lead to a wide variety of conditions ranging from clumsiness to paralysis.

At the same time, the microcephaly epidemic raises questions of economics and reproduction. The majority of individuals affected by the epidemic live in 24 different countries in Latin America. Countries with the highest rates of suspected infection (Brazil, Honduras,

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www

Eli is a freshman in Ezra Stiles college. His major is undecided.

He can be contacted at elijah.rami@yale.edu.

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PHOTOGRAPHY

BRAZIL

By Harland Dahl

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lthough most cases remain concentrated in northeastern and southeastern Brazil, the distribution of the Zika virus continues to grow throughout the country. As of February, Brazil was one of thirty countries in the Americas facing a Zika threat. Since the outbreak of Zika virus in Brazil, the disease has been linked to microcephaly, a condition in which an infant is born with an abnormally small head, usually as a result of stunted brain development.

Although Brazil has undergone serious health system reform over the past two decades, many of these reforms have yet to reach Brazil's indigenous populations living in the Amazon basin. Indigenous peoples make up 900,000 of Brazil's 198 million people. As a poor, rural, and underrepresented portion of the Brazilian population, indigenous communities often face shortages of health professionals, medication, and technical medical equipment. These deficiencies make the prospect of Zika in indigenous populations particularly threatening, as treatment and control of the disease will be particularly challenging without sufficient access to care and treatment.

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Harland Dahl is a sophomore in Pierson College. She is a Political Science major and is from San Luis Obispo, California.

She can be contacted at harland.dahl@yale.edu.

RESEARCH & INNOVATION

CANCER:

Risks Associated with Red and Processed Meats

By Rebecca Slutsky

Steven Depolo

I

t’s a tough time for lovers of hot dogs, bacon and beef jerky.

After twenty years of research, the World Health Organization’s cancer research group recently announced that there is significant evidence that processed meat is a carcinogen that can cause colorectal cancer in humans.1 In addition, the research concluded that there was strong, but still limited, evidence of a connection between eating unprocessed red meat and colorectal cancer. The group’s data also showed a link between eating processed meat and an increased risk of developing stomach cancer, as well as, according to the journal Lancet Oncology, an association between red meat and cancers of the pancreas and prostate.2 The suspected link between red meat and cancer has been mounting for years, but this concrete evidence is now leaving many consumers wondering what foods are safe to eat and whether we all need to become vegetarians or vegans.

What is the World Health Organization (WHO) and why are they involved with this research? WHO is an agency of the United Nations, headquartered in Geneva, Switzerland.

Its mission is to improve global public health by preventing diseases through research and dissemination of information to governments around the world. According to WHO, red meat and processed meat need to be classified separately in terms of cancer risk. Red meat refers to all muscle meat from mammals, including beef, veal, pork, and lamb. It also includes mutton, horse, and goat, which are consumed throughout the world.3 Processed meat refers to meat that is not sold fresh, meaning

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meat that has been transformed through salting, smoking, curing, fermentation, or adding chemical preservatives to enhance flavor or improve preservation.4 These may include cold cuts, ham, pepperoni, corned beef, sausages and canned meat. Furthermore, hamburgers and minced meat are only considered processed meat if they have been preserved with salt or chemical additives.5 The WHO committee that issued the new report on October 26, 2015 was the International Agency for Research on Cancer (IARC). This group focuses their research on environmental and lifestyle factors that may contribute to cancer. For the past 45 years, the group has evaluated more than 900 different factors as part of its “Monographs” program, assigning each factor to one of five different classification groups based on the probability of it causing cancer. About 120 of these factors have been placed in the agency’s Group 1 category, meaning the factor is carcinogenic to humans. The other groups range in classification from ‘probably carcinogenic’ (Group 2), ‘possibly carcinogenic’ (Group 3), ‘not classifiable’ (Group 4) and ‘probably not carcinogenic’ (Group 5). 3 These rankings demonstrate the IARC’s confidence that a factor causes cancer, but not how hazardous that factor is in causing cancer. Further, the IARC does not make specific health recommendations. Instead, the IARC Monographs are used to guide policies both nationally and internationally in order to minimize cancer risks. For example, governments may choose to include the cancer hazards of a targeted factor in their dietary guidelines. 1

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The IARC committee, which consisted of 22 public health and cancer agencies from 10 countries, spent two years reviewing and evaluating 800 studies conducted over the past 20 years that investigated associations of more than 12 types of cancer with the consumption of processed or unprocessed red meat in many countries with diverse diets. Some of the studies provided data on both types of meat. More than 700 epidemiological studies provided data on red meat and over 400 epidemiological studies provided data on processed meat. 6 After thoroughly evaluating these studies, the IARC classified the consumption of red meat as probably carcinogenic to humans (Group 2).7 This link was observed mainly for colorectal cancer, but associations were also seen for pancreatic and prostate cancer. Even more alarmingly, processed meat was classified in Group 1 as carcinogenic to humans. This classification was based on sufficient evidence in humans that eating processed meat is linked to colorectal cancer.8 An association with stomach cancer was also seen but the evidence was not conclusive. While other factors placed in Group 1 include alcohol, asbestos and tobacco, they do not all share the same hazardous level of risk. The cancer risk of asbestos and tobacco is much greater than the risk associated with eating processed meat.1 However all factors placed in Group 1 are concluded to be carcinogenic to humans. Therefore, the risk of eating processed meat is small but real. This reality is important for worldwide public health because processed and unprocessed meat consumption is increasing not only in underprivileged communities in the United States, who tend to buy “cheaper” meats, but also in low- and middle-income countries around the world.

The WHO report has identified some of the ways red meat and processed meat may increase cancer risk, although research continues in order to fully understand the specific epidemiologic

connection. The main culprits appear to be certain chemicals found in the meat itself. Red meat contains the chemical haem, which is part of the red pigment in the blood of the meat. Haem is broken down in our intestines to create a series of chemicals called N-nitroso compounds.4 These compounds damage the lining of the colon, so that the cells in the lining have to replicate more in order to heal. This increased cell replication can increase the risk of errors developing in the cells’ DNA that can possibly lead to cancerous cells forming in the lining of the colon. 7 Further, in order to process meat, nitrites are used as preservatives to prevent bacterial growth and as coloring agents. However, nitrites can form the N-nitroso compounds, which are cancer-causing agents.5 Cooking meat at high temperatures, such as grilling, frying or broiling, can form two cancer promoting chemicals, heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs). PAHs are specifically found in the char on the outside of the meat.1

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There is significant evidence that processed meat is a carcinogen that can cause colorectal cancer in humans.

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Just how big is your risk of cancer if you eat processed meats (independent from other environmental and lifestyle habits)? According to an independent academic research group called The Global Burden of Disease Project, about 34,000 cancer deaths per year worldwide are caused by diets high in processed meat.

Further, the group estimates that diets high in red meat could cause at least 50,000 cancer deaths per year around the world.1 To give some perspective, there

are about 1 million cancer deaths worldwide each year from tobacco smoking and 600,000 people worldwide die each year from alcohol consumption.1 The WHO data indicates that a person who eats slightly less than 2 ounces of processed meat a day (a small hot dog or 2 slices of cold cut) is 18% more likely to develop colorectal cancer than another person who eats no processed meat.7 “For an individual, the risk of developing colorectal cancer because of their consumption of processed meat remains small, but this risk increases with the amount of meat consumed,” says Dr. Kurt Straif, Head of the IARC Monographs Program. Furthermore, “in view of the large number of people who consume processed meat, the global impact on cancer incidence is of public health importance.”6 There have been major debates over the WHO findings on the cancer link, including significant resistance from the meat industry on one hand, and from environmental groups on the other, who are calling for warning labels on processed meat. The National Cattlemen’s Beef Association (NCBA) believes the evidence does not support the link between meat and cancer. The NCBA asserts that it is not realistic to isolate a single food as a cancer-causing agent from an entire dietary pattern, especially as it is complicated by lifestyle and environmental factors. The NCBA believes the studies on red meat consumption and cancer are weak and, therefore, it is wrong to conclude that red meat is an independent cause of cancer. It is also critical of the IARC review process and accuses the group of secrecy, selective inclusion or exclusion of studies and an overly general interpretation of study results.9 Therefore, the meat industry continues to assert that its products are safe to eat as part of a balanced diet. On the other end of the spectrum, states like California, which has taken the lead in consumer-oriented initia-

— Quick Facts — • 34,000 cancer deaths per year worldwide are caused by diets high in processed meat • A person who eats slightly less than 2 ounces of processed meat a day (a small hot dog or 2 slices of cold cut) is 18% more likely to develop colorectal cancer than a person who eats no meat

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PleaseRomaineCalm

Meat being processed to create beef jerky.

tives, are evaluating the WHO results to determine whether to add red meat and processed meat to a cancer-alert list.

The inclusion of red meat and processed meat on the list could reduce consumer demand and hurt major producers and processing companies.

It could also encourage consumers diagnosed with colorectal cancer to sue the meat companies costing them billions of dollars and potentially bankrupting them. 10 Nevertheless, the environmental group, Center for Biological Diversity, believes that since WHO has put processed meat in the same category as cigarettes in terms of certain cancer risk, states need to come forward with public health warnings in the form of labels on meat packaging, signs, or menu notation

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where the meat is sold. Needless to say, the debate on both sides will continue in America and worldwide.

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Can a healthy diet still include meat and processed meat? Although the WHO report does not make dietary recommendations, the American Cancer Society Guidelines on Nutritional and Physical Activity and Cancer Prevention currently advises people “to limit how much processed meat and red meat they eat.” 3 Guidance from the American Institute for Cancer Research (AICR) includes specific amounts of meat in its dietary recommendations.

They recommend that people avoid eating processed meat, or reserve eating it to only a few special occasions per year.5 For red meat, the AICR recommendations call for eating no more than

Trying to eat smaller portions of red meat by adding more beans, fruit, vegetables and fish in your diet ar all healthy ways to lower risk of cancer.

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”

18 ounces of cooked red meat per week.

This equals six card-deck size portions, or 3-ounce servings, of red meat weekly. 4 It is important to remember that eating red meat in moderation is fine as it can be a good source of nutrients including protein, iron and zinc.8 In developing countries, governments and international regulatory agencies need to conduct risk assessments in order to balance the risks and benefits to its people. But trying to eat smaller portions of red meat by adding more beans, fruits, vegetables and fish in your diet are all healthy ways to lower risk of cancer. In fact, plant based foods contain polyphenols, which are determined to be dietary antioxidants that offer protection against the development of cancers.12 So remember to eat your vegetables. Tofu is still optional! www Rebecca Slutsky is a sophomore in Silliman College. Rebecca is an undeclared major.

Contact her at rebecca.slutsky@yale.edu.

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F

rom the first cases reported in the early 1980s up until today, the HIV/AIDS pandemic has emerged as one of the world’s foremost public health crises. In 2014, there were 36.9 million people living with HIV – an increase of 6.9 million from 29.8 million in 2001.1 Such a drastic global issue has understandably garnered a large amount of foreign intervention. Although international bodies such as the World Health Organization, the Global Fund, and UNAIDS have made many large-scale efforts to combat HIV/AIDS, the United States has been and is still by far the largest single national donor for global HIV/ AIDS intervention, committing over $4 billion in approved funding in 2010 alone.1 This funding comes primarily through the President’s Emergency Plan for AIDS Relief (PEPFAR), created in 2003 under George W. Bush’s administration. Ample evidence has shown the positive effects of such mass funding; PEPFAR funding has provided anti-retroviral treatment for over 3.9 million people and testing and counseling for over 40 million people in 2011 alone.1 Although PEPFAR has contributed significantly to the reduction of new HIV infections and HIV-related mortality, its policies and funding have also resulted in harmful consequences due to the inclusion of an anti-prostitution clause in the Global AIDS Act of 2003 that authorized PEPFAR. The anti-prostitution clause states: “no [PEPFAR] funds … may be used to provide

Wikimedia

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HIV/AIDS:

assistance to any group or organization that does not have a policy explicitly opposing prostitution.”2 This pledge to actively oppose prostitution was introduced and ratified by conservative policy-makers, many of whom were motivated by the traditional Christian view that prostitution is immoral. According to policy researchers, “the pledge has received strong support from activists and politicians in the United States who take a philosophical or religious stance against prostitution.”2 Although the Supreme Court ruled this clause unconstitutional in 2013 due to its violation of the First Amendment, the PEPFAR anti-prostitution pledge clearly illustrates the persistent focus on HIV/AIDS in moral terms. Rather than effectively reducing HIV transmission, the dominant approach of focusing on individual moral actions stigmatizes the very people who need the most help. Policymakers should instead shift to a more accurate view of the HIV pandemic as a collective, systemic issue that can be addressed through a community-based, holistic approach.

OPINION

The Limits of Moral Ideology

The ideological stance against prostitution views the HIV pandemic, especially among people in prostitution, as an accumulation of individual moral choices: individuals make the immoral decision to enter the sex trade or pay for sex, effectively choosing to put themselves at risk. With this mindset, PEPFAR and other ideo-

logical H I V

By Akielly Hu intervention schemes actively oppose and work to eradicate prostitution as a means of reducing HIV transmission. Viewing the issue of prostitution through this moral lens, however, fails to recognize the factors outside of individual control, such as widespread poverty and lack of employment opportunities. A study by the World Health Organization on prostitution in Asia emphasizes these outside pressures through its findings that “[m]ost of the people who sell sex in Asia do so because they are compelled by economic and social inequality and by terribly restricted life chances. Especially in the poorer countries of the region, they have no other realistic option.”3 Contrary to the PEPFAR and traditional HIV/AIDS policy perspective, these collective issues—not the immoral decisions of individuals—result in the extensive sex trade that drives HIV transmission. Elizabeth Pisani, an HIV/AIDS epidemiologist working in Indonesia, reiterates the need to remove moral judgment in relation to HIV/ AIDS. She argues that in many instances, the lucrative nature of the sex trade makes prostitution financially the best option for poor women: “In the factory, you earn 19 cents an hour. In the brothel, your take-home pay averages about US $3.15 an hour.

Two horrid jobs; one pays sixteen times more than the other.”4 Geetha Das, a woman in prostitution in Sonagachi, a red-light district in India, echoes the significant role of sys-

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temic factors such as poverty in driving the sex trade: "Would I have been able to pay for [my children’s] studies if I had stayed at home? Society should first look at itself before condemning us… Did anyone give us a good job? Society has failed people like me.”5 The experiences of Das and others like her illustrate the responsibility of the entire society, rather than individual decisions, in driving the issue of commercial sex trade and HIV transmission. The huge disparity between the wages of the limited employment opportunities (namely, factory work or prostitution) for women in impoverished communities further demonstrates that most people enter the sex trade out of economic necessity, rather than their own lack of morality. Rather than effectively reducing HIV transmission, the dominant approach of focusing on individual moral actions stigmatizes the very people who need the most help.

Viewing HIV transmission as an individual moral choice not only is inaccurate, but can also lead to disastrous consequences in policy implementation. Because of the anti-prostitution clause, many foreign HIV/ AIDS intervention projects previously funded by PEPFAR were forced to discontinue their efforts due to “lack of compliance.”

Such was the case with the Lotus Project, a non-governmental HIV/AIDS program in Svay Pak, a brothel district close to Phnom Penh, Cambodia. Located above and serving in conjunction with a Médecins Sans Frontières clinic, the Lotus Club offered workshops on health, social, and economic issues as well as other topics suggested by people in prostitution themselves. These included instruction on how to use the female condom, individual counseling, English lessons, and basic computing lessons.6 Facilitation of community participation and empowerment provided numerous qualitative benefits, such as strengthened relationships and increased support through workshops and discussions.7 This collective approach to combatting HIV proved extremely successful in increasing measures to prevent HIV transmission.

Despite its effectiveness, the Lotus Club was brought before the House Committee on International Relations in 2002 as a ‘Foreign Government Complicit in Human Trafficking’ due to failure to “comply” with the anti-prostitution pledge.6 The denunciation and eventual discontinuation of the Lotus Club is a clear example of the failure of the current approach to HIV/AIDS intervention. The most telling example of the ig-

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norance of systemic factors occurred when ideological U.S. policymakers condemned the Lotus Club staff for never having called the police. They viewed this inaction as support of prostitution, when in reality, corrupt Cambodian police often cracked down on brothels and demanded bribes in order to supplement their incomes.6 The lack of understanding of the corrupt police shows how focusing singularly on the moral ideology of prostitution fails to address actual systemic factors, such as corruption, that perpetuate prostitution.

Right or wrong, viewing prostitution through a moral lens also leads to ineffective HIV reduction. If people in prostitution are condemned and therefore unable to receive support from non-governmental organizations (NGOs), they lose access to tools such as counseling and condoms that can actually reduce HIV transmission. After the implementation of the anti-prostitution pledge, the Lotus Club struggled to maintain an effective relationship with the Svay Pak community. Out of fear of losing further funding, the Lotus Club was unable to provide its previous services that had benefitted the people in prostitution and prevented HIV transmission, and these difficulties eventually dismantled the entire project.

The Lotus Club case study shows how imposing a moral ideology on the NGO stifled its prior efforts to address the realities of the local systemic issues and the complex onthe-ground realities of HIV transmission.

Because the HIV pandemic results from of a web of systemic factors including poverty, lack of employment opportunities, and corruption, it requires a community-level, holistic intervention. One successful example of this approach is the Sonagachi Project, an empowerment HIV/AIDS intervention project in the red-light district of Calcutta, India. Along with promotion of condom usage and the establishment of free STD and healthcare clinics, Peer Outreach Workers gave free medication, cared for an assigned caseload of people in prostitution, and provided social and physical support. As the project continued, the Sonagachi workers and Peer Outreach workers provided literacy classes, HIV awareness education, child-care, a micro-loan service, and even created a condom sales business.8 All evidence points towards the effectiveness of this systematic, community-based approach to combatting HIV/AIDS. While other cities in India such as Bombay, Delhi and Chennai had HIV rates of 50% to 90%, in Calcutta the rate dropped to about 11% despite the tens of thousands of people in prostitution in its red-light district.9 Condom use also rose as a result of Sonagachi, from 3% in 1992 to 90% in 1999.9 The Sonagachi Project focused on the facts of the issue of HIV in Calcutta: namely, the lack of STD treatment and testing services, the lack of education and child-care, the need for economic support and the need for measures for occupational safety and support. By addressing these systemic changes

Remi Kaupp

The Tanzania Federation of the Urban Poor in Aruhsa attempts to get couples tested for HIV before beginning a relationship.

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khym54

khym54

Top: Home-based care for HIV/AIDS patients in Lilongwe. Bottom: HIV/AIDS women's support group in rural Kenya.

in the Calcutta community rather than focusing on attacking the “immoral” choices of individuals, the Sonagachi Project achieved significant, quantifiable outcomes in reducing HIV transmission.

Another systemic change the Sonagachi Project addressed was the need to engage and mobilize the people in prostitution themselves to combat HIV transmission. Though they are at the highest risk of contracting HIV, people in prostitution are often stigmatized and therefore too disempowered to take action against this shared issue of HIV transmission. The extreme success of the Sonagachi Project was due in part to its recognition of this disempowerment and its policies to instead empower and engage people in prostitution in the fight against HIV. The leaders of the Sonagachi Project began doing so by reframing prostitution in their official policies as a means of survival and not as an immoral state of being. These policies empowered people in prostitution by recognizing that the stigma that people in prostitution are immoral and “seeking personal gain” is false. Instead, they recognized the fact that people enter this “employment” as a desperate means of surviving. The Sonagachi workers asserted that like most other people who desire marriage and family, people in prostitution are humans who require income to survive and deserve to be protected against HIV. When they realized the legitimacy of their needs and their ability to take action such as promoting negotiation of condom use, people in prostitution were able to overcome the issue of disempowerment and instead enact systemic change in order to reduce HIV transmission.

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Solving the global HIV/AIDS pandemic requires not only continued funding of research and policy implementation, but also a concerted effort to shift our attention from the morality of the pandemic to the fact-based community-level approaches that can be taken to most effectively address these issues. The HIV/AIDS pandemic in particular can often be a morally contentious issue, as high-risk groups include men who have sex with men (MSM), those who engage in unprotected sex, and people in prostitution.

However, as the Lotus Club Project and other case studies have shown, focusing too narrowly on the inherent morality of individual actions ignores the more relevant and pressing systemic factors that cause these issues, such as the inevitability of people entering the sex trade and the subsequent need for occupational safety such as increased condom usage. Effective reduction of HIV/AIDS therefore requires the recognition of the pandemic as a collective issue and a community-based, holistic approach to intervention. www

Akielly Hu is currently a freshman in Berkeley College and a prospective Global Affairs major. Akielly is especially interested in issues surrounding global health and the regions of Southeast and East Asia.

She can be contacted at akielly.hu@yale.edu.

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a4gpa via Flickr

HEALTH POLICY

ADDRESSING URBAN VIOLENCE The Cure Violence Public Health Approach

By Sophia Kecskes

T

his July, in response to the tragic killing of a seven-year-old boy in Chicago, Mayor Rahm Emanuel said, “adults here are letting the children down—from failures of the criminal justice system to the immoral nature of street gangs. You have a time and place where you have too many guns on the street, too many people repeatedly using those guns, and too little values.”1 In 2012, 500 people were murdered in Chicago, making it the city with the largest number of homicides in the country that year.2 This is not unusual, as Chicago has been one of the top three cities with the most murders every year since 1985.2 However, substantial improvement has occurred over the last fifteen years – the city’s murder rate peaked at 928 murders in 1998.2 Chicago has a murder rate of 18.5 murders per 100,000 people. While in comparison to cities such as Flint, Michigan where the rate is 62 murders per 100,000 people, Chicago’s rate might seem low, it is still four times the national average.2 Chicago’s murder rate as of September 2015 was up 21% from the previous year, with the non-fatal shooting rate 20% higher than at the same point in 2014.3 Clearly, change is necessary to promote safer lives in the Windy City.

THEORIES REGARDING URBAN VIOLENCE Young, black men who live in certain neighborhoods are the most likely to be victims of gun violence.4 However, to then conclude that all young, black men in those areas are at risk is a gross oversimplification. Elijah Anderson describes the societal tendency to group

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blacks together and make assumptions, relegating a large group of people to one role in society.5 The assumption that having certain risk factors—such as being a young black man who lives in a certain neighborhood – substantially increases your risk for gun violence is a broad-sweeping claim that neglects to acknowledge the complexity of urban violence. Simply analyzing risk factors leaves out a significant piece of the explanation, even if the risk factors considered are more comprehensive and include characteristics such as dropping out of high school, being unemployed, using drugs and alcohol, or being impoverished.4 Yale sociologist Andrew Papachristos (2014) argues that an individual’s social networks can predict the likelihood of getting shot.6 He notes that gun violence is transmitted in a very similar manner to public health epidemics such as HIV/AIDS or cholera; therefore, we should “treat gun homicide like a blood-borne pathogen, something that is transmitted from person to person through risky behaviors.”7 Further, he stresses that it is not just your friends’ risky behaviors that increase your risk, it is also your friends’ friends’ behaviors. Papachristos further suggests that our strategies to combat gun violence should not be wide reaching policies that touch a large proportion of the population (such as “stop and frisk” in New York City), but instead should target specific, high-risk individuals.7 While Papachristos’ research is unique in that it explicitly and quantitatively links gun violence to social networks, the conception of gun violence as a public health epidemic has been

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Applying a public health approach to the epidemic, Slutkin determined that the best strategy to combat gun violence is to interrupt transmission. Slutkin started a program initially called CeaseFire, now called Cure Violence, which does just this. The program collaborates with trusted community members, many of whom are ex-gang members themselves, to act as mediators at the “epicenter of violent behavior.”8 The key role of these “interrupters” is to “move out of judgment [and] into understanding,” much like a public health official or doctor in an emergency room.8 APPLYING THEORY TO PRACTICE: CURE VIOLENCE PROGRAM DESCRIPTION Cure Violence was founded in Chicago in 1999. This program targets three key causal factors that are believed to be the major determinants of violence: community norms, limited knowledge about the available alternatives to violence, and underestimating the severe consequences of violence for the community.9 These causal factors are addressed through five central strategies: “Street-level outreach, public education, community mobilization, faith leader (clergy) involvement, and police and prosecutor participation.”9 The graphic above depicts the program’s theory of change.10 In short, through community collaboration and engagement with respected community leaders, Cure Violence encourages a dialogue with young people around shifting social norms away from violence as a conflict resolution strategy, as well as highlighting the costs of violence. The program also provides immediate, on-the-ground mediation of conflicts to diffuse situations and encourage alternative solutions. Violence “interrupters,” who are trusted community leaders, work in pairs or alone directly in the aftermath of a shooting – either

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Cure Violence

prominent for 15 years. Gary Slutkin, an infectious disease physician who spent the beginning of his life working with the World Health Organization to fight HIV/AIDS and tuberculosis in Africa, moved to Chicago in the late 1990s and was moved to action by the city’s high murder rate. He made a key discovery when he began to analyze the challenge of gun violence using an epidemiological lens. By analyzing patterns of violence he discovered two things: first, that violence is predictable, and second, that it spreads person-to-person, similarly to a contagious disease.8 The Cure Violence program's theory of change.

on the street or in hospitals when gunshot victims are brought in – to talk with distraught family members, friends, and gang leaders to de-escalate situations and stop the cascade of retaliatory shootings that often occur following an initial tragic incident.9 The program in Chicago is largely funded by the state of Illinois and carries a high cost—$11 million of funding from 2004 - 2006.11

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Cure Violence encourages a dialogue with young people around shifting social norms away from violence as a conflict resolution strategy.

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Collaboration with the Chicago Police Department is vital to the Cure Violence model. When a shooting occurs, the police department notifies interrupters immediately so they arrive on the scene with enough time to evoke a behavior change.

This program operates alongside other police initiatives, including an increased emphasis in Chicago on community policing and efforts to build trust between communities and law enforcement officers. In some ways, the Cure Violence initiative has helped to promote better police-community collaboration, as local individuals appreciate the program’s utilization of local assets (trusted community leaders) to save their children’s lives.

This success, and the perceived trust of

local leaders, has opened avenues for police-community dialogue which otherwise may not exist.12 POSITIVE IMPACTS OF CURE VIOLENCE IN CHICAGO To investigate the efficacy of the Cure Violence program, several independent evaluations have been conducted. One evaluation, conducted in 2007 by Northwestern University, examined eight communities where Cure Violence operated.

It found statistically significant reductions in shootings and killings varying from 41% to 73%, reductions in shooting hot spots of up to 40%, and a 100% elimination of retaliations killings in five of the eight neighborhoods.10 In these eight communities, Cure Violence caseworkers were involved with 660 youth, 84% of whom were very high risk. More than 70% were Black and 26% were Hispanic. In addition to violence de-escalation work, 86% of the youth reported that Cure Violence had helped them find a job.10 A qualitative study conducted in 2013 by the McCormick Foundation and University of Chicago found similar results.

Notably, the study found that the Cure Violence initiative has an additive effect on the reductions in violence precipitated by police actions, therefore accelerating the development of safer neighborhoods.

Many youth explained that they trusted Cure Violence representatives because they had had similar life experiences, with one youth explaining that he trusted his representative because “they lived the life I live.” The study discovered that the program served to counteract the severe isolation felt by at-risk youth. One young man said, “Ceasefire [the former name for Cure

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Kathy Buettner

CURE VIOLENCE AROUND THE WORLD UNITED STATES:

23 cities with as much as 73% reductions in shootings/killings

PUERTO RICO:

Homicides in Loiza down 50% in 2012, maintained in 2013

HONDURAS: More than 700 interruptions/mediations in the first year of operation SYRIA:

70% of trainees reported mediating a conflict within their first three months

IRAQ:

Almost 1,000 interruptions and 14,000 people reached from 2008 to 2013

SOUTH AFRICA:

Cape Town shootings down 79%, killings down 67%, 49 days without a shooting in 2013

KENYA:

Partnered with PeaceTXT to reduce election violence through text messaging

UNITED KINGDOM:

38% reduction in violent incidents and 95% reduction in group attacks at the Cookham Wood Youth Detention Center in 2013 43

YALE GLOBAL HEALTH REVIEW

Violence] taught me that life is more than the block. I can be bigger than the block.” Finally, this study reported that reductions in violence (greater than can be attributed to a general decrease in Chicago crime) occurred within just one month of program initiation.13 Following the successes demonstrated in Chicago, an excellent publicity strategy, and the release of the award-winning documentary The Interrupters, the Cure Violence model has expanded throughout the United States and overseas. While the direct focus of this analysis is implementation in Chicago, the statistics provided to give a snapshot of the program’s broader impact.

CRITICISMS AND LIMITATIONS OF THE CURE VIOLENCE MODEL Despite noteworthy successes, there are important criticisms of the Cure Violence program. One controversial aspect of this program is the effort to recruit and employ community members whom young people respect. The program hires many people who have previous records of incarceration and illegal behavior. Some people praise the program for hiring those who may otherwise not have found stable work, with one minister saying, “It’s nice that they have jobs. That’s the best part of the program. I would support it just for that.”9 However, others criticize the program for this very reason. For example, one Illinois State Senator said, “The over $18.5 million given to Operation CeaseFire has done more to legitimize gang leaders’ portfolios than actually stopping violence.”9

to those involved in a shooting immediately afterward because the interrupters are working to de-escalate a heated conflict.

To address some potential challenges with hiring individuals who have been incarcerated in the past, the organization imposes strict standards for employment, which include routine drug checks for all employees.

These, in conjunction with unstable funding, result in high staff turnover. This hinders the organization’s ability to build trustworthy relationships over a long period of time with community members.9 Community relationships are also tense because hires are conducted by an external panel, not by community members, and some site directors are perceived to be “political” hires, not based on merit—for example, one state representative appointed his former chief of staff as a site director without a public comment process and without considering any other candidates.9

It was challenging for Cure Violence to find staff members Martin Grandjean who were sufficiently respected and connected with gang members and those involved with the drug trade, This social network graph, created using force-based but who were not involved in these activities network visualization, is strikingly similar to maps themselves. In fact, according to Tio Hardicreated of gun violence in Chicago man, Cure Violence’s Illinois Director, six of their 300 outreach workers had returned to Other key challenges to the violence intercrime after being hired.15 This caused tense rupters work include that they are awarded relationships between law enforcement offi- one 900-hour contract at a time, and often cials and the outreach workers, as the police- they have to stop working between contracts. men were wary of working with individuals This is disruptive at times to community relawho they’d arrested in the past. Similarly, tionships and on-going mediations between some policemen criticize the interrupters for gangs.9 Similarly, the program depends on not alerting them when illegal behavior oc- yearly fund appropriations from the state curs and for not allowing policemen to talk government, funds that were decreased

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during the recession, and are unreliable yearto-year. One particularly critical Chicago Tribune article highlighted that problem shortly after Cure Violence’s budget was reduced.

The article noted that after Cure Violence ended operations in several neighborhoods, five young men were shot in or just next to these same neighborhoods, thus suggesting that long-term partnership with communities is key and that abruptly terminating the program can have consequences.16 CONCLUSION While there are certainly areas where Cure Violence can improve, the program has demonstrated significant success in changing social norms about violence as a conflict-resolution strategy. Thanks to these cross-community dialogues, in addition to other community development strategies such as job placement, Cure Violence has made a substantial and long lasting positive impact on the neighborhoods in which it operates. Improvements could certainly come through more reliable funding from the state government and re-doubled efforts to hire individuals who are not involved in gang behavior or use drugs, but the underlying theory of change associated with this program appears to be effective. By viewing gun violence as an epidemic spread person-to-person, and by targeting specific individuals who are at the highest risk of shooting or being shot, the Cure Violence initiative utilizes a conceptualization of gun violence as spreading through networks to “interrupt” violence after a first incidence and stop retaliatory killings. This public health based strategy to combat gun violence is incredibly effective; continuing to promote similar creative thinking and problem solving is vital for continued progress on pressing challenges. www Sophia Kecskes is a junior in Pierson College.

Sophia is a Political Science major and a Global Health Fellow, and is in the 5-year accelerated BA/MPH program.

Contact her at sophia.kecskes@yale.edu.

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AUTISM:

FIELD WORK

By Ava Hunt

Experiences in the Pediatric Emergency Department

Creative Commons

I

n recent years, Autism Spectrum Disorder (ASD) has been at the center of one media frenzy after another. Although far less data exist about the prevalence of ASD outside of the United States, the rising prevalence of autism, the apocryphal allegations that autism could be caused by vaccines, and the increased portrayal of autistic characters in film and television in the United States have all contributed to a rising public awareness, or a rising public panic, about ASD. However, despite the media hype, most Americans have little knowledge of what life is actually like for autistic individuals and even fewer have any understanding of the difficulties they face on a day-to-day basis. Even simple acts, such as seeking medical care in a time of illness or injury, can pose unique challenges for people with ASD. As I stood outside Room 3, I couldn’t help but feel slightly troubled. After a summer working in the Pediatric Emergency Room (PED) at Yale New Haven Hospital, I had become accustomed to many upsetting sights. However, I never quite got used to the sight of a child in four-point restraints. The staff member sitting outside the door adjusted her purple uniform polo shirt and glanced at me resolutely. I got the hint and finished my duties before returning to the nurse’s station. When I got there, the attending pediatricians were talking about the boy in Room 3. They seemed frustrated. Everything should have been ready for him to be admitted to one of the pediatric inpatient psychiatric facilities, but they had hit a bit of a roadblock on transport.

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“Every time we try to remove the restraints, even just one of them, he starts hitting himself again,” a resident was saying.

“It’s illegal to transport someone in restraints,” one of the attending physicians said. “If we can’t remove the restraints, we’re going to have to sedate him before he can be admitted.”

He sighed. “Sometimes I really wonder whether that’s actually any better for the kid. It’s kind of a lesser of two evils.”

As I listened, I couldn’t help but wonder the same thing.

Yale New Haven Hospital has formal policies for the use of restraints, but individual decisions about specific patients remain quite subjective and difficult. 1 In my time working in the PED, I only saw two children in four-point restraints, and both were presented in the ED with severe aggressive or self-harming behaviors. Both had been previously diagnosed with Autism Spectrum Disorder (ASD). There are many times when restraints are necessary for a patient’s safety as well as for the safety of the staff attempting to treat them. However, I could not help but question whether there might be more that the PED could do to mitigate such extreme situations and avoid having to resort to drastic measures. Although staffed by an incredibly talented group of doctors and nurses, it seemed that the PED was not conducive for children with ASD. Were there other approaches and better options available? The use of patient restraints in hospital settings is an accepted practice in hospital emergency rooms when patients pose a danger to

YALE GLOBAL HEALTH REVIEW

themselves or others. The American College of Emergency Physicians (ACEP) has endorsed principles to guide hospitals and healthcare practitioners in their use and state laws regulate many aspects of the practice, including their use with children.2 These protocols seek to balance an individual’s rights to refuse care and to maintain freedom of movement against the interests of the hospital to protect its staff, the public, and patients against harm, even if self-inflicted. In every instance, physical restraints of all forms, including seclusion or the use of psychopharmacologic agents, are last resort interventions applied only after a careful assessment. That being said, there is no discounting the emotional impact that physical restraints have on all involved and the importance of minimizing the frequency or their use.

For most people, children and adults alike, the emergency department of a hospital is an overwhelming, and often intimidating environment. The pace is incessant.

Countless staff members in a rainbow of pastel-colored scrubs are always on their feet, scurrying from room to room in response to a seemingly incomprehensible clamor of beepers and pagers. Monitors flash and ping with no obvious pattern or rhythm and there always seem to be numerous conversations going on at once. To make matters worse, many patients are experiencing discomfort that can range from dizziness and nausea to intense and unremitting pain. It is a lot for anyone to handle.

Now, imagine what the emergency department experience must be like for a child with ASD. Distracting visual and auditory stimuli can cause children with ASD to become confused, distressed, or even fearful and anxious. Staff members who move too quickly can overwhelm a child and even the seemingly simple act of entering a crowded, noisy waiting room can trigger difficult behaviors. This sensory overload and anxi-

53% of children with ASD who visit emergency departments are restrained

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ety can cause a child to become aggressive towards hospital staff and equipment or to engage in self-injury.3 Non-verbal or mostly nonverbal children can also have trouble communicating what is wrong or how much pain they are in. Many individuals with ASD have trouble identifying emotions on the basis of facial expressions. Thus the commonly-used Wong-Baker FACES pain reading scale is not particularly effective for autistic patients, making it difficult for clinicians to understand what an autistic child is experiencing or how much pain relief they might need.4 Since the hospital staff is usually not informed of the arrival of a patient with ASD in advance, providers sometimes react inappropriately to a child’s behavior, even exhibiting fearfulness, pity, or embarrassment.

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Despite the media hype, most Americans have little knowledge of what life is actually like for autistic individuals.

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Environmental factors aside, while in the ED, children with ASD are frequently subject to potentially distressing procedures. A study on emergency department outcomes for individuals with ASD found that restraints were used in about 53% of psychiatric and behavioral emergency department visits. This is an upsettingly high number considering that the majority of emergency department visits of children with ASD recorded in the study were the result of episodes of physical or verbal aggression (54%) or self-harm and/or suicidal behavior (13%).5 That finding is even more striking when considered in the broader context of restraint use among all pediatric

80% of children with ASD have at least one other comorbid disorder

emergency visits. A wider study on the use of restraints among all pediatric patients regardless of ASD diagnosis found that 6.8% of the total number of pediatric psychiatric patients were restrained either physically or chemically.6 There has been a good deal of push back in recent years against the use of restraints in schools and group homes as a common source of abuse that has, in some cases, resulted in injury or even death, and there is a clear consensus that they should never be used as a form of discipline. Although restraints may be necessary in some emergency situations, they are often highly distressing and even traumatic to children.

That being said, the challenging behaviors associated with ASD that manifest themselves in a healthcare setting can at times make it difficult for healthcare practitioners to perform their jobs. Children with ASD can have trouble generalizing learned social skills to new healthcare providers in an unfamiliar setting such as an emergency department. That disconnect can create anxiety and cause them to act out. Noncompliance, hyperactivity, sensory defensiveness, and self-injury are among the most commonly triggered behaviors that occur in these settings. All can prove challenging to deal with unless healthcare providers have a plan in place for managing them. Despite these difficulties associated with emergency department visits, children with ASD are far more likely to visit the emergency department than their peers without ASD. About 9% of children with ASD visit an emergency room in any given year compared to 7% of non-autistic children. Overall, children with ASD are 20% more likely to be treated in a hospital setting than children without an ASD diagnosis.7 There are many reasons why this may be the case. On a fundamental level, the higher rate of hospitalizations may be partially attributable to the nature of ASD as a disorder. The injury treatment rate for children

34.4% of pediatric emergency department visits are somewhat or very inappropriate

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with ASD is significantly higher statistically than the rate for children without a disability. Children with autism and Pervasive Developmental Disorder (PDD) experience 7.6 times higher treatment rates for poisoning, 2.5 times higher treatment rates for upper limb injuries, 3 times higher treatment rates for fractures, and statistically significantly higher treatment rates for self-inflicted injuries and suicide attempts.7 Additionally, 80% of children with ASD have at least one comorbid psychiatric disorder. Partially as a result of this higher rate of mental illness, children with ASD are nine times more like to have a psychiatry-related ED visit than children without ASD, most often for externalizing behavior problems or psychotic disorders.8

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The challenging behaviors associated with ASD... can at times make it difficult for healthcare practitioners to perform their jobs.

Creative Commons

A quality pediatric care relationship is essential for positive health outcomes in any community.

although community therapists are highly motivated to receive more training in ASD diagnosis and common behavior problems, many do not have access to sufficient training programs.10

A lack of sufficient access to outpatient services also contributes to this increased rate of hospital visits. A recent study of pediatric emergency department visits for children both with and without ASD implied that around one third (34.4%) of pediatric emergency department visits could be deemed either somewhat or very inappropriate. Therefore, it can be argued that many children who come to the emergency room could easily be treated in an outpatient context.9 However, for children with ASD, there are few adequate outpatient services available.

The higher rate of emergency department visits may also be financially motivated. ASD is not a reimbursable diagnosis for mental healthcare among many private insurance plans, making it even more difficult for children with ASD to afford adequate outpatient mental healthcare.8 As a result, children with ASD have a higher utilization and cost of healthcare than children without ASD, with an average annual hospitalization cost two times greater in comparison.11 In the same way that uninsured parents are more likely to bring their children to an emergency department rather than to a general practitioner, parents of children with ASD who are unable to obtain coverage through their insurance plans may be more likely to frequent emergency departments than outpatient services when their children are in need of a psychiatric help.

Community mental health services in particular have come under fire from parents who view their care as ineffective and are frustrated by the lack of training on the part of staff members, as well as their children’s slow progress. A study of therapists working in community mental health services in California revealed that, although children with ASD make up about 21% of their caseload, many therapists feel they lack adequate clinical preparation to work with autistic children and have found their typical treatment strategies to be ineffective.10 Preliminary study results have indicated that community therapists who have received ongoing training in ASD are more successful in reducing their client’s problem behaviors. However,

Given the demonstrated need for emergency services for children with ASD, there has recently been a push to make more emergency departments more “autism-friendly.”

Some hospitals have begun to institute more extensive training for staff members on how best to relate to children with ASD, while others have made environmental modifications to the emergency department itself in order to make it a more ASD-friendly space.

Even in the absence of specific policy changes, providers in many EDs around the country have begun to adopt simple, common sense accommodations to ease the ED experience for children with ASD. For example, procedures can be explained to a child before they are performed or can be demonstrated

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on a parent or staff member to build trust between the child and the provider and avoid the stress of unexpected or unusual sensations. A child can be taken directly to triage to avoid a crowded waiting room and then placed in a quiet area with the lights dimmed to avoid sensory overload. The number of staff members who interact with the child can be minimized to lessen the discomfort caused by large groups of unfamiliar faces.

Alternatives to specialized equipment can be created using easily accessible items.

For example, if a weighted blanket is not available, a lead apron of the type typically used for x-rays can be substituted to calm a distressed autistic child.3 For children with communication difficulties who do not carry their own visual communication systems, emergency departments can easily create their own communication boards with clipart images of medical devices and procedures. Whether or not such steps effectively address the many challenges hospitals face when treating children with ASD is yet to be seen, but it is difficult to deny that there are still many potential areas for improvement.

However, the recent initiatives provide some hope that perhaps there is a better way. It is impossible to know whether the story of the child I saw in four-point restraints in the YNHH PED could have had a happier ending. However, it is still encouraging to imagine a world in which more children with ASD have positive PED experiences and where more stories have happy endings. www Ava Hunt is a junior in Ezra Stiles College majoring in Molecular, Cellular & Developmental Biology Contact her at ava.hunt@yale.edu.

YALE GLOBAL HEALTH REVIEW

CDC and PHIL

RESEARCH & INNOVATION

FECAL MICROBIOTA TRANSPLANTATION:

Fecal microbiota transplantation (FMT), previously known as “fecal bacteriotherapy,”2 transfers human stool from a healthy donor into a patient’s stomach, colon, or small intestine.3 The procedure attempts to restore the balance of bacteria in the digestive tract by replenishing the population of “good” bacteria that had either been killed or suppressed by the over-population of “bad” bacteria.8 Processed FMT capsules contain microbiota preparations that have been thoroughly screened and processed, and these pills can be administered orally, through the lower gastrointestinal tract via colonoscope or enema, or into the upper gastrointestinal tract via the nasogastric or nasoduodenal tube.4 During an enema, a solution is injected into the lower bowel through the rectum,5 whereas a colonoscopy consists of the insertion of a tube into the colon through the same pathway.6 In 2011, approximately 75% of the estimated 325 cases of FMT that had been reported worldwide were treated by colonoscopy or retention enema, and the other 25% by nasogastric or nasoduodenal tube.3 FMT ultimately introduces a community of stable gut microorganisms to stabilize the imbalanced microbiome.2 The human microbiome, defined as “the collection of all the microorganisms living in association with the human body,” plays a crucial role in human health.9 The gut microbiome has the greatest bacterial density of all microbial communities that populate human body surfaces, and many consider gut microbiota a “distinct human organ,”

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responsible for many functions of energy metabolism and immunity.2 The evolution of the two branches of our immune system occurred alongside the acquisition of diverse microbiota in our bodies, suggesting that the immune system evolved to maintain the symbiotic relationship between humans’ complex microbiota so that microbiota could adjust and promote aspects of the immune system in return. Many believe that the microbiome regulates immune responses, because events in high-income countries, such as the overuse of antibiotics and diet changes, have been linked to the selection of microbiota lacking the diversity and resilience needed to establish balanced immune responses.10 Data suggest that gut microbiota play a role in various aspects of the development and function of the innate and adaptive immune system in the intestines,11 such as regulating immune homeostasis as well as aiding the development of helper T cells and the maintenance and function of intestinal cytotoxic T cell populations.12 Strong evidence supports the benefits of FMT for the gut microbiome,13 and research in FMT has increased largely due to growing interest in the relationship between the human microbiome, health, and disease. Many studies have suggested that changes in microbiome composition are correlated with disease, so the microbiome offers potential targets for therapy.14 The desire to understand our microbiome led the NIH to launch the Human Microbiome Project in 2008, which examines the role of these microbial communities in health and catalyzes research to characterize and further analyze the human microbiome.9 The nonprofit organization OpenBiome, which became the United States’ first stool bank in 2012, works to improve access to FMT and increase the amount of research done on the human microbiome.15 The success of FMT in the battle against Clostridium difficile demonstrates the potential efficacy of therapeutic

The Future of Feces

W

ith almost a third of the world’s population either obese or overweight, and no end to the epidemic in sight, the need for pharmacological aids to stem global weight gain has only increased over the past decade. This issue most deeply affects the United States, since we have the highest proportion of obese people in the world.1 The emergence of a potential new therapy for this rising health hazard might come as a surprise to many… human feces.

By McKenna Tennant

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microbiota alterations for certain diseases. Infection with C. difficile (CDI) causes inflammation of the colon and commonly occurs as a complication of antibiotic therapy. It typically spreads via fecal-oral transmission, and has become the most common cause of healthcare-associated infections in U.S. hospitals.16 CDI can cause severe disease and death, and in 2011, it was associated with approximately 29,000 deaths in the U.S..17 Upon the discontinuation of standard CDI antibiotic treatment, recurrent infection may occur.2 Extremely high rates of mortality and colectomy, or colon removal, associated with this form of CDI often result from the death of most “good” bacteria, which often die during the course of such intense antibiotic treatment.2 The CDC, on its CDI webpage, claims that “fecal transplants” currently represent the most effective treatment of CDI, resulting in the total eradication of infection with a success rate of approximately ninety percent.16 Reports have also shown that FMT treats recurrent CDI more effectively than antibiotics, and few incidences of adverse effects or complications as a result of FMT have yet occurred.18 In the United States, FMT currently has FDA approval only for the treatment of recurrent CDI not responsive to standard therapy, with the added requirements of signed patient consent and donor stool testing. The FDA classified fecal matter as an Investigational New Drug (IND) in the spring of 2013, so that only physicians who possessed an approved IND applicaWikimedia

Vials of Fecal Microbiota Transplants.

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tion could perform FMT for clinical practice or research. This decision effectively reduced the number of physicians qualified to work with fecal transplants to less than twenty.8 Later that year, however, the FDA announced its intent “to exercise enforcement discretion regarding the IND requirements for the use of FMT.”19 This declaration meant that physicians without an IND application could perform FMT as treatment for recurrent CDI outside of a clinical trial. IND applications, however, must be filed in order to use FMT as a treatment for other diseases.20 Given the success of FMT with CDI, we must now look toward other health issues that could benefit from the use of FMT. Recent findings have shown that an imbalanced intestinal microbiome not only predisposes the human body to CDI but also to inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). As a result, FMT has been used to treat IBD, IBS, ulcerative colitis, and even non-gastrointestinal disorders. Four publications have described FMT use for refractory ulcerative colitis in a total of nine patients, all of who experienced complete resolution of all symptoms. Multiple infusions, however, seem necessary to maintain remission, and controlled trials need to establish the role of FMT or even determine if one truly exists for ulcerative colitis. A case series study of patients with IBS and IBD treated with FMT reported a cure in 36% of the patients, decreased symptoms in 16%, and no response to FMT in 47% of the patients. While FMT does not appear

to be incredibly effective against IBS and IBD, in another study of 45 patients who underwent FMT treatment for chronic constipation, 89% of patients experienced relief immediately after the procedure, demonstrating the potential benefits of FMT treatment to those whom it does help.21

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The CDC, on its CDI webpage, claims that fecal transplants currently represent the most effective treatment of CDI, resulting in the total eradication of infection with a success rate of approximately ninety percent.

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Observations of improvement have occurred even for extra-intestinal conditions not thought to be related to microbiota, so new possibilities for FMT materialize every day. FMT treatment has been linked with the normalization of severe multiple sclerosis symptoms, as well as an improvement of chronic fatigue syndrome.2 Fourteen of the 34 patients who underwent FMT for a long-term follow-up study on the improvement of chronic fatigue syndrome obtained continuous relief, and 7 reported mild or gradual improvements.2 Three patients with multiple sclerosis underwent FMT for chronic constipation, but they also experienced improvements in motor symptoms and urinary function, allowing them to remove their catheters and regain the ability to walk. Additionally, neurological improvement was reported in one patient with Parkinson’s disease who underwent FMT for chronic constipation. In addition, intestinal microbiota metabolize ingested nutrients for the host and commensal bacteria, and can modify their metabolism depending on nutrient availability.21 Because gut microbiota alter energy metabolism, the microbiome influences body size. One woman successfully treated with FMT for CDI recurrence developed obesity after receiving

YALE GLOBAL HEALTH REVIEW

stool from her overweight but otherwise healthy daughter. The woman was unable to lose weight, even on a medically supervised diet and exercise program, even though she had never been obese before FMT.22 Given that FMT can affect obesity, it might also enable weight loss.

The potential of FMT to treat a variety of health disorders, including obesity, has sparked research that is currently underway to study the relationship between altered gut microbiota and disease development. A study on the impact of gut bacteria taken from a pair of twins, one obese and one lean, in separate groups of recipient mice showed that microbiota influence the body weight phenotype of host mice. Adiposity, defined by the Merriam-Webster medical dictionary as the quality or state of being fat,23 was transmitted from the obese twin to the recipient mice through the transplantation of human fecal microbiota, and the mice experienced increases in body weight and mass.24 Furthermore, humans have utilized gut bacteria modification to promote weight gain in farm animals for more than 50 years.26

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The microbiome may affect fat storage, and, by means of increasing or decreasing the amount of energy harvested from ingested food, it provides or limits calories; mixes of certain gut microbiota, therefore, possibly offer protection from excessive weight gain.

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Several publications have hypothesized that individuals with or lacking certain gut microbiota may face greater risk for obesity.25 The microbiome may affect fat storage, and, by means of increasing or decreasing the amount of energy harvested from ingested food, it provides or limits calories. Mixes of certain gut microbiota, therefore, possibly offer protection from excessive weight gain.26 Restoring

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the microbiome to a healthy state might improve obesity-associated conditions and help maintain healthy weight.27 Currently, preparations have begun for a March 2016 clinical trial that will study the impact of FMT capsules on weight.

The study, which will enroll 21 obese subjects, is expected to run for 12 weeks, and will transfer stool from a metabolically healthy, lean subject to an obese subject.28

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The FDA classified fecal matter as an Investigational New Drug (IND) in the spring of 2013, so only physicians who possessed an approved IND application could perform FMT for clinical practice or research.

some researchers may hesitate to prepare fecal microbiota for sale, making access to the procedure a challenge and creating a potential risk for the rise of fecal sales on the black market.29 The risk of the potential transmission of infectious agents, another source of concern, warrants very strict regulation and screening processes for fecal donors.3 Because FMT remains in the early stages of therapeutic application, with the number of total FMT treatments in the U.S. estimated below five hundred,8 the future of FMT remains obscure. We need more knowledge about the role of gut microbiota in health maintenance, calling for an increase in the number and range of FMT trials. The undoubted link, however, between gut microbiota and weight demands a greater exploration into the possibilities of FMT, especially for its potential influence on obesity. www

Agricultural Research Service

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Ultimately, more research needs to be done to determine the role of the microbiome in human metabolism and weight.

The main cause of obesity often lies in an imbalance between energy intake and expenditure; however, many researchers agree that a clear link exists between gut microbiota and metabolic diseases like obesity.25 Before FMT can be applied widely, however, we must overcome various challenges and barriers, such as the obvious “yuck factor” that surrounds the topic of human feces.2 If queasiness over feces threatens to overwhelm the conversation on FMT, it must be considered that FMT is not necessarily a novel treatment.

The first documentation of fecal transplant comes from 4th century China, where it was known as “yellow soup,” dating the practice of FMT to around 1,700 years ago.

In some parts of the world, it is also customary to give a newborn a sample of its mother’s feces because of the belief that it immediately provides a population of good bacteria for the baby’s colon, thus stimulating the newborn’s immune system.8 Other barriers also limit future applications of FMT. Because of the legal ambiguity created by the FDA’s enforcement discretion on its IND classification,

McKenna Tennant, originally from Los Angeles, California, is a sophomore in Davenport College. She is currently pursuing a major in History of Science, Medicine, and Public Health. McKenna's interest in global health emerged as a result of the classes that she has been able to take at Yale, and she is particularly interested in the study of infectious diseases.

McKenna is a member of Yale's Varsity Swimming and Diving Team.

She can be contacted at mckenna.tennant@yale. edu.

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T

he leaders of my gap year program heard about a nearby refugee camp, where Burmese citizens sought safety before crossing the river into China. We timed our visit with a global health organization that was there for regular vaccinations. Before arriving, we bought as many toys, books, and school supplies as we could afford. The entire village was warm and friendly. We played soccer with the children and spoke with the English teacher there. The children loved seeing photos of themselves that we had taken, with reactions varying from gleeful giggling to intense concentration. One student interviewed the village elders about the political situation in Burma, which was more precarious than they had told the children. The medical staff there handled all of the inoculations, while we watched with the children. What struck me the most was seemingly innocent—many children had runny noses but never blew them. Amid political turmoil and serious medical threats, something as inconsequential as a runny nose was discarded, whereas in the US it would be considered a nuisance and constantly blown. Out of everything I saw on my visit, that small detail struck me the most.

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PHOTOGRAPHY

BURMA

By Kira Tebbe

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Kira Tebbe is a junior in Pierson College. She is double majoring in Sociology and Applied Mathematics and is from Chicago, Illinois.

She can be contacted at kira.tebbe@yale.edu.

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TURNING A BLIND EYE:

HEALTH POLICY

A Look at Unjust Health Outcomes Among the Deaf, Blind, and Physically Disabled

By Holly Robinson

H

ealthcare providers have a responsibility to the most vulnerable members of their communities. However, problems arise when a population’s most vulnerable members are not part of the community, when they are pushed to the side and deemed unfit to contribute to society. This is the reality for many around the world who suffer from physical disabilities. The physically disabled are often excluded from participating in society. The way that the health system treats the disabled is particularly important, as studies have shown that those with disabilities experience greater vulnerability to secondary conditions, co-morbid conditions, and premature death. They are also more likely to be unemployed or illiterate.1 With over one billion people in the world considered disabled, health equity for the physically disabled must be a primary focus for all healthcare professionals.

Contrary to popular belief, the factors that prevent disabled persons from leading healthy and successful lives often do not include the physical disability itself. Rather, factors such as stigma, physical barriers, and inadequate training within the healthcare system cause substantial harm to the physically disabled. The World Health Organization’s definition of disability encompasses these unjust social factors. The WHO states, “Disability is the interaction between individuals with a health condition and personal and environmental factors (e.g. negative attitudes, inaccessible transportation and public buildings, and limited social supports).”1 Healthcare providers and able-bodied members of the community more generally must consider not only the abilities that disabled persons may lack, but also the way in which disabled persons are prevented from participating in society and, more specifically, in healthcare systems in both high- and low-income countries.

Persons with physical disabilities face many barriers to receiving care, many of which relate to the physical challenges of reaching a healthcare facility if one has limited sight or mobility. Disa-

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bled persons often must be accompanied to the hospital or health center, which may not be possible in situations in which family members cannot afford to take a day off for fear of termination or loss of income. In addition, disabled persons have fewer public transportation options available to them because public transport vehicles, or the routes to access the public transport, may not be accessible to disabled persons. These physical obstacles to seeking out healthcare are especially problematic given that people with disabilities often have greater need for healthcare.1 Unfortunately, these needs largely go unmet and unnoticed. Disabilities also greatly affect socioeconomic status of entire families, as disabled persons are likely to have limited employment opportunities.2 This creates an economic barrier to care.

Once at the healthcare facility, the physically disabled may continue to struggle to access the medical treatment they need. People with disabilities are reportedly three times more likely to be denied care when they are able to reach a health facility.1 Stigma and preconceptions that the disabled are lazy or defective prevents disabled people from being taken seriously when they ask for healthcare, which can be life-threatening. Furthermore, once a disabled person is granted admission to a healthcare facility, they often find that the equipment is not suited for persons with a particular disability.

For example, examination tables are often not able to be height-adjusted, making it more difficult for patients in wheelchairs to be properly examined. Mammography equipment requires a woman to stand, and many examinations require an ability to follow verbal instructions. While hospitals in high-income countries often do have adjustable beds, transportation services, and other measures in place to guarantee proper care for disabled patients, in facilities that lack the proper equipment and personnel, disabled patients do not receive the care they deserve. Approximately 80% of the world’s persons with disabilities live in low-income countries, where facilities are both fewer in number and less equipped to ac-

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commodate the unique needs of the disabled.3 The poor and disabled lack access to even the most basic of services, especially at the most critical times.

To add to these injustices, healthcare providers are often ill prepared to treat patients with disabilities, which acutely affects the deaf and blind. The WHO found that people with disabilities were more than twice as likely to report finding the skills of healthcare providers to be inadequate.1 This is especially prevalent for members of the deaf and blind communities, who are at a disadvantage in interactions with fully-hearing or fully-seeing practitioners. To illustrate this point, imagine a deaf woman in a low-income country who suffers from mental illness. There are most likely few mental health professionals in her area and, as previously described, making the journey to visit one involves a family member recognizing her need for services and taking a day off from work to accompany her to the health center. Furthermore, the mental health professional may lack the ability to communicate with her. Other than providing medication, the practitioner cannot do much in terms of therapy or even emotional support. Her physical disability (or rather, the practitioner’s inability to treat someone with her disability) exacerbates her mental health issues, leading to further co-morbid disease or even premature death, which can only be seen as an unjust and unacceptable health outcome.

In higher income countries, the same deaf woman may fare a bit better, but her experience with the healthcare system may still be wrought with issues. Many hospitals do not have on-site sign language interpreters and instead rely on connecting with interpreters via Skype or other video conferencing services, which can be unreliable.4 More importantly, however, the

interpreter often does not have a medical background and therefore may not know much of the medical terminology necessary to facilitate information between the doctor and patient. The same issues arise when family and friends attempt to help.4 In order to make care for the disabled more equitable, the WHO recommends that disability education be integrated into both undergraduate and higher-level education for all healthcare professionals.1 This includes community health workers, who often play a large role in the health of poor, rural populations. However, other groups argue that the best way to achieve culturally and linguistically appropriate care is to seek out deaf practitioners who know the local sign language and to create assessment tools in major sign languages such as American Sign Language and British Sign Language.5 There is a particular pressure for this within the realm of mental health. Most mental health initiatives and treatments are inclusive only of hearing populations, as they often focus on verbal communication. This is a critical concern, as there is a higher prevalence of mental health problems among the deaf.5 There are not many deaf people trained as physicians and psychiatrists, even in the most resource-rich countries, perhaps due to lack of opportunity or a curriculum designed for an exclusively hearing population. In the United States, just a handful of deaf doctors have been certified since the first deaf doctor, Dr. Judith Pachciarz, graduat-

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A boy in Afghanistan in a wheelchair struggles to traverse the poorly paved roads.

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ed from the University of Louisville School of Medicine in 1983.6 It is easy to imagine that in low-income countries where a disabled person is unlikely to receive even a basic education, deaf persons are excluded entirely from the possibility of medical training.

Though the integration of deaf persons into the field of medicine poses many challenges, it is part of a broader goal for health systems and healthcare providers to focus on providing inclusive care for people with disabilities. Health promotion activities and campaigns rarely select disabled persons as their target audiences.1 For example, in the US, the way sex education is taught in schools for the blind is crucial to both the physical and social development of blind adolescents. Resources developed by Perkins School for the Blind cite the importance of helping the blind to understand their sexuality and gender identity in addition to understanding things that the seeing-community takes for granted, such as what is a public and what is a private location.7

Due to factors such as stigma, discrimination, and neglect, social problems become embodied in the lives of the disabled.

Studies also show that physically disabled adolescents are more likely than their non-disabled peers to engage in risky sexual behavior, perhaps due to the lack of sex education for the disabled. A 2010 study in South Africa showed that risky sexual behavior among disabled adolescents led to an increased prevalence of HIV among disabled populations.8 The team behind this study concluded that these results point to a need to include disabled adolescents in health promotion activities related to sex education. The inclusion of the physically disabled in such activities is not only important from an ideological perspective, but also from a physical health perspective. Health educators and practitioners cause unintended harm by excluding the disabled from important health education programs.

It is impossible to paint a picture of the health of disabled populations without considering the substantial social implications of disability in various communities throughout the world. These social factors negatively impact health and often place disabled persons in a more vulnerable

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position in society. Due to factors such as stigma, discrimination, and neglect, social problems become embodied in the lives of the disabled. Disability is as much a social issue as it is a biological issue. The effects of social exclusion and discrimination manifest themselves within the health system.

Studies by the WHO have shown that disabled persons are four times more likely to report being badly treated when they seek medical care.1 Additionally, only two percent of children with disabilities in low-income countries receive the rehabilitation necessary for their conditions.3 Exclusion of the disabled also extends far past the health system. Members of the deaf community are often excluded from the wider community, which has a profound impact on their development. Education is a particular concern for the deaf in many parts of the world. Rather than attending school, many deaf children stay at home, where they are shielded from the community.9 This is especially prevalent in rural areas.

However, health education and communication more broadly begins at the community and family level. In many communities, there are additional constraints that prevent deaf children from becoming fully engaged with their peers or in society more generally. Social factors often prevent parents from dedicating time to the communicative development of their disabled children. For example, in rural China, researchers report that parents of deaf children express interest in learning sign language and other ways of communicating with their children.9 However, poverty and workload places a major constraint on both their time and resources, preventing them from taking classes led in the community. In situations where each day’s wages are crucial to make ends meet, working hours cannot be dedicated to sign language classes. Unreliable or unavailable transportation also plays a major role, as many households are far from the urban locations where sign language experts work.9

Flickr

In Kenya, a deaf child is examined by a physician with the help of an interpreter.

without active and ongoing effort from the family. It is crucial that deaf children are able to learn in everyday social contexts, just as hearing children do.9 However, researchers have found that, as in rural China, parents in countries such as Sri Lanka and Afghanistan are unable to spend the amount of time necessary for their children to develop communication skills.9 There is a need for societal level change in many communities in order to allow families to properly provide for their disabled children. A cost effective solution to such issues has been tested in Papua New Guinea. By simply educating family members on the importance of developing communication with their deaf children, researchers observed a significant improvement in deaf children’s ability to engage with the community and participate in society.9 This has major implications for the mental health of the deaf, as it allows children to develop in a fully supportive environment.

Health educators and practitioners cause unintended harm by excluding disabled from important health education programs.

It is difficult to develop communication between a hearing person and a deaf child

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In order to mitigate unjust health outcomes, many organizations and foundations throughout the world work to eliminate barriers to care and promote the inclusion of the physically disabled in all aspects of society. The National Association of the Deaf, for example, is a US organization that advocates for the civil rights of the deaf.10 The organization focuses on the core issues facing the deaf in Ameri-

ca, which includes problems with healthcare, housing, and education. Broader in both ideological and geographical scope is Handicap International, which advocatews for disability rights and inclusion in low-income countries.11 They consider inclusion in all senses—educational, social, economic—and emphasize the importance of inclusion during times of crisis and emergency.

Currently, they are working to provide rehabilitation to physically disabled Syrian refugees and those affected by the Nepal earthquake.11 Their work in non-emergency settings also focuses on the importance of inclusion in a disabled person’s life course.

They state, “Exclusion from education further perpetuates the vicious cycle of disability and poverty.”11 The question remains of what more can be done to ensure the rights, inclusion, and health of those with physical disabilities worldwide. The exclusion and stigma against those with physical disabilities not only violate civil rights, but also have profound consequences for health. Until the health system is fully inclusive, the world will not see the achievement of health as a human right. www

Holly is a junior in Branford College majoring in Russian. She is in the 5-year accelerated BA/ MPH program and a staff writer for the Yale Global Health Review.

She can be reached at holly.robinson@yale.edu.

YALE GLOBAL HEALTH REVIEW

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INCLUSION, NOT EXCLUSION: Expanding Healthcare Access to Undocumented Immigrants in California

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EBOLA & MARBURG: An Evolutionary Perspective on Viruses

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SOUTHEAST ASIA: Where Being Queer is a Risk Factor

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BLUE GOLD: The Global Cost of Water Privatization

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CHINA: Saying Goodbye to the Aging Population and One Child Policy

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ZIKA: What History Can Tell Us About the Current Epidemic

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CANCER: Risks Associated with Red and Processed Meats

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Cancer Research. Retrieved from http://www.aicr.org/assets/docs/pdf/brochures/ red-processed-meats.pdf.

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HIV/AIDS: The Limits of Moral Ideology

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ADDRESSING URBAN VIOLENCE: The Cure Violence Public Health Approach

By Sophia Kecskes 1. Hackman, M. & Peters, M. (July 6, 2015). One boy’s death draws renewed attention to Chicago’s street violence. The Wall Street Journal. Retrieved from http://www.wsj.com/articles/one-boys-death-draws-renewed-attention-to-chicagos-street-violence-1436220637.

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3. Madhani, A. (September 29, 2015). Six killed in another surge of violence in Chicago. USA Today. Retrieved from http://www.usatoday.com/story/ news/2015/09/29/chicago-homicides-leave-six-dead-eight-wounded/73020014/.

4. Papachristos, A. (November 3, 2015). “Connected in crime: Using network science to explain urban gun violence.” New Haven and the American City.

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6. Papachristos, A. & Wildeman, C. (2014). Network Exposure and Homicide Victimization in an African American Community. American Journal of Public Health 104(1): 143-150. Retrieved from http://ajph.aphapublications.org/doi/ full/10.2105/AJPH.2013.301441.

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AUTISM: Experiences in the Pediatric Emergency Department

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2. Physical Restraint, Medication and Seclusion of Persons Receiving Care, Education or Supervision in an Institution or Facility, Chapter 814e. (2011).

Connecticut General Assembly. Retrieved from https://www.cga.ct.gov/current/ pub/chap_814e.htm.

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4. Bechtel, T. (2014, March 28). Considerations for EMS response to Autistic patients. EMS World. Retrieved from http://www.emsworld.com/article/11362588/considerations-for-ems-response-to-autistic-patients-and-undertanding-autism-challenges-in-emergency-situations.

5. Tint, A., Robinson, S., & Lunsky, Y. (2011). Emergency department assessment and outcomes in individuals with Autism Spectrum Disorders. Journal on Developmental Disabilities, 17(2), 56-59.

6. Dorfman, D. H., & Mehta, S. D. (2006). Restraint use for psychiatric patients

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in the pediatric emergency department. Pediatric Emergency Care, 22(1), 7-12.

7. McDermott, S., Zhou, L., & Mann, J. (2008). Injury treatment among children with autism or pervasive developmental disorder. Journal of Autism and Developmental Disorders, 38(4), 626-633.

8. Kalb, L. G., Stuart, E. A., Freedman, B., Zablotsky, B., & Vasa, R. (2012).

Psychiatric-related emergency department visits among children with an autism spectrum disorder. Pediatric Emergency Care, 28(12), 1269-1276.

9. Soto, E. C., Frederickson, A. M., Trivedi, H., Le, A., Eugene, M. C., Shekher, M., . . . Correll, C. U. (2009). Frequency and correlates of inappropriate pediatric psychiatric emergency room visits. The Journal of Clinical Psychiatry, 70(8), 1164–1177.

10. Brookman-Frazee, L., Drahota, A., Stadnick, N., & Palinkas, L. A. (2012).

Therapist perspectives on community mental health services for children with Autism Spectrum Disorders. Administration and Policy in Mental Health and Mental Health Services Research, 39(5), 365-373.

11. Croen, L. A., Najjar, D. V., Ray, G. T., Lotspeich, L., & Bernal, P. (2006). A comparison of health care utilization and costs of children with and without autism spectrum disorders in a large group-model health plan. Pediatrics, 118(4), e1203-e1211.

FECAL MICROBIOTA TRANSPLANTATION: The Future of Feces

By McKenna Tennant 1. Murray, C. & Ng, M. (n.d.). Nearly one-third of the world’s population is obese or overweight, new data show. Institute for Health Metrics and Evaluation. Retrieved from http://www.healthdata.org/news-release/nearly-one-thirdworld’s-population-obese-or-overweight-new-data-show.

2. Borody, T. & Khoruts, A. (2012). Fecal microbiota transplantation and emerging applications. Nature Reviews Gastroenterology and Hepatology, 9(2), 8896.

3. Surawicz, C. M., Brandt, L. J., Binion, D. G., Ananthakrishnan, A. N., Curry, S. R., Gilligan, P. H., ... & Zuckerbraun, B. S. (2013). Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. The American Journal of Gastroenterology, 108(4), 478-498.

4. Treatment Formats. (n.d.). OpenBiome: The Microbiome Health Research Institute. Retrieved from http://www.openbiome.org/safety/.

5. Enemas. (n.d.) Gale Encyclopedia of Medicine. Retrieved from http://medical-dictionary.thefreedictionary.com/Enemas.

6. Marks, J.W. (2014). Colonoscopy. MedicineNet.com. Retrieved from http:// www.medicinenet.com/colonoscopy/article.htm.

7. Types of feeding tubes and terms to know by the Feeding Tube Awareness Foundation. (n.d.). RAREDaily by Global Genes. Retrieved from https://globalgenes.org/raredaily/types-of-feeding-tubes-and-terms-to-know-by-the-feedingtube-awareness-foundation/.

8. What is Fecal Microbiota Transplant? (n.d.). The Fecal Transplant Foundation. Retrieved from http://thefecaltransplantfoundation.org/what-is-fecaltransplant/.

9. About the Human Microbiome Project. (n.d.). NIH Human Microbiome Project. Retrieved from http://hmpdacc.org/overview/about.php.

10. Belkaid, Y. & Hand, T.W. (2014). Role of the microbiota in immunity and inflammation. Cell,157(1), 121-141.

11. Purchiaroni, F., Tortora, A., Gabrielli, M., Bertucci, F., et al. (2013). The role of intestinal microbiota and the immune system. European Review for Medical and Pharmacological Sciences, 17(3), 323-333.

12. Wu, H. & Wu, E. (2012). The role of gut microbiota in immune homeostasis and autoimmunity. Gut Microbes, Volume 3(1), 4-14.

13. Nield, D. (2016). Human trials will test freeze-dried poop pills as a weightloss treatment. ScienceAlert. Retrieved from http://www.sciencealert.com/human-trials-will-test-freeze-dried-poop-pills-as-a-weight-loss-treatment.

14. van Nood, E., Speelman, P., Nieuwdorp, M., & Keller, J. (2014). Fecal microbiota transplantation: facts and controversies. Current Opinion in Gastroenterology, Volume 30(1), 34-49.

15. About. (n.d.). OpenBiome: The Microbiome Health Research Institute. Retrieved from http://www.openbiome.org/about.

16. Clostridium difficile Infection Information for Patients. (2015) Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/hai/organisms/cdiff/Cdiff-patient.html.

17. Lessa, F.C. et al. (2015). Burden of Clostridium difficile Infection in the

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United States. New England Journal of Medicine, 372(9), 825-834.

18. Kinross, J.M. et al. (2008). The human gut microbiome: Implications for future health care. Current Gastroenterology Reports, 10(4), 396-403.

19. Guidance for industry: Enforcement policy regarding investigational new drug requirements for use of fecal microbiota for transplantation to treat Clostridium difficile infection not responsive to standard therapies. (2013). US Food and Drug Administration. Retrieved from http://www.fda.gov/biologicsbloodvaccines/guidancecomplianceregulatoryinformation/guidances/vaccines/ ucm361379.htm.

20. FMT and the FDA. (n.d.) OpenBiome: The Microbiome Health Research Institute. Retrieved from http://www.openbiome.org/the-basics/.

21. Aroniadis, O.C., Brandt, L.J. (2013). Fecal microbiota transplantation: Past, present, and future. Current Opinion in Gastroenterology, 29(1), 79-84.

22. Alang, N. & Kelly, C.R. (2015). Weight gain after fecal microbiota transplantation. Open Forum Infectious Diseases, 2(1).

23. Adiposity. (n.d.). Merriam-Webster Dictionary. Retrieved from http://www. merriam-webster.com/medical/adiposity.

24. Ridaura, V.K. et al. (2013). Gut microbiota from twins discordant for obesity modulate metabolism in mice. Science, 341(6150), 1241214. http://science.sciencemag.org/content/341/6150/1241214.full-text.pdf+html.

25. Valiquette, L., Sirard, S., & Laupland, K. (2014). A microbiological explanation for the obesity pandemic? The Canadian Journal of Infectious Diseases & Medical Microbiology, 25(6), 294-295.

26. Tsai, F., Coyle, W.J. (2009). The microbiome and obesity: Is obesity linked to our gut flora? Current Gastroenterology Reports, 11(4), 307-313.

27. Ley, R. E. (2010). Obesity and the human microbiome. Current Opinion in Gastroenterology, 26(1), 5-11.

28. Yu, E.W. (2016). Fecal microbiota transplant for obesity and metabolism.

ClinicalTrials.gov. Retrieved from https://clinicaltrials.gov/ct2/show/study/ NCT02530385.

29. Smith, P.A. (2014, February 17). A New Kind of Transplant Bank. The New York Times. Retrieved from http://www.nytimes.com/2014/02/18/health/a-newkind-of-transplant-bank.html.

TURNING A BLIND EYE: A Look at Unjust Health Outcomes among the Deaf, Blind, and Physically Disabled

By Holly Robinson 1. Disability and Health. (2015). The World Health Organization. Retrieved from http://www.who.int/mediacentre/factsheets/fs352/en/.

2. Disability and Socioeconomic Status. (n.d.). American Psychological Association. Retrieved from http://www.apa.org/pi/ses/resources/publications/factsheet-disability.aspx.

3. People with Disabilities. (2012). International Federation of Social Workers.

Retrieved from http://ifsw.org/policies/people-with-disabilities/.

4. McDaniels, A. (2015). Deaf patients say it can be difficult to communicate at hospitals. The Baltimore Sun. Retrieved from http://www.baltimoresun.com/ health/maryland-health/bs-hs-sign-language-hospital-20150913-story.html.

5. Weisberg, D. (2012). The Psychological Wellbeing of the Deaf Community: A Social Exclusion Perspective. Retrieved from https://www.academia. edu/1711910/The_Psychological_Wellbeing_of_the_Deaf_Community_A_Social_Exclusion_Perspective.

6. Dr. Judith Ann Pachciarz. (n.d.). National Library of Medicine. Retrieved from https://www.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_244.html.

7. Issues in Social Skills & Sex Education. (n.d.) Perkins School for the Blind.

Retrieved from http://www.perkinselearning.org/videos/webcast/issues-social-skills-sex-education#chapter4.

8. Maart, S. & Jelsma, J. (2010). The Sexual Behavior of Physically Disabled Adolescents. Disability and Rehabilitation, 32(6), 438-43.

9. Lehtomaki, E. (2001). Inclusion and Deafness: Linking the Family, School and Community. Enabling Education Network. Retrieved from http://www.eenet. org.uk/resources/docs/lehtomaki.php.

10. About Us. (n.d.). National Association of the Deaf. Retrieved from http:// nad.org.

11. What: Taking Action in Situations of Poverty and Exclusion, Conflict and Disaster. (2016). Handicap International. Retrieved from http://www.handicap-international.us.

YALE GLOBAL HEALTH REVIEW