YGHR Vol 3 No 1

FALL 2015

VOL. 3, NO. 1

THE YALE

GLOBAL HEALTH REVIEW

CHINA:

THE NOT-SOSWEET RISE OF TYPE 2 DIABETES

BY MICHAEL MARCEL P. 24

Human Health and Climate Change: The Co-Benefits of Climate Change Mitigation

New in Tech: Yale Undergraduates Develop Neonatal Sepsis Diagnosis Test

India: Resilience-Based Responses to Sexual Violence

By Claire Chang p. 19

By Alexandru Buhimschi p. 22

By Aaron Berman p. 30

CONTENTS

LETTER FROM THE EDITOR FALL 2015

VOL. 3, NO. 1

ABOUT THE COVER ART

Dear Readers, We are thrilled to release our first edition of the Yale Global Health Review as Editors-in-Chief. The hours spent on this issue seem to be countless, and we’re really excited to share these articles with the Yale community. Both of us are deeply passionate about global health and hope that the following pages will help raise the prominence of these topics on campus and spark conversations about what students can do to help. These undergraduate student-written articles range in topic from one student’s experience teaching sexual education to girls in Tanzania to a shocking portrayal of the mental health impacts of work in a slaughterhouse.

Production & Design Editors Julia Carnes Al Nurani Selcen Yuksel YALE GLOBAL HEALTH REVIEW: VOLUME 3, ISSUE 1

Business Team Caroline Tangoren Jennifer Godfrey Writers & Photographers Aaron Berman, Anna-Sofia Young, Alexandra Cadena, Alexandru Buhimschi, Carlin Sheridan, Claire Chang, Chloe Yee, Farah Al Hadid, Hanh Nguyen, Mara Blumenstein, Max Goldberg, Michael Lebwohl, Michael Marcel, Sofia Lapides-Wilson, Sophia Kecskes, & Vincent Tran

by Alexandru Buhimschi

MENTAL HEALTH

A CALL TO ACTION 4

by Claire Chang

by Michael Lebwohl

THE ANTI-VACCINE MOVEMENT 44

NIAID

by Farah Al Hadid

WOMEN’S HEALTH

Find us online at www.yaleglobalhealthreview.com or email us at yaleglobalhealthreview@gmail.com.

TANZANIA 34

Resilience-Based Responses to Sexual Violence

The Girls’ Group

by Sofia Lapides-Wilson

by Aaron Berman

FEATURE ARTICLE

HAITI 10

Access and Implementation of Reproductive Rights in Urban Haiti

CHINA 24

by Mara Blumenstein

by Michael Marcel

DRC 52

Midwife Certification & The Key to Reduced Maternal Mortality

The Not-So-Sweet Rise of Type 2 Diabetes

Emile B

OP-ED

VIETNAM 7

Height Initiative Faces Growing Criticism

by Anna-Sofia Young

by Hanh Nguyen

PHOTOGRAPHY MORE ONLINE...

FIELD EXPERIENCE

INDIA 30

UK DFID

by Alexandra Cadena

Mental Health of Syrian Refugees in Jordan

by Carlin Sheridan

Nevil Zaveri

Will Newly Found Drugs Stop the Emerging Tuberculosis Outbreak?

SYRIA 54

A Lesson in Ignorance

SPONSORS We would like to thank the Yale Global Health Leadership Institute, Yale China, and the Yale Undergraduate Organizations Committee for their support.

Psychological Harm in Slaughterhouse Workers

TEIXOBACTIN 50

Farm Studio Field

Associate Editors Beah Jacobson Lexi Butler Katherine Fang Amy Chang Kevin Nguyen Shea Jennings Julia Yao Akhil Upneja

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.

Yale Undergraduates Develop Neonatal Sepsis Diagnosis Test

Nick F

The Co-Benefits of Climate Change Mitigation

ABOUT US

Online Editor Lelina Chang

NEW IN TECH 22

HUMAN HEALTH AND CLIMATE CHANGE 19

We hope you enjoy this issue which features a diverse set of opinions and backgrounds authored by Yale students from all around the world. We aim to foster a rich dialogue about these issues so please feel free to contact our writers or our executive board to share your thoughts!

Arts Director Rosa Chung

ANGOLA 16

by Vincent Tran

Rosa Chung (SY ‘18) wanted to depict the omnipresent and pervasive influence of fast food in China through her artwork. The hamburger, coupled with the Chinese flag, symbolizes the westernization of China’s growing food market and it’s deleterious effects on health.

Editors-in-Chief Sophia Kecskes Amber Tang

INNOVATION

Health Care in a War-Torn Country

We believe improving health worldwide is one of the most important issues of the early 21st century. The field of global health is currently gaining prominence on Yale’s campus and abroad. One’s ability to live a happy, successful life is directly tied to their health, and the universal human right to health is deeply interconnected with other fields such as politics, medicine, law, and economics. True health improvements, therefore, need to be achieved through a collaborative, international effort which unites individuals across disciplines.

Best wishes, Amber Tang and Sophia Kecskes

GLOBAL HEALTH TODAY

QUBRADA CALI 36

by Chloe Yee

Flickr M M

UNITED STATES 47

Hippocratic Loyalties and Unwilling Judges

by Max Goldberg

UGUANDA 40

by Sophia Kesckes

MENTAL HEALTH

A CALL TO ACTION:

Psychological Harm in Slaughterhouse Workers

“D

By Michael Lebwohl

own in the blood pit they say that the smell of blood makes you aggressive. And it does. You get an attitude that if that hog kicks at me, I’m going to get even. You’re already going to kill the hog, but that’s not enough. It has to suffer. When you get a live one you think, Oh good, I’m going to beat this sucker.1 These words do not come from the mouth of someone that society would classify as mentally well. However, they are words that sadly represent a class of workers present in civilized countries across the world: slaughterhouse workers. In America alone, over seventy thousand individuals work on slaughter lines2 and face the daily burden of killing several hundred animals every hour.3 These workers perform a job that, by its very nature, puts them at risk of psychological disorder and pathological sadism.

This risk emerges from a combination of many factors of slaughterhouse work, one of which is the stressful environment that slaughtering creates. A large portion of this stress comes from the exceptionally high rates of injury among the workers. Slaughter facilities boast nonfatal injury rates of up to twenty out of every hundred workers, a proportion that is steadily decreasing but still makes meatpacking far and away the most dangerous profession in the United States.3 This monstrous rate mainly comes from everyday workplace hazards that are especially present in slaughterhouses, such

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as repetitive motions and heavy lifting. Yet, a significant portion comes from other, unpredictable dangers that serve as a more severe sources of everyday stress. Employees’ interactions with live, frightened, and dangerous animals that must be contained and controlled means that every minute of work is another minute of profound danger.

The workers who are most acutely in danger are those that belong to a group called “stickers,” or workers who slit the throats of animals so they bleed out. Theoretically, all non-poultry livestock must be stunned before being bled out, generally with a contained bolt-gun or “knocker,” or by a large electrical shock. In many operations, however, this is rarely achieved.

Foremen often tinker with the settings on knockers and electric shock guns in order to protect the quality of the meat and set line speeds to be excessively fast, leading to conscious, active animals often flying down the line towards stickers. The stickers then face the danger of being struck by the large, terrified animals. Making this more perilous, and thus more stressful, is the fact that

Watershed Post

the stickers hold sharp knives for the purpose of sticking the animals. These knives, when combined with the kicking animals, put stickers at risk of injuries ranging from the cosmetic to the gruesomely fatal.1,4 However, the dangers of slaughterhouse work are not unparalleled. Many industrial jobs come with hazards that contribute to worker stress. However, slaughterhouse work is unique among major industries due to its innate violence. Though there have been few truly scientific attempts to quantify how this violence affects slaughterhouse workers’ mental health and behavior, one of the most prominent studies investigat-

YALE GLOBAL HEALTH REVIEW

ed the impact of having a slaughterhouse in a community on crime rates within that community, using this as a metric for psychological health. The study used the FBI’s Uniform Crime Report date in combination with the US Census to look at how crime rates changed as new industries came to town. They took data for over five hundred counties between the years 1994 and 2002, and then compared slaughterhouses’ effect on crime to that of other industries. Though the industries they used for comparison were nearly identical in other predictors of changes in crime (namely worker demographics, potential to create social disorganization, and effect on unemployment

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in the surrounding areas), slaughterhouses outstripped all others in the effect they had on crime. They led not only to a larger increase in overall crime, but, disturbingly, disproportionate increases in violent crime and sexual crime.5

“I’ve had ideas of hanging my foreman upside down on the line and sticking him. I remember going into the office and telling the personnel man I have no problem pulling the trigger on a person—if you get in my face I’ll blow you away.”1

The authors of the crime study theorized that the reason for this increase was “spillover” in the psyches of the slaughterhouse workers, an explanation that is backed up by sociological theory and anecdotal evidence.6 This is seen in one worker’s testimony about how working a long shift slaughtering livestock affected how he viewed and treated his coworkers:

Social theorists would consider this behavior to be a “progression” from animal abuse to human violence.6 However, this progression is distinct from the typical progression discussed in sociological and psychological literature. Most of the relevant literature addresses animal abuse preceding homicide6 or domestic abuse7 cases where the mental predisposition to abuse

5

symptoms similar to those of individuals who are recipients of trauma: substance abuse, anxiety issues, depression, and dissociation from reality.8 Once again, studies of this psychological phenomenon have largely ignored the slaughterhouse worker community, but they have addressed the issue in analogous populations, primarily Nazis and executioners.8 Without resorting to formal study, however, it is still possible to see that the symptoms (and causes) of PITS fit neatly with slaughterhouse workers’ testimonies about their experiences:

Southern Foodways Alliance

“And then it gets to a point where you’re at a daydream stage. Where you can think about everything else and still do your job. You become emotionally dead.1 So a lot of guys at Morrell [a major slaughterhouse] just drink and drug their problems away.

Some of them end up abusing their spouses because they can’t get rid of the feelings. They leave work with this attitude and they go down to the bar to forget.”1 These stories echo those of combat veterans and survivors of disasters who suffer from stress disorders. The need to dissociate from reality to continue with their work leads individuals down a path that some may term “pathological”.

seniju

Top: A worker in a slaughterhouse, preparing meat to be sent off for further processing and consumption.

Bottom: Pigs hanging from the ceiling in a typical American slaughterhouse.

already exists and animals serve as a convenient outlet for aggression, a relatively easy first step before moving to human targets. In slaughterhouses, the predisposition to abuse is not necessarily preexisting, but killing animals may serve a similar purpose in those without a predisposition as it does in those with one by acting as a first step that desensitizes workers to further violence aimed at humans.

“good” moral character and having another self that can mechanically end lives for hours each day not only serves as another source of psychological stress for workers, but exposes workers to the risk that their pathologically un-empathetic work selves will slip into their community lives. This is another explanation for the “spillover” that affects slaughterhouse workers’ minds and communities.

Psychologically speaking, this desensitization may also be explained through the mechanism of “doubling,” in which individuals are compelled to create dual selves, one good, one bad.8 This coping mechanism is often necessary to deal with morally dubious employment. Doubling has most notably been studied in the case of Nazi doctors, a situation which may be comparable to the institutionalized and necessarily un-empathetic killing of animals in slaughterhouses.8 Creating and sustaining oneself with

A combination of these mental acrobatics and stressors contributes to psychological disorder, and specifically may create a type of post-traumatic stress disorder called perpetration-induced traumatic stress (PITS).8 Unlike many forms of traumatic stress disorders in which sufferers have been victims in a traumatic situation, sufferers of PITS are the “causal participant” in a traumatic situation.9 In other words, they are the direct reason for another being’s trauma. Living with the knowledge of their actions causes

6

Currently, slaughterhouse work is still a necessary evil in American society, and precisely because of this, it deserves more academic attention than it has received. Significant theoretical and anecdotal evidence underlies the idea that slaughterhouse work is mentally harmful. Yet, without hard, empirical, quantitative evidence to support that assertion, little can be done to ameliorate the situation. Studies that result in policy improvements to protect these workers are especially necessary considering that slaughterhouse workers generally come from demographics that lack the agency to stand up for their own rights, or to remove themselves from such profoundly damaging work conditions.3 Continued failure to acknowledge and address this issue is an inexcusable danger to workers’ personal health and the health of their communities.

www

Michael Lebwohl is a junior in Pierson College majoring in Chemistry.

He can be contacted at michael.lebwohl@ yale.edu.

YALE GLOBAL HEALTH REVIEW

OP-ED Guy Montag

VIETNAM:

Height Initiative Faces Growing Criticism

T

he Vietnamese government recently announced an ambitious USD 287 million plan aimed at increasing the average height of Vietnamese men and women. The plan seeks to raise height averages for 18-year-old men and women from current meager figures of 1.67 and 1.56 meters to 1.685 meters and 1.575 meters, respectively, by 2030. These statistics place Vietnamese people among the shortest in the region. Approved by Prime Minister Nguyen Tan Dung in 2011, the plan targets pregnant women and children from birth until 18 years of age. Action programs work to increase awareness and promote healthy habits, with heavy—almost exclusive—emphasis on milk consumption.1 At the core of this multimillion-dollar endeavor is the premise that the short stature of the Vietnamese people is caused by poor nutrition and lack of physical activity. In motivating the project, co-mastermind Dr. Do Thi Kim Lien of the National Nutrition Institute estimates the influence of genes on adult height to be only 23%, compared to 31% for nutrition, 20% for physical exercise, and 16% for environmental and other factors. Dr. Lien stresses the critical importance of school feeding programs, in particular the success of the Sữa học đường (literally translated as Milk in Schools) initiative, which collaborates with Vinamilk, Vietnam’s largest dairy corporation, to provide a glass of milk for preschool and elementary school children three times a week for the entire nine months of the school year.2

VOLUME 3, ISSUE 1

The feasibility of the plan has been put into serious question, and for a good number of reasons.

A FRAGMENTED VIEW OF NUTRITION In November of last year, VTV (Vietnam Television) partnered with the Ministry of Education to carry out a program called Vươn cao tầm vóc Việt (literally translated as Reaching for a New Vietnamese Height), which provided free physical checkups and nutritional advice for optimum growth achievement to students in Hanoi’s public junior high schools. The official broadcast of the program shows masses of students having their height- and weight-for-age taken, as well as bone mass measurements.

Even more, the broadcast shows adult height figures being predicted, before cutting to a brief interview with a student who states, rather robotically, that she will strive “to drink more milk, exercise more, and sleep before 11pm.”3 The more than two thousand students who participated in the program went home with the same message.

Current recommendations single out one “special” food—milk—and one “special” nutrient—calcium—for height growth and bone health. This and other similar initiatives fail to question whether milk’s predominance among available sources of calcium is ideal. A critical effect of this black-and-white, single-nutrient, single-food view is a woeful lack of knowl-

By Hanh Nguyen

edge of equally, if not more, efficient nutrient sources. Indeed, milk is promoted in Vietnam as a height-boosting super-food, to the exclusion of other calcium-packed non-dairy options.

While milk is certainly calorie-dense and nutrient-rich, we cannot cherry-pick nutrients in our food to absorb, but must instead consume the whole package. Overconsumption of calcium solely from milk, as it turns out, may even put one at risk to detrimental side effects from its other components.

Historically, numerous national height initiatives in Vietnam resulted in milk-drinking crazes, with the country ultimately ranking among the highest in milk consumption growth. Sales of white, flavored, and powdered milk along with other drinking milk products pushed VND 23.1 trillion (USD 1.1 billion) in 2013, a near-quadruple increase from eight trillion Vietnamese Dong (USD 379 million) in 2008.4 My childhood memories, for one, are riddled with colorful cartons of strawberry- and orange-flavored milk and drinking yogurt, which have become wildly popular in Vietnam in recent decades as break-time or after-school snacks.

In her book Re-imagining milk, Audrey Wiley points out the fact that politically and economically powerful nations tend to have the highest levels of milk consumption and the tallest citizens. This idea “creates a

7

package of meanings that allows milk consumption to be an essential ‘mark of new money.’” While this may explain the privileged status of milk in national nutritional recommendations and school feeding programs,5 there is little scientific evidence to support this favoritism.

First, it is likely that the recommended intake of calcium is highly exaggerated.

The minimum requirement based on scientific research is a mere 150-200 mg a day for adults. Citizens of many underdeveloped countries—much of the world’s population—consume 300-500 mg/day and develop healthy adult skeletons.6 Based on this observation, the World Health Organization acknowledges that 500 mg is sufficient, though they ultimately recommend an inflated 1000 mg.7 Meanwhile, the USA Food and Nutrition Board recommends up to 1000-1300 mg/day, and the National Nutrition Institute of Vietnam has followed in its footsteps. Thus, according to this standard, the 482 mg average daily calcium intake of Vietnamese people puts most people in the category of calcium deficiency, when they still consume well above the minimum requirement.8

Khanh Hmoong

8

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Dr. Do Thi Kim Lien of the National Nutrition Institute estimates the influence of genes on adult height to be only 23% compared to 31% for nutrition, 20% for physical exercise, and 16% for environmental and other factors.

”

A 1994 study of elderly men and women in Sydney, Australia similarly showed that higher dairy consumption was actually associated with increased fracture risk.12 Although a premature conclusion, the studies at the very least underscore that milk consumption growth can not be used as an appropriate metric for measuring health improvement.

Secondly, according to Nguyen Van Tuan, senior researcher on bone genetics at the Garvan Institute of Medical Research in Australia, there is very little evidence that genes only account for 23% of adult height achievement. The actual figure, Tuan notes, is likely to be much higher at 65-87%.9 Most importantly, deeply entrenched as it is, the view that height growth necessarily requires milk consumption remains unsubstantiated. Indeed, despite strong historical correlations between dairy consumption and height increase, studies that even begin to establish a causal relation between milk consumption and growth are virtually nonexistent. The few controlled supplementation trials that have been performed lack even a control group with any caloric equivalent of the milk supplement, making it impossible to draw conclusions about how milk consumption leads to differences in growth. These differences rarely exceed 1 cm in the first place, and the studies do not distinguish between the effects of the specific supplement and those of the higher general caloric intake.10

Compelling evidence suggests that deriving calcium from milk may result in increased rates of obesity and chronic diseases. According to Moschos & Mantzoros (2002), published in Oncology, the rise in Insulin-like growth factor I (IGF-1) levels is a powerful promoter of growth for cancers of the breast, prostate, lung, and colon.13 These findings are corroborated by provocative results from a large-scale study that documents in-depth interviews with tens of thousands of Japanese each year, analyzing diets and rates of major “diseases of modernity” since 1946. The study shows that in the same time frame that dairy consumption in Japan increased 15-fold from 5.5 pounds of dairy products per capita per year to 117.4 pounds, rates of cerebral vascular disease (strokes) increased by 38%, heart disease by 35%, and breast cancer and colon cancer by 77%. Furthermore, the physiology of young Japanese girls was also greatly altered, with the average girl experiencing menarche more than 3 years earlier.14

Further studies discount the widely accepted claim that drinking milk builds strong bones. The Harvard Nurses’ Health Study, a 12-year study of 78,000 women, found that women who drank milk three times a day later suffered from more fractures than those who rarely drank milk.11

Despite its important implications, the study largely fell into oblivion. The view that a diet without animal protein, like dairy, is not inherently “deficient” remains unpopular today, preventing critical scientific findings from reaching the radar of policy-makers.

YALE GLOBAL HEALTH REVIEW

VOLUME 3, ISSUE 1

16%

23%

20% 31%

A SUPERFICIAL GOAL At some point, one must ask if the goal of the Vietnamese government’s height initiative is a superficial, height-based national power or health improvement. These height initiatives raise a real public health threat—they divert attention away from the country’s actual health challenges.

Van Tuan notes pointedly that the money funneled into height programs would be more wisely invested in improving overall standards of living, including, for example, those of rural children stunted by malnutrition.15 Indeed, due to major budgetary constraints, as much as half of the population still lacks basic necessities such as clean water, which contributes to the continued prevalence of preventable infectious diseases—notably, malaria. Despite impressive progress since the 1990s, Vietnam’s healthcare system continues to face quality and access issues that often plague developing nations. In the 1990-2009 period, the infant mortality rate fell from 44.4% to 16.0%, the under-five mortality rate from 58.0% to 24.5%, and the maternal mortality ratio from 233 to 69 deaths per 100,000 live births.16 However, these levels remain concerning and are rooted in systemic issues that could be alleviated with greater governmental attention.

Specifically, weak incentives for doctors and healthcare providers to serve rural locals contributes to not only a general shortage of qualified health professionals but also a concentration of resources in urban areas. There is an overwhelming focus on the wealthier sections of society,17,18 while lower-income Vietnamese face a myriad of

“

Current recommendations single out one “special” food— milk—and one “special” nutrient—calcium—for height growth and bone health.

”

access barriers. Assuming access is possible, people must navigate through “maddeningly opaque bureaucracies,” countless “informal fees,” and their own distrust in the healthcare system.19

According to Nguyen Duc Hinh, president of Hanoi Medical University, equity-centered concerns must be a major focus for the success of the health system in Vietnam.20 With this in view, attention to height initiatives retards progress by erroneously shifting focus from the need for comprehensive reforms in at-risk communities to small-scale changes that have little meaning outside of the context of a middle-class, urban population. At a time when the majority of resources should be going towards furnishing basic healthcare services and rebuilding trust in a healthcare network, height efforts strike many as wasteful and absurd.

Ultimately, failure to consider all relevant scientific literature, together with a one-sided understanding of nutrition, give reason to doubt the feasibility and effectiveness of current measures to raise the height of Vietnamese people. Focusing on this superficial indicator detracts from more urgent equity-based public health concerns.

These observations reveal a critical need to reconsider domestic height initiatives as a whole.

www Hanh Nguyen is a junior in Morse College majoring in Sociology.

She can be contacted at hanh.nguyen@yale. edu.

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WOMEN’S HEALTH

R

eproductive and sexual rights encompass a woman’s right to control her body by making and implementing her own decisions.1 These rights include the right of access to information and the right to decide and control the spacing and timing of reproduction. Importantly, these rights are not limited to a woman’s right to make decisions about her personal reproductive choices. Rather, they also encompass the right to implement those decisions in order to establish control of her body, life, and livelihood.

In urban Haiti, demand for contraception is higher than in rural areas because people generally want fewer children. In urban areas, more children means more mouths to feed whereas in rural areas, more children means more hands to help produce food. Focusing on urban Haiti allows for an understanding of how well the demand for contraception is met. Two studies are highlighted, both conducted in urban parts of Haiti, to understand urban family planning. In the first, researchers from Duke University interviewed sixteen women from Leogane, Haiti, about their use of and views on contraception. In the second, researcher Catherine Maternowska observed a clinic in the city of Cite Soleil and interviewed the clinic’s patients. Both studies included extensive interviews with Haitian women, which provided valuable insight into the nuances of their family planning decisions. Although the opinions and experiences of these women do not represent those of all Haitian women, the interviews provide a personal look into Haitian family planning. A holistic investigation of reproductive rights may elucidate the path forward towards universal reproductive rights.

DEMOGRAPHICS OF HAITI While numbers only capture a small part of the story, they do provide a necessary background on the current state of reproductive rights. As of 2001, Haiti was the only country in the western hemisphere that fell into the “high risk” group when looking at pregnancy and childbirth. Haiti’s maternal mortality rate is among the highest in the world.2 Forty percent of Haitian women who are fertile, sexually active, and do not currently want to become pregnant do not have access to contraception.3 As of May 2013, the fertility rate was 1.5 children higher than the desired fertility rate, a difference that stems from the huge unmet demand for family planning. Furthermore, thirty-two percent of married women of childbearing age do not want to become pregnant and are not using contraception, and in both urban and rural Haiti, forty-six percent of women are not satisfied with their current contraceptive options.4 These statistics provide a glimpse into the dire state of reproductive rights in urban Haiti. Many women lack access to a reliable form of birth control, and many end up with more children than they can reasonably care for. Unwanted pregnancies also contribute to the high maternal mortality rate. The large difference in desired versus actual birth rates causes a strain on the already fragile Haitian economy and environment, as the high birth rate results in more mouths to feed and bodies to house.

HAITI:

Monik Markus

By Mara Blumenstein

Access and Implementation of Reproductive Rights in Urban Haiti 10

YALE GLOBAL HEALTH REVIEW

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Reproductive rights … rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.

International Conference on Population and Development, 1994

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EXPANDED DEFINITION OF REPRODUCTIVE RIGHTS

Leogane lacked factual information about modern birth control methods.

While the core tenant of reproductive rights is that people should be in direct control of their bodies5, it is important to note that a larger goal of modern movements toward more secure reproductive rights is to ensure woman’s empowerment and gender equality. It is not enough to focus solely on individuals when trying to improve reproductive rights. Cultural, religious, and economic factors are key to a woman’s ability to make and implement her own decisions.

Given the myriad of factors that impact a woman’s decision1, investigating the barriers that Haitian society impose on women’s reproductive rights is the first step in overcoming those barriers and guaranteeing women their rights.

Many of the women also mentioned the role of the community in spreading information about birth control. However, this means of inter-communication may be more harmful than helpful if it helps propogate misinformation within the community.

One woman explained her contraception education: “It is not in a seminar. It is not in school. It is during [a] sitting with adult people. When people say I’ll use birth control, you understand! When I asked what the timeline is, something to be taken for injection for not having more children. Afterwards, I got started on things.”6 Spreading birth control information via word of mouth often leads to misinformation. Yet, this persistent spreading of misinformation in Leogane exemplifies the existence of a strong community network.

CASE STUDY: LEOGANE In June 2012, a group of researchers working under Fan Yang of Duke University interviewed sixteen women of varying ages and socioeconomic statuses in Leogane, Haiti, a suburb of about 30,000 outside of Port-au-Prince. The goal of the study was to learn about the women’s uses and views of modern birth control methods.6 The study found several notable barriers to modern contraceptive use among the

“

The Leogane study highlights the fact that examining reproductive rights solely at the individual level does not provide a complete picture. The choices a woman makes are influenced enormously by her society. Factors like the beliefs of peers and family members, inadequate knowledge, and fear of side effects may limit women’s reproductive rights even if it seems that women are able to independently make their own choices. Capitalizing on strong Haitian social networks with the creation

As of 2001, Haiti was the only country in the western hemisphere that fell into the ‘high risk’ group when looking at pregnancy and childbirth. Haiti’s maternal mortality rate is among the highest in the world.

sixteen women. Many of the women mentioned that it was “widely recognized” that they should only begin using contraception after having had their first child for fear of becoming infertile. All sixteen women said they only began using contraception after having at least one child. Experiencing negative side effects or even just hearing about side effects from others also decreased birth control use. Another barrier was the use of traditional methods of contraception in place of modern methods. Some of the women in the study believed in the effectiveness of traditional methods such as the consumption of salt water and parsley as a means of contraception. This served as an indication that some of the women in

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of community groups to increase the flow of knowledge about modern contraceptives could support women’s abilities to make informed decisions about contraception.

In summation, the Leogane women interviewed generally had a positive view of birth control and, though they held some misconceptions, they fully understood the independence that family planning could help them achieve.6 CASE STUDY: CITE SOLEIL Cite Soileil, a densely populated city of 400,000 on the northern edge of Port-auPrince, provides the perfect urban location

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13 Feed My Starving Children Haiti

40% of Haitian women who are fertile, sexually active and do not want to become pregnant do not have contraception

for an investigation of women’s reproductive rights. Catherine Maternowska, an anthropologist specializing in reproductive health, conducted interviews with residents and observed a family planning clinic in Cite Soleil to analyze the correlation between health, contraceptive use, and quality of life of the women in the city. The clinic Maternowska observed receives most of its funding from USAID, which operates under the “quality of care” framework.2 This framework dictates that women should feel comfortable, taken care of, informed, and in control of their treatment. Clinics following these guidelines prioritize creating positive experiences for their patients instead of trying to maximize the number of patients served or the amount of contraception dispensed.2

“

As of May 2013, the fertility rate was

1.5 children higher than the desired fertility rate

reported that many of their questions were left unanswered.

Maternowska proposes an explanation for this treatment of patients in the stratification of social classes in Haiti. Clinic doctors would purposefully “distance [themselves] from social inferiors by emotional and physical means,” a practice that contradicts the USAID framework.2 Maternowska concluded that the clinic did not provide adequate care for the women it served. Not only did doctors ignore women’s questions, concerns, and preferences, but they also created a hostile environment that made procuring contraception difficult. Doctors took advantage of the power they had over the women, due to their socioeconomic status and education level, by treating them

...Doctors at the clinic did usually ask women what method of birth control they preferred, but would then ignore the answer when prescribing a method.

Women typically waited over an hour for a meeting with a doctor that lasted, on average, two minutes.

While beneficial in theory, these guidelines did not actually lead to quality care for the women served by the clinic. Maternowska observed that some doctors at the clinic did usually ask women what method of birth control they preferred, but would then typically ignore the answer the women provided when prescribing a method of contraception.2 Women typically waited over an hour for a meeting with a doctor that lasted, on average, two minutes. Once they finally met with a doctor, women experienced harsh treatment and generally

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as inferiors and making reproductive decisions for them.2 Maternowska found it clear that, “the clinic ‘had little do with satisfying people’s real needs.’”2 If this clinic is representative of other clinics in Haiti, then even women with access to a family planning resources are not guaranteed their full reproductive rights.

Although the Cite Soleil clinic failed to implement its “quality of care” guidelines, the underlying framework centered on helping each individual woman did, at

32% of married women of childbearing age do not want to become prenant and are not using contraception

least, exist. From this study, we can glean the valuable lesson that while the quality of care framework seems to be a good starting point, focus must be put on the actual implementation of the ideals it promotes.

BARRIERS TO FULL REPRODUCTIVE RIGHTS IN HAITI 1. Side Effects As discussed in both the Leogane and Cite Soleil case studies, a fear of side effects constitutes a large barrier for women in exercising their reproductive rights. In general, providers of family planning services often underestimate or even ignore the influence that side effects may have on a woman’s decision whether or not to use birth control effectively.7 2. Cost / Financial Burden The financial burden of contraception acts as a significant barrier for many Haitians. Some family planning administrators argue that when people have to pay even just a small amount for their method of contraception (as opposed to getting it at no cost), they are more likely to use it due to its increased perceived value. Maternowska questions this argument based on its lack of evidence, as well as the fact that this mindset belittles the client and his or her ability to make autonomous decisions.2 Moreover, patients at the Cite Soleil clinic discussed the “hidden costs” involved when seeking contraception. While the clinic was advertised as providing services at low to no cost, follow-up appointments and other expenses could lead to a substantial financial burden.2 Women in the Leogane study mentioned that the cost of transportation often prohibited them from being able to go to the free clinic.6

YALE GLOBAL HEALTH REVIEW

46%

5.3%

94%

of women are not satisfied with their current contraceptive options

of Haitian women ages 15 to 49 reported their partner using a condom regularly

of women had their health choices made by their husband or partner

PARTNERS AND GENDER ROLES Neither study provided considerable insight on the influence of male partners on a woman’s reproductive choices. However, according to a 2010 UN study, only 5.3% of Haitian women ages 15 to 49 reported their partner using a condom regularly. Haitian men’s refusal to use condoms because of the possibility of decreased sexual pleasure relates to the culture of male superiority that still permeates Haitian society.2 Similarly, a study of pregnant women in rural Haiti found that 94% of women had their health choices made by their husband or partner.2 Equivalent statistics for urban Haiti were unavailable, but it is likely that many Haitian women in urban areas also lack autonomy when making health decisions. The doctors of the Cite Soleil clinic seemd to view women as inferiors, resulting in poor treatment and unanswered questions. While socioeconomic differences between doctors and patients contributed to this disparaging treatment, gender roles also influenced the actions and attitudes of the male doctors.

CONCLUSION Currently, many women in urban Haiti are not guaranteed their full reproductive rights. In the future, family planning

VOLUME 3, ISSUE 1

Feed My Starving Children Haiti

should not be based on an attempt to lower the birth rate and control population growth. Rather, the motive for family planning should be to improve the level of universal rights in Haiti by providing women with the information and means to implement their family planning choices. Capitalizing on the strong information networks already present in Haitian communities could be one way to improve the level of family planning knowledge. In both aforementioned case studies, women received the majority of their family planning information from friends and family.

Increased collaboration between medical professionals and communities to take advantage of these networks and spread information would improve the accuracy of information that women receive. Regard-

less of what tangible steps are taken, the first priority should be to guarantee women their full array of reproductive rights. This will not only expand women’s individual freedoms and opportunities but will also promote economic growth and prosperity.

www

Mara Blumenstein is a sophomore in Silliman College. Mara is an undeclared major.

She can be contacted at mara.blumenstein@ yale.edu.

15

ANGOLA:

GLOBAL HEALTH TODAY

Health Care in a War-Torn Country

A

By Vincent Tran

long the Atlantic coast of Sub-Saharan Africa lies Angola, a country attempting to recover from decades of war and turmoil. Widespread tropical diseases, poor health care, and inadequate education all contribute to a startling life expectancy of fifty-two years, one of the lowest in the world.1 Compared to the US life expectancy of seventy-nine, the difference in quality of life is apparent. Angola’s struggle to rebuild its health care system is due in part to its deeply impoverished population, but largely is a result of its turbulent history.

From 1961 to 1974, Angolan nationalist parties fought against Portugal’s centuries-long colonial rule in a war for independence. After the war, these same parties struggled for power. This Guerilla warfare conflict was exacerbated by ethnic fissions, and was largely funded by illegal “blood diamonds.” Various factions also received support from foreign powers.

The main conflict occurred between the Soviet Union-supported “Popular Movement for the Liberation of Angola” (MPLA) government and the United States-supported “National Union for the Total Independence of Angola” (UNITA) opposition. This long conflict, which was fueled by Cold War hostilities, lasted for 27 more years and finally ended in 2002 when both nationalist parties signed a peace agreement. However, decades of war had left Angola in ruin; over 500,000 people were killed and a third of its population was displaced.2 Like much of Sub-Saharan Africa, Angola was home to numerous tropical diseases, and the country’s war-torn infrastructure was poorly equipped to provide quality health care to its constituents. Approximately 65 percent of medical facilities were destroyed; considering that a higher concentration of damage occurred in rural areas, this damage resulted in drastically limited access to healthcare.3 The uneven distribution of healthcare coverage has resulted in a severe inequities in quality of life, especially among children.

Children in rural areas are much more affected by malnutrition and lack of immunization than those living in urban areas. This disparity is even more apparent in children who live in areas that were seriously affected by conflict.4 For example, Luanda, the capital city, is a rapidly developing urban center and port at the forefront of Angola’s oil and mineral industries. On the other hand, cities such as Lubango have much higher incidences of tropical diseases and infant mortality. Now, cites like Lubango are beginning to receive more attention from international organizations to address these challenges. Despite this aid, however, regional inequities persist and there is a great demand for hospitals and clinics in rural areas.

Another key issue in Angola’s health care system is the lack of trained healthcare professionals. During the Angolan Civil War, many child soldiers were used for guerilla warfare. Forcefully recruited at an early age, these children did not receive any education during the war. Many of the soldiers

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Flickr Nite_Owl

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who were lucky to survive did return home after years of fighting, but they lacked the skills and education needed to pursue careers. Nearly an entire generation’s capacity to contribute positively to society was lost, a loss that disproportionately damaged the healthcare system. This “Lost Generation” found itself relying heavily on international organizations for medical care immediately following the war; the strikingly low supply of trained professionals meant few healthcare facilities were well equipped to handle the need.

Despite its weak infrastructure, Angola is one of the countries with the most natural resources in Sub-Saharan Africa. Capitalizing on these resources, which include enormous reserves of oil, natural gas, and minerals, has been a high priority for the Angolan government over the past several years. While this goal is laudable, it means that only a small proportion of the national budget is dedicated to the provision of public health services. However, Angola’s economic growth has actually been a key factor in the improvement of healthcare. Because many foreign oil and natural gas companies build facilities inside the country, they often provide health services and facilities for their employees. Many Angolans benefit from these private company provisions.

This is one example of how foreign influence may benefit more than just Angola’s economy in the long-term. Yet, because Angola is able to depend on these companies and international organizations for healthcare provision, the government has not emphasized rebuilding its national health care

system – this is unsustainable. Federal total health expenditure in 2012 was only 3.5

number of doctors in Angola is now approximately 3,000; triple 2005 levels.7

“

Nearly an entire generation’s capacity to contribute positively to society was lost; a loss that disproportionately damaged the healthcare system.

”

percent of gross domestic product (GDP), compared to the United States’ expenditure of 17.9 percent of GDP.5 Further, corruption and the capture of federal funds for private gain are prevalent in Angola – this hinders the efficacy of the already small budgetary allocation for healthcare.

Yet, despite these advancements, Angola still struggles to rebuild its health care system. The end of the civil war was relatively recent, and its effects are still very visible in society. Even in comparison to wars in other Sub-Saharan African countries, the Angolan Civil War was devastating. The road to recovery has been understandably slow, and unfortunately a large portion of the country has not observed improvements in its healthcare in over a decade.

However, despite the enduring effects of civil war, Angola has substantial resources and a rapidly developing economic structure that is on the path toward a modern healthcare system and improved quality of life for all. The past few years of progress have shown that readily available access to quality health care in Angola is not too far in the future.

Today, the state of Angola’s health care is noticeably improved. In the past several years, the government has opened five universities, forty-five health worker training schools, and several clinics. For now, foreign intervention aids the country with service packages that include mosquito nets, vaccinations, and other necessities.6 In Angolan national clinics where UNICEF staff distribute service packages, significant health improvements have been observed. Specifically, Cuba has emerged as an especially effective partner in healthcare improvements. A strong partner of Angola since the Angolan Civil War, Cuba recently sent 800 doctors to the Sub-Saharan African nation. Also, a significant number of Angolan doctors receive medical training in Cuba. Thanks to more widely available education and training opportunities, the

www Vincent Tran is a sophomore at the University of Texas at Dallas majoring in Biochemistry.

He can be contacted at triet.tran@utdallas. edu.

FACTS & FIGURES. EFECTS OF THE ANGOLAN CIVIL WAR (1975-2002)

AVERAGE LIFE EXPECTANCY- 2012 Angola

52 years 79 years

U.S.

>500,000 1/3 ~65%

people killed

of the population displaced

HEALTH EXPENDITURE, TOTAL (% GDP)- 2012

3.5%

of medical facilities destroyed

17.9% TIMELINE

Angola

18

GLOBAL HEALTH TODAY

U.S.

2002 MPLA & UNITA Peace Agreement

Nov. 1975 Independence from Portugal

1961-1975 War of Independence

Danumurthi Mahendra A farmer in the Bogor Regency of West Java, Indonesia ploughing a rice field during a drought. Due to lack of irrigation in rural areas, farmers who grow rain-dependent crops such as cucumbers, onions, and rice—staple foods in Indonesia—will be forced to delay planting or rely on other crops during droughts.

HUMAN HEALTH AND CLIMATE CHANGE: The Co-benefits of Climate Change Mitigation

By Claire Chang

1975-2002 Civil War

YALE GLOBAL HEALTH REVIEW

VOLUME 3, ISSUE 1

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T

he International Panel on Climate Change predicts that the global mean surface air temperature in 2016 to 2035 will be between 1 and 1.5°C warmer than the global mean temperature in 1850 to 1900.1 As one of this century’s biggest environmental threats, climate change influences both social and environmental determinants of human health. It is widely agreed by scientists that the effects of climate change on human health will be overwhelmingly negative.2 Scientists and public health organizations seek to understand the many ways that climate change has already, and will continue to, affect human wellbeing.

helminth infections. Other previously unaffected regions may also experience the emergence of these diseases.5 In addition, the climate change driven displacement of both human and animal populations could give rise to new diseases and infections. Droughts associated with climate change will likely cause food shortages, and the nutritional content of staple foods may fall as carbon dioxide levels rise in the atmosphere.6 Also, as ocean surface temperatures rise, toxic algal blooms may occur more frequently, and changes in ocean biochemical properties may lead to the con-

tamination of fisheries.2 In addition, more frequent extreme rainfall events may contribute to a rise in water-borne diseases.7

difficult to reduce global greenhouse gas emissions through policy and individual lifestyle changes.

Even when the human health effects of climate change are considered in isolation, climate change is an undeniable problem that must be addressed. It is important to remember that climate change is not only an environmental threat, but also poses serious human health risks. Carbon reduction policies have the “co-benefit” of improving human wellbeing.8 Unfortunately, social, economic, and political barriers make it

In September of 2014, Dr. Maria Neira, the director of the World Health Organization’s Department of Public Health and the Environment, offered specific recommendations about how to translate the scientific community’s increasing knowledge on the impacts of climate change into action. One of her recommendations is to maximize the “twin benefits” of efforts to mitigate climate change and improve human health.9 These “twin benefits” are vital justification for calls to reduce greenhouse gas emissions immediately.

“

Carbon reduction policies and behaviors can be designed to not only mitigate the human health risks associated with climate change in the long-term, but also provide immediate benefits to human health. The use of low-emission household cook stoves, for example, would both reduce emissions of air pollutants and greenhouse gases as well as significantly improve indoor air

As one of this century’s biggest environmental threats, climate change influences both social and environmental determinants of human health.

”

Climate change has many direct effects on human health. With mean global temperatures on the rise, extreme heat events are expected to increase.3 These heat waves not only lead to heat exhaustion, heat stroke, and death, but also can exacerbate preexisting diseases.4 Hurricanes and floods will occur more frequently; therefore, casualties from these events will rise. Climate change also increases cancer risk. The depletion of the ozone layer increases exposure to UV radiation, a substantial risk factor for skin cancer and cataracts. Furthermore, climate change has many direct effects on air quality. Rising concentrations of dust, fine particles, pollen, mold spores, and ground level ozone can raise the incidence of respiratory problems, as well as exacerbate preexisting respiratory conditions.2

Moreover, the indirect impacts of climate change on human health are even more numerous than the direct impacts.

Since precipitation patterns and temperature changes determine the breeding zones, maturation rates, and feeding patterns of vectors like mosquitoes and ticks, climate change is likely to affect the distribution and seasonal transmission of vector-borne diseases. In some areas, changes in climate may reduce the distribution of vector-borne diseases like malaria, Chagas disease, and

20

quality, which is a main cause of illness in many developing nations.10 A study in the United Kingdom found that interventions to improve the energy efficiency of households, such as changes in construction materials, fuel use, and ventilation, not only reduced carbon emissions, but also reduced disability adjusted life years in the population.11 Furthermore, many studies have demonstrated that establishing improved public transportation systems and promoting urban walking and cycling would both improve cardiovascular fitness and reduce emissions from vehicles.8 The impacts of climate change on human health vary by geographic region, and some populations are more vulnerable than others. The elderly, infants, and socioeconomically disadvantaged populations are particularly vulnerable to the adverse health effects of temperature extremes.2 People who live in areas with poor infrastructure are less able to access healthcare during floods or other extreme weather events. In places that already experience food insecurity and high rates of chronic

and infections diseases, the physical stress associated with climate change may have more acute effects on health.

Nevertheless, global climate change poses health risks for everyone across the globe. Atmospheric carbon dioxide levels continue to rise and climate change is becoming increasingly irreversible. Global greenhouse gas emissions must be reduced as soon as possible. The potential for climate change mitigation efforts to minimize serious health risks must serve as an impetus for more drastic policy and behavior changes.

www

Claire Chang is a sophomore in Pierson College. Claire is an undeclared major.

She can be contacted at claire.chang@yale. edu.

Marison Grandon/ Dept. for Intl. Develpment

Adrian Jones Above: A woman collecting water in a dried up riverbed in northern Kenya during a drought. In 2011, the Government of Kenya declared a national disaster due to the drought which affected more than 3.5 million people in the country.

Below: Dead fish in the Choptank River in Maryland, likely due to a toxic algal bloom.

YALE GLOBAL HEALTH REVIEW

OxFam East Africa A man in Somalia tending to his goats during the 2011 East Africa drought. Him and his family rely on livestock both as a source of food and means of living; however, due to the drought, the majority of his livestock have died from thrist and starvation.

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NEW IN TECH:

INNOVATION

Yale Undergraduates Develop Neonatal Sepsis Diagnostic Test

By Alexandru Buhimschi

M

ore than a third of the four million neonatal deaths occurring annually are caused by severe infections.1 Nearly one million of these annual deaths can be traced to neonatal sepsis, a bacterial infection in newborn infants.

Neonatal sepsis can arise early (≤3 days after birth) or late (4-90 days after birth).

Three quarters of newborn deaths occur during the first week of life, making early-onset neonatal sepsis (EONS) one of the biggest contributors to neonatal mortality.2 Moreover, since 41% of under-five deaths occur among newborn infants, treating EONS is critical for addressing the United Nations Millennium Development Goal Four, which seeks to reduce under-5 child mortality by two-thirds.3 While certainly challenging, it is estimated that this goal can be reached if effective health measures are provided during the first week of life.1 EONS is a global health problem that affects both the developed and the developing world. This is due, in part, to the difficulties associated with recognizing the vague signs and symptoms of the disease. Addressing this difficulty is a high priority for clinicians, and as a result, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) held a workshop in January to provide “evidence-based guidelines for the diagnosis and management of pregnant women and newborn infants suspected of neonatal sepsis”. The confusion amongst healthcare providers arises because the signs of sepsis in a mother and newborn are very nonspecific, making identification of infants in need of treatment very difficult. The constellation of perinatal risk factors guiding suspicion of EONS (e.g. maternal fever, preterm rupture of membranes, intra-amniotic infection, etc.) are neither sensitive nor specific and can lead the mother and newborn down very dis-

22

tinct disease pathways. It is not surprising then that “suspected” sepsis is one of the most common diagnoses made in the neonatal intensive care unit.4 Making the problem even more difficult, current diagnostic tests are not helpful in deciding which newborns are in need of immediate treatment .

The current standard of care in the US for diagnosing and treating EONS is to place any newborns with “suspected” EONS on intravenous antibiotics within 24 hours of birth. This practice is known as “empirical antibiotic therapy.”5 However, even the classification of “suspected” EONS is problematic due to the lack of an established set of criteria and antenatal risk factors for the disease. While antibiotics are effective, this practice of overtreatment has been shown to lead to adverse neonatal outcomes as well as an increased risk of generating antibiotic resistant strains of bacteria.6 Improving antibiotic administration practices is a national priority in the US, as evidenced by a 2014 Executive Order entitled Combatting Antibiotic-Resistant Bacteria. Following classification of the newborn as being “suspected” of EONS, the doctor then seeks to confirm “clinical” EONS. The final diagnosis of “clinical” EONS is made following a blood culture,

a diagnostic test that has not seen much refinement since its original development in the early 20th century. It is well known among practicing neonatologists that blood cultures show poor positive predictive value, and doctors will often keep newborns on antibiotics in spite of negative test results. One study even showed the ratio of non-infected to blood-culture-positive neonates treated with antibiotics was between 15:1 and 28:1.7 The technique assumes that conditions required for E. coli or Group B Streptococcus growth will also allow detection of other infectious strains, which is certainly not the case. Furthermore, blood cultures are expensive (often over $50 per test) and require trained lab personnel and equipment to be carried out reliably.

As such, blood cultures are impractical in the developing world, where EONS incidence and mortality is the highest. Furthermore, with time as critical as it is for EONS management, the 2-7 day timeframe for blood culture results to return prohibits selective initiation of antibiotic therapy.

Thus, there exists a clinical need for a test that reliably diagnoses EONS so that only newborns in need of treatment receive antibiotics. This would ensure that those who do not have the disease are not

>1/3 of the

4,000,000 neonatal deaths occuring annually are caused by severe infections

~1,000,000

of these can be traced to neonatal sepsis YALE GLOBAL HEALTH REVIEW

unnecessarily exposed to antibiotics and prolonged stays in the hospital environment, which by itself is a risk of late onset sepsis. The ideal EONS diagnostic test should be rapid, non-invasive, and usable without prior training. More than 99% of neonatal deaths occur in the developing world, and a quarter of these deaths can be attributed to neonatal sepsis.8 Given that half of all mothers in such countries do not receive skilled care during or immediately after birth,1 if an EONS diagnostic test is to reach its full global impact, it must be point-of-care and easy to use. In areas of the world where neonatal care is not easily accessible, information provided by such a diagnostic test could help direct limited resources to high-risk newborns in need of immediate care.

While Buhimschi et al. did not translate this work to a commercial product, the three students realized the potential for a haptoglobin test to change global EONS clinical practice. The team has currently developed an alpha prototype test for haptoglobin. The test has been optimized for conditions presented at the point-of-care

born as well as the risk of antibiotic resistances. In the developing world, where the burden of EONS mortality is the highest, this test would promptly identify the highrisk neonates in need of immediate care.

The team has identified India as an initial market due to its high incidence of EONS (~140,000 deaths per year), coupled with the need for rapid point-of-care tests in the rural regions of the country.11 To enter the market, they seek to target under-resourced Indian hospitals in urban environments with the facilities to administer treatment before moving the product into more rural areas of the country.

With the homebirth market comprising the majority of annual Indian births (15/25 million births occur at home), the test would be ideal for untrained birth attendants seeking to identify newborns in need of Recognizing the global impact higher levels of care. However, by of EONS and the lack of a reliable targeting urban hospitals initialdiagnostic test with functionally, the team believes it can build a ity in the developing world, three network amongst Indian clinicians Yale undergraduates, Alexandru to facilitate a progression built to Buhimschi ’17, Anoj Ilanges ’16, and enable fast adoption across the Jiahe Gu ’16, are currently workcountry. Rural clinics with fewer ing on a product that could solve well-trained personnel will be more these issues and change the clinical willing to integrate the test into their management of EONS worldwide. management of EONS newborns, The team is working with technolonce success is demonstrated both ogy that has the potential to give Possible Health in reducing hospital expenditures a diagnostic result within an hour, and in improving patient outcomes involves no direct puncture of A child on the fourth day of recovery from neonatal sepsis. at higher levels of care. Due to the the neonate, and is readily usable by anyone- even an untrained mother. The (e.g. heat stable, minimal sample prepa- low manufacturing costs associated with test relies upon detection of haptoglobin, a ration, etc.). Current focus is directed at lateral flow devices, this test could cost protein produced in much higher amounts building a platform that will allow easy clinics and hospitals as little as $3 per test. in the cord blood of EONS newborns. It is integration of relevant EONS biomarkers The team was recently accepted as part well known that haptoglobin is an acute- before moving to formal product developphase protein and acts as part of the innate ment. Following this phase, the team aims of the third cohort of the Yale Entrepreneurimmunity to sequester and degrade free to translate its prototype to a paper-based ial Institute’s Venture Creation Program. hemoglobin in the bloodstream. During in- lateral flow assay by the end of the sum- They aim to continue product development fection, it is likely that haptoglobin seeks to mer that can then be refined under regu- into the coming semesters with the final limit the oxidative capacity of hemoglobin latory constraints following consultation goal of attaining FDA approval within two and the metabolic advantages it confers to with professional microfluidics companies. years. Successful development and implementation of such a device would reliably bacterial pathogens. A study conducted in A new diagnostic test for EONS would diagnose neonatal sepsis, change clinical 2011 by Buhimschi et al. identified haptoglobin upregulation as being predictive impact clinical management of the disease practice, and most importantly, save lives. of EONS and poor neonatal outcome in a worldwide. Understandably, when bringcohort of 200 women. Moreover, the study ing a new diagnostic test to market, clini- We would like to acknowledge the valuable support showed haptoglobin to be superior to the cians are most concerned with the test’s we have received from Wendy Davis, Drs. Irina and current methods for classification of clinical ability to change clinical practice and im- Catalina Buhimschi, and Dr. Vineet Bhandari.

EONS. Using haptoglobin as a marker for prove patient outcome. In developed counwww sepsis would have reclassified nearly 30% tries, the problems with EONS manageof EONS diagnoses, directing treatment ment lie in the overtreatment of non-EONS Alexandru Buhimschi is a junior in Pierson to the proper newborns and eliminating newborns with empirical antibiotics. Such a College majoring in Molecular, Cellular, and test, in the developed world market, would unnecessary antibiotic exposure and assoDevelopmental Biology. ciated expenses.9 Buhimschi et al. issued a help to lower the number of unnecessary patent with Yale in 2014, describing the use antibiotic administrations, decreasing asso- He can be contacted at alexandru.buhimschi@ of haptoglobin as a biomarker for EONS.10 ciated long term consequences for the new- yale.edu.

VOLUME 3, ISSUE 1

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FEATURE ARTICLE

CHINA:

The Not-So-Sweet Rise of Type II Diabetes

By Michael Marcel

A typical McDonalds in Guangzhou, China

24

YALE GLOBAL HEALTH REVIEW

VOLUME 3, ISSUE 1

25 jo.sau

I

“

n 1987, KFC brought its signature fried chicken to Beijing, becoming the first Western fast food chain to open its doors in Mainland China. By 2011, the number of KFCs in China had grown to over 3,000 across 650 cities, with one new restaurant opened per day.1 McDonalds, Pizza Hut, and other American fast food joints are now ubiquitous in many Chinese cities and are one of the many signs of the rapid economic development that has occurred over the past several decades. However, recent changes in diet and lifestyle have also brought about a sharp increase in the prevalence of many chronic diseases. As the country with the world’s largest population (over 1.3 billion), such changes have serious financial and structural implications.

The meteoric rise in the prevalence of type II diabetes in China is particularly striking. While only 1% of the population was reported to have type II diabetes in 1980, the prevalence rose to 11.6% as of 2010; China now has the largest number of individuals with diabetes in the world.2 Alarmingly, 50.1% of the population is estimated to have prediabetes - a veritable ticking-time bomb without intervention.2 Over the course of China’s transition from a centrally planned economy to a market economy, the country has had extraordinary successes in health system reforms, especially in the fields of infectious disease, child and maternal mortality, and infrastructure. However, efforts to curb the rise of diabetes and other non-communicable diseases have been relatively slow. Alarmingly, representative samples suggest only 30.1% of those with diabetes are diagnosed and are aware that they have the disease.3 Furthermore, while type II diabetes continues to affect the growing elderly population, it is increasingly affecting young people and marginalized groups, which will undoubtedly be detrimental to quality of life, productivity, and health-care systems.

Costs associated with diabetes are projected to reach 360 billion RMB (almost 60 billion USD) by 2030.4

istolethetv

Humans evolved in a physically strenuous world where food was scarce and pathogens were prevalent; as such, our genes and traits have optimized efficient energy storage and swift stress and inflammatory responses.

”

istolethetv

Red bean and sweet taro pies can be found at McDonalds in China—an example of how Western fast food chains have adapted to Chinese markets.

“

In modernizing socieites characterized by food abundance, psychosocial stress, and physical inactivity, these genetic features may actually put us at risk of diabetes, obesity, and other chronic illnesses.

”

China’s economic transition has created what many call an “obesogenic environment,”8 in which rapidly changing lifestyle habits manifest themselves in weight gain and disease, such as type II diabetes. Prevailing theories on the creation of an obesogenic environment highlight how the mismatch between human biology and societal modernization can have negative consequences for human health. As the story goes, humans evolved in a physically strenuous world where food was scarce and pathogens were prevalent; as such, our genes and traits have optimized efficient energy storage and swift stress and inflammatory responses. However, in modernizing societies characterized by food abundance, psychosocial stress, and physical inactivity, these genetic features may actually put us at risk of diabetes, obesity, and other chronic illnesses.9 China’s economic boom and assimilation to western culture over the past several decades seem to follow this story. While traditionally, the Chinese lifestyle involved arduous physical activity and a low-calorie diet rich in carbohydrates and low in animal fat, globalization after economic reform in 1978 has led to increased consumption of sugar-sweetened beverages, animal products, and high-fat foods.10 However, east-west exchange is far from the only cause: high rates of tobacco use, increased consumption of refined rice and salt in recent decades, and increased use of cars associated with urbanization and modern lifestyle have also contributed to the creation of an obesogenic environment in many areas of China.10 Interestingly, the average daily caloric intake has not changed in past decades, implicating physical inactivity and dietary changes as the main drivers of obesity.11 The prevalence of over-

OVER THE YEARS...

Only 1% of the population was reported to have type II diabetes

“

The prevalence of diabetes rose to 11.6% and China now has the largest number of individuals with diabetes in the world

Alarmingly, representative samples suggest only 30.1% of those with diabetes are diagnosed and are aware that they have the disease.

26

1980s

KFC brings its signature fried chicken to Beijing as the 1st Western fast food chain to open its doors in Mainland China

”

2010-11

The number of KFCs in China grows to more than 3,000 across 650 cities

Costs associated with diabetes are projected to reach 360 billion RMB (~60 billion USD)

2030 Kyle Taylor

YALE GLOBAL HEALTH REVIEW

VOLUME 3, ISSUE 1

27

THE SCIENCE

jill brown

Type II diabetes is a metabolic disorder characterized by hyperglycemia, or high blood sugar levels, and insulin resistance, as well as relatively lower levels of insulin production. Normally, beta-cells in the pancreas produce the hormone insulin in response to higher than normal levels of blood sugar right after a meal. Insulin is dual-purposed, it not only maintains blood sugar levels within a non-toxic range, but also allows cells to metabolize glucose for energy production. However, in patients with type II diabetes, this system does not function harmoniously. In most patients, insulin resistance first develops before the onset of type II diabetes and is strongly linked to obesity. Insulin resistance is a physiological condition in which the cells in the body become less sensitive to the action of insulin, therefore reducing the blood glucose lowering effects of insulin, and forcing the pancreas to produce more and more insulin in an effort to reduce high blood sugar levels. Insulin resistance transitions into type II diabetes when beta-cell dysfunction also occurs, which means that these pancreatic cells can no longer produce enough insulin to compensate for the high levels of blood sugar. Type II diabetes can cause a number of complications over a person’s lifetime, including increased risk of cardiovascular disease, lower limb amputation, blindness, dementia, and frequent infections, as well as higher rates of hospitalization.5,6,7 Typically, type II diabetes is associated with a ten-year-shorter life expectancy.5

weight and obesity increased by 4.1 times in China from 1982 to 2002, and these statistics are only continuing to increase.12,13 While the broader societal trends fueling the diabetes epidemic in China seem to resemble the narrative in other rapidly modernizing countries, the pathophysiology of type II diabetes in Chinese and other East Asian populations is also of interest.

A nationwide study in China concluded that the Chinese population is especially susceptible to type II diabetes, developing the disease at a considerably lower BMI than European populations.14 This means that while, on average, most Westerners developing diabetes are overweight or obese, most Chinese people developing type II diabetes are actually considered to be normal weight. This increased risk of diabetes at lower BMI has been partly attributed to the fact that East Asian populations, including the Chinese, have a tendency to accumulate fat viscerally, or in the abdominal region, compared to other ethnic groups.15 However, the biological intricacies of type II diabetes in the Chinese population do not stop there; the pathological conditions that lead to type II diabetes in the Chinese population are also distinct from those seen in other ethnic populations. In type II diabetes patients, the proportion of insulin resistance versus beta-cell dysfunction causing the disease differs. This means that some patients have insulin resistance and only a slight defect in beta-cell insulin production, while others have minor insulin resistance and beta-cell dysfunction is the main driver of their disease. In most westerners, insulin resistance is the initial and primary cause of type II diabetes. However, compared to other ethnic populations, Chi-

28

nese patients have worse beta-cell deterioration in the early stages of their disease.15 Considering these unique trends and the nature of the type II diabetes epidemic in China, it is important that strategies to prevent, manage, and treat this disease are not taken directly from other countries– in other words, China must write its own prescription in its fight against diabetes. The Chinese Ministry of Health has already made efforts to address this escalating public health crisis. In 2012, the China National Plan for Non-Communicable Disease Prevention and Treatment (2012-15) was formulated, proposing a long-term strategy to use public measures, inter-sector collaboration, and social participation to promote a healthier environment, integrate prevention with treatment, and reform the healthcare system. Initiatives targeted specifically at diabetes might include identifying and reaching out to high-risk individuals (prediabetics), and promoting self-management through education and support, with a specific eye toward maximizing the potential of new technologies that can allow for greater doctor-patient interaction and communication between healthcare providers.16 In the meantime, more research will be needed to understand the specific risk factors affecting Chinese populations in order to create the optimal policy approach.

“

A nationwide study in China concluded that the Chinese population is especially susceptible to type II diabetes, developing the disease at considerably lower BMI than European populations...The increased risk of diabetes at lower BMI has been partly attributed to the fact that East Asian populations, including the Chinese, have a tendency to accumulate fat viscerally, or in the abdominal region, compared to other ethnic groups.

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Michael Marcel is a senior in Ezra Stiles College majoring in Molecular, Cellular, and Developmental Biology.

He can be contacted at michael.marcel@yale. edu.

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WOMEN’S HEALTH

H

ow do vulnerable communities come to reckon with the unthinkable? The question of how best to respond to communal atrocities in the wake of violence has occupied much scholarly discourse in response to recent outbreaks of violent conflict.

In particular, a recent trend toward collective acknowledgement and verbal elaboration of trauma, an intervention technique designed as a cathartic release of the damage wrought by such violence, has emerged in both humanitarian and academic spheres. This trend contrasts strongly with historical precedent set by instances of collective amnesia—intentional silence surrounding shared trauma and community violence—providing ample space for comparison and analysis of the causal mechanisms behind resilience-based healing.

INDIA:

Resilience-Based Responses to Sexual Violence

Sexual violence is a frequently used tool in violent conflict, employed to inflict physical and emotional trauma on vulnerable populations. Communal reckoning with shared histories of sexual violence in community-led interventions is a critical mechanism undergirding resilience-based approaches to rape and other forms of sexual assault. For instance, feminist empowerment interventions against domestic violence in India illustrate the causative power of this collective reckoning both in the wake of violent conflict as well as in its absence.

By Aaron Berman

CONCEPTUAL FREAMWORK FOR COMMUNITY-LED INTERVENTIONS ON SEXUAL VIOLENCE Community-led interventions are central in responding to cases of conflict-related rape and other forms of sexual violence—in contrast to other frequently applied techniques such as medical treatment and recourse to legal and other structural forms of justice. Specifically, this framework defines ‘community-based’ or ‘community-led’ intervention as any intervention that does not rely on official government or judicial mechanisms to ameliorate the effects of violence. The marked absence of effective governmental, judicial, or other punitive mechanisms for handling reported cases of sexual assault is one of the primary factors necessitating community-led approaches in settings of conflict; therefore, community-based interventions take precedence over other modes of intervention in this conceptual model.

One of the key components of this framework, moreover, is its emphasis on resilience, which underlay all three identified classes of intervention to varying degrees. Stevan Hobfoll, the author of “Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence,” identifies five essential elements that effective resilience-based trauma interventions promote: a sense of safety, calming, a sense of self- and collective-efficacy, connectedness, and hope. These qualifiers are useful additions to a framework within which specific interventions can be systematically analyzed, because they offer concrete metrics against which a given intervention can be designated as “resilience-building.”1 EXTRA-GOVERNMENTAL ADJUDICATION OF DOMESTIC VIOLENCE IN INDIA Traditionally, women in India have faced significant levels of socially sanctioned domestic violence within the household. In addition to rape, moreover, impoverished Indian women have been faced with societally imposed marital restrictions in relation to the dowry system—depriving them of agency in their choice of marital partner. The burden of domestic violence—both physical and sexual—falls disproportionately on women living in low-income households in urban slum settings.2 In response to these grievances, Indian women have developed all-women courts, known as mahila panchayats, to empower and offer legal protection to women at risk for domestic violence and abuse. Action India, a Delhi-based NGO, has been instrumental in ensuring the successful creation of mahila panchayats as well as the execution of their punitive recommendations.

Ahron de Leeuw

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Significantly, the need for mahila panchayats in India grew out of a perceived failure of existing legal and judicial mechanisms to provide women with adequate redress of their domestic violence-related grievances.

One Indian woman described her experience with the mahila panchayat system as such:

Similarly, it must also be acknowledged that community-led interventions are not the only mechanisms by which societies can apply a resilience-based approach to healing from rape and sexual violence. In fact, many effective resilience-based interventions in cases of sexual violence successfully incorporate both community-led and structural or policy-based components.

Furthermore, provision of adequate and timely medical treatment for victims of rape in immediate conflict zones remains a key priority for humanitarian interventionists worldwide.

“

Law was made for justice...but, for us [women] the law means nothing. We’ve seen that the law, when it is implemented, doesn’t work for us. It actually works against us. But, we know what works...So, we decided to form our own panchayat—the mahila panchayat.3

”

The mahila panchayats are modeled after traditional community-led court hearings called biradari panchayats, which Action India has identified as fraught with caste-based corruption and patriarchal influence—a key instrument of suppressing slum-dwelling Indian women’s legitimate grievances against their husbands.3 As traditional biradari panchayats have a “long history and prominent place in the lives of slumdwellers,” the all-woman makeshift courts provide a recognizable context within which to realize collective behavioral change.2 Most significantly, the mahila panchayats actively engage the accused perpetrator of domestic violence in the intervention process, facilitating mutually agreed upon action steps between spouses to engender meaningful and lasting peace within the household.

Mahila panchayats came into existence in the absence of any Indian post-conflict scenarios. It may be noted tangentially, however, that although no significant experiences of interpersonal violence constitute the backdrop against which this iteration of women’s courts took shape, the structural violence that the women in question experience—given their low-income status in a country with sub-optimal standards of gender equality—is nonethe-

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Fig. 1: Conceptual diagram of community-based intervention in conflict-related sexual violence settings

less tangible and immensely significant.

Furthermore, recourse to mahila panchayats often entails reformative measures for the perpetrator of sexual violence. Thus, the case of extra-governmental adjudication of domestic violence cases in India provides a compelling argument emphasizing the effective power of collective reckoning in fostering resilience in fragile communities.

The formation of mahila panchayats for extra-governmental adjudication of domestic violence cases clearly employs resilience frameworks to collectively heal afflicted communities. In particular, its emphasis on creating courtroom structures filled entirely with women, many of whom have experienced similar incidents of domestic violence within their own homes, underscores the connectedness of women in a given residential community. Furthermore, the independent initiative by which mahila panchayats have been organized exclusively by women enhances the self- and collective-efficacy that Hobfoll identifies as central to resilience-based interventions.

Finally, the lasting resolution of domestic violence that the mahila panchayats have successfully created in Indian households is conducive to restoring and promoting safety, calm, and hope for a brighter future.

IMPLICATIONS FOR FUTURE INTERVENTIONS The majority of this analysis of sexual violence intervention strategies has focused on active and public acknowledgement of shared traumas as a pathway to resilience.

However, other intervention strategies

have previously relied on conscious collective forgetting as a healing mechanism.

Yet while ‘official amnesia’ has been embraced as a tool to reduce the possibility of recurring episodes of vindictive violence in certain post-conflict settings, such as in postwar Spain and Cambodia, younger generations of socially conscious youth have demanded public reckoning of past traumas, if for no other reason than “to ensure that there can never be a repetition” of such atrocities.4 Indeed, ‘official amnesia’ approaches to rationalizing conflict narratives eschew the principles of strong resilience-based interventions, precluding future generations from security in adopting a resolute ‘never again’ mentality toward incidents of violent conflict.

Community-led interventions alone are certainly prone to certain shortcomings in the scope of their effective power, and these limitations must be carefully considered when applying intervention strategies locally. Though collective acknowledgement of trauma has the capacity to provide the catharsis necessary for a resilience-based approach to healing from sexual violence, it nonetheless bears noting that “many can never recover from… terrible injuries and losses” associated with such violence.4 Therefore, while collective reckoning can be an impactful first step toward resilience building, it must not be conflated with the desired end result of augmenting the health of fractured communities. Rather, collective reckoning and bearing witness are crucial preliminary steps toward a much broader and more extensive communal healing process.

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This analysis of successful iterations of women’s courts prompts an equally important discussion—though one with drastically fewer concrete answers—of the community apparatuses available to male survivors of sexual violence. Though sexual violence in conflict and non-conflict settings has occupied the policy agenda of many local and international advocacy organizations, the experiences of men and boys who have been subjected to sexual violence is markedly absent from the majority of such discourse.5 Indeed, within the framework of the aforementioned intervention case study, no spaces exist for male survivors of sexual violence to share their experiences—to take part in the collective reckoning with experienced atrocities. Future interventions will do well to more pointedly accommodate the particular needs and experiences of male survivors.

It is clear that collectively bearing witness to communally experienced trauma is a key pathway through which resilience can be fostered in fragile or vulnerable settings—especially as it relates to healing in the wake of sexual crimes. The distinct sense of connectedness and collective efficacy that these interventions create are essential in fostering resilience in the face of crisis, even if such

resilience in itself is not able to fully ameliorate the physical and emotional trauma such violence can inflict on individuals. Most importantly, what these and other interventions share in common is a commitment to making visible the atrocities that are all too often kept hidden in conflict, post-conflict, and non-conflict settings alike.

The implications of the successes of community-led interventions are far-reaching and exceptionally fertile. Indeed, the act of bearing witness has effective applications that extend beyond the realm of sexual violence and community health. For example, “truth commissions” in post-conflict states such as Chile have been successfully employed as tools of collective reckoning with a shared past experience of wartime atrocities, with the goal of enumerating concrete action steps toward once again making communities, as well as entire nations, whole. More broadly, future interventions in conflict settings might make use of this resilience-based conceptual framework in order to mitigate experiences of trauma during immediate crises, rather than simply to promote communal healing after violence concludes.

In any case, the act of collective reckoning—of bearing witness to the unspeakable—is an undeniably effective tool in tailoring pointed resilience-based interventions in post-trauma settings.

www Aaron Berman is a senior in Saybrook College majoring in Global Affairs, is a Global Health Fellow, and is pursuing a Yale Masters in Public Health degree.

He can be contacted at aaron.berman@yale.edu.

British High Commision

A panel discussion on violence against women held in Chandigarh, India part of a worldwide series of events marking the Global Summit to End Sexual Violence in Conflict in 2014.

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FIELD EXPERIENCE

TANZANIA:

T

The Girls’ Group

he alarm went off at 6, and I dragged myself out of bed, ate the three pieces of white bread that constituted breakfast, and headed out to school. The walk to get there took about twenty minutes. I treked over a brook, through corn, banana and coffee fields, past small shops and even smaller mud houses. The children yelled mnzungu (white person in Swahili) as I walked past, and I greeted everyone I met with a smile and the appropriate greeting. Throughout it all, Mount Meru hovered above in the hazy background.

By Sofia Lapides-Wilson

I took a gap year between high school and college, and spent the fall semester living in a village outside of Arusha, Tanzania through a Global Routes gap year program.

While in Arusha, I taught 10th grade math.

I had four classes of 60 students, about half of whom spoke English. Only 20% of the 10th graders would pass the National Exam to enter their final years of high school. After school, my American partner and I ran a girls group, where we discussed sex education and emotional wellbeing.

This girls group was similar to what I’d done since middle school, when the teachers would separate the boys and girls, and then would give the girls the period talk.

None of my Tanzanian students had ever had a talk of this kind with their teachers.

Most of their information on health and wellness comes from their families or impersonal lectures in school. On the first day, we had the girls write an anonymous question on a notecard. Here were some of them: “What happen to me because I am sick every day head?”

“I am 15 years I live at -----. Why peoples likes to do the sex?

“Why the women can cry on the sex?”

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“There is a boy that I love, but he never love me back. I try to forget him but my heart cannot stop think about him and sometimes he make me jealous, angry, but I still love him. I need to get him out of my heart. What do I do? Please help me.”

“When mother have pregnancy and she suffers from HIV/AIDS, what things can she do to prevent her baby from this disease?”

“I’m 16 years old do I allowed to have a boyfriend?”

“Why is sexual between male and female?”

“If I’ve my boyfriend and he promised me that he will marry me and he staying away from me, should I wait for him or should I search another boy?

“There are some girls which are affected by HIV/AIDS what can I advise them?”

“How do I get my family out of poverty?”

We spent the next hour talking through them. How do you know when a boyfriend is being abusive? What should someone do when they are diagnosed with AIDS? We even said that sex does not have to be between a man and a woman, which is controversial and illegal in Tanzania. Moreover, many of the girls shared the misconception that if a boy says he loves you, that you have to love them back. We received six or seven notecards with the question, “what do you do if you don’t want a boyfriend and a boy says he loves you?” Questions like this reveal that there was little conception of the idea that these girls’ have a right to autonomy in their emotional lives. To follow up on this conversation, we talked through what it means to take care of yourself in a relationship, and how to self-advocate.

The conversation echoed any health class in the United States. Though, for some

questions, the stakes were higher. For example, homosexuality is illegal in Tanzania.

The question, “how do I get my family out of poverty?” can be one of life and death.

But, all the questions had the same essential teenage quality – how do I navigate relationships with my parents, friends, and boyfriends? What does it mean to grow up?

What is sex? And how do I believe in myself, and navigate the world before me as I move away from my parents and create a family of my own?

In its essence, global health focuses on promoting the wellbeing of people around the world. But often, this statistically driven field ignores the individuals themselves.

Tanzania desperately needs assistance to fight issues of malnutrition, malaria, and others; these efforts will improve the overall wellbeing of the society. Yet, I think some focus on the day-to-day sexual and mental wellbeing of students and individuals is essential to creating a healthy populace. Major depressive disorder is one of the leading causes of disability in the world, and is on the rise in low-income countries.

Addressing more simple issues, such as sex education and mental wellbeing, not only improves the overall wellbeing of a population, but also prevents sexually transmitted diseases and combats depression.1 While we continue to look at the big picture of health, we should also notice the small-scale aspects of health that can make a huge impact in young people’s lives.

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Sofia Lapides-Wilson is a junior in Davenport majoring in History.

She can be contacted at sofia.lapideswilson@ yale.edu.

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Chloe Yee is a sophomore in Davenport College majoring in History of Science, Medicine, and Public Health.

PHOTOGRAPHY FEATURE

She can be reached at chloe.yee@yale.edu.

QUEBRADA CALI W

By Chloe Yee

e arrived in Panamá Tocumen airport in the late afternoon. A group of 24 Yale undergrads, mostly strangers to each other and to the country, we found ourselves sardine-packed into a tiny bus. With our luggage and medications strapped to the roof almost two stories high, we headed towards a location that our translators could only describe as “East.” We arrived two hours later at El Palmar, where we would stay, a short drive away from Quebrada Cali. Jet lagged and generally dehydrated, we stepped off the bus and were immediately faced with the immense humidity of late-March. Turquoise, bright orange, and lime green colors of homes, fabrics, and the storefronts seemed to sway with the heat waves.

It would be in Quebrada Cali, a small, rural community vibrant and rich with colors and life, that the group of us would set up a week-long medical clinic offering dental care, consultations, and a

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fully-stocked pharmacy to the local people. We would come across newborn infants suffering from scabies, young mothers with parasitic infections, and over 200 people in need of critical medical attention, almost all of which were treatable or curable with the help of our two sole physicians, our supply of antibiotics and medications, and a little bit of hope.

We had a lot to offer the people in Panama, but not as much as they had to offer us. The entire community welcomed us without hesitation, the women of the Kuna Tribe laughed with us (or maybe at us), the children curbed our inner-adolescent desires and played soccer with us, and the local doctors showed us the true meaning of compassion, dedication, and altruism. We were no different than them, all looking towards one another for support, relying on those we call our friends and community, and ultimately gaining an appreciation for life that we had never before had.

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UGANDA

PHOTOGRAPHY FEATURE

I

n Uganda, community-based health promotion initiatives are vital.

These pictures strive to provide a sense of life in Uganda, and depict the strong communal ties that unite individuals both in rural and urban areas. Literacy support, healthy food, and supportive communities where youth feel loved and empowered help much more to promote health in rural villages than many of the fanciest, new technologies.

By Sophia Kecskes

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Sophia Kecskes is a junior in Pierson College. Sophia is a Global Health Fellow and is majoring in Political Science.

She can be reached at sophia.kecskes@yale.edu.

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GLOBAL HEALTH TODAY

THE ANTI-VACCINE MOVEMENT:

as many as 68 percent of children incompletely vaccinated.2 “According to World Health Organization data, such numbers are in line with immunization rates in developing countries like Chad and South Sudan.”2 The danger of unvaccinated children affects more than just the individual; as a society, we rely on herd immunity to quell the spread of disease. Herd immunity holds that there will be a threshold percent of every community inoculated against a disease. This barrier can protect the elderly, infants, pregnant women, and those who for medical reasons were unable to be vaccinated.

Perhaps the most recognizable and widely distributed of anti-vaccine arguments is the supposed link between the vaccination of children under two and the development of autism. The movement has found a martyr in Andrew Wakefield, the man who in 1998 published a study linking the measles mumps and rubella

A Lesson in Ignorance

By Carlin Sheridan

P

arents want what is best for their children. In the modern era where many first world families with the means to do so pursue healthy lifestyles centered on organic food, natural household care products, and homeopathic remedies, some have begun to question the safety and regulation of vaccines. Despite consistent and clear evidence proving the contrary, advocates continue to link vaccines to developmental disabilities such as autism. This mindset goes beyond mere ignorance; it is recklessly irresponsible and places entire communities at risk.

Beginning with Edward Jenner’s smallpox vaccine, inoculations have steadily developed over time to create a near perfect defense against a number of diseases that throughout history had devastating effects on humans. Polio, measles, rubella, mumps, and diphtheria are among the many illnesses that have nearly disappeared in developed countries due to their widely accessible vaccination programs. A study published in the New England Journal of Medicine “estimated the numbers of cases of polio, measles, rubella, mumps, hepatitis A, diphtheria, and pertussis that were prevented by vaccines by subtracting the

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reported number of weekly cases after the introduction of vaccines from a simulated counterfactual number of cases that would have occurred in the absence of vaccination.”1 Researchers estimate that a total of 103.1 million cases of these diseases have been prevented within the United States since the development of inoculations.1 The CDC currently recommends that children be vaccinated against 16 diseases. For many

years, these advancements in preventive care were celebrated as achievements that improved the health, safety, and comfort of our society. In recent decades, however, a misinformed minority has banded together to become more vocal and advocate on behalf of the anti-vaccine movement.

The pushback against the vaccination schedule that is currently recommended by most doctors and the CDC has emerged in primarily upper middle class and well-educated communities. It is rooted in distrust for the government and its relationship to pharmaceutical companies, as well as the recent trend in pursuing supposedly natural lifestyles. Doctors point to an entitled mentality prevalent among patients in the Internet era; some begin to feel as though they should have complete freedom to control their medical lives and that online research empowers them and enables them to debate medical theory with their physicians.

Advocates combat this message by arguing “that authoritarian, paternalistic approach[es] to medical care [aren’t] going to work in the 21st century.”2 Many of the areas at highest risk wikipedia are extremely wealthy communities in California, a state that allows parents to relatively easily submit a personal belief exemption (PBE) if they do not want to vaccinate their children in accordance with most school mandates. In certain parts of California, the average PBE rate is as high as 9.1 percent of preschool age children, with some schools having

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“

CDC Global

A young girl receiving an oral vaccine for polio.

(MMR) vaccine to the onset of developmental disabilities. The study was originally published in The Lancet, though the journal has since retracted the publication.

Wakefield examined twelve boys who had been diagnosed with autism around the time they received the MMR vaccine and concluded that the correlation indicated causation.3 This singular study set off a wave of seemingly untenable public response and backlash against vaccination.

It struck a chord with parents of autistic children who were desperate for any explanation for their children’s disability and spurred fear among parents everywhere that they were unknowingly damaging their children while trying to protect them. This anti-vaccine movement moved swiftly into media headlines, especially as celebrities like Jenny McCarthy and Jim Carrey jumped onboard as anti-vaccine advocates. This is noteworthy, considering that “24% of parents surveyed by the University of Michigan say they place “some trust” in information provided by celebrities such as McCarthy about the safety of vaccines.”4 The backlash against

The antivaccine movement is rooted in distrust for the government and its relationship to pharmaceutical companies, as well as the recent trend in pursuing supposedly natural lifstyles.

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Wakefield was immediate and widespread in the medical community. All efforts to replicate his research failed, and study after study showed that there was no link between the MMR vaccine and autism.

The Journal of Child Psychology and Psychiatry published a study that utilized Japan’s unique MMR vaccination program to examine the rates of incidence of Autism Spectrum Disorder for all children born between 1988 and 1992 in Yokohama, Japan.

“MMR vaccination rates declined from 69.8% in the 1988 birth cohort, to 42.9%, 33.6%, 24.0%, and a mere 1.8% in birth cohorts 1989 to 1992.”5 Despite the decrease in the rate of MMR vaccination, the rate of Autism Spectrum Disorders in the area rose and continued to rise even after MMR vaccination fell to zero coverage in more recent birth cohorts.

This is just one of many studies definitively concluding that there is no link between the onset of autism and vaccination. Andrew Wakefield had his medical license rescinded by a British General Medical Panel and it has since been shown that his work was teeming with ethical violations. For example, he failed to disclose funding from lawyers who were mounting a case against manufacturers, misrepresented timelines, and subjected mentally handicapped children to unnecessary invasive testing.6 Despite this, many fiercely determined anti-vaccine advocates still herald him as a scapegoat and victim of a conspiracy between big pharmaceutical companies and government agencies.

Andres Rueda

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Numerous blogs and websites designed to spread awareness of the supposed danger of vaccines, such as ThinkTwice, VacTruth, Safe Minds, and VacLib, continue to link developmental delays to vaccination.

After Wakefield’s original claim was discredited, some turned to an alternative explanation of the autism-vaccine link: thimerosol, a mercury-containing preservative that previously was present in many childhood vaccines.7 Even though thimerosol was banned from all vaccines in 2003, many parents of disabled children associate it with the neurological problems their children face. The Omnibus Autism Proceedings combined the cases of nearly 5,000 families with autistic children who were seeking compensation from the National Vaccine Injury Compensation Program because they claimed thimerosol caused or worsened their children’s autism.8 Ultimately, the court ruled against the families, stating that they had failed to prove the link between vaccines and autism.

out of vaccinating their children. Though well-intended, a recent study published in Pediatrics concluded that not only are educational campaigns largely ineffective, they can actually solidify anti-vaccine sen-

the development of vaccines due to fear of litigation. Public health officials face an uphill battle to combat the confirmation bias that runs rampant among a generation of anti-vaccination advocates who have never witnessed the truly devastating impact of diseases like measles, polio, and whopping cough. This is especially detrimental because of the significant disparities in vaccine allocation; “globally, one in five children lack access to immunizations that help keep children in the U.S. healthy. Every 20 seconds a child in the developing world dies from a vaccine-preventable disease.”14

Hippocratic Loyalties and Unwilling Judges

By Max Goldberg

As the anti-vaccine movement sweeps through privileged communities throughout the United States, large groups of people are being put at risk. “There are the 26 states plus the District of Columbia that don’t meet the Department of Health and Human Services’ guidelines of 95% coverage for the MMR vaccine. There are the 37 states that don’t even meet the CDC’s standards for properly gathering data on vaccination rates in the first place, and there are the 11 states with optout rates of 4% or higher.”15

A study published in Pediatrics examined the diagnostic rate of Autism Spectrum Disorders in Denmark before and after the removal of thimerosol from vacThose who rely on herd imRaed Mansour cines. Researchers found that the munity for their own health and incidence of autism increased A poster advocating that vaccines work despite what supporters of the safety are rightfully angered by and continued to rise after the re- anti-vaccine movement claim. the view taken by advocates who moval, therefore indicating that dismiss the advice of thousands thimerosol had no significant impact on timent in parents who are considering the of scientists and medical professionals in the prevalence of autism in the population.9 decision. In this study, 1759 parents were favor of conspiracy theories. Studies have Additionally, a 2007 study published in the randomly assigned to one of four different consistently and conclusively shown that New England Journal of Medicine involved informational groups or a control group. vaccines do not cause autism or other degiving 1047 children between ages 7 and 10 Researchers concluded, “none of the inter- velopmental disabilities, but it can be hard tests for 42 neuropsychological outcomes. It ventions increased parental intent to vacci- for doctors and public health officials to jolt detected very few associations between thi- nate a future child.”11 people from their own willful ignorance. As merosol exposure and affects on neuropsythe rates of infectious diseases like measles chological function, and these affects were Following the consistent conclusion of and whooping cough begin to rise again, largely split between beneficial and detri- multiple studies that vaccines pose no se- hopefully people will begin to look beyond mental outcomes.10 Ultimately, the benefits vere health risk to the typical infant, many the surface clamor and see that society as children receive from inoculation against have come to feel that “given the sheer a whole benefits when every child is given disease far outweigh any potential risks. numbers of lives at stake there is a strong the chance to live a healthy, disease-free argument that the burden of proof be shift- life.

In the face of growing numbers of un- ed to the detractors.”12 Valuable research vaccinated children, health and govern- dollars are being allocated to studies that www ment officials are scrambling to gain con- many view as tautological and a waste of trol over the dissemination of information. funds; this money would be more impactAttempts to combat the anti-vaccination ful if used to explore alternative causes of movement have included new education- autism and other illnesses.13 Dangerous Carlin Sheridan is a sophomore in Trumbull College. She is an undeclared major. al mandates that require parents in certain trends in public health are emerging as states to consult healthcare providers or outbreaks of vaccine-preventable disease She can be contacted at carlin.sheridan@yale. watch informational videos before opting rise and pharmaceutical companies slow edu.

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UNITED STATES:

OP-ED

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Seattle Municipal Archives

W

hile primary care physicians play a pivotal role in determining levels of disability benefits in the United States, their perspectives are largely ignored in both media accounts and scholarly examinations of national and state-level disability benefits.

Drawing jointly from interviews I conducted with eleven physicians from March 27 through April 16 and cross-state data from the 2012 American Community Survey (ACS), I studied how physicians interact with these benefits and the complex moral conundrums that they face. I focused primarily on the programs that impact the poor, but many of its conclusions are applicable to the public system at large.

In the United States, disability benefits function on both state and national levels. Federal benefit programs for the disabled include Social Security Disability Insurance (SSDI) and Medicare, both of which are contribution-funded and cover the permanently disabled.

Supplemental Security Income (SSI) also covers the permanently disabled, but is a means-tested, payroll tax-funded benefit program.

The federal government pools money with the states to fund Medicaid, an insurance program for low-income individuals and families that provides healthcare benefits to the poor, including some disability coverage. Since the federal baseline for Medicaid benefits is minimal, the level of state funding creates large differences in Medicaid programs between states. Some states (California, New York, New Jersey, Rhode Island, and Hawaii) also have state-level disability insurance programs, funded by employers. These programs provide time-limited coverage for temporarily disabled people, and for permanently disabled people awaiting decisions about their qualification for federal benefits. Finally, private insurers provide disability coverage through plans that unions and employers can purchase.

In general, the state benefit schemes (which are all time-limited) give physicians a great deal of influence over the disability benefit process, and, beyond a few basic eligibility requirements, give leeway to the physician in terms of defining what counts as a disability.

One California physician I interviewed summarized how easy the process is in his state: “It is super easy to help [patients] get state benefits. I just have to complete an annoying form that takes about ten minutes.”1 In contrast with the state programs, the Social Security Administration (SSA), which manages SSI and SSDI, has extremely stringent requirements for what constitutes a disability. A physician summarized the application process as “cumbersome…with detailed forms to fill out, overly lengthy documentation, and often unclear process[es] that neither patients nor providers understand.”1 Beyond

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the sheer difficulty that providers have filing the forms, the format of the evaluation itself restricts the medical opinions that physicians can provide. Another doctor recounted how the SSI process is frustrating because the amount of work he has to do “depends upon whether [patients] have clearly defined qualifying diseases, or several processes that alone do not qualify, but together result in a disability. The former is easy, the latter takes more time.”1

“

legal counsel anyways, as the vast majority of initial SSI applications are denied. Nearly all physicians wished they had more control over the patient’s level of benefits, and they are all extremely dissatisfied with the way the system currently functions.1 When one California doctor was asked whether she thought her role in the disability benefit determination process was appropriate, she emotionally replied, “I do not like my role.

I think that my job is to help patients get

reasons why “lobby groups representing disabled people have campaigned against the ‘medical model’” of disability.5 Fundamentally, the idea of linking medical problems with benefit levels is flawed because it does not take into account the level of capability or impairment. For the impairment benefit system to work well, it must operate on a “‘social model’ that sees disability as a result of the failure by society to provide an environment in which people with impairments” can work. Australia, Britain, and New Zealand––all liberal regimes like the United States––have to some degree implemented programs that set employment goals for those receiving disability benefits.

While this is a far cry from the types of societal reforms that disability activists would like to see, it is a step in the right direction as these countries’ systems embody a far more “enabling” ideal than the United States’ does.5

In addition to their medical evaluations, the SSA requires doctors to evaluate qualities of the patient that are clearly not medical in nature, such as the patient’s ability to manage funds prudently...several physicians were troubled by questions which they interpreted as asking them to evaluate ‘if the individual can contribute to the economy in any way’ as a criterion for disability.

In addition to their medical evaluations, the SSA requires doctors to evaluate qualities of the patient that are clearly not medical in nature, such as the patient’s ability to manage funds prudently. On the form for Social Security benefits, several physicians were troubled by questions which they interpreted as asking them to evaluate “if the individual can contribute to the economy in any way”1 as a criterion for disability.

One physician provided an example of the ethically precarious situations that regularly appear in his work: “I might see someone who’s been disabled from their work, an ironworker who’s 59 and can’t change his job.

All he knows is ironwork, and he can’t do that any more…Say he comes in…unable to work––what do I do? He’s clearly disabled, and can’t do his job, but he doesn’t meet the [official] criteria. [The SSA] isn’t going to understand.”1

This California doctor’s sentiments echo those of Hale, Alabama’s Dr. Timberlake.

When he evaluates poor residents of the depressed towns for disability benefits, he asks his patients what grade they finished, reasoning that since “people who have only a high school education aren’t going to be able to get a sit-down job,” they cannot work if they are in severe physical pain. The SSA places these physicians in a morally untenable position: don’t tell the full truth on the application, or fail to obtain the care that your patient needs.2 The physicians and patients always have the option of referring to a disability evaluation specialist, who can provide supplemental information. But this evaluation comes at a price, and the primary care doctor’s recommendation still holds the most sway. Of course, this is far cheaper than the option of getting a lawyer and fighting for the case in court: most patients end up having to retain

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better or to live with their illnesses. I hate being a judge.”1 When these physicians passed their exams and became medical doctors, each of them took an oath as a symbol of their commitment to the medical profession. While there are many medical oaths, not a single one puts the needs of the state above the obligation to patient care, and only one relatively obscure oath mentions obedience to “the law.”3 Yet, in a 1991 ruling that codified existing common law doctrine, the SSA placed the responsibility of evaluations firmly upon primary care physicians.4 Underlying this ruling was the idea that primary care doctors had longitudinal data that no examiner could obtain.4 But with the increased corporatization and privatization of medical care and the complete dominance of managed care plans over traditional fee-for-service plans from the 2000s onwards, it is unlikely that this informational advantage still exists on a systemic level.4 Furthermore, in general, the physicians interviewed feel that the process is unclear, unfair, and that the responsibility of being a government arbiter conflicts with their primary responsibility as a patient advocate.

The inability of doctors to ethically comply with the SSA’s regulations is one of the

”

While federal and state disability benefits operate differently on the micro-level, it’s not immediately obvious how the difficulties that physicians face impact broader health policy. Comparing data from the Census’s national ACS survey yields answers about some key policy differences between states and the interaction between state and national disability benefits. For national benefits, it is important to examine SSI because, unlike SSDI, it is means-tested rather than contribution-funded. The congenitally disabled are usually not covered by SSDI, and SSI has a broader impact on the poor. For state benefits, both Medicaid and state-level disability insurance should be examined.

First, states with a greater percentage of disabled people on state-funded Medicaid also have a greater percentage of disabled receiving SSI. This result intuitively makes sense: since both SSI and Medicaid are means-tested, it would follow that poorer states would have higher levels of each, while richer states would have lower levels.

However, this result persists even after we control for the percentage of disabled people living below the poverty line, though we would expect the states with broader Medicaid coverage for the disabled to have less people drawing on SSI, since Medicaid pays for many of the accommodations that disabled people need. A disabled person with a less generous Medicaid plan might have to use more of their own money to

YALE GLOBAL HEALTH REVIEW

cover healthcare expenses. Second, in states with state level disability benefits, we also see a ceteris paribus correlation between state level disability benefits and the percentage of people drawing on SSI. For the same reasons, this seems like a puzzling result.

fornia. Alabama has no state-level disability insurance, and has a relatively ungenerous Medicaid system. According to Public Citizen, an independent non-profit consumer-rights advocacy group, Alabama’s Medicaid system is the second-least generous in the nation, scoring 91.6 out of 350 possible points.7 California is practically the polar opposite, with a well-established state-level disability benefits program and a Medicaid system that ranks fifth in the nation,

Alabama and California, yet the policies disparately influenced Nasos’ decision to work and the symptoms that he presented to his physician, thereby forcing the doctors to make different recommendations even though the medical facts were the same.

Ultimately, the dual state-national sysThese confusing results are explained tem of disability benefits is unfair both to by how state policies like Medicaid and physicians and patients, and leads to unstate-level disability interact with SSI. A reasonably unequal and inefficient out1998 study by A.S. Yelowitz found that comes between states. One way to solve more generous Medicaid programs lead to these problems would be to replace the higher SSI participation for at least one hodge-podge of state and national disNasos lives in a boat on the Alabama of two reasons: a) disabled people ability benefit schemes with a sinshore. He’s a long-line fisherman, and spends who would work—and thus be gle, means-tested social insurthe better part of his life on water, collecting the ocean’s ineligible for Medicaid and ance program. Physicians bounty and singing sea shanties to pass the time. At the end of the SSI—under low levels of could have full control day, he brings his fish to market and makes a modest living. That’s what it’s Medicaid benefits cut over medical coverage been like for the last 58 years of his life. Now, the skin on Nasos’ hands is thick and back on their work decisions, such as rough. Flogged by decades of errant waves, the wrinkles on his face are all that remains time to become provision of specifof what was once a youthful, healthy glow. His lungs ache from the pain of a pack a day for the eligible for both ic medication, relast forty-something years, and his hands have hardened from arthritis; every day it gets harder SSI and Medichabilitative therto cast the lines. aid if the benapy, assistive efits are high devices, and One day, Nasos is having a couple beers at the bar when his friend Joe mentions that he recently stopped enough to so on, while fishing and sold his boat. When everyone asks him how he’s paying for his beer, he tells them about the SSI compensate independent benefits that he’s receiving for his back pain. Everyone laughs at Joe and calls him old, but Nasos gets an idea. for the lack nonmedical He goes to see the Dr. Timberlake, who is flabbergasted at Nasos’ health and is surprised that he’s still able to work of work examiners given his medical conditions. The doctor explains to Nasos, that, though he isn’t yet eligible for Medicare, he’s poor income or would be enough to qualify for healthcare under Medicaid, and schedules a follow-up to do a disability evaluation. Back on his b) disabled in charge boat, Nasos logs on to www.disabilitysecrets.com and learns that if he stops working due to inability, he can collect p e o p l e of deterSSI and what meager Medicaid benefits Alabama offers. But, because the additional benefits from Medicaid are low, who are mining and because his friends will make fun of him, Nasos decides that he can’t afford to stop working. Dr. Timberlake does eligible for degrees of everything in his power, save lying, to get Nasos the SSI benefits, but, unfortunately, Nasos doesn’t qualify because Medicaid incapacity, he doesn’t show clear signs of impairment—he isn’t “unable to work” in the eyes of the SSA. and SSI but in consultado not want tion with the The next day, an enormous tidal wave sweeps up Nasos’ boat and drops him off, remarkably unscathed, in to shoulder primary phySan Francisco Bay. After establishing residency in California, Nasos schedules an appointment with world-rethe stigma sician as neednowned doctor Sigrun Kahl. In the waiting room, Nasos grabs a pamphlet on Medicaid benefits and is surcost of welfare ed. Additionalprised to see how much more he would get in California. Nasos explains to Dr. Kahl that his hands hurt under low levly, in keeping so much that he can no longer work, since fishing is all he knows how to do. She is very sympathetic, els of Medicaid with the liberal and tells him that while it is hard to get SSI, she thinks he has a strong case and will do her best. benefits will pay ideals that underIn the meantime, she fills out a quick form to get Nasos covered under time-limited state benethe stigma cost if pin the American fits. Since Nasos has demonstrated to the SSA that his arthritis has progressed to a point the Medicaid benefit welfare state, the federwhile he is no longer able to work, he qualifies for increased Medicaid coverage as becomes high enough.6 al government could crewell as SSI. Nasos is still poor and his friends call and make fun of him, but Since average levels of emate work opportunities suithe enrolls in rehabilitation program that’s covered by Medicaid and ployment do not have a strong able for the disabled. With this is far better off than he had been in Alabama. effect in the model that I have detype of a system, physicians would veloped, reason b) seems like the more not have to worry about not being the likely scenario for the 2012 data. Within this best advocates for their patients, and the modified version of Yelowitz’s theory, the disabled could be sure that they would redata makes clear how the existence of state with a score of 258.9.7 These differences ceive fair and equitable coverage regardless disability benefits is an almost perfect ana- are illustrated through the story of Nasos, of where they happen to live. logue for Medicaid in the model. which, although factually implausible, elucidates the differences between the two www Because physicians mediate the inter- state’s systems. action between the government and the benefit recipient, understanding their role The story of Nasos, while somewhat Max Goldberg is a junior in Pierson College is critically important to understanding the simplistic, clearly illustrates the distinc- majoring in Ethics, Politics, and Economics. structure of American incapacity benefits. tions between the problems of the physiAs a model, let’s consider the difference be- cians’ position. Nasos’s medical condition He can be contacted at max.goldberg@yale. tween Dr. Timberlake’s Alabama and Cali- and ability to work was the same in both edu.

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The Javorac

INNOVATION

TEIXOBACTIN:

Will Newly Found Drugs Stop the Emerging Tuberculosis Outbreak?

By Alexandra Cadena

T

he past year has had the global health community reeling. While tensions ran high over the Ebola outbreak in West Africa, another emerging disease was also witnessing record increases in multidrug resistance. The BBC conducted a candid interview with a Swaziland woman to reveal the global implications of this disease: “TB (tuberculosis) is an airborne disease. My mom died, my dad died, my sister died and I’m next and I feel that I am alone in this world.”1 This woman, and many others, experience the isolation and stigma that surround TB patients in Swaziland and many other African countries. There are over 8 million infected in the country,1 and the vast majority of those infected carry not merely TB, but MDR-TB (multi-drug resistant TB), which is caused when TB patients fail to complete their drug course. What makes the emerging trend of MDR-TB especially alarming is that if a MDR-TB patient infects someone else, that person will get the MDR-TB strain rather than normal TB. This mode of transmission hinders efforts to change the course of this epidemic. And while most cases of multi-drug resistant strains of TB may be highly recorded in middle and low-income countries, our era

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of globalization and travel has given diseases such as TB a global arena on which they can wreak havoc.

In 2014, the World Health Organization (WHO) and TB Global Alliance found that due to international travel, lethal, multidrug resistant versions of TB had spread to Europe. Nokbega, a 12-year-old in Swaziland diagnosed with MDR-TB, corroborates this. “I think anyone can get TB. It’s not choosy,” she said.1 Not only is the disease not choosy, but the treatment for it is as deadly as the disease. No new drugs have been produced to combat TB in the past 40 years. The treatment is archaic, toxic, long -- it lasts approximately two years -- and costly. With this treatment plan, side effects include vomiting, severe weight loss, diarrhea, and permanent loss of hearing. Failure to finish the drug treatment for TB breeds drug resistance.2 Though the statistics are dire, a new paper published in Nature offers a game changer to the war against multi-drug resistance, particularly bacterial variants associated with TB. Teixobactin sounds like a rather menacing name, but for the researchers at Northeastern University at Boston, it is the new drug that could make significant contri-

cure TB. Scientists planted electric chips in soil to grow microbes and then isolated their antibiotic chemical compounds. The method is groundbreaking and for many researchers and doctors, it signals a shift from the thinking that efforts must be spent on bringing old drugs up to date, with the hope that bacteria won’t catch up. According to Professor Neil Woodford, Head of Public Health England’s Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, because of Teixobactin, efforts will shift towards discovering completely new drugs that bacteria have yet to encounter.2 When it comes to discussing the implications the drug will have on TB, all of this sounds great on paper. Not only is Teixobactin highly effective against Mycobacterium tuberculosis, but it will also, with the success that it has had in mice, be available to humans in five years.2 However, there are many different factors at play in the global TB problem, and there is a complex network involved in the creation and distribution of a new drug, such as Teixobactin. It is also difficult to determine if this new drug will fulfill patient and doctor expectations once it is out on the market and how much it will benefit those currently living with

TB. As of right now, MDR-TB outbreaks in North America and Europe kill 4 out of 5 people who are diagnosed, and each year half a million people are diagnosed as carrying some new variant of the TB bacteria.

Currently, 1 out of 25 TB cases are MDR-TB because less than 3% of the total number of people infected with TB worldwide successfully completes their drug treatment.4 Furthermore, patients use a combination of drugs to combat the disease. Thus the discovery of Teixobactin begs the questions of whether one drug will replace all the other drugs currently used to fight TB. Is there a market for TB and will big pharmaceutical companies pick up the demands of manufacturing and distributing this new drug?

Who will get this new drug first? Yale/GWU Public Health Professor, Richard Skolnik, sheds light on many of these questions and other potential issues that may arise from the introduction of Teixobactin.

For one, Professor Skolnik reveals that we need to care about the impeding TB epidemic: “...there are 9 million new infections a year and one and a half million people die of those newly infected. Furthermore, of those 9 million diagnosed approximately 10% are drug resistant

butions in the fight against increased microbial resistance, which has in part been spurred by the tendency to over prescribe drugs. The first antibiotic discovered was Penicillin in 1928, and since then approximately 100 compounds have been created, but no new class of drugs has emerged since 1987, until now. Teixobactin has been found to successfully clear common bacterial infections in mice, such as tuberculosis, septicemia and C. diff with minimal side effects.2 What sets Teixobactin apart from current antibiotics that treat TB and even Penicillin is that it attacks the bacteria in multiple active sites, not just one. As a result, researchers predict that bacteria will not become resistant to Teixobactin in the next 30 years. This time frame could potentially assuage the current global levels of MDR-TB. Teixobactin sounds like a potential wonder drug; however, finding this drug was a struggle for scientists.

Finding or creating new antibiotics is incredibly difficult to do in lab settings. Approximately 99% of microbes will not grow in labs, meaning that researchers will have no way to access potentially life-saving drugs.3 But the method by which Teixobactin was discovered excites microbiologists more than the implications it may have to

YALE GLOBAL HEALTH REVIEW

due to incompletion of treatment. Economically speaking, TB causes a huge burden on low- and middle-income countries. For a person diagnosed with TB, nearly 40% of their income is dedicated to combating the disease. The therapy is long course and there has not been new investments into the disease. Moreover, HIV has exacerbated the TB epidemic.”

Though some definite progress has been made in combating TB, there is still much work to be done and this new drug could help with that movement. However, the development of the new drug may take longer than five years. Big pharmaceutical companies are not known to invest in drugs that would benefit lower and middle-income country endemic diseases. Furthermore, merely creating the new drug will not solve all of our TB problems. According to Professor Skolnik, “Any drugs that shorten the course of therapy, eliminate resistance, are affordable, and last approximately 6 months can only be a good improvement.

However, one of the biggest gaps in TB is diagnostics. The creation of an accurate diagnostic machine that is cheap and relatively easy to use, in conjunction with this new drug, could meet the global TB demands.”

While Teixobactin is indeed promising, TB, like many other diseases, cannot be effectively eradicated with vertical programs such as administering drugs or vaccinations. The long, arduous treatment plan contributes to the multi-drug resistance of the disease. Thus, if we are to embrace this new method of antibiotic discovery, we must also begin to embrace the mentality of being outcome-orientated when trying to execute TB control. It is one thing to create and send new drugs and entirely another to make sure that people take those drugs and continue to take them. Hopefully, the discovery of this new drug will propel the global health and science community to not squander it, but rather combine forces to ensure that this opportunity to curb the war against a deadly disease is taken advantage of, so that we may live in a future without TB.

www

Alexandra Cadena is a junior in Berkeley College majoring in Ecology and Evolutionary Biology.

NIAID

A colored scanning electron micrograph of Mycobacterium tuberculosis, the bacteria that causes TB.

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She can be contacted at alexandra.cadena@ yale.edu.

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DRC:

WOMEN’S HEALTH

Midwife Certification & The Key to Reduced Maternal Mortality

B

By Anna Sophia Young

ers in their 20s.4 Poorer and less educated women are also more likely to succumb to maternal disorders because they lack information or resources to prevent these complications. Exacerbating this problem is a low level of female education: only 25 percent of school-aged girls are enrolled in school, and 44 percent of women in the nation are completely illiterate.3 Many complex factors influence why certain women are more susceptible to maternal mortality than others. Socioeconomic status, distance from health care, lack of information and inadequate services, as well as hygiene and sanitation problems all contribute to the high maternal mortality rate in the DRC. Although midwives are authorized to administer “life-saving interventions,” poorer women often have less access to healthcare, particularly emergency care, and do not receive a midwife’s services. In addition, rural women are less likely to receive adequate care before, during, and after giving birth, causing, on average, 854 birth complications per day.3 Finally, even a lack of information about basic self-care methods during pregnancy has major effects. The United Nations Population Fund estimates that with appropriate medical information services, 74 percent of mothers’ lives internationally could be saved.4

elvie is lying on a mat in a hut in a deaths worldwide, it can be treated with rural village in the south of the Dem- just one injection – an intervention that, ocratic Republic of Congo (DRC). As sadly, the DRC’s government policies forher two children, Claude and Ruth, play bid midwives from administering. Furtheroutside, she is trying to give birth to her more, while the number of midwife-trainthird child. Belvie has not had any antena- ing schools in the DRC has increased in the tal care, and though she has given birth alone before, she just realized that this time there is an unusual amount of blood. This is not a particularly unusual situation in the DRC, where each year 540 out of every 100,000 women who give birth will die in childbirth.1 Belvie will likely be among them. While in the United States such a fate is highly unusual, maternal disorders are the top cause of death for Congolese women between the The consequences CDC Global ages of 15 and 24.2 of maternal mortaliMain factors that con- The provision of basic midwifery techniques and tools could transform childbirth for women in ty encompass much tribute to these tragic small villages. more than the tragedy deaths are the deficit of skilled attendants last 5 years due to government initiatives to of preventable deaths. By reducing the size present during birth, as well as the fact that increase enrollment, there are still just 0.6 of the labor force, maternal death shrinks a few women receive the four-visit antenatal midwives, doctors or nurses for every 1000 nation’s production capacity. In addition to care recommended for pregnant women. citizens.3 serving as educators and protectors, women comprise 70 percent of the African labor Women in the DRC have a one-in-24 Certain groups of Congolese women are force and produce 80 percent of the contirisk of death related to maternal disor- particularly vulnerable to complications nent’s food.5 Clearly, high maternal morders.3 Worldwide, the three most preva- in childbirth. Adolescent mothers account tality rates are deleterious to the economy. lent maternal disorders are hemorrhage, for 12.7 percent of the women giving birth Women’s unpaid house and farm work preeclampsia (high blood pressure) and in the nation, and are more susceptible to amounts for about one third of many Afriobstructed labor, all of which can be pre- complications because their bodies are not can nations’ Gross Domestic Product, and vented by a properly trained and equipped developed enough to support a child. Ac- the annual economic loss worldwide due healthcare attendant. In fact, while hem- cordingly, mothers under 15 are five times to maternal mortality is estimated at US$15 orrhaging causes 27 percent of maternal more likely to die in childbirth than moth- billion per year.6

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As a result of mothers’ poor health, fathers must often sacrifice working hours to care for children. Moreover, poor maternal health forces families to spend a large portion of their money on healthcare, necessitating loans and reductions elsewhere, such as in the meals provided to other family members. This has a negative impact on child nutrition, which impacts future GDP by harming the human capital development of the nation’s youngest generation.

As a result of the aforementioned factors, approximately US$313.20 per family is lost as a result of maternal mortality in the Democratic Republic of Congo.7 If the DRC truly wants to address maternal disorders, its top policy priorities should be to properly train and certify more midwives and to create a government agency that works to make births safer by regulating midwife licensing and practicum. Despite significant efforts to encourage more women to become officially trained, only 82 percent of spaces available at midwifery schools are filled, according to 2009 statistics.3 Secondly, a vital step in the nation’s broader solution to maternal mortality is through a government initiative to legalize more life-saving actions for midwives so women receive proper care before, during and after birth.

The Ministry of Health should create a program devoted to the training, licensing and regulation of midwives. Such a program would equip midwives to provide higher-quality care during more births.

Through regulation, the state should also monitor for unlicensed midwives, therefore enhancing mothers’ safety. Unfortunately, the Ministry of Health will need a substantial funding increase to undertake such ambitious midwifery reform.

In urban areas, formal schools are the best way to certify midwives. To address instruction challenges in rural areas, the DRC should create a contingent of travelling midwives who serve as teachers in rural areas. There, they would teach local midwives basic methods to improve the sanitation and effectiveness of their work, therefore improving the quality of care for mothers across the nation. However, government subsidies or a partnership with an NGO will be necessary to incentivize trained midwives to volunteer in rural areas.

A system that awards two different tiers of midwifery licenses would be the best model to address the DRC’s specific challenges. The upper-tier license would

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Marie Cacace/Oxfam

Marie Cacace/Oxfam

Top: It is not uncommon for women in the Democratic Republic of Congo to have many small children.

Bottom: Children in Democratic Republic of Congo are at high risk for becoming orphaned.

allow for more freedoms in practicum for fully trained midwives, while the lower one would be for midwives who have received basic training, but lack full technical knowledge. The higher-level midwives would, for example, be authorized to provide life-saving medicines that no midwives are currently authorized to provide, such as the one that stops preeclampsia. Lower-level midwives could be taught how to administer the most basic drugs. Increasing access to these drugs would positively impact mothers. Further, these second tier midwives could gain certification to administer more advanced and complex drugs as they pass through additional stages of formal training. As the nation develops and urbanizes, greater access to city centers would swell the ranks of midwives with higher-level certification.

ing would be present to help Belvie. Her children would be healthier because she would get proper care throughout her pregnancy —and most importantly—she would likely survive labor. In the end, increased training and authorization of midwives would benefit not only individual mothers like Belvie, but also the DRC as a whole. All Congolese women would eventually receive better care, leaving both them and their children healthier and ultimately fuelling the nation’s development.

With this kind of authorization, a midwife who knows how to treat hemorrhag-

She can be contacted at annasophia.young@ yale.edu.

www

Anna Sophia Young is a junior in Calhoun College majoring in Global Affairs.

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SYRIA:

MENTAL HEALTH

Mental Health of Syrian Refugees in Jordan

By Farah Al Hadid

W

hen Syrian refugees cross the border to Jordan, their physical injuries are clearly evident. The mental injuries that they have incurred, on the other hand, are far less apparent.1 It is estimated that, on average, more than 50 percent of refugees worldwide manifest mental health problems ranging from chronic mental disorders to trauma, distress, and great suffering.2 Close proximity to horrific events and the loss of loved ones can result in post-traumatic stress disorder and clinical depression, among other psychiatric disorders. However, these mental issues often go untreated because aid workers are overwhelmed with imminent physical injuries. Yet, when left unchecked for long periods of time, the mental issues developed during war and the relocation that often follows may evolve into schizophrenia or another serious psychiatric disorder.3 The public health community must work towards reversing the tide of mental illness among Syrian refugees by increasing immediate treatment, involving local psychiatrists, and training these psychiatrists in mental health wellness programs to create a “new normal” for refugees.

lack of interest in life, and hopelessness.

Roughly 26 percent felt “so hopeless they did not want to carry on living” and nearly 19 percent felt “unable to carry out essential activities for daily living because of feelings of fear, anger, fatigue, disinterest, hopelessness, or upset.”6 Children who were asked to draw a “safe place” in counseling groups seemed to be unable to access any nonviolent memories; instead they drew tanks and soldiers. According to the UNHCR Jordan Health Unit, there were 10,911 cases of mental health illnesses in UNHCR-supported clinics in the first half of 2014. Of those

cases, 24 percent were patients with severe emotional disorders, 16 percent had epilepsy and seizures, and 7 percent had psychotic disorders.7 These statistics demonstrate an urgent need for better mental health care for the displaced Syrian population.

According to a study about the mental health of Syrian refugee children, adults are more likely to suffer mental health ailments than children. This is because a child’s body is more likely to demonstrate resilience in the face of outstanding circumstances.6 According to Rutter et al., “Resilience does not

“

Children who were asked to draw a ‘safe place’ in counseling groups seemed to be unable to access any nonviolent memories; instead they drew tanks and soldiers.

Trocaire

”

Refugees are persons who flee their home country to escape conflict, an experience that can leave them mentally scarred.

The term refugees may include asylum seekers—those who leave their country to avoid prosecution—and internally displaced persons—people who are forcibly displaced to another site within their home country.4 As of June 2014, Syria was the leading country of origin for asylum seekers, according to the United Nations High Commissioner for Refugees (UNHCR).5 Many of the refugees who travel from Syria to Jordan have witnessed or been subject to torture, murder, kidnappings, and sexual assault.

An assessment of the mental health and psychological needs of displaced Syrians in Jordan revealed persistent fear, anger,

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YALE GLOBAL HEALTH REVIEW SpaceShoe

VOLUME 3, ISSUE 1

European Commision DG ECHO Top: Ratiba Awad pictured with her three children, Ouday, Ahraa, and Batoula (5 years, 4 years, and 7 months old resepctively). They live in an old cow shed with 20 other Syrian refugees who were also forced to abandon their homes during the Syrian war.

Bottom: Many refugees that cross the border are young children, escaping violent conditions in Syria.

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constitute an individual trait or characteristic… Resilience involves a range of processes that bring together quite diverse mechanisms operating before, during, or after the encounter with the stress experience or adversity.”8 In a twelve-year study of 31 adolescents who survived the horrors of the Pol Pot regime in Cambodia, 50 percent initially demonstrated PTSD, as opposed to 35 percent in a follow-up study. Similarly, an initial 48 percent demonstrated depression, with only 14 percent in the follow-up.

This study presents a strong example of the ability of children and young adults to adjust to severe life situations. However, for these adjustments to be completely successful, they require the intervention and help of a team of mental health experts who begin treatment immediately after children flee their countries.8

treated, especially among adults. A study conducted by Hermasson et al., investigated the mental health of war-wounded refugees after they had spent at least eight years in Sweden. The study included 44 war-wounded refugee men between the ages of 24 to 54 from 9 different countries around the world. Their mental health was assessed using three instruments: HSCL-25, PTSS-10, and a well-being scale. The HSCL25 is the Hopkins Symptoms Check List-25, which is a commonly used screening instrument designed to identify common psychi-

AT A GLANCE As of June 2014, Syria was the

leading country of origin for asylum seekers.

regardless of physical ailments, should be tested for mental health disorders. The presence of chronic pain, on the other hand, was associated with an overall lower level of mental health.11 Despite the overwhelming evidence that treatment of mental health issues is essential to the well-being of refugees, there are several challenges to achieving equitable mental health care for refugees. In Jordan, for example, addressing the physical health of refugees is already a public health issue, and now the nation is running out of resources. Since 2011, the country’s health sector has been straining to care for a huge influx of Syrian refugees. The Ministry of Health spent about US $53 million on care to refugees between January and April of 2013, with only US $5 million provided in support by UN agencies.12 Under these conditions, receiving extra support for mental health treatment seems nearly impossible, but it is essential.

*** Considering the importance of menAlmost tal health treatment, it is tragic that the bursuffer from mental health disorders. den of mental disorders is *** likely to be unThese dervalued due to a poor understanding of the connection Among some, there because aid workers are overwhelmed. between mental health is also considerable amand other physical health biguity surrounding the *** conditions. Health services mental illnesses of refugees There were are not provided equitably to and debates about whether people with mental disorders; they should even be considered inequality of access to treatment diseases. Many authors debate the is greatest in developing countries accuracy of labeling refugees who of mental illnesses in UNHCR-supported clinics. like Jordan. This is dangerous because are suffering psychologically from mental disorders increase one’s risk for trauma as mentally ill. These individucommunicable and non-communicable dis- atric symptoms; and PTSS-10 is a scale used als suggest that emotional suffering from eases, and contribute to injury.9 Mental to assess the presence of Post-Traumatic severe trauma should be seen as a normal illnesses increase patients’ risk of contract- Stress Disorder. According to the HSCL- reaction to refugees’ catastrophic experiing infectious diseases, according to recent 25 test results, 43 percent of war-wounded ences.13 The danger of mental illness exists research by Prince et al. For example, is refugees in the study had scores indicating when refugees’ immediate concerns are not estimated that people with schizophrenia both anxiety and depression. Using the addressed and these emotions later develdie on average 25 years earlier than people PTSS-10 test, 50 percent of participants in- op into severe mental illnesses. Immediate with similar backgrounds who do not have dicated at least a “quite severe reaction.” mental health services are key to restoring the disorder. Premature death in these indi- General well being, which was measured basic psychological functioning and supviduals occurs due to high rates of suicide, by the Well-Being scale, did not improve porting the wellbeing of all. acute and chronic lower respiratory tract significantly over time, even though 20 perillnesses, chronic cardiovascular disease, cent of the men sought treatment for psyAnother challenge with refugee mental and diabetes.10 Mental health and physical chiatric reasons. This study supported pre- illness treatment is the cultural stigma that illnesses are co-morbidities; depression can vious literature regarding the prevalence of is often associated with mental illness, and cause physical illness, and the persistence PTSD among refugees and demonstrated the lack of adequately trained local docof physical illness can cause depression. that men with PTSD also usually had anx- tors. Many foreign psychological doctors Refugees are at heightened risk for both. iety and depression. Interestingly, no cor- do not fully understand the cultural idioms relation was found between the severity of and methods through which suffering is Though they may be less obvious as time the physical injury and the mental health expressed in refugee communities. Westpasses, mental health issues persist if not of these men—indicating that all refugees, ern-style clinical interventions are often

50% of refugees

mental issues often go untreated

10,911 cases

56

YALE GLOBAL HEALTH REVIEW

culturally inappropriate and do not adequately address the mental health needs of refuges.

Similarly, well-intentioned international humanitarian help is only marginally effective, due to several key factors: First, this international aid is not sustainable; it promotes community reliance on the expertise of foreign organizations. Second, it hinders local capacity building, which is an important long-term solution to the mental health crisis. Instead of directly serving refugees, international aid workers should train local doctors in mental health care.

These local doctors may help victims feel more comfortable in talking about and expressing their struggles, considering their similar cultural and religious backgrounds.

Also, they may better understand the religious taboos and cultural stigma associated with mental health. Jordan currently lacks its own trained mental health practitioners; training such doctors is vital to any solution.

Additionally, a fear of victimization makes refugees reluctant to share traumatic experiences with a mental health practitioner. A community-based approach can help ameliorate this challenge, especially among a population that has experienced similar atrocities.

earn income, such as cooking, sewing, and making crafts or household objects. Benefits of these classes include: restoring a routine to women’s lives, which is essential to mental health healing; helping them regain a purpose in life, and empowering them to be self-sufficient by awarding them for their hard work.

Similar strategies can be used to promote children’s mental health. Simply recreating social relationships and establishing routines is deeply helpful. This is why school is such an important factor for chilren’s healing. The Center for Victims of Torture (CVT) estimates that 2.5 mil-

“

prevalence of mental health disorders is based on sociocultural factors and other environmental parameters.2 Syrians who are now arriving in Jordan, after witnessing years of atrocities committed by Assad regime and, more recently, ISIS, may be more mentally distraught than refugees that fled the country earlier on. The quick provision of care for such individuals is vital.

Furthermore, treatment efficacy increases not only when the local community is involved, but also when the international community is cooperating. There are many organizations working in the Zaatari camp: the UNHCR, the Jordan Health Aid Society, the WHO, and the Red Cross, among many other international and local groups. In order for mental health and physician training programs to be successful, it is important for these organizations to cooperate, share information, and pool resources.

However, the road toward Recently, there has been a sigsuccess is still long. The nificant increase in mental health basic factors essential to awareness, as evidenced by the number of organimental health—education tremendous zations that specialize in mental care. The stigma assofor children, employment for health ciated with mental health care has also significantly subsided. adults, comortable and san- However, the road toward success is still long. basic factors itary living conditions— essential to mentalThehealth—edufor children, employment are not yet available to forcation Several specific approaches have adults, comfortable and sanitary many Syrian been designed to treat refugees’ menliving conditions—are not yet availtal health challenges. One model calls able to many Syrian refugees. Moreover, refugees. for a holistic method of treatment that mental health care facilities and local speaddresses interwoven physical and psychological problems in conjunction. This approach lessens the stigma associated with treatment of mental health illnesses as a unique and separate process from treatment for physical ailments.

A second approach emphasizes practical treatments. This method aims to create a new normal for refugees, who may simply require help developing a system or a routine in order to feel better. In this approach, volunteers and practitioners help promote practical outcomes such as access to employment and education.14 Considering that 25 percent of Syrian women are the head of their household, women’s education is vital for both these women and their children.

For some individuals, emotional therapy and assistance with practical matters is sufficient to ameliorate their condition. Some advocates of this approach suggest that the Zaatari camp set up classes geared towards teaching women basic skills to help them

VOLUME 3, ISSUE 1

”

lion Syrian youth still face restricted access to education. A better education system with more funding is needed in order to achieve universal education in Syria. The CVT, whose clinics in Amman and Zarqa have been fairly successful in establishing a “new normal” for refugees, have a very clear objective in mind: “to facilitate a shift in self-image from passive victim to active survivor.”15 Although this shift is not easy to incite in devastated refugees, change is possible.

Although almost 50 percent of refugees suffer from mental health disorders, it is important not to assume that an entire refugee population is mentally disturbed, as psychiatric morbidity and psychological complications depend on the nature and time span of the crisis. Additionally, the

cialists are lacking. Jordan needs to build a program, with the help of expert international organizations, to train physicians in mental health care and to establish a program to reverse the tide of mental health ailments among the Syrian refugee population.

www

Farah Al Hadid is a sophomore in Jonathan Edwards College. She is an undeclared major.

She can be contacted at farah.alhadid@yale. edu.

Photo caption: An aerial view of the Syrian Zaatari refugee camp located in Jordan. According to the UNHCR, over 80,000 people currently reside at the Zaatari camp.

57 Sharnoff’s Global Views

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VOLUME 3, ISSUE 1

Goldberg *This paper uses California as a model for this type of insurance because its system is fairly well developed and shares key similarities with the other states’ plans.

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