YGHR Fall 2016 - Vol 4 No 1

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FALL, 2016

THE YALE

VOL. 4, NO. 1

GLOBAL HEALTH REVIEW

THE UNSEEN CONSEQUENCES OF WAR BY OHVIA MURALEETHARAN P. 25

MENTAL HEALTH IN SRI LANKA

Wikimedia


LETTER FROM THE EDITORS FALL 2016

VOL. 4, NO. 1

Dear Readers, We hope you enjoy this fall issue of the Yale Global Health Review! The global discourse on health is becoming increasingly visible, especially as we face humanitarian crises abroad and more fully realize the transnational nature of infectious disease. Interdisciplinary and international cooperation is critical in the field of global health as events half a world away can intimately affect our lives. In this issue, the article on dengue fever highlights challenges in the global spread of infection and is a key topic to follow as climate change and urbanization contribute to the changing dynamics and geographical reach of the disease. Furthermore, we are excited to feature a piece by Ohvia Muraleetharan on post-conflict mental health in Sri Lanka. In writing this article, she drew on experiences of her own family who grew up in Sri Lanka and experienced first hand the consequences of the civil war, which ended in 2009. As the world continues to struggle with conflicts in countries like Syria and South Sudan, the prevalence of mental health challenges will continue to grow. We hope that Ohvia’s piece, in addition to the article about stigma and mental health challenges in Mexico, will draw attention to the need for creative solutions to address this growing burden of disease. Even in the United States, one of the richest countries in the world, severe health disparities exist and continue to be a major challenge in domestic healthcare today. Three pieces in this issue detail examples of these inequalities from food insecurity in the “salad basket” of America to desolate living conditions in towns on the Texan border. As this country heads into a period of change, we will consider hard questions about health policy prioritization. We hope these pieces will help shed light on the importance of health equity and the difficulties that many Americans today continue to face. This is our last issue as Editors in Chief and we’re so happy to have had the opportunity to work with our phenomenal staff to produce this publication. Again and again we have been inspired by the hard work and passion that has gone into the magazine. Thank you to everyone on our Executive Board, and to the writers who worked so hard to create this issue. While we are sad to be stepping down, we are extremely excited about the future of YGHR and hope that it will continue to grow on campus as a platform for students to share their knowledge and collaborate on innovative solutions to health problems around the world. Sincerely, Amber Tang and Sophia Kecskes

OUR TEAM Editors-in-Chief Amber Tang, Sophia Kecskes

Senior Online Editor Elizabeth Kitt

Senior Editors Hannah Krystal, Kai DeBus, Lauren McNeel, Rachel Arnesen

Online Editors Al Nurani, Carlin Sheridan, Caroline Tangoren

Associate Editors Cassandra Lignelli, Claire Chang, Jessica Schmerler, Ohvia Muraleetharan

Staff Writers Akhil Upneja, Anabel Starosta, Holly Robinson, Rebecca Slutsky, Sarah Spaulding

Production & Design Team Holly Zhou, Jessica Schmerler, Maheen Zakaria, Xindi Chen

Web Master & Social Media Director Sarah Barreto Ornellas

Copy Editors Dhikshitha Balaji, Hannah Krystal, Katerra Logan, Neha Anand

Business Team Erica Kocher, Harland Dahl, Mary Chandler Gwin, Paul Won

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CONTENTS FEATURE ARTICLE

MENTAL HEALTH MEXICO 13 Depression: Stigma and its Policy Implications

THE UNSEEN CONSEQUENCES OF WAR 25 Responding to Sri Lanka's Mental Health Burden

INTERVIEW

A CONVERSATION WITH KAVEH KHOSHNOOD 35

Paths Through a Career in Global Health

by Diana Gonzalez & Mauricio Alvarez

by Cassandra Lignelli

by Ohvia Muraleetharan

Creative Commons

GLOBAL HEALTH TODAY

DENGUE FEVER 3 Endemic to Epidemic by Sarah Spaulding

LOW-COST 38 DIAGNOSTICS

REPRODUCTIVE HEALTH REPUBLIC OF KOREA 9 An Increased Response to a Decreased Fertility Rate

AMERICAN HEALTH INEQUITIES NORTH DAKOTA 6 The Decline of Rural Healthcare

by Sukriti Mohan

by Myles Odermann

IRELAND 19

AMERICA'S 45 FORGOTTEN CITIES

Restrictions on Abortions

Advancements in Global Health

by Ariela Zebede

Public Health Crises in the Texas Colonias by Eli Rami

by Wen-Yi Low Army Medicine

Creative Commons

HEALTHCARE POLICY

PAKISTAN & BRAZIL 23 The Current Narrative of Healthcare Reform

OPINION

by Mahurkh Shahid

FOOD INSECURITY 17 In the "Salad Bowl of America"

AT THE HELM 33

RUSSIA 41

by Claire Chang

by Aviva Rabin-Court

The Sickness of a Nation Wikimedia

FOOD SECURITY

United States Foreign Policy and Reproductive Rights

by Chaney Kalinich Wikimedia

ABOUT US

SPONSORS

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.

We would like to thank the Yale Global Health Leadership Institute, Yale Global Mental Health Program, Yale China, the Yale School of Public Health Admissions Department & the Yale Undergraduate Organizations Committee for their support.

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GLOBAL HEALTH TODAY

Rio Plus Centre

DENGUE FEVER: Endemic to Epidemic By Sarah Spaulding

T

oday, a bite from the wrong mosquito can cause severe fever, organ failure, and even death. No, this mosquito is not carrying malaria as you may have thought, it is carrying dengue. According to the World Health Organization (WHO), dengue fever is a viral infection carried by female mosquitoes of the species Aedes aegypti (Ae. aegypti), the same species responsible for transmitting diseases such as yellow fever and Zika. Infection causes symptoms similar to that of the flu, and can be lethal if it develops into “severe dengue.” Currently, severe dengue is one of the most common causes of illness and death in many Asian and Latin American countries. 1 Dengue is unique because it has no known treatment and prevention relies solely on mosquito vector control. Despite these difficulties, early detection of the virus and standard medical care brings fatality rates under 1%.1 Although the recent resurgence of dengue fever is extremely complex and involves many interconnected external factors, there are four major probable causes of the global spread of the disease: increased urbanization, higher rates of international trade and travel, poor vector control, and global climate change. The first documented case of dengue-like symptoms dates back to the Chinese Jin Dynasty (265-420 AD) with a Chinese encyclopedia description of a “water poison” carried by flying insects.2 The disease was not identified and named until 1779, and was immediately followed by simultaneous epidemics in Asia, Africa, and North America in the 1780s. In 1789, the first confirmed case

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report of definite dengue symptoms came to light. The author, Benjamin Rush, coined the term “breakbone fever” due to the symptoms of myalgia (muscle pain) and arthralgia (joint pain). 2 Yet despite more frequent occurrences of the fever, it was not until the 20th century that the causes and transmission of the disease were uncovered.2 Since then, a combination of complex economic, social, and environmental factors has led to a massive spread of dengue across more than 100 countries, including a concerning resurgence in the most recent decades. In the past 50 years, rates of dengue have increased 30 times over.3 Currently, experts estimate there are approximately 390 million annual dengue infections and 3.9 billion people at risk of infection globally.1 At the heart of the current dengue crisis is the climbing rate of urbanization. In 1950, less than one-third of the world’s population lived in urban areas.4 The year 2007 was the first year that the global urban population was greater than the global rural population, and as of 2014, 54 percent of Earth’s population resided in urban areas.4 This phenomenon is expected to continue; the UN estimates that by 2050, the global population will be two-thirds urban and one-third rural.4 This urbanization provides the perfect niche for the Ae. aegypti vector to flourish. The development of “urban port cities” allows the mosquito to establish and adapt itself to the human population. Although the mosquito originally bred in small, natural stationary bodies of water, Ae. aegypti now proliferates in extremely small bodies of water created by

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One of the greatest difficulties regarding the control of dengue is the lack of any cure, vaccine, or even treatment of the disease.

urban living, such as water in discarded trash, bottles, plastic, and tires. In addition, water storage containers in areas that lack clean running water provide a convenient breeding ground for the mosquito. Furthermore, Ae. aegypti has adapted to prefer indoor living to the outside world, and favors humans rather than other animals for feeding. Duane Gubler, director of the Asia-Pacific Institute of Tropical Medicine and Infectious Diseases at the University of Hawaii at Manoa in Honolulu, believes this acclimatization makes Ae. aegypti “perfectly adapted to the urban environment.”3 Urbanization also provides optimal conditions for Ae. aegypti to thrive on a smaller scale. Cramped living spaces, poor public sanitation of water, sewage, and waste, and substandard housing provide a wealth of opportunity for Ae. aegypti to succeed. The effects of this have been seen already: the rapid economic growth

and urbanization of southeast Asia postWorld War II provided ideal conditions for a dengue epidemic. The virus’s progression during this time reached a tipping point and led to the first reports of dengue hemorrhagic fever (DHF), a much more severe and lethal form of the disease that is accompanied by hemorrhaging and often death.3 DHF has spread exceptionally far since this first introduction; current WHO estimates hover around half a million cases and 22,000 deaths due to DHF each year, largely among children.3 Today’s rapid urbanization has the potential to lead to the spread of severe forms of dengue and even greater specialization of Ae. aegypti to humans. Another one of the biggest propellers of the global spread of dengue is increased air travel and trade across international borders. In 1980, approximately 227 million people crossed international borders via airplanes.5 As of 2012, that number had risen to over a billion people per year, and according to the UN World Tourism Organization (WTO), could reach 1.8 billion international tourist arrivals by 2030.5 This movement of people and goods to new regions allows dengue to grow at unprecedented rates by allowing different dengue strains to come in contact with each other frequently. In turn, this sharply increases the risk of developing the more severe DHF, which is often accompanied by a higher mortality rate, a phenomenon that

has been seen multiple times throughout the history of the disease. Most recently this occurred in 1981 when a strain of dengue was imported from southeast Asia. This led to the first DHF outbreak and eventual epidemic in the America. Following the introduction of the first strain, all four strains of dengue have since spread throughout the Americas and are now endemic in several countries.3 As rates of international air travel continue to skyrocket, it is likely that they will play an increasingly larger role in the global spread and resurgence of dengue. One of the greatest difficulties regarding the control of dengue is the lack of any cure, vaccine, or even treatment of the disease. Currently, the only mechanism for control is managing the vector, Ae. aegypti, and poor vector control is one of the most prominent flaws in the effort to eradicate dengue. According to the WHO, control of the vector is achieved by “eliminating container habitats” that lend themselves to the laying or depositing of vector eggs and facilitate the development of aquatic stages.6 Based on a number of factors, including local ecology, resources available, and cultural context, methods of control can include a host of different tactics, such as biological agents, adulticides, larviciding with insecticides, and elimination of larval habitats.6 However, recent research has shown that often generalized “cleanup campaigns” and application of pesti-

Aedes aegypti, the dengue vector, drawing blood from a human. Wikimedia

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cides have a limited or even negligible effect on rates of dengue incidence.7 Even in cases where eradication efforts have been successful, there are often higher levels of cases once the effort shrinks or comes to a halt altogether. This can be seen in the virtual elimination of dengue in the Americas due to yellow fever eradication efforts of the 1950s and 1960s. The Pan American Health Organization (PAHO) targeted Ae. aegypti (which also transmits yellow fever) with DDT. In 1972, DDT was banned in the US and the Ae. aegypti elimination effort was deemed successful.3 The effort was subsequently abandoned as President Nixon turned his attention to the “War on Cancer.” Today, Ae. aegypti has reinfested almost every region from which it was eliminated.3 The public health infrastructure needed to combat this complex disease has declined in the past 30 years, largely due to competing global health issues and limited resources. Currently, many countries’ approach to vector-borne diseases are “end of the pipe solutions,” working to respond to epidemics by implementing emergency control measures, rather than prevention programs.8 In order to effect serious change in the rates of dengue incidence, vector control measures that are both effective and consistent over time will need to be put in place.

Today, Ae. aegypti has reinfested almost every region from which it was originally eliminated.

Arguably the most highly-contested cause of dengue dissemination is global climate change. Research has consistently shown that there is a clear weather-related pattern involved with dengue fever. Higher rainfall and temperatures correlate with higher rates of vector spread and likelihood of virus transmission to humans. These rates go down in cooler climates due to the length of virus replication. According to senior research fellow Simon Hales at the University of Otago, New Zealand, it is probable that in cooler climates, the time it takes to replicate the virus would exceed the lifespan of Ae. aegypti, meaning the mosquito would likely die before transmission to humans. Accordingly, many research studies predict that the future of the Earth’s climate will increase the risk and frequency of dengue epidemics.3 The UN Intergovernmental Panel on

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Water Journalists Africa

A child stands next to a rainwater tank full of stationary water.

Climate Change’s Fourth Assessment Report on Climate Change Impacts: Impacts, Adaptation and Vulnerability concludes that climate change could increase the populations at risk for dengue due to environmental variable such as “El Niño, temperature, rainfall and cloud cover.”3 Despite this, researchers are divided on the causal relationship between climate change and dengue. Some experts, such as Laura Harrington, a medical entomologist at Cornell University, disagrees with those who say global warming is a clear cause of the spread of dengue.3 She and many others argue that climate change may influence dengue indirectly in its impact on water transport and management, but none of the climate data points to a direct link between climate change affecting rates of dengue incidence. Additionally, some researchers contend that policy-makers use global warming as a political tool to account for the lack of prevention of a very controllable disease.3 Ultimately, the science behind climate change and all of its impacts has yet to be explored fully, but it is clear that the climate and weather patterns play at least some role in the distribution of dengue fever globally. Despite the lack of knowledge about dengue and the many facets of such a complicated disease, many relief efforts are promising. Research involving every element of the dengue virus continues to add to the scientific body of information we can use to combat the spread of this disease. Mathematical models are being developed that are work-

ing towards predictions and simulations that may aid in the challenge of multiple strains infecting the same region and may support development of immunizations for the disease. Additionally, the Grand Challenges in Global Health program is working towards creating genetically modified vectors that would be unable to transmit dengue to humans. All of these efforts will push towards the reduction of dengue, but ultimately much of the research leads to similar conclusions: the disease will eventually require a vaccine. Ongoing research at the Pediatric Dengue Vaccine Initiative is working to overcome the obstacles of vaccine development by aiding companies with clinical trials, field research, and establishing health infrastructure for eventual vaccine dissemination.3 As the fields of science, global health, and policymaking move forward, the world will look forward to a dengue-free future.

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Sarah Spaulding is a junior in Jonathan Edwards College from Wilmington, North Carolina. She is a double major in Environmental Engineering and Ecology & Evolutionary Biology. She can be contacted at sarah.spaulding@yale.edu

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AMERICAN HEALTH INEQUITIES

NORTH DAKOTA:

The Decline of Rural Healthcare

Pixabay

By Myles Odermann

I

n the past several decades, the population of rural America – particularly the Midwest – has seen a drastic decrease. This plummet in rural citizens has led to schools closing and local businesses failing due to lack of students, employees, and customers. Despite this steady decline of rural Midwest residents, the average age of the populace continues to increase; consequently, so has the percentage of residents that require frequent medical care. There are few healthcare providers to care for this aging rural population in the United States. A number of changes contribute to the decrease in the population of rural America; one is the advancement of agricultural technologies. These technologies include machines that are larger and more productive than their predecessors, allowing farmers to manage more land than in the past. For instance, the average acreage of US farms increased from 589 acres in 1982 to 1,105 acres in 2007.1 For Midwestern farms, however, this figure is a conservative estimate. Some states like California and Virginia have seen the average farm grow less than 50% since 1982.1 During the same period, all 12 Midwestern states witnessed the average farm size increase by more than 100%.1 Since these states are experiencing the most rapid expansion of farms, they are also experiencing the largest decrease in rural population. Notably, improvements in agriculture technology in the rural United States are not the only contributor to the rural population slump. Although rural, scenic regions like the Rocky Mountains and southern Appalachia have recently experienced

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an increase in residents because of migrating retirees, the rural Midwest’s population continues to decline because fewer people, both young and old, desire to move there.5 A recent Harris Poll asked people of various demographics in which states they would most want to live; of the top fifteen states, not one was in the Midwest.3 However, the Midwest shone brightly on the list of bottom fifteen states. One-third of the states listed on the bottom—including Illinois, Michigan, North Dakota, Kansas, and Missouri—were Midwest states. Since these areas are not desirable to the majority of people, rural areas continue to decrease in population while urban populations soar. As rural populations decline, so does the quality and availability of healthcare for the remaining occupants; Ursula and Boyd Shaw experience the deleterious effects of this phenomenon. Fifty years ago, when they were in their early twenties, Ursula and Boyd moved to Parshall, a town of 1,000 people in rural North Dakota. During the school year, Ursula operated a day-care service and Boyd taught at the town’s only high school. When summer rolled around, they grew crops on their newly purchased family farm. When they first moved to Parshall, there were two clinics, two pharmacies, a dentist, a nursing home, and many other thriving businesses. During their final years there, however, Parshall hardly resembled the town it once was. Most of the businesses had closed because they lacked customers. For healthcare, the only remaining providers were a dentist open twelve hours a week and a pharmacy technician who filled prescriptions through telepharmacy (video calling a pharmacist

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so technicians can legally fulfill prescriptions). When asked why Parshall was no longer the boisterous town it once was, Ursula said, “The farms got bigger. Before, you had a farmer on every quarter of land. And now, for a mile, you might not find a farmer. Businesses couldn’t stay.”

I thought I was going to die in Parshall. I'd still be there. We'd still be there. We had nothing wrong with living in Parshall.

Businesses were not the only ones who could not stay. Last year, Ursula and Boyd had to leave their home for the same reason as many other rural elderly: Healthcare in Parshall was insufficient. After the local clinic closed in 2013, Parshall could no longer provide resources for their basic medical needs, so they had to travel one hour each way to the nearest city, Minot, for healthcare. Between therapy, dentistry, and primary care, the Shaws traveled to Minot every week; eventually, it became implausible to live in Parshall. So after living for nearly a half-century in a community they loved, Ursula and Boyd saw no other option than to move to a city that could provide care for their basic health needs. “I thought I was going to die in Parshall,” Ursula said as she hid her displeasure with a forced laugh; “I’d still be there. We’d still be there. We had nothing wrong with living in Parshall.” Many seniors adore their rural communities as much as Ursula, but since their clinics are closing too, they are left with the same difficult decision.

During routine activities, Andre started to notice that his hand would tingle spontaneously throughout the day. As weeks passed, the tingling became more apparent and his physical ability started to deteriorate. After several doctor appointments two hours away from where he lived, Andre was diagnosed with a herniated disk, an injury that would require surgery. His neurosurgeon, who was educated at a prestigious medical school and practiced in the Northeastern United States for many years, told him that it would take at least three months to recover from the operation, and he might never regain his same function due to permanent damage to the spinal cord. The surgery was performed successfully, but then Andre had to begin the real challenge: physical therapy. The physician prescribed various exercises for Andre’s recovery and told him that he would send the prescription to his local physical therapist. Unbeknown to the urban neurosurgeon, the majority of towns the size of Andre’s no longer had physical therapists. So three times a week for twelve weeks, Andre had to be driven by his wife for two hours to complete physical therapy. This was equivalent to countless sick days, over seventy hours of driving, and five hundred dollars worth of fuel; unfortunately, many urban health professionals like Andre’s surgeon do not realize the

sacrifices their patients make to obtain adequate healthcare. The Shaws, Andre and his wife, and millions of other rural Americans experience the inadequacy of rural healthcare regularly. Although the population of rural America as a whole is decreasing, the population of people who require regular healthcare, the elderly, remains consistent. But, why are healthcare centers closing their doors? According to Dr. Leonard Cohen, a former family practitioner in rural Virginia, when his clinic was forced to shut down, “it [was] not because of a shortage of patients.”4 Instead, Cohen said that the primary reason his clinic was forced to close was a scarcity of medical workers. Upon completion of their education, many healthcare professionals like doctors, nurses, and physical therapists prefer to live and work in an urban-setting due; there, they receive higher wages and can access an abundance of resources. Hilda Heady, former president of the National Rural Health Association, explained in the Vail Daily News, “Rural communities frequently suffer from a shortage of physicians because many doctors feel they cannot sustain a viable practice in a rural setting.” 2 So, with hesitations about the rural lifestyle and uncertainties about sustainability of rural clinics, most medical workers decide to Boyd and Ursula Shaw in their new home.

Seniors citizens are not the only victims of the current rural healthcare system. In rural areas, spending a few hours driving for a yearly check-up is not too much of a burden. But when someone sustains an injury that requires longterm recovery, that multi-hour drive to see a healthcare professional becomes arduous. Andre Hoyte, a healthy man in his forties, lived in a Midwest town that had a population of a couple thousand people.

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Myles Odermann

YALE GLOBAL HEALTH REVIEW


Myles Odermann

Formerly Boyd and Ursula Shaw's local clinic, this abandoned building is now one of many in Parshall.

follow the safe route and work in urban or suburban places.

In rural clinics, the doctor-patient relationship is more intimate because of the smallcommunity feel.

Physicians like Stephanie Brown, however, find work in rural communities is more rewarding than in cities. Brown says that in rural clinics, the doctor-patient relationship is more intimate because of the small-community feel.2 The same atmosphere that Ursula and Boyd now long for is the one that Andre traveled seventy hours on the road to

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feel when he returned home. Many of the physicians in these rural areas attended their state’s public medical school, known for their rural medicine programs—these train doctors in the hope that they will stay and practice medicine in their state. Even though many universities are trying to produce doctors and other medical workers for their region, the shortage of health professionals is still apparent. Some say that the future of rural medicine lies in telemedicine—where patients can come to a clinic to have a videoconference with their doctor—however, how can someone visually perform a physical examination? They lack any sort of touch to inspect the ears, nose, abdomen, and all other parts of the body. Nothing can replace a doctor’s hands; by forcing rural areas to rely solely on this technology, these residents receive second-rate medical care. But, there is another option. Instead of subjecting rural citizens

to mediocre medical care, healthcare professionals can move to small communities, providing access to quality healthcare, a service so foundational to a strong community. If more providers moved to rural places, residents would welcome them with open arms, rejoicing that they can remain in their small-town communities.

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Myles Odermann is a sophomore in Saybrook College from Parshall, North Dakota. His anticipated major is Environmental Studies. He can be contacted at myles.odermann@yale.edu

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REPRODUCTIVE HEALTH

REPUBLIC OF KOREA: Philippe Teuwen

An Increased Response to a Decreased Fertility Rate By Sukriti Mohan

I

n a world where we often worry about overpopulation, there are certain nations struggling to stimulate higher numbers of births. Concern about declining fertility and birth rates has risen drastically during the last few decades, and many worry that the decreased number of young residents will weaken the future labor force and economy of their respective nations. In addition, the young are traditionally responsible for the care and well-being of elderly populations, so a low fertility rate leads to fear of a forgotten and unsupported aging population. Consequently, nations such as the Republic of Korea, Japan, and Singapore have embarked on a journey to establish political and health interventions aimed at reversing the decreasing fertility and birth rates. This piece will provide general background on the Republic of Korea’s healthcare system and family planning services, analyze the methods that Korea uses to stimulate its low fertility rate, and finally, pinpoint

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the barriers this nation continues to face. Methods that will be discussed are the limitation of abortions, pronatalist policies, more generous family leave policies, and more accessible maternal and child healthcare. Obstacles that discussed include workplace stigma, illegal abortions, and cultural norms. Health services in the Republic of Korea are largely provided by the private sector; yet, they are financed by national health insurance, which covers 96.7% of the population. Consequently, this nationalist health insurance system provides healthcare for the vast majority of pregnant women, mothers, and children.1Â In Korea, almost all children receive medical benefits through insurance and the healthcare system. This is in contrast with the United States, where many children still do not have access to medical insurance benefits, often because they are not enrolled in Medicaid nor do they have access to

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private insurance. One of the advantages of Korea’s national medical insurance system is the relative lack of racial discrimination, especially compared to the US, where the black population, for example, faces significantly higher rates of single motherhood, pre-term births, and infant deaths.2 Of course, Korea’s low levels of discrimination are aided by its predominantly homogenous ethnic population: The 2.8% of the population that identifies as non-Korean is mainly Chinese.1 After the population boom that followed the Korean War, the government worked to decrease the fertility rate through the Family Planning Project. 4 Condoms and birth control pills were disseminated by the government. 3 As in the US the use of contraceptives began to rise in the 1960s and continued well into the 1990s. 5 Similarly to the Netherlands, Denmark, and the United States, rates of abortion in Korea rose in the 1960s and early 1970s, although it was and remains illegal. In the late 1970s, the rate of abortions peaked. During this time, the increase in both contraceptive use and abortion contributed to the drastic fall of the total fertility rate and family size.5 As of 2015, Korea’s fertility rate had dropped to a staggering 1.2 births per woman. Today, the elderly make up a considerable portion of Korea’s population, which has led to concerns over the low fertility rate and the future of

Korea’s economy. In the last two decades, Korea’s low fertility rate has driven many social and economic policies targeted toward increasing family size. These include the decreased tolerance of abortion and the implementation of pronatalist policies. These policies also include positive incentives such as more generous family leave policies and an increased emphasis on maternal and child health.

The elderly make up a considerable portion of Korea's population, which has led to concerns over the low fertility rate and the future of Korea's economy.

As of 2012, approximately 440,000 childbirths were reported annually in Korea; yet, approximately 340,000 abortions are performed annually, despite national regulations that make 95.6% of these abortions illegal. According to Article 14 of the Mother Act, abortion is only legal in cases of genetic disease or disability, infectious disease, rape, incest, or danger to the pregnant woman.

Although illegality of abortion has not changed significantly in the last half-century, there has been a change in the government’s treatment of abortion. In the 1960s and 1970s, while the government was attempting to decrease the fertility rate through the Family Planning Project, abortion, albeit illegal, was used as a demographic policy. With Korea’s fertility rate drastically lower today than just a few decades ago, abortion is now treated less as a family planning tool, and more as a crime. The most important worries with regard to abortion policies are the following: First, each of the instances in which abortion is legal has been defined quite narrowly. 4 Therefore, women seeking abortion often avoid safe facilities such as hospitals and clinics. This is exacerbated by the fact that the punishment for doctors aiding abortions is much graver than for women receiving them. As harsher punishments for medical personnel are implemented, the incidence of unsafe practice and its negative health consequences increase. Second, when abortion’s legality is dictated by demographics and population growth, the government’s emphasis on low family sizes can skew the sex ratio at birth. Females are disproportionately aborted and male children are disproportionately born due to male favoritism. Until the recent past, these social differences between the sexes were even legally cod-

24.4%

National health insurance covers

of women signed a recommended resignation form under pressure after maternity leave.

96.7%

of the population.

Fewer than

20%

of pregnant Korean women take advantage of maternity leave benefits.

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Jeon Han

Agabang & Company is one of Korea's many baby companies. Korea has encouraged fertility by providing boxes of beef and baby clothes to new mothers.

ified—male children inherited the family register, greater inheritances than sisters and mothers, and the title of family head. Therefore, there is still a great deal of social pressure on women to bear male children.4 In addition to implementing more stringent punishments for those undergoing or aiding in abortions, Korea created many pronatalist policies in 2006. Called the First Basic Plan for Low Fertility and Aged Society, it worked to provide incentives for higher birth rates through the following methods: 1. Decreasing the socioeconomic burden of childcare 2. Expanding childcare infrastructure 3. Expanding support for pregnancy and childbirth 4. Increasing the compatibility between home and work 5. Engendering family social culture emphasizing gender equality 6

The government offers tax incentives for childcare, an untaxed allowance to aid in paying for childbirth and childcare, and baby bonuses. In the civil service, temporary employees are often hired to substitute for parents on leave, and new parents often have the option to work part-time. 8 Unfortunately, it seems that these policies did not effectively

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encourage people to have more children — the number of births per woman has remained less than 1.5 since 2000. In 2013, President Geun-hye Park cited low fertility rates as one of the government’s significant concerns. Although since 2010, the federal government has not implemented a new set of pronatalist policies uniformly across Korea, fertility encouragement grants are provided at the borough level. 6 Boxes of beef and baby clothes are disseminated to families with newborn children, and health workers buy newspaper ads to welcome the births. 3

Many women return from maternity leave to find that their desk is no longer in the office, that they are assigned to another team... or that they are transferred out of town.

Along with the creation of pronatalist policies, Korea also revised family leave policies in the early 2000s in the following ways: 1. In 2001, the Labor Standards Act was amended to increase maternity leave from 60 to 90 days. 2. The Act on Equal Employment and Support for Work-Family Reconciliation was amended to allow an increase in wage replacement levels during leave, and termination during leave was prohibited. 3. In 2001, the Employment Insurance Act was revised so that those on leave were eligible for wage replacement through the national employment insurance fund. Additionally, in 2005, the Constitutional Court upheld penalties for violation of family leave laws, which include up to 5 years of jail and a maximum monetary penalty of $30,000 USD for employers who illegally terminate their employees on leave. Despite these changes, 48% of businesses were in violation of parental leave laws that year. It comes as no surprise that less than 20% of pregnant women take advantage of family leave. In a 2011 survey, 24.4% of women stated that they had signed a recommended resignation form under pressure after their use of leave. They cited fear of dis-

YALE GLOBAL HEALTH REVIEW


Jeon Han

South Korean President Park Geun-Hye celebrates Children's Day with schoolchildren. Recent government policies have increased childcare infrastructure to decrease the burden of raising a family.

rupting the workplace, guilt from fellow employees, policy inadequacy, fear of dismissal, and loss of salary and promotions as reasons for not taking maternity leave. Myunghwa Lee, who writes for the Asian American Law Journal at Berkeley Law, found that “Many women return from maternity leave to find that their desk is no longer in the office, that they are assigned to another team...or that they are transferred out of town.” Although modernization occurred quickly in Korean society, traditional values such as hierarchy in social structures have remained. Consequently, industry practices and business customs prevail, even at the expense of government policies. The preference for male employees, as well as low female workforce participation—only approximately 50% over the past two decades—hinders the effective implementation of family leave policies.8 Unfortunately, the rate of male participation in parental leave has remained less than 3% during the last decade. Many women argue that this increases the stigma of maternity leave and decreases the chances of women taking advantage of such policies.7 Therefore, neither male nor female parents are likely to take family leave, which makes it difficult to raise fertility rates.9 The last manner in which Korea has worked to increase fertility rates is through the positive incentive of high quality ma-

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ternal and child healthcare. The Ministry of Health and Welfare is especially involved in the promotion of health and prevention of disease in mothers and children.2 In the last two decades, the Korean government has placed an increased emphasis on national programs to improve healthcare for pregnant women and children. Between 2000 and 2011, Korea also implemented programs to diagnose deafness early in life, prevent the blindness of preschoolers, prevent maternal hepatitis B infection, and support teenage mothers, as well as provide information on pregnancy, childcare, and breastfeeding.

Future policy must focus on reconciling the roles of women as both mothers and members of the workforce, as well as decreasing the negative connotations associated with male parental leave.

These changes will hopefully have a twofold effect—the availability of social support may persuade more women to have children, and the increased health benefits may lead to better overall health for those new mothers and children. Future policy must focus on reconciling the roles of women as both mothers and members of the workforce, as well as decreasing the negative connotations associated with male parental leave.9 Similarly, efforts must be made to diminish the negative effects of preference for male children. An unbalanced sex ratio nationwide may lead to a fewer number of female residents, who would therefore have even fewer children, aggravating the current situation. Hopefully, with various economic and social initiatives, the Republic of Korea will soon be able to simultaneously minimize stigma associated with female children and employees, increase the fertility rate, and improve the quality of life and health outcomes of Korean mothers and children.

www Sukriti Mohan is a senior in Silliman majoring in History of Science, Medicine and Public Health and is in the accelerated 5-yr BA/MPH program. She can be contacted at sukriti.mohan@yale.edu.

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MENTAL HEALTH

MEXICO

Depression: Stigma and its Policy Implications By Diana Gonzalez & Mauricio Alvarez

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Irais Esparza

YALE GLOBAL HEALTH REVIEW


T

he Vice-Minister of Integration and Development of the Health Sector of the Mexican Ministry of Health, Eduardo González Pier, claims that “an important segment of the population with a mental health problem does not seek medical attention, simply because they do not consider it an illness; however, this is not a minor problem. In Mexico,…depression-related disability represents 9.8% of the total [burden of disability-adjusted life] years…in the country.” He says, “If I had to implement only one change, it would be to fortify the proactivity of the National Health System for the identification and treatment of mental illnesses… [and] raise the awareness [among] the population and the decision-makers in the health sector regarding mental health problems in the whole country.”1 Mortality Statistics, INEGI

DEPRESSION AND ITS RELEVANCE FOR PUBLIC HEALTH Depression is a common mental illness that is characterized by negative changes in mood, cognition, and behavior.2 Such changes may include increased sadness or irritability, loss of appetite, weight changes, insomnia, reduced energy, loss of interest in pleasurable activities, feelings of guilt and hopelessness, difficulty concentrating, and/or suicidal thoughts.3,4 Depression is one of the leading causes of disability, morbidity, and mortality in the world, and is a major risk factor for suicide and physical health problems such as heart disease, diabetes, arthritis, and respiratory diseases.5,6,7,8 Contrary to common belief, depression can be diagnosed at all ages, even as early as one’s preschool years.9 Children and adolescents are more prone to anxiety and anger, but they are less likely than adults to verbalize any helplessness they may feel.10 Despite these differences, the course of depression seems to be consistent among all age groups.11 There is also a greater tendency for comorbid aggressive and antisocial behaviors during adolescence, as well as an increased risk for suicide, possibly due to the late maturation of the prefrontal cortex of the brain, greater emphasis on social status, reduced adult supervision, lack of sleep, and increased risk-taking behavior.12,13 Furthermore, suffering from depression before 13 years of age is thought to have a long-lasting effect on development, potentially creating a “cognitive scar” that may predispose children to depression, antisocial behaviors, substance abuse disorders later in life and increase resistance to treatment.14,15,16,17,18,19,20 Depression and depressive disorders are highly treatable with competent care. If treat-

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ment is begun early, there is a 20-60% remission rate after 1-2 years of treatment and a 70% rate after 5 years.21 However, despite the relatively high recovery rates, once a person has suffered an episode, he or she is more likely to relapse and suffer long-lasting negative effects in his or her relationships, self-esteem, and physical health.22,23 Furthermore, increased severity of depression, the presence of suicidal thoughts during adolescence, and comorbidity with other disorders worsen the prognosis and increase the likelihood of relapse.24 There are multiple risk factors for developing depression, including young age, low education, and history of trauma, especially during childhood.25 Low socioeconomic status has also been related to a greater risk.4,22 Negative life experiences, such as ethnic or sexual discrimination, are also highly associated with depression, particularly among adolescents and young adults.4 Women have a greater risk for depression than men, with a 2:1 female-to-male ratio of prevalence.26 This may be because women have been found to have a greater tendency to ruminate on symptoms of distress, and more negative self-inferences when facing undesirable outcomes, compared to men.27 However, further evidence is needed to understand this gender disparity. DEPRESSION IN MEXICO Mental health in Mexico is recognized as one of the main unresolved issues within the government’s health policy agenda. Recently, the subject has been gaining relevance due to the increasing prevalence of mental disorders and its correlation with increased prevalence of other issues within the country, such as violence, inequality, and poverty. In addition to this correlation, mental disorders have been

shown to increase the risk of other communicable and non-communicable diseases, and are strongly associated with the prevalence of chronic diseases.28 Individuals with chronic diseases are more prone to suffer from depression or other mental health disorders. Mental disorders also affect the physical and professional development of individuals, directly decreasing their economic productivity. Discrimination might further prevent patients from accessing the labor market, lowering their household income and making their reinsertion into society more difficult. Statistics from the National Institute of Statistics and Geography (INEGI) show that the number of deaths due to mental and behavioral disorders decreased by 29% between 1998 and 2008, but then increased by 33% between 2008 and 2014. During this latter period, there was a decrease in mortality associated with these disorders among individuals between 0 and 29 years old and an increase in mortality among 50 to 54 year olds. Additionally, the mortality associated with mental health disorders increased during the same period for both men and women, at 17% and 18% respectively.29 The global financial crisis of 2008 and the Mexican government’s war against drugs, which started in 2006, may have created an atmosphere of social unrest that led to these trends. According to the Institute for Health Metrics and Evaluation, depressive disorders represent 4.19% of the total Disability-Adjusted Years (DALYs) in Mexico—a measure of the country’s burden of disease—for both sexes.30 DALYs are globally-recognized indicators that account for the gap between a country’s current health status and the ideal health situation, in which the entire population lives to an advanced age, free of disease and disability.31

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Depressive disorders in Mexico create a comparable disease burden to that of interpersonal violence, road injuries, or congenital anomalies, and a greater burden than that of cerebrovascular disease, HIV/AIDS, or some types of cancer. This evidence indicates that, in addition to the medical relevance of the subject, the individual and societal costs associated with mental disability must be considered when prioritizing policies in the health sector’s agenda. In 2002, a Mexican National Comorbidity Survey employed the World Mental Health Composite International Diagnostic Interview (WMH-CIDI), a comprehensive interview developed by the World Health Organization (WHO), to assess the epidemiological profile of mental disorders in Mexico.32 The survey found that 1 out of every 8 Mexican citizens suffered a depressive disorder, and about half of that population had suffered a depressive episode within the past year. They also found that low income was strongly correlated with increased severity of mental disorders, and that widowed, separated, and divorced individuals had an increased risk for depressive disorders. Other studies found the prevalence of depressive disorders is even higher in individuals over

80 years old at 21.7-25.3%.33,34 In 2012, among the total number of hospital discharges of people over 60 years old, 12.3% were related to depressive disorders.34 This suggests that mental health issues in Mexico will become more relevant as the country undergoes a demographic transition to an older population. Despite this already high prevalence, it is possible that even more people suffer from depression in Mexico than have been accounted for. This is mainly because studies do not usually account for indigenous communities, and there are multiple factors—such as stigma against mental disorders and cultural differences—that can create significant report biases and lead to underestimations of the prevalence of depressive disorders. For example, Weller, Baer, Garcia de Alba, and Salcedo Rocha found that many Mexican communities call these disorders “nervios” (nervousness) or “susto” (fright), rather than using their medical names, which increases underreporting.35 Stigma and underreporting of depression is usually linked to the popular belief in “machismo” (male chauvinism). Some examples of the effects of this belief on stigma

The presence of this stigma deters individuals from seeking care and continuing treatment, and therefore contributes to the further underestimation of the prevalence of disorders.

against mental health disorders are the popular misconceptions that depression is only in the mind and can be cured with positive thoughts; depression is a disease for weak persons, and strong and mature individuals do not suffer from it; men cannot suffer from depression; because nobody can die from depression, what does not kill you makes you stronger; and seeking mental health treatment is simply an escape for those who cannot handle their daily problems. The presence of this stigma deters individuals from seeking care and continuing treatment, and therefore contributes to the further underestimation of the prevalence of disorders.36 OBSTACLES AND CHALLENGES FOR AN ADEQUATE DIAGNOSIS AND TREATMENT OF DEPRESSION IN MEXICO

Creative Commons

According to the National Alliance on Mental Illness, Frida Kahlo was diagnosed with minor depression, but experienced two major depressive episodes and suicide attempts during her lifetime.

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Mental health diagnosis and treatment face many obstacles and barriers in both high-income, and low- and middle-income countries. In high-income countries, between 35% and 50% of patients with mental health disorders do not receive treatment. In low- and middle-income countries, this percentage lies between 76% and 85%. To tackle this public health problem, the WHO issued the Mental Health Gap Action Programme (mhGAP) in 2008 and the Intervention Guide (mhGAP-IG) in 2010.39 In 2002, a “New Model of Care for Mental Health” was issued and authorized in Mexico to eliminate human rights violations caused by the old model, such as inhumane care and involuntary psychiatric treatment. In 2004, the “Secretariado Técnico del Consejo Nacional de Salud Mental” (STCONAME) was founded as an organization dedicated to establishing public policies and national strategies for mental health.37

YALE GLOBAL HEALTH REVIEW


While there is no current disease-specific policy for depression in Mexico, the government has recently given more emphasis to mental health. One of the main strategies that demonstrates this emphasis can be found within the Specific Action Program for Mental Health 2013-2018, which is aligned with the National Development Plan 2013-2018 and the Health Sector’s Plan. The strategy is called Miguel Hidalgo’s Model for Mental Health, and is focused on the promotion and prevention of mental disorders, with the aim of increasing early diagnoses, increasing quality of care, and reducing cost of care. The main actions of the plan include increased mental health promotion, the implementation of ambulatory care in “Centros de Salud” (primary care level clinics) and “Centros Integrales de Salud Mental” (specialized clinics open to the public with multidisciplinary teams of specialized professionals), the installation of psychiatric units in general hospitals and Transition Villas, and improved rehabilitation and social reinsertion through a “Protective Workshop”, where patients develop skills and competencies needed to relate to others, reintegrate themselves into the community, and engage in social activities, all while receiving a wage.38 Likewise, a new mental health policy implemented by Mexico City’s government leaves screening for depression in the hands of general physicians, while also promoting the use of a telephone line for psychological assistance.40 However, in addition to the stigma, discrimination, and low public awareness of mental health issues, Mexico faces two large problems that prevent the effective implementation of a large scale program for the treatment of these disorders: (1) the lack of specialized human resources and (2) the general budget restrictions on health care initiatives. In 2011, the WHO observed that Mexican mental health services were understaffed, underfunded, and not completely integrated with other public health programs. Multidisciplinary teams–composed of psychologists, physicians, social workers, and other non-mental health specialists–are scarce. Therefore, the majority of mental health problems are treated in psychiatric hospitals, which increase service costs and hinder early detection and prevention strategies. Furthermore, most mental health services are located in metropolitan areas, making them inaccessible to indigenous communities. According to the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), only 2% of the health sector budget is assigned to mental health services, and of that percentage, 80% is earmarked for psychiatric hospitals.43 There is also a lack of special mental health programs for children, adolescents, or older adults. Like-

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wise, most public schools lack services for the prevention, assessment, and referral of mental health issues, including depression.

The WHO observed that Mexican mental health services were understaffed, underfunded, and not completely integrated with other public health programs.

Within the mhGAP-IG, the WHO describes an effective program to assess and manage depression as one that: (1) promotes psychoeducation; (2) addresses current psychosocial stressors; (3) reactivates social networks; (4) considers antidepressants; (5) if available, considers interpersonal therapy, behavioral activation, or cognitive behavioral therapy; (6) if available, considers adjunct treatments such as structured physical activity programs, relaxation training, or problem-solving treatments; (7) does not manage the complaint with other ineffective treatments (e.g. vitamins); and (8) offers regular follow-ups.39 Moreover, the U.S. Preventive Services Task Force (USPSTF), an independent panel of health-care experts, recently recommended regular “screening for depression in the general adult population, including pregnant and postpartum women.”41 The USPSTF assigns one of five letter grades (A, B, C, D or I) to each recommendation, according to the level of certainty of obtaining a net benefit from the initiative, and recommends a level of provision for the specific service.41 In this case, USPSTF gave a B grade (high certainty of a moderate benefit) to this screening recommendation, which is the same as its grading for yearly mammograms, diabetes screening in overweight and obese patients, and lung-cancer screening for at risk patients. One article in the Atlantic stated that, “past research has shown that without any sort of systematic screening, general practitioners miss nearly half of all cases of major depression.”40 Much more effort is needed to ensure that the current mental health programs in place are effectively diffused and implemented, and that the expert-recommended screening, assessment, and treatment guidelines are adequately followed. Making primary care the articulating axis of mental health and establishing screening procedures is a first step. However, considering alternative strat-

egies centered around prevention teams led by nurses or social workers rather than general practitioners, who are already saturated with other programs and only have around 15 minutes to see each patient, strengthening the construction of more specialized facilities to treat mental disorders, and establishing screening in schools can make an immense difference in how mental health is perceived and treated in Mexico. CONCLUSION The most relevant challenges for the Mexican mental health programs lay in strengthening prevention programs, establishing primary care as the articulating axis for mental health, improving the training of health workers, and improving patient rehabilitation and reinsertion. In order to improve the effectiveness of any new programs, investment in mental health services must first be increased, and both families and service users must be incorporated into the program planning and development, 44 In response to these unmet needs, multiple training and prevention programs—most of which are recognized by the Mexican National Commission of Science and Technology (CONACYT) with financial and research support—have been developed.42 Service users and family members are also gaining a greater voice in service improvement and research by being invited to collaborate in service user panels. However, the mental health system is still considerably understaffed and has not yet integrated multidisciplinary teams.42 Further work is needed to manage this burden of disease, which might become an even larger issue within the next decades.

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Diana Gonzalez is a 2017 candidate for a Master of Public Health Policy with a concentration in global health. She can be contacted at diana.gonzalez@yale.edu. Mauricio Alvarez received a Master of Science degree in Neuroscience and Psychopathology at University College London in 2016 and was a Postgraduate Fellow at the Child Study Center at the Yale School of Medicine. He can be contacted at mauricio.alvarezmonjaras@yale.edu.

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FOOD SECURITY

FOOD INSECURITY in the "Salad Bowl of America"

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By Claire Chang

icknamed the “salad bowl of America,” the Salinas Valley of Monterey County, California, reigns as one of the most productive agricultural regions in the world. As a whole, Monterey County contributes significantly to America’s total annual vegetable production. For example, the county produces 61% of leaf lettuce, 57% of celery, 56% of head lettuce, 48% of broccoli, and 28% of strawberries grown in the United States.1 According to Monterey County’s 2014 Crop Report, the total value of its major crops exceeded 3.7 billion dollars.1 Since the first half of the twentieth century, the Salinas Valley has consistently produced immense quantities of vegetables. Examining agriculture in the Salinas Valley through the lens of farmworker health reveals the valley not as a place of consistency and fertility, but rather as one of contradiction and injustice. The people who live and work in the “salad bowl of America” face widespread food insecurity, a glaringly unfair paradox. Food insecurity is defined as “limited or uncertain availability of food, or uncertain ability to acquire acceptable foods in socially acceptable ways,” due to restricted financial resources.2 According to the 2014 annual report of the USDA’s Economic Research Service, 14% of all US households face food insecurity, and 5.6% of households struggle with very low food security, such that one or more family members experienced disrupted eating patterns or hunger at some point during the year.3 In 2008, the California Institute for Rural Studies (CIRS) undertook a project to identify strategies that might increase food security among agricultural workers

in Monterrey County. The project’s surveys found that only 34% of farmworkers who participated in the study were food secure.4 The level of food insecurity in Monterey County rises far above nationwide averages, and the severe struggle to acquire food seems especially tragic because Monterrey County is one of the highest grossing crop-producing counties in the US.4 One reason for the rampant food insecurity of the Salinas Valley is that growers rarely allow workers to take food from the field home for their own consumption. Although 42% of farmworkers in the Salinas Valley reported that their employer “always” or “almost always” allowed them to bring fruits and vegetables home from the farm, 38% of workers “rarely” or “never” were permitted to bring produce home for family consumption.4 Carrying home fruits and vegetables for personal consumption could significantly improve nutritional status in farmworker households. Families of agricultural workers often live below the poverty line and their diets consist of low-cost, energy-dense foods of low nutritional value.5 The Fresno Farmworker Food Security Assessment found that the ability to bring food home from the farm was associated with a 10% increase in the likelihood of food security and provided nearly an entire additional serving of fruits and vegetables per day.6 While taking food home from the field would likely improve nutrition among farmworkers, this intervention alone would not lead to food security. Most farmworkers in the Salinas Valley grow lettuce, artichokes, strawberries, or garlic for months at a time, so heavy reliance on these foods would lead to insufficient, homogenous diets.

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YALE GLOBAL HEALTH REVIEW


Immigration policies have also shaped the demographic composition of the Salinas Valley’s workforce; the vast majority of farmworkers are immigrant laborers who do not receive federal assistance or other forms of support. Vegetable production in the Salinas Valley is labor-intensive, especially compared to grain production. During World War II, growers in the Salinas Valley faced a labor shortage, so they began to import laborers from Mexico under the Mexican National Program. The program was an agreement between the United States and Mexican governments that regulated the migration of Mexican citizens to work as contract agricultural laborers. With the passage of the Migrant Labor Agreement in 1951, this program became known as the Bracero Program. The program brought five million Mexicans to America before its end in 1964.7 Growers kept wages for seasonal Mexican laborers extremely low, so the workers cost even less than mechanized cultivation processes. Even after 1964, unauthorized immigrants continued to travel to the United States in search of employment on farms. Neoliberal trade reforms, such as the passage of the North American Free Trade Agreement (NAFTA) and the restructuring of the Mexican government in the 1980s, greatly reduced the economic viability of many small, subsistence Mexican farms.8 The economic situation in Mexico forced increasing numbers of Mexican citizens to migrate to the US, in order to work as agricultural laborers in places like the Salinas Valley. In California today, roughly 90% of farmworkers are Mexican-born.9

The nature of farm work also contributes significantly to the prevalence of food insecurity in the Salinas Valley. The seasonality of farm employment leads to fluctuations in household income, so farmworkers often struggle to determine whether they qualify for food-assistance programs.4 During labor-intensive seasons, family members do not have time to purchase ingredients and cook meals, so they eat processed foods that they can prepare quickly.10 Although farmworkers do bring home-prepared foods to the fields for breaks, they do not have access to cold food storage or reheating during the workday, so they often turn to highly processed, prepackaged foods.10 Even intermittent periods of food insecurity can lead to many negative health outcomes. Food insecure households lack dietary diversity and consume lower levels of fruit and vegetables than food

“

The fact that undocumented immigrants constitute such a large proportion of laborers is one of the reasons for low usage rates for food assistance programs. According to a 2008 study of workers in the Salinas Valley, 78% of surveyed workers took advantage of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program if they had children less than five years of age.4 Only one-third of farmworkers who were eligible to receive food stamps, however, reported participation in the food stamp program.4 Many farmworkers failed to take advantage of food assistance programs because they lacked documentation status papers and feared that receiving food assistance would impede citizenship in the future.4

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According to a study done by CIRS, only about 34% of farm workers are food secure.

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secure households. As a result, members of food insecure households often have nutrient deficiencies.11 In addition, members of food insecure households are more likely to develop diabetes than members of food secure households.12 The majority of food insecurity research has focused on children, and has found that food insecurity is associated with increased risks of birth defects, anemia, cognitive problems, aggression, and anxiety.13 Interestingly, food insecurity is correlated with obesity in adults, but studies have not found similar associations between food insecurity and obesity among children.14 A possible reason for this contradiction is that parents sacrifice their own food resources to feed their children as well as possible.14 Another of the theorized ways in which food insecuri-

ty contributes to weight gain and obesity in adults is that periods of insufficient food cause binge-eating behavior at times when food is plentiful.15 Furthermore, depression and suicidal ideation are more prevalent among individuals in food insecure households than food secure households. Several interventions could improve food security levels among farmworkers in the Salinas Valley. Education and outreach efforts to increase the use of federal food assistance programs among those who qualify would help many families meet their nutritional needs. Furthermore, Congress could expand food assistance programs to better accommodate workers with fluctuating incomes, as well as those whose annual income is barely above the poverty line. Feeding a family with food assistance dollars is a tremendous challenge, but some form of assistance is often better than no aid at all. Policies could also require growers to allow, and even encourage, workers to bring food home from the farm. In addition, farmworkers in the Salinas Valley have demonstrated great interest in developing community, school, and apartment gardens as a means of improving access to fresh, affordable food.4 The willingness of growers to allocate some land to employee gardens has not been thoroughly explored, but could enable farmworkers to create variety in their diets.4 Many immigrant workers previously farmed for sustenance in Mexico, and already have the knowledge required to cultivate food for their families.6, 16 Without interventions to improve food security, the tragic irony of inadequate access to food in one of the most agriculturally productive regions of the country will persist. We may continue to enjoy the lettuce and strawberries that grow in the Salinas Valley, but without policy changes, the workers whose labor makes our consumption of such luxurious produce possible will never achieve food security. www Claire is a junior in Pierson majoring in Environmental Studies. She is also a Global Health Scholar. She can be contacted at claire.chang@yale.edu.

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REPRODUCTIVE HEALTH

IRELAND:

Restrictions on Abortion By Ariela Zebede

William Murphy

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reland has some of the strictest abortion laws in the world, only allowing abortion in order to save the life of the mother. The laws are unclear in some situations, however, sometimes leaving pregnant women trapped in situations that may damage their mental or physical health. Moreover, victims of rape and incest are denied the possibility of an abortion. As a result, many travel outside the country to abort unwanted pregnancies, but this option is unavailable to the poor and undocumented. Ireland, despite these distressing facts, has a stellar reputation for gender equality.1,2 Seemingly positive statistics hide the dire, inequitable climate for women that the country’s strict abortion laws have created. Ireland’s abortion laws gained public attention in 2012 when Savita Halappanavar died from pregnancy complications. Even after Halappanavar began to suffer from serious infections and her doctors declared that a miscarriage would be inevitable, her doctors told her that under Irish law, “if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart[beat].” Her illness progressed until the fetus’s heartbeat stopped, but by that point, she was beyond saving.3 The political uproar surrounding Savita’s preventable death lead to the 2013 Protection of Life During Pregnancy Act (PLDPA). The new legislation specified the circumstances under which doctors could legally perform an abortion. These circumstances include: (1) the “real and substantial” risk of loss of life from physical illness; (2) the “real and substantial” risk of loss of life from physical illness in an emergency, or (3) the “real and substantial risk” of loss of

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life from suicide. Critics of the new law, however, have argued that it “fails to properly protect women’s lives and further criminalizes women who access abortion service.”3 This failure comes, in part, from the legislation’s lack of clarity about what is considered a “real and substantial risk.” At what point does an illness shift from a threat to health to a threat to life? Few medical choices are black and white, and doctors cannot be absolutely certain that a person will die until it is likely too late to save them. Moreover, current law threatens doctors with up to 14 years in prison for an unlawful abortion, which may cause medical personnel to err on the side of protecting the fetus, allowing the mother’s condition to worsen and decreasing the likelihood of successful treatment later on.3 A law that allows for abortion only when there is a risk of death disregards longer-term risks associated with allowing an illness to go untreated. These future health issues can become more expensive for the state down the line and, more importantly, the untreated patient may experience lifelong health complications and a significant decrease in quality of life. The suicide provision seems like it could be interpreted broadly, but the law actually outlines extremely specific rules under which it applies. The Irish Department of Health’s “Guidance Document for Health Professionals” elaborates on the PLDPA. In order for someone to qualify for an abortion, they must demonstrate “suicidal intent.” This language implies that doctors may only deem a woman qualified if she is actively suicidal, or suicide is imminent.3 The line between “imminent” and too late, however, is extremely fuzzy.

YALE GLOBAL HEALTH REVIEW


Logistically, approval for an abortion must be granted by three different doctors: an obstetrician and two psychologists. All three doctors must have very specific qualifications. These measures are meant to prevent a mentally stable person from using the suicide exception to abort an unwanted pregnancy, but the need for such an exhaustive process suggests a general skepticism about women’s mental health. Furthermore, this process is particularly burdensome for a woman who is already in a difficult mental state. The effort to prove one’s suicidal tendencies to three skeptical doctors, all while carrying an unwanted child, will exacerbate a preexisting mental illness. In all three life-threatening scenarios, doctors must certify that the only way to protect the life of the patient is by terminating the pregnancy.4 Even if an abortion would alleviate her condition, abortion is still avoided at all costs. With so many types of alternative medical treatments available, only an extremely specific scenario would require an abortion to evade all risk. An illness that merely worsens because of pregnancy would not qualify. Specifically, in the case of suicide, determining that only an abortion will mediate the risk of death is nearly impossible. Suicidal intent and ideation result from a combination of factors that may only worsen when a mother-to-be is forced to carry an unwanted pregnancy. Ireland’s abortion laws even exclude provisions included as exceptions to the “strict-

er” abortion laws of many other nations. For example, in cases of fetal impairment so severe that the child will die almost immediately after birth, a pregnant woman must carry that fetus for the full course of nine months, and give birth to the child with the knowledge that that he or she will soon die. In addition to the typical physical tolls of pregnancy, such as nausea, bladder control issues, and the process of childbirth, this situation will cause expectant mothers significant emotional strain. One woman who traveled abroad for an abortion recounts, “How cruel would it be to …. put me through a full pregnancy, I would have the breast milk, I would have everybody asking me how long are you gone?... How could they think that would not affect someone mentally? I could never have gone through that, I just couldn’t.”3 A growing baby bump serves as a constant reminder of the tragedy that a mother will ultimately face. Even looking at the live baby while knowing that he will soon die can be devastating. In cases of rape, a reality for approximately 7.5% of Irish women, abortion is still criminalized.5 Incest, too, bears no abortion exception.3 Ireland’s current laws provide no support for victims of rape or incest. On the contrary, the government ultimately forces them to choose between committing a crime and bearing the children of their predators. A woman who has already experienced a great deal of trauma, both psychologically and physically, must instead face the obstacles that stand between her and an abortion. The United Nations’ Committee Against Tor-

ture points out that, when abortion in cases of rape, incest, or an unviable fetus is illegal, victims are “constantly reminded of the violation committed against them, which causes serious traumatic stress and carries a risk of long-lasting psychological problems.”6 If a woman tries, for example, to obtain an abortion through the suicide exception, she will be forced to relive her traumatic experience three times, with three different doctors. She will likely fail in her efforts to qualify for an abortion; the growing fetus, then child, will constantly remind her of her trauma.

Few medical choices are black and white, and doctors cannot be absolutely certain that a person will die until it is likely too late to save them.

Because legal abortions are essentially unavailable in Ireland, women who want them must look for other options. Some pursue illegal abortions, primarily induced by medication (typically mifepristone and misoprostol). Those who buy these medications spend approximately €177 (roughly $200) on

As a legal alternative, about

7.5% of Irish women have experienced rape or attempted rape in adulthood

8.3% of women in Ireland live in consistent poverty

300

Getting an illegal abortion in Ireland is punishable by up to

women and girls travel from Ireland every month to terminate pregnancies

14 years

In 2014, Irish customs and the Health Products Regulatory Authority (HPRA) seized

1,017

in prison

The average financial burden for traveling abroad to obtain an abortion is approximately

€1000-€1500 ($1125-$1695)

tablets of mifepristone and misoprostol from the mail

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average, a doable price for most. But taking medication illegally and without medical supervision puts pregnant women at risk for untreated complications; in addition, these pills earn women up to 14 years in prison under the PLDPA. Still, many women continue to pursue that option for its affordability. In 2014, Irish customs and the Health Products Regulatory Authority (HPRA) seized 1,017 tablets of mifepristone and misoprostol from the mail.3 Ireland’s restrictive abortion laws put pregnant women at risk for both medical complications and significant jail time. Furthermore, approximately 300 women and girls travel from Ireland to Britain every month in order to terminate their pregnancies.7 This number, however, is an underestimate as it does not include those who travel to countries other than Britain, or those who do not provide their Irish addresses for confidentiality reasons. Although travel is a legal option used by many, it is not problem-free. First, Irish healthcare practitioners do not offer women much information about this option. The Regulation of Information Act restricts information about abortion abroad, and bans any information that advocates or promotes abortion. This act prevents doctors from giving their patients all of the necessary information, compromising the doctor-patient relationship. Moreover, the journey is both costly and complicated. Amnesty USA describes how Women and girls in Ireland must first identify a reputable clinic or hospital and then try to book an ap-

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pointment on a date that they are able to travel, and that meets their medical and financial restrictions. Once an appointment is made, the woman may then need to arrange for her medical records to be sent to the clinic or hospital abroad. Employed women, and their travel partners, must arrange to take time off work – clinics typically operate only on weekdays. Women with children need to arrange childcare. In order to enter the [United Kingdom] or another [European Union] country they must have identification that shows their nationality, ideally a passport. Flights or ferries must be booked and, for some, accommodation reservations made.3 After all of these preparations, women must then pay for the actual procedure. In total average cost for the entire trip ranges from €1,000 to €1,500 ($1,225 to $1,695).3 Women who travel to get abortions are also unable to receive follow up care upon their return, making it difficult to receive treatment if complications arise or an abortion is incomplete. Others who make the trip, discover upon arrival that they cannot undergo an abortion for various medical reasons. A woman who has delayed her travel in order to obtain necessary funds, for example, may no longer be able to undergo a safe abortion.3 While just over one fifth of English women aborted their pregnancies at ten weeks or later, one third of Irish women receive such lateterm abortions.8

The PLDPA states that the act does not limit the freedom to travel in order to receive an abortion.9 Although many Irish women take advantage of that option, travel isolates groups of women who either cannot afford to make the journey, or are unable to do so for other reasons. 8.3% of women in Ireland live in consistent poverty; they can neither pay for travel expenses, nor afford to take time off of work.10 Asylum-seekers receive a weekly allowance of €19.10 or $22, a small compensation that leaves them poor and trapped in Ireland until their refugee or immigration status is determined, a process that can take years to resolve. Migrant women, too, may need special papers to travel. These women may seek abortions

The laws in place provide no support for these victims. On the contrary, the government ultimately forces them to choose between committing a crime and bearing the children of their predators.

YALE GLOBAL HEALTH REVIEW


not only for personal reasons, but also because they may not have the means to support a child. In a state of desperation, women are more likely to pursue illegal, dangerous options. The United Nations Human Rights Committee expressed concern for poverty-stricken women, but Irish representatives retorted that they had “no solution” for women who are unable to travel.11 The government seems to justify its restrictive abortion laws by protecting the “freedom” to seek abortions elsewhere. This freedom, however, is limited to those who can afford to travel and have the requisite documents on hand. The government’s inaction on behalf of those who do not have the means to leave Ireland effectively prevents certain groups from receiving an abortion. This inequality can be psychologically and physically devastating, and reinforces preexisting inequalities within Ireland. Ireland’s Eighth Amendment considers the right to life of the unborn equal to that of the mother. This amendment has implications that extend beyond abortion laws. The Association for Improvements in the Maternity Services Ireland writes: [T]he Eighth Amendment is repeatedly used in the context of maternity rights to deny the right to bodily autonomy in terms of decision making in pregnancy, in labour, in birth and in the postpartum period. Women have reported being forced into caesarean births, forced into invasive procedures during labour,

threatened with social services, and in some cases threatened with the Gardaí [police] and mental health services for trying to assert their right to bodily autonomy.3 In December 2014, a clinically dead pregnant woman was kept on life support despite her family’s insistence that she be allowed to die, violating principles of informed consent that typically regulate doctor-patient relationships. Another woman who shared her story stated simply, “It was always what was best for the baby, not what was best for both of us equally.”3 Research on maternal health has shown that an emphasis on maternal health maintenance positively impacts the health of future generations.12 The mental health impact upon mothers who cannot acquire abortions cannot be understated. Because of the active pro-life movement in Ireland, the stigma surrounding abortion is so strong that many who seek abortions abroad travel in secret to prevent discovery by their neighbors. The trauma experienced by victims of rape and incest only grows when very little can be, or is, done to alleviate the trauma. For those who decide to seek abortions, travelling or pursuing illegal alternatives cause significant stress, as well. Irish doctors have confirmed that the financial pressures, as well as the isolation from health services and family, that women experience when they are forced to travel abroad for safe abortion services negatively affects their health.8 These mental stresses upon the mother can have negative impacts on the child as well, as studies have

About ten thousand people attended a rally in Dublin in memory of Savita Halappanavar

suggested that women who experience high levels of stress during pregnancy are more likely to deliver premature babies.12 All in all, Ireland represents an atypical case. Typically, strict anti-abortion laws are associated with countries that are either underdeveloped or generally unsupportive of women’s rights and health. Meanwhile, Ireland’s GDP per capita is comparable to that of the United States, the World Economic Forum ranks Ireland fifth (behind four Scandinavian countries) in gender equality, and Ireland boasts a low maternal mortality rate compared to that of the rest of the world.13,2 But statistics can be misleading, and here, they mask real harm and inequality. The gender equality statistics mostly take into account economic, political, and educational issues, allotting little weight to female life expectancy and sex ratio at birth. No statistic on female body autonomy or women’s treatment even exists in the health system. Even so, Ireland’s “subscore” for life expectancy is ranked at 56 world-wide. Moreover, Ireland’s maternal mortality rate is actually average for developed countries.14 The country’s economic status implies that more people can afford to travel abroad in order to obtain an abortion. It is possible that traveling prevents many would-be maternal deaths. Also, it is possible that records list pregnancy as only an indirect cause of death, one of a number of contributing factors. Extended pregnancy, for example, may cause later health complications that ultimately lead to death. These health complications, rather than the pregnancy, would be listed as the “cause of death.” Furthermore, similar to laws that establish a clear distinction between “health” and “death,” cause of death statistics ignore the importance of quality of life. Pro-life advocates in Ireland use Ireland’s maternal mortality rate as justification for its abortion laws.15 Health systems should, however, strive to protect not only the lives, but also the health of all patients. The Irish system does not accomplish such a goal. Instead, Ireland limits the options of pregnant women, creating a toxic environment for women’s health.

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Ariela Zebede is a sophomore in Pierson College from Miami Beach, Florida. William Murphy

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She can be contacted at ariela.zebede@yale.edu

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PAKISTAN & BRAZIL:

HEALTHCARE POLICY

The Current Narrative of Healthcare Reform By Mahrukh Shahid

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arlier this year, the Prime Minister (PM) of Pakistan, Nawaz Sharif, launched a state-run health insurance program called the Prime Minister’s Health Program (PMHP). The scheme initially targeted 15 districts, but PM Sharif quickly announced plans to expand PMHP to 23 districts and expressed hope that the program would soon become available in all 128 districts, plus the seven tribal agencies of the country.1 Under this program, the PMHP will issue special cards to families in need, providing them with USD 2,865 per year for free treatment.1 The government will pay for the insurance from its own coffers. PM Sharif highlighted his motivations behind the program by describing PMHP as the first step towards making Pakistan a welfare state.1 However, several features of this endeavor may prove problematic, including its severely restricted scope. In order to fully evaluate PMHP, we must consider the larger picture at hand and how the issues plaguing PMHP fit into the history of failed healthcare reform in Pakistan. Furthermore, a comparison between healthcare in Pakistan and Brazil—a country that has recently made major strides towards a universal, integrated, and accessible healthcare system—will hopefully contribute further perspective on the nuanced issue of healthcare policy and reform. The histories of Pakistan and Brazil bear two very noticeable commonalities: the

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marks of colonialism and dictatorship. Both countries have been ruled by superpowers who aimed to exploit their resources for maximum economic gain. After achieving independence, the two nations have both struggled with political upheavals, and fights for the right to democracy.2,3 When it comes to healthcare, Brazil’s civil society used the struggle for democracy to institute health as a basic human right and duty of the state, but in Pakistan, widespread mobilization of the common people around this basic necessity has failed to occur. Even in 2016, healthcare reform is initiated at the behest of the political leadership, with questionable political motives, instead of a grassroots movement. A comparison of these two countries demonstrates that Pakistan’s topdown model is less effective than Brazil’s mass mobilization for the issue of health. In 1988, the Brazilian constitution recognized health as a basic right, resulting in the creation of the Unified Health System (SUS). The SUS provides and finances health services at the federal, state, and municipal levels. The healthcare reform that inspired the SUS was “driven by civil society rather than by governments, political parties, or international organizations.”2 This movement joined forces with the struggle to restore democracy in the late 1970s, and its ability to combine different societal initiatives gave the movement widespread influence. Middle class

populations, trade unions, illegal left-wing parties, health professionals and professors, and grassroots movements all joined forces to present a unified front.2 In the face of stiff resistance from a strong, organized private health sector, the health reform movement gained approval for reform from the National Constituent Assembly of 1988 and, despite political upheaval during the next decade, the government successfully implemented the SUS and various other initiatives, such as the National Tobacco Control Program.2,4 The will of the people drove these measures forward in Brazil. In contrast, Pakistan was unable to pass a 2013 Reproductive Healthcare and Rights Bill through the Senate.5 This Bill sought to enact policies and programs promoting reproductive health and associated rights in order to reduce maternal mortality and morbidity, as well as prenatal mortality.5 The bill also aimed to promote the right to reproductive healthcare information.5 It is alarming that the democratic process failed to uphold basic reproductive health rights of the people whom the process ought to serve. This failure begs a question about the behavior of the Pakistani people, after the state refused to even recognize such essential rights in 2013: where is the action? Naheed Aziz, a civil society activist, noted, “civil society should try to resubmit the bill with amendments, because only that is how the issues of maternal and neo-

YALE GLOBAL HEALTH REVIEW


natal health can be addressed.”5 Though the failure of the bill to pass through the Senate can be seen as democracy in action (and Brazil has experienced such obstacles as well), such a setback should not prove insurmountable, especially when the rights in question are central to the very structure of society.2 In Brazil, the health reforms were introduced in a structured, timely manner. A central policy of the SUS was decentralization and the process of decentralization “involved complementary legislation, new rules, and administrative reform at all levels of government.”2 Health councils and intermanagerial committees were set up at the state and federal levels so that health decision-making would occur by consensus. Each level of government took on more responsibility for its clearly defined functions, and had a stake in the implementation of the reformed health policy.2 All of these changes shifted toward the narrative of health as a universal right. Following the 18th Amendment to the onstitution in 2010, the Pakistani government also pursued a policy of decentralization.3 The Federal Ministry of Health was abolished completely, and health became a provincial concern.3 According to a Lancet article, some improvement in health systems performance indicators occurred after decentralization, but Pakistan still lags behind its peer countries, and performs badly on key health indicators.3 Approximately 78% of the population pays for health expenses out of pocket, and 55% of the population lives on less than $2 a day.3 Even the very poor are forced to pay out of pocket, and “catastrophic health expenditure accounts for more than 70% of the economic shocks for poor households.”3 Though isolated attempts to ease this hardship have taken place, they are not part of a wider reform movement, but represent just another, problematic link in a series of jilted government programs designed to gain votes close to election years. Eight years before the Prime Minister’s Health Program, the previous Pakistani government launched the Benazir Income Support Program (BISP), which provided a small amount of money (approximately USD 10) to female heads of “deserving” households. At the time, the program was lauded as an innovative approach toward extreme poverty, as BISP significantly increased the “amount of social welfare the Pakistani government was spending on the poor.”5 There were reports, however, that these funds were sequestered for political purposes. BISP began a pilot “Means for Health” program for the very poor comprised of group life insurance

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programs for the extremely underprivileged, with “basic income support measures to access health care and to cope with a variety of health shocks.”8 Research found, however, that the funds were misallocated for political ends, and even the money that reached poor families failed to serve its intended purpose: to help mothers and children cope with extreme hardship. Instead, reports commented that “most of the recipient women spent it on their male family members.”5

The bottom line feature that drove these measures forward in Brazil was the will of the people.

Though statistics on the implementation of PMHP have not yet been released, similar problems can be expected because the government failed to place substantial safeguards against corruption. According to the PMHP, when a cardholder is admitted to the hospital, a representative of the State Life Insurance Corporation will visit him or her. The ministry of National Health Services will supposedly enact separate mechanisms to ensure transparency, but the government has not released detailed plans for these safeguards.1 Considering the corruption of the existing bureaucracy, only extraordinary measures could prevent this program from falling prey to the politicized bureaucracy. In Brazil, the implementation of the Family Health Program of the SUS enabled the system to evolve with time. Initially, the program “offered mainly maternal and child health services to more needy or atrisk populations,” and focused on “structuring municipal health systems.”2 Similarly, PMHP has worked toward modest aims. The government has negotiated charges for some basic health needs, such as USD 120 for the delivery of a child. PMHP has also listed the priority diseases that it will insure, including cancer, accidents, burns, diabetic complications, heart bypass, and infections.1 PMHP does not seek, however, to reform the system of implementation. The success of the Brazilian model depended upon the creation of a relationship between health centers and the local community, and the SUS placed “emphasis on the reorganization of primary clinics to focus on families

and communities and integrate medical care with health promotion and public health actions.”2 This relationship was self-reinforcing, as both parties recognized the benefits associated with cooperating. PMHP, on the other hand, has no such features, and uses the preexisting system of one-way bureaucracy to implement its objectives. The bipartite- and tripartite-level committees and councils in the Brazilian model, in contrast, must reach decisions by consensus, ensuring that a greater level of cooperation and transparency exists even within the bureaucracy.2 Neither Brazil nor Pakistan has established a stable mechanism of securing funding for its healthcare programs. Brazil has struggled to raise enough taxes to fully fund the SUS. In fact, the percentage of health services paid for by public resources actually fell by 12% between 1981 and 2008.2 The problem lies in taxation effectiveness, an issue endemic to the largely informal economy of Pakistan, as well. Tax revenue represents only 11% of Pakistan’s GDP income and, without improvements in tax collection and a widening of the tax net, socialized healthcare in Pakistan will remain an unrealized dream.7 During his speech at the launch of PMHP, Prime Minister Sharif talked about a social mobilization campaign to make people aware of and enroll in his initiative.1 Instead of limiting the scope of this “mobilization” campaign to PMHP, the effort should initiate a nationwide struggle to make people conscious of their basic health rights. Perhaps it is counterintuitive to suggest that a government should remind its own citizens of their civic duty, but the people need to care about their own welfare as much as, if not more than, the state. Health is an intrinsic human right and should not be awarded on the benevolent whim of a leader. The people need to demand the healthcare that they wish to receive. Only when they urgently mobilize for universal healthcare will their government, or even the governments of many nations, feel compelled to make widespread policy changes. The basic principles of health reform in Pakistan need to change but, at least for now, the status quo will not allow that reform to occur.

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Mahrukh is from Pakistan and a junior in Morse College. She is majoring in Molecular, Cellular and Developmental Biology. She can be contacted at mahrukh.shahid@yale.edu.

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FEATURE ARTICLE

THE UNSEEN CONSEQUENCES OF WAR:


Creative Commons

Responding to Sri Lanka's Mental Health Burden By Ohvia Muraleetharan


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lthough many refer to Sri Lanka as a success story in achieving high health outcomes despite its low income, a crucial side of its past often remains unaddressed. An island country of only 25,300 square miles, Sri Lanka has a bloody history, full of war and ethnic conflict.1 After a brutal 50-year civil war ended in 2009, the people of Sri Lanka took their first steps on a long path toward recovery. Many suffered conspicuous physical injuries, but the most pressing damage was invisible to the naked eye. As a country where mental health issues still carry harmful cultural stigma, Sri Lanka struggles to provide adequate treatment for the mental illnesses caused by the conflict. The Sri Lankan Civil War was, at its core, a struggle for territory and power between the ethnic minority Tamils and the majority Sinhalese. Early tensions caused by ethnic differences were exacerbated by institutionalized discrimination against the Tamil population.2 This chauvinism revealed itself everywhere, from “affirmative action” laws put in place by the mainly Sinhalese government to limit the number of Tamil university students, to stereotypes made permanent in classroom textbooks.2,3 The first acts of organized violence began in 1956, and culminated in a series of race riots in 1983, which became known as Black July.2 Once the violence began, many different players entered into the conflict. This list included the Sri Lankan army, the Sinhala militant group, Janatha Vimukthi Perumana (JVP), the Indian Peacekeeping Force, which entered Sri Lanka in an effort to help the government resolve the conflict, and the Liberation Tigers of Tamil Eelam (LTTE), a group dedicated to fighting for an independent Tamil state in the Northeast.4 All parties involved used terror as a weapon. Common “counter-insurgency techniques” used by the Sri Lankan army included torture and mass displacement.4 The induction of child soldiers also became increasingly common, especially within the LTTE, because it proved easier to condition children into fearless obedience than adults.5 One Sri Lankan recalls how, in 1984, “the army had set up random checkpoints throughout the Tamil areas. When you saw an army truck, you didn’t want to run because they might think you were guilty. But sometimes, especially right after an [LTTE] attack, they would shoot civilians and Tigers alike, at random.”6 By the peak of the conflict in 1995, every group involved was under scrutiny by Amnesty International for multiple human rights violations, including torture, mass disappearances, and extrajudicial executions.7 The war ended in 2009, when the Sri Lankan Army brutally defeated the separatist forces, and any remaining members were exiled. Even after the fighting had ceased, a general sense of uneasiness remained as a result of the sheer amount of destruction. The damage was especially severe in the mainly Tamil northeast region of the country, where the LTTE had been based before being massacred by the army. The terror wreaked by the conflict lasted through multiple generations, and the trauma it created became normalized. Dave Sacco, a volunteer with the United Nations High Commission for Refugees (UNHCR) based in Sri Lanka from 1995-1996, explains “The war lasted a long time, but the fighting was only acute for short, nasty periods… People adapted and life moved on, mostly because it had to. There were times when, aside from all of the people with guns, life seemed challenging but still ‘normal.’”8 The effects of this continual state of war seeped into all aspects of society. Both Tamil and Sinhalese citizens learned passivity and submissiveness in order to survive. Those who dared to question authority were weeded out with various intimidation techniques.

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This forced obedience and loss of leadership resulted in “the vital capacity to rebuild and recover… being suppressed.”4 The Tamil people learned to mistrust the Sri Lankan government, and remain suspicious today. After the war, internally displaced peoples (IDPs) became dependent on monetary handouts for income, and lost the self-motivation to succeed.2 Social norms shifted, and both substance abuse and domestic violence became much more prevalent. One study reported that 95.6% of children in the Northeast, the most war-affected region, had experienced at least one incidence of family violence after the war and in 64.2% of the families, the violence was recurrent. Over 18% of children had suffered at least one injury as a result of family violence.9 The same study found that both substance abuse and exposure to the war were strong predictors of violence in the home. The Sri Lankan Civil War may have broken the psyche of its people, but the cycle of violence and societal changes the war effected continued to break the minds and spirit of the people, even after the fighting had ended. The Sri Lankan people began to experience a host of mental disorders, but neither the health system nor society was prepared to address them. Post-traumatic stress disorder (PTSD), various anxiety disorders, major depressive disorder, and somatization disorder — a disorder marked by numerous medically unexplainable physical symptoms due to psychological distress — became common among those affected by the war.2 One study showed a strong relationship between exposure to war and the number of PTSD symptoms reported, drawing a direct connection between the war and the mental disorders affecting the population.9 The number of suicides skyrocketed, reaching 17.1 per 100,000 citizens in 2012 and making Sri Lanka the country with the 22nd highest suicide rate in the world.10 The government, however, neglected the mental health issues plaguing its citizens, and focused most of its rehabilitation efforts on the treatment of physical illnesses. This lack of awareness was likely caused by the cultural stigma against mental disorders that was due, in part, to Buddhist and Hindu religious beliefs in illness as punishment for poor karma, familial concern for the negative marital effects of mental disorders, and an irrational fear of unprovoked violence caused by mental illness.11 Dave Sacco, the UNHCR volunteer, described how this stigma presented itself during the peak of the conflict: “People were very stoic, they didn’t tend to talk much about their troubles. When I finally heard [about their troubles], they were pretty matter-of-fact; [there was] usually not much anger or resentment expressed. [There was much more] stoicism and fatalism. And suicide.”8 The stigmatization of mental health issues resulted in social exclusion of those with mental disorders, widespread lack of awareness, and lack of belief in the efficacy of prescription medicine and therapy.11 These factors led to low participation rates in existing mental health programs.11 Stigma continues to present a significant obstacle to improved mental health within Sri Lanka today. Among those affected by the war, children, especially those who experienced the conflict throughout their formative years, are most vulnerable to mental disorders. Although most children were affected in some way by the war, the conflict was largely concentrated in the northeast region of the country and therefore disproportionately affected Tamil children. In one survey conducted in a northeast province, 92% of the children reported experiencing severely traumatizing events and 79% had had some form of combat experience.12 Immediate impacts on children due to these kinds of traumatic events have been found to include numbness, hyper-vigilance, shock, unresponsiveness, muteness, and/or frantic behav-

YALE GLOBAL HEALTH REVIEW


“

The terror wreaked by the conflict lasted through multiple generations, and the trauma it created became normalized.

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The Sri Lankan Civil War destroyed many homes and displaced thousands of people causing immense mental stress.

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Map depicting key regions of the Sri Lankan Civil War in the northern theater.

ior.2 Longer term effects included increased aggression, anxiety, depression, suicidal behavior, and/or attention deficit disorders.13 Children are also particularly susceptible to permanent personality scarring during periods of emotional, cognitive, and endocrinological development. Because the Sri Lankan conflict has extended throughout multiple generations, it has severely impacted children’s lives and health.12 The most common disorder caused by extensive trauma, however, is PTSD. The impact of PTSD is very evident in northeast Sri Lanka, where 25% of children meet the criteria for a diagnosis.12 In situations of extensive and brutal violence, PTSD can often become malignant, resulting in an addiction to violence.2 Because children are more susceptible to influence from their environs, it can be hypothesized that the children directly involved with the conflict also proved more susceptible to malignant PTSD than adults. This correlation has yet to be investigated, but data shows that PTSD in children is often accompanied by many different complications. Almost 12% of the children who suffered from PTSD in

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the northeast region suffered concurrent anxiety disorders, and were more likely to experience depressive and/or somatic symptoms.12 This high prevalence of concurrent disorders indicates the immense need for more comprehensive treatment. In several studies, UNICEF has emphasized the need for thorough, post-conflict psychosocial and physical healthcare for children in order to prevent them from drifting into a life of “further violence, crime, and hopelessness.”5 Sri Lanka’s initial rehabilitation efforts during the war, however, did not meet this need, and actually exacerbated the psychosocial issues of those targeted by mental health programs. The government viewed child soldiers who were captured or surrendered during the war as criminals, and therefore, designated the responsibility of their rehabilitation to the Sri Lankan army, rather than trained mental health workers.2 This criminal treatment is ineffective at best, and, at worst, aggravates pre-existing conditions and creates new ones. Even if children could return home after being displaced, the deteriorated social climate due to the war con-

tinued to affect their psyches. The increased prevalence of violence at home meant children were continually exposed to trauma, increasing their risk of experiencing PTSD as adults.14 In addition, exposure to domestic violence is associated with long-lasting cognitive impairment, and low intellectual and academic outcomes.13 These effects, along with the disruption of education by the conflict, decrease a child’s ability to maintain financial stability after the war and increase the likelihood of future mental stress. Despite initial failures, the Sri Lankan government has now realized the need for action, and currently partners with several non-governmental organizations (NGOs) to implement various programs throughout the country. Although a largely unmet need for trained mental health professionals still plagues Sri Lanka, such that only one psychiatrist is available per every 500,000 citizens, community workers are often employed to increase the accessibility of services.11 In at least one city in the northeast, local medical students, nurses, and primary health workers undergo training in basic

YALE GLOBAL HEALTH REVIEW


mental health, and general mental health awareness programs have been implemented at all levels of schooling.2 In some communities, locals have created programs with the help of NGOs to train counselors in trauma therapy, who are then employed to generate support systems and provide catharsis for both children and adults.2

The Sri Lankan Civil War may have broken the psyche of its people, but the cycle of violence and societal changes the war effected continued to break the minds and spirit of the people, even after the fighting had ended.

Western medical techniques may not, however, represent the most effective method of addressing Sri Lanka’s mental health burden. Stigma and lack of awareness cause few patients to seek help, and those that do so will often go to traditional healers, rather than Western-trained health workers. Some traditional relaxation techniques, such as yoga and meditation, have been found to be effective, but the preference for traditional healers causes a delay in Western psychosocial treatment that can decrease the efficacy of medical treatment, once begun.11,15 If traditional healers are trained to identify major disorders and refer their patients to medical workers, they can become a major asset for mental health. Once Sri Lanka has increased its capacity for trauma therapy, this kind of partnership with traditional leaders will be needed to reach as many patients as possible. Before a partnership can be established, the Sri Lankan government must openly address the mental health burden and take action to decrease the still-present cultural stigma against mental illness. The need for improved education remains high. Specific programs targeting medical workers and those in positions of authority, such as teachers and religious leaders, are also needed to effectively decrease stigma. Cur-

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rently, the burden of mental healthcare falls mainly on the shoulders of community health workers; however, due to the stigma against their work, they themselves often experience burnout and psychological stress.11 The lack of mental health knowledge among trained medical workers further exacerbates this stress by extending this stigma into the medical field. The government has acknowledged the need for action to decrease this stigma, as well as the existence of high suicide rates and increased prevalence of psychological symptoms, but still claims that only 2% of its population suffers from “serious” mental illnesses.16 Only after admitting the full extent of the mental health issues among its citizens can the government take action to raise awareness among other authority figures, and effectively address the mental health burden. The involvement of these authorities, including community leaders, teachers, and religious figures, is necessary to ensure the distribution of care to all groups. Teachers have already proven to be a large asset in addressing the mental health burden of children. School-based cognitive behavioral therapy has previously been effective in trauma treatment in Armenia, and Sri Lankan teachers have proven reliable when completing diagnostic assessments of their students’ mental health, two factors that indicate the potential success of similar programs that may be launched across Sri Lanka in the future.17,12 Before these additional countrywide programs can be implemented, the organization of the existing programs must be improved. The current lack of communication among mental health workers, for example, impedes the efficacy of their work.11 As of 2012, training of a few workers within the existing primary healthcare infrastructure had begun, but this training must be made universal in order to become truly effective.11 Additionally, the government must first rebuild the pre-war healthcare system, which collapsed during the fighting, before implementing any further programs. While preparing for post-war recovery, Sri Lanka must also adjust its health system to meet the new demands of a country undergoing an epidemiological transition: the shift from a mostly communicable burden of disease to a much larger, non-communicable disease burden.18 Mental disorders account for 11.5% of this new burden of disease.19 Therefore, Sri Lanka desperately needs localized facilities dedicated to mental healthcare. Current evidence has shown that patients often fail to reintegrate with

95.6% of children in the northeast experienced at least 1 incidence of family violence. In 64.2% of familes, violence was recurrent.

25% of children in the northeast met the criteria for PTSD. 12% of these children suffered from concurrent anxiety disorders.

92% of children from the northeast province reported experiencing severely traumatizing events.

79% of children from the region reported having some form of combat experience.

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The Sri Lankan Army was only one of the players involved in the conflict, but, at one point, every party involved was under scrutiny by Amnesty International for multiple human rights violations, including torture, mass disappearances, and extrajudicial executions.

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their families and communities after psychiatric hospitalization, due to long-term separation in distant mental health hospitals.17 The government currently plans to address this problem by establishing an acute inpatient ward within each of the country’s 25 districts, but steps must be taken to ensure that all populations, especially rural ones, can access these facilities.16 The plans outlined above can help address the massive mental health burden that Sri Lanka currently faces, but only if they are made with special consideration to the contexts of family, community, and society. Programs must be comprehensive, treating symptoms while maintaining focus on the core issues. Seven years have passed since the end of the Sri Lankan Civil War, and the government has finally begun to work towards recovery and rehabilitation. But many steps are still needed to fully heal the people. Due to a uniquely long and brutal war, a series of complex issues, including collapsed health infrastructure, an extensive mental health burden among children, and a shift in the burden of disease, must be addressed. Awareness of the full extent and complexity of these mental health issues must be raised among both the Sri Lankan government and the general population in order to successfully implement effective treatment programs. With the dedication of time and resources, however, these programs may allow the people of Sri Lanka to prosper for the first time in over fifty years.

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Ohvia Muraleetharan is a junior Biomedical Engineering major in Pierson College. She can be contacted at ohvia.muraleetharan@ yale.edu.

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AT THE HELM:

OPINION

United States Foreign Policy and Reproductive Rights By Aviva Rabin-Court

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n January 1973, the United States Supreme Court passed Roe v. Wade. That case, a watershed decision, acknowledged a constitutional right to abortions and rejected a theory of personhood based on religious convictions, creating a more secular national policy.1 Roe v. Wade shifted the national understanding of abortion from a largely criminal enterprise to an accessible medical procedure. Rather than a moral issue, the court case reframed the right to abortion in terms of privacy, individuality, and control. The decision not to have a child became an issue of agency and autonomy, not life or death. The question of regulation depended on the point at which a pregnancy entered the public domain; when the government could begin to exercise its claimed interest in a woman’s body (specifically, in her womb). A flood of legislation assailed this decision, carefully excising abortion from US policy and programs.3 The Helms Amendment, one of the first laws passed in reaction to Roe, states, “No foreign assistance funds may be used to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortions.”2 The amendment shifted the US government away from a pro-choice stance, by refusing to monetarily endorse abortion. The United States enacted this law in spite of the fact that abortion had just been recognized as a right for women within its boundaries, and the inequitable, hypocritical moral imperialism of this double standard still haunts US foreign policy today. The United States Agency for International Development (USAID) openly pointed out this contradiction when first confronted by the legislation. USAID wrote that, while the Foreign Assistance Act “explicitly acknowledges that every nation is and should be free to determine its own policies and procedures with respect to

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population growth and family planning,” the Helms Amendment worked against these principles, placing “US restrictions on both developing country governments and individuals in the matter of free choice among the means of fertility control…that are legal in the US.”2 Even interpreted in its most generous iteration, the Helms Amendment restricts women’s reproductive rights and erodes the internal sovereignty of the 140 nations to which the US provides aid.

Aid may be conditional, coercive, and self-serving, but it should never enforce societal norms that harm women and turn wombs into obligations.

After Roe v. Wade, the judiciary branch of the United States government set to work corroding the reproductive rights of women within its borders, case by case. In 1992, the Supreme Court upheld a Pennsylvania law that required a 24-hour waiting period between a doctor’s visit and the abortion procedure, excising only the clause that required wives to acquire written permission from their husbands before receiving an abortion. In 2006, the court also sustained the Partial-Birth Abortion Ban Act despite noted factual inaccuracies in the Act, including scientific findings that directly contradicted those of the American College of Obstetrics and Gynecology.5 Pro-life states continue to restrict access to abortion, and have begun to directly

attack abortion clinics. Ten states currently mandate that women receive an ultrasound before an abortion, and that doctors offer the woman a chance to see the images.3 In some ways, Donald Trump’s recent comment that women who have abortions “must be punished in some way” reflects what pro-life activists have carefully avoided saying for a long time: that women who have abortions are degenerate, amoral, and have gone astray. These women must be lead back to the fold, but not too gently. They must be forgiven, but not all too quickly. The legal structure enacted in Roe v. Wade has been slowly eroded since its passage, but the legal apparatus replacing the right to abortion has existed in US foreign policy since 1973. The Helms Amendment and its satellite amendments reveal a legal structure that seeks to remove abortion from the national consciousness and dialogue. The Siljander Amendment bans the use of US foreign aid to lobby for or against abortion, the Biden Amendment bans the use of US foreign aid to fund biomedical research related to abortion, and the newly-repealed Mexico City Amendment required non-governmental organizations (NGOs) to certify that they will not use US foreign funds to perform abortions.2 Each of these amendments institutionalizes governmental disapproval and disavowal of abortions, not only as a medical procedure, but also as a moral choice. The careful, detailed purge of US support ensures that abortion remains a charged procedure, enacted against the wishes of the US government. Helms and its accessories, even if watered down to their gentlest forms, export a severely attenuated version of reproductive rights, a version in which abortion is neither allowed nor discussed. Furthermore, these amendments are not instituted in their gentlest possible forms. For instance, USAID has adopted a policy

YALE GLOBAL HEALTH REVIEW


that bans the purchase of manual vacuum aspiration kits and misoprostol, a drug useful not only for abortions, but also for the treatment of incomplete abortions and postpartum hemorrhage.10 Furthermore, NGOs, fearful of being defunded, often hesitate to provide abortion counseling to women who have been victims of sexual violence.1 Although the language of the legislation implies certain exceptions, banning abortion “as a method of family planning,” but not in cases of rape or incest have not been carried out in real-world implementations of the Helms Amendment. The amendment also restricts care available to women emerging from war zones and, in doing so, denies these women both agency and autonomy.

thus stripping these women of a sense of control over their own bodies and lives. For women who escape from terror groups like Boko Haram, which use sexual violence as means of control or reproduction, loss of bodily autonomy is a daily hazard. Boko Haram arrived on the public radar for many when, two years ago, they kidnapped almost 300 Nigerian schoolgirls. The girls are still missing and Boko Haram

Of the approximately 44 million abortions that take place annually, half occur under unsafe conditions, undertaken by women desperate enough to seek untrained practitioners and procedures that “do not conform to minimal medical standards.”12,13 Each year, 47,000 women die of botched abortions, and many more are injured.14 The bulk of these deaths occur in developing nations. The history of abortion in the US, pre-Roe v. Wade—think gory images of coat hanger abortions and unanesthetized women bleeding out on the table—that we hear from pro-choice activists is still a reality for much of the developing world. By denying access to safe abortions to women abroad, US foreign policy codifies unequal abortion access, access which is already too limited within our borders. The Helms Amendment is not simply a question of choice, but of fundamental rights. The World Health Organization (WHO) defines access to safe abortions as a human right.15 Moreover, a recent WHO report on the prevalence of violence against women highlighted the need for a more effective, holistic response to sexual assault from the healthcare sector.16 The WHO called for comprehensive treatment for victims of sexual violence, including abortion (in nations where abortion is legal).17 US foreign policy fails to live up to international standards of care for women. This failure is particularly egregious considering the long history of rape as a tool of war. Women who escape from regions of conflict and violence often find themselves with unwanted pregnancies as a result of rape, because US foreign policy refuses to provide access to safe abortions,

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continues to ravage cities in Nigeria with suicide bombings and kidnappings.18 Women are taken from their homes and repeatedly raped, as militants in Boko Haram have been said to “pray before mating, offering supplications for God to make the products of what they are doing become children that will inherit their ideology.”19 When women escape to camps for displaced persons, they are often met with policies that refuse to acknowledge the depth of the violation they have experienced, as well as policies that ignore the issue of unwanted pregnancies and their implications for women’s mental and physical health.

Pressure from NGOs like Ipas, which provides safe, respectful, and comprehensive abortion care, and PAI, which advocates for global reproductive rights, have resulted in promises from Democratic presidential nominees to change the interpretation of the Helms Amendment, or even to overrule it. These promises represent a passable start, but a more thorough overhaul of this country’s dedication to reproductive rights as a whole is in order. Abortion legislation cannot represent a way to control and regulate female bodies. The Helms amendment does not show the failure of US foreign policy alone, but reveals a far more insidious and threatening truth about the government’s commitment to women, both within its borders and beyond. The Helms Amendment sets up a contract for aid where the onus is placed on the individual female body. In doing so, this law perpetuates a moral imperialism where women are stripped of the ability to choose, despite the alleged right to do so. The government commits this damage in the name of women’s health. But a policy that restricts abortion is not a policy “for women’s health,” when tens of thousands of women die of unsafe abortions every year, and hundreds die of complications from childbirth every day. The Helms Amendment, and the domestic policies that seek to reproduce its limitations within US borders, commits an act of violence. The role of the US government is not to regulate bodies from afar, nor to implement inequality between women of developing and developed nations. And the role of USAID is certainly not to participate in the erosion of women’s autonomy and control over their bodies. Aid may be conditional, coercive, and self-serving, but it should never enforce societal norms that harm women and turn wombs into obligations. The Helms Amendment violates the very women that it allegedly tries to help, and, as a result, cannot be called aid at all.

www Aviva is a sophomore in Saybrook College majoring in Molecular, Cellular, and Developmental Biology. She is a member of the Yale Political Union and spends most of her time contemplating switching to WGSS. She can be contacted at aviva.rabin-court@ yale.edu.

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INTERVIEW

A CONVERSATION WITH KAVEH KHOSHNOOD Paths Through a Career in Global Health Interview by Cassandra Lignelli To start off, how did you first become interested in Public Health?

I got interested in public health because I had this dual interest in medicine and social justice. I come from a family of two physicians, so I had medicine in the background. But as a person born in Iran, I was also quite interested in social science and social justice. Honestly, at that time, I didn’t know what public health was. My father, who is a dermatologist, mentioned it, and as I looked into it, it made sense for me. As you know, public health is all about population-level health. It is about understanding why entire communities and populations are disproportionately affected by certain problems and trying to figure out what the root problems are—which often intersects with issues of social justice. So it was a nice marriage of my various interests and I liked many aspects of it, including this need to understand communities: their norms, beliefs, values, and what’s important to them. That was so intriguing to me.

How, then, has your career turned more globally focused since those earlier years?

In terms of global health, in the late 80’s, when I came to Yale to do an MPH, there was no global health per se. There was literally one seminar called “Seminar in International Health,” which I took. Actually, now that I think about it, the professor said, “pick a topic you’re interested in and research it.” I picked refugee health, and I don’t know why, which is interesting because decades later I’m looking at refugee health now. So, the term global health really hadn’t been coined. But there was this notion at the time that there were health issues in a United States setting, and then there were health issues that affect low-income countries, and that they were very different. As an immigrant I was interested in that. So I looked for opportunities to go abroad and learn about what health looks like in other settings. I managed to do some of that and really liked it, so it stuck with me.

Something a lot of Yale students struggle with is the decision whether or not to engage with health by becoming a physician or by following a different path, such as public health. How did you come to the decision not to become a physician, and instead work in health as an academic?

Medicine seemed so narrow that I decided to move away from medicine and focus on public health. I really didn’t look back, which was just a personal thing. I just didn’t see myself as a physician. I didn’t have the affinity for that work. I really like the social and political aspects of public health—you can’t get into that as much as a physician. Let me just say that by no means should people in public health shy away from medicine. In fact, some of the most influential people are those who’ve managed to marry medicine and public health. So that’s a fantastic career path for some people—to work in public health through combining it with medicine.

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YALE GLOBAL HEALTH REVIEW


Kaveh Khoshnood knows global health. He has been at the Yale School of Public Health since completing his MPH, working almost exclusively on HIV/AIDS and health among the most vulnerable populations in the US and worldwide. Even more remarkably, he has devoted his career to training the next generation of public health workers. He teaches a popular class at the Yale School of Public Health called "Responding to Violent Conflict: Epidemiological Methods & Public Health Interventions" and is the Director of Undergraduate Studies at the Yale School of Public Health. The Yale Global Health Review sat down with Kaveh to discuss global health, career choices, and finding your passions.

Looking back, would public health still be the path you’d take? Yes, absolutely. I’ve thought about this many times. I do have an interest in medicine and I think if I had to go to medicine, I’d do psychiatry. But public health was the right decision for me; it was the right career path. I haven’t regretted it at all. You know, there may be things about your job you don’t like, but that’s any job! It’s been incredibly rewarding. And, as you know, I have an academic job. But you could also do public health in very different settings. You could work for governments, non-governmental organizations (NGOs); but I work in academia so I have a specific way I do public health.

Another thing on undergraduates’ minds is trying to figure out which specific health issues are important to them. How did you determine which specializations in health you really cared about? First of all, picking a topic initially doesn’t mean you stick with it for the rest of your life. To a large extent, I tell students who are just starting, especially undergraduates, it honestly doesn’t really matter. Maybe you want to do lung cancer, you want to do drug abuse, or you want to do women’s health. That’s great, but there will be opportunities to work on many different projects throughout your career. It has to be something that intrigues you, speaks to

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you, and something you connect with on a personal level. Sometimes you personally, or your family, has dealt with it. The topics you work on tend not to be purely intellectual, although sometimes they could be. One way or another, it has to speak to you and you have to connect with it. Because then you will spend the time, effort, and energy to really delve into it deeper and not just do something superficial. Whatever speaks to you, do that, do it well. You’re going to learn, you’re going to make a ton of mistakes. You’re going to problem-solve. And those lessons—you will be able to carry a lot of those to the next issue you’ll tackle. So pick a project you connect with on some personal level. Work on it hopefully more than just a few weeks and months. Get deeper, and you’ll see all the different layers of it. Think. Be reflective about what it is you’re doing before you move on to the next thing.

How then did you figure out that you were passionate about HIV/AIDS? I learned about HIV in the School of Public Health, and there was a sense that this clearly was a new, devastating epidemic. There were community campaigns, people going door-to-door to teach people about transmission, etc. So there was a sense of politicization about it, which I loved. I was going with outreach workers on Saturdays and literally knocking on doors and talk-

ing with people about it—it was that kind of a grassroots campaign. That was the issue that kind of caught my imagination and I went with it for almost 20 years exclusively—different aspects, different populations, different countries, but only HIV/ AIDS for a long time. It just caught my imagination. I saw all the different things I was interested in public health in this topic: there are the scientific questions of HIV, there was certainly grassroots organizing around HIV, social justice, activism, policy, it had the whole spectrum of public health issues that intrigued me.

Now, Yale College has a global health program, but not a general health studies or public health program. What is your advice for those who are interested in domestic health? If you’re really passionate about health in the US, do that! There’s no reason for you to feel the need to go overseas and do something. You have to go overseas to low-income settings for the right reasons. Not for adventure. Not to go somewhere exotic. That’s usually not a good motivation to work abroad. I would say in my own career, I learned to do public health, mostly around HIV/AIDS and drug use, in New Haven. To this day, when I travel to faraway places I draw lessons from the experiences of having worked on HIV drug use in this city. That’s the ground on which I’ve built my skills.

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Yale GHLI

What have been your major challenges to working in global and public health? Well I think the biggest challenge perhaps is trying to ensure that knowledge we generate in academia is translated into appropriate policies and programs. We have not been that successful in doing so. If I think of my work in HIV prevention among drug users, one of the key issues was access to syringe exchange programs: making sure people have access to clean syringes and quality drug treatment programs. The evidence is overwhelming that these are all good ideas but when it comes to policies and programs, they are not there. So that is really the frustration—you won’t see the changes you hope for or the policies you write at the end of your academic papers. Some of those may not come to fruition for decades. You’d like to see evidence move policy in your lifetime and have an impact, which is the most frustrating.

What have been the major rewards to working in global and public health? Having said what I just said, we’ve had plenty of success stories integrating aca-

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demia and policy. The city of New Haven went from not having a syringe exchange program to adopting one and then expanding it to five other cities in Connecticut. Now, we’ve seen New York change its policy along with other state/federal policy and legal changes in the US and beyond. So a lot of good policy has come out of the work we’ve been involved with. It’s not that policy is never impacted by public health, it’s just to really deal with this issue of HIV, you have to be forceful about it and sometimes governments will not respond vigorously. But plenty of good policies and programs have been created. The other major source of satisfaction for me, personally, is students. Seeing students be quite turned on to tackling some of these global health issues is so inspiring. I tell them: “look, we don’t have the solutions. We’ve run out of ideas here, so see what you come up with.” And it’s remarkable to see quite young students, early in their career, commit themselves in a significant way to tackle some of these challenges with really minimal guidance from us, which is so rewarding to watch. As a final question, a lot of undergraduates are trying to balance their passions with realistic concerns about financial security in the future. What is your advice to students making choices in this regard?

Be very aware and honest with yourself about these things. That issue of balancing personal/family well-being and your work will be a constant for the rest of your life, no matter what you end up doing. I’d say that public health is much more elevated in society today than in the past, and it’s not just in the US. I mean, a MPH degree is recognized around the world, so there are more jobs. There is a lot of new money and organizations that need people who are trained in public health. In my case, I work in academics and it’s more than sufficient to have a good life and raise your family, so it is possible. www

Cassandra is a junior in Davenport college majoring in anthropology. She is also a Global Health Scholar. She can be contacted at cassandra.lignelli@ yale.edu.

YALE GLOBAL HEALTH REVIEW


LOW-COST DIAGNOSTICS:

GLOBAL HEALTH TODAY

Advancements in Global Health By Wen-Yi Low

I

magine you are in a rural clinic in a Zimbabwe village. A child walks in with a fever. Such a fever could be a symptom of any one of a number of life-threatening infectious diseases. There is limited health infrastructure available. There is a lack of storage equipment, access to sophisticated laboratory equipment, and trained workers to conduct or analyze any available diagnostic tests. How can you go about diagnosing and treating this child? Diagnostics are crucial for the proper identification of both diseases and disease-causing agents, yet tools for diagnosing disease can be expensive, insufficient, or ineffective and can even hinder a patient’s ability to be diagnosed if used improperly. Moreover, despite the key role diagnostics play in healthcare, they tend to receive less attention than novel therapeutics or preventive strategies.1 This issue seems to be improving, with the number of publications on point-of-care tests and diagnostics increasing exponentially from around 100 in 2002 to almost 1000 in 2012.2 Although various research groups have started to pay great-

er attention to the potential of diagnostics, there are still several challenges to bringing these technologies from the lab to the field.2 Despite the fact that research on novel therapeutics and preventive strategies tends to lead to faster commercialization and greater lucrative rewards than research on diagnostics, the importance of improving diagnostics must not be overlooked. Diagnostics are crucial for identifying the presence and origins of disease. They enable the design of appropriate courses of treatment, measure the effects of interventions, and determine drug resistance or recurrence of existing disease. For therapeutics and preventive strategies to work effectively, there must also be accurate and reliable diagnostics available. Currently, the research and development of new diagnostic tests for illnesses that disproportionately affect low- and middle-income countries are highly dependent on donations from private sources, such as the Bill and Melinda Gates Foundation and pharmaceutical companies.4 This limited funding hinders the development of diagnostic

tools that are needed to expedite delivery of treatment and increase chances of survival in resource-limited countries. The insufficient investment can also result in a final cost of USD 2 to 10 million and five to ten years for the development of one new diagnostic test.4 All of this is despite the fact that, at times, the development of a new diagnostic test can be over an order of magnitude more cost-effective than the development of a new drug.4 Hence, there is a need for increased education on and awareness of the importance of diagnostic tests in the global fight against disease. To be able to quickly, easily, and affordably diagnose diseases, it is necessary to understand the challenges currently facing the developing world that inhibit proper and accurate diagnoses. These challenges include the lack of available resources—human, financial, and energy-related, the lack of proper storage and efficient transportation of samples, the unmet need for trained personnel to conduct and analyze test results, which can lead to variability in the analysis, and the lack of access to appropriWhitesides research group

The Whitesides research group has developed the use of bubble wrap for the storage of biological samples.

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Whitesides research group

A 3-dimensional paper-based microfluidic device, designed by the Whitesides research group, with well-defined channels that can direct the flow of liquids.

ate tests. It is essential to develop affordable and efficient tools that can be easily used by healthcare workers in these settings. While these challenges to development are well-defined, solutions are still required that can meet these constraints. The ASSURED test (Affordable, Sensitive, Specific, User-friendly, Robust, Equipment-free, and Delivered), developed by the World Health Organization to describe the ideal characteristics of a diagnostic test for use in a resource-poor setting, provides a useful guide for designing and developing tools. These criteria are useful for development, but are meant to serve as guidelines, rather than requirements, for effective tests. This is due to the natural variability in the ideal conditions needed for each test, which are dependent on the specific disease and location. For instance, the “equipment-free” criterion is perhaps more applicable to a rural, community setting rather than a local hospital setting where it might be possible to support small-scale equipment. In this case, limiting equipment may serve to constrain the diagnosis rather than improve it.5 Low-cost diagnostic tests that meet the ASSURED criteria can help tackle some of the world’s most pressing health problems and advance global health. Much of the development of these tests is influenced

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by the research of the Whitesides research group, led by Professor George M. Whitesides of Harvard University, which has developed tools and techniques that are both high-quality and low-cost.6 Like most research on the development of diagnostic tools, Whitesides’ global health research is funded by the Bill and Melinda Gates Foundation. What differentiates Whitesides from other groups is their ability to use this funding to rethink the development of diagnostic tools that are simple and easy to use, by employing a creative and practical approach. As the Director-General of the World Health Organization, Margaret Chan, aptly puts it: “Not all innovation needs rocket science…Given the world’s most pressing health problems, the true genius of innovation these days resides in simplicity.”7 The Whitesides’ focus on simplicity allows them to combine excellent engineering and design with an awareness of the limited resources that are available, to develop diagnostic tools that are reliable, predictable, and consistent. The Whitesides’ simplicity principle has prompted the group to make use of cheap, readily available items in designing high-performance diagnostic systems. One notable technique they have produced is the application of paper-based diagnostics. The inspiration for the design of these di-

agnostics came from the printing of comic books. By taking advantage of the same inexpensive, large-scale solid wax printing and paper that most comic book manufacturers employ, as well as resources that are already readily available in many places, the complete production of these paper-based diagnostics only requires the designing, printing, and melting of wax paper. Hence, in just three steps, one can print hydrophobic patterns onto the surface of paper, designing channels to direct the flow of liquids. These papers can then be stacked and connected with tape to create 3D microfluidic devices.8 Although the design may be simple, the significance of these paper-based diagnostics should not be underestimated. Prior to this discovery, the construction of precise microchannels for efficient point-of-care diagnostics relied on the use of silicon, a much more expensive material.9 Now, paper-based diagnostics the size of microchips or postage stamps are being created that are cheap and can take advantage of paper’s natural ability to allow the free movement of liquid. Moreover, the paper-based chip can be easily and safely incinerated for disposal, preventing any unnecessary exposure to disease or infection. The Whitesides group has also developed a colorimetric system for these devices, which allows the results to be interpreted by untrained individuals

YALE GLOBAL HEALTH REVIEW


and further improves the cost and simplicity of use in low- and middle-income countries. This invention can help resolve issues with the sorting and classification of fevers of unknown origin. The device contains multiple spots for testing, each of which tests for a marker of a particular disease. These paper-based diagnostic tests have already been employed in India and Vietnam for only USD 0.05 per test, and Dr. Whitesides’ nonprofit engineering company, Diagnostics For All, is continuing to develop and optimize this technology to further improve its potential for use in the field.8 Outside Whitesides, this technology has inspired other research groups to look into researching paper-based diagnostics for various diseases. Engineers at MIT have now developed a paper test that works like a pregnancy test, detecting the presence of specific cancer-associated proteins and revealing within minutes whether a person has cancer.10 The Whitesides group has also worked to develop low-cost storage containers for biological samples. They have pioneered the use of bubble wrap as test tubes to store liquid samples and perform analytical assays. The usage of this packing material as a test tube-like container for medical and environmental samples is highly advantageous in resource-limited areas, because the material is widely available and inexpensive. Additionally, should the bubble wrap break, it will not result in sharp edges that could potentially harm individuals. Bubble wrap can serve as an effective medical storage device because the interior of the bubbles are sterile, allowing the storage of urine, blood samples, or chemicals, without the need for costly autoclaves that require electricity.11 By injecting liquids into these air-filled pockets with syringes and sealing the holes with nail hardener, the bubble wrap can be used to store samples and subsequently, run tests for diseases such as anemia or diabetes. One major obstacle that the Whitesides research group currently faces is that this process for storing samples can be somewhat tedious and requires both syringes and nail hardener, tools that may not be as readily available as bubble wrap. Nevertheless, the Whitesides research group remains optimistic about its material adaptation ideas and believes that it can work to solve this limitation. In addition to its simple, electricity-free devices, the Whitesides research group has also integrated digital technology into some of the diagnostics it has developed. For example, the group has recently developed

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the universal Mobile Electrochemical Detector (uMED), a handheld electrochemical detector that can perform chemical analyses and transmit the results to a cloud database from any mobile phone, even low-end models. Data that is collected with this device is transmitted off-site to be analyzed in real time, which allows the comparison of results with those stored in a cloud database and the consultation of a medical expert through text message.12 Moreover, a simple cell phone equipped with a camera can be coupled with other diagnostic tools to make the tools even more simple to use. For instance, a cell phone can be used in combination with a paper diagnostic tool, such that when the colorimetrics have developed after testing, one can take a picture of the device with a cell phone and send it to a central laboratory for analysis. The cost of these diagnostics is then lowered significantly because there is no longer a need for an onsite doctor or trained individual to perform the test analyses.

Academic groups excel at basic research and innovation, but lack the key skills needed to bring their product to the field.

Development of these low-cost diagnostic tools has tremendous potential to revolutionize the current state of healthcare in the developing world. However, several challenges remain in bringing this technology from the lab to the field. One of the major challenges that research groups face is the lack of funding. While the final diagnostic products that are developed are low-cost, the process of development itself is not cheap.7 Additionally, given the nature of these low-cost diagnostic tools, there is little to no financial incentive for private companies to invest in such research, which makes it even more difficult for research groups to secure funding for development. Academic researchers usually excel in researching these new diagnostic methods and technologies, but they often lack the proper resources, motivation, and experience to execute the trials, regulatory clearance, manufacturing, and quality control necessary to fully develop a product. Thus, there are often research groups who, upon discovering a new technology, seek to sell their product to phar-

maceutical companies, hoping that these companies can help bring their inventions into the field. However, when they do agree to invest, pharmaceutical companies tend to have a vested interest in the development of diagnostic tools. For instance, Novartis Pharmaceutical Company and Ciba-Gigy Corporation (the predecessor of Novartis) were at one point accused of having “planned, conspired and colluded to create, develop, and promote the diagnosis of Deficit Disorder to increase the market for its product Ritalin (a drug used to treat ADHD).”13 This pharmaceutical company had a stronger interest in making profits than optimizing the diagnostic tool for use. The success of the Whitesides research group in overcoming this challenge can be largely attributed to its willingness to combine academia, industry, and medicine, all while ensuring its work remains nonprofit. The Whitesides group acknowledged the fact that academic groups excel at basic research and innovation, but lack the key skills needed to bring their product to the field. Thus, Whitesides created a business plan competition at the Harvard Business School, which brought together students at the school and scientists from the group.2 The result, the establishment of the nonprofit organization, Diagnostics for All, ensured that high quality engineering and optimization was maintained while effectively addressing the needs of the developing world. Diagnostic tools play a key role in advancing the progress of global health. As demonstrated by the Whitesides group, innovative diagnostic tools need not be complex. In fact, the Whitesides’ focus on simplicity and the use of readily available materials has the potential to change how we measure patients’ health conditions in resource-stricken areas and can help overcome the various challenges that prevent low- and middle-income countries from carrying out proper and accurate diagnoses. However, research groups still face several challenges in bringing their products from the lab into the field. Major players in global health should be made aware of the benefits and potential far-reaching impacts of funding research on diagnostic tools, which go beyond the systematic financial gains of the development of such devices.

www Wen Yi Low is a visiting international student from the National University of Singapore (NUS) majoring in Chemistry. She can be contacted at wenyi.low@yale.edu.

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RUSSIA:

HEALTHCARE POLICY al sources of income.6 Patients generally cannot afford many of the medications prescribed for them, and hospitals lack the facilities to carry out necessary procedures.3 Different specializations are still divided between clinics, and this “stovepiped” system represents a serious barrier to treatment for people with comorbidities.7 Health programs are chronically underfunded, while corrupt public officials often skim sizeable portions of the medical budget.6 Ultimately, due to poor government planning and corruption, the Russian healthcare system remains poorly equipped to manage public health crises.

The Sickness of a Nation By Chaney Kalinich

T

he probability that a 15-year-old boy in Russia will die before he reaches the age of 60 is greater than 40%.1 The ongoing health crisis in Russia presents a frightening picture of a nation’s leaders undermining its own citizens’ lives through neglect, corruption, and a quest for power. Russia is a wealthy country with vast resources at its disposal—an estimated 40% of the world’s natural resources—but these riches have limited benefit for its citizens’ health.1 Typically, a country’s overall health improves with industrialization and increased wealth, but male life expectancy in Russia is 13 years shorter than that of its counterparts around the world.2 Russia is widely regarded as one of the world’s superpowers, yet it suffers from HIV infection rates higher than most developing countries, and one of the highest rates of alcoholism in the world. Russia’s massive public health problems result from complex and deep-seated societal norms paired with a government that has demonstrated inadequate interest in fixing them. During the Soviet era, healthcare was labeled a basic human right and was available and free for all citizens.3,4 The state owned healthcare facilities and employed all doctors and healthcare workers.5 Doctors were severely overworked, lacked resources and training, and received the same compensation as common laborers.5 Hospitals lacked basic equipment, sufficient beds, plumbing, and proper hygiene.3 The payment of bribes to obtain faster or higher quality treatment became necessary, and therefore commonplace.3 Obsessed with compartmentalization, Soviet hospitals were inexplicably divided by specialty area, result-

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ing in disjointed treatment for patients with multiple health issues, and troublesome compartmentalization of essential medical information.5 The Soviet system was wasteful and inefficient, but it was free.3

Ultimately, due to poor government planning and corruption, the Russian healthcare system remains poorly equipped to manage public health crises.

Following the collapse of the Soviet Union, the new Russian Federation promised universal healthcare in its constitution. In 1996, this promise was put into effect through a mandatory health insurance mechanism.5 Unfortunately, the new system retains many problems of the old Soviet model.6 Doctors remain undertrained, usually with no more than two years of post-undergraduate medical training, and hospitals continue to lack the funding necessary to purchase critical resources.3 Russia’s annual healthcare expenditure reaches just 158 USD per capita, as opposed to 4,187 USD in the US.5 Under-the-table medication deals persist and patients continue to pay substantial bribes to obtain better care as underpaid doctors seek addition-

ALCOHOLISM To accompany their struggles with chronic disease and viral epidemics, Russians—especially working age men—have for some time been drinking themselves to death. Russians’ alcohol consumption is among the highest in the world, and the rate of alcohol-related deaths is estimated to be 10 times higher than in other countries.8,9,10,11 It is estimated that half a million people in Russia die each year from illness directly related to alcohol consumption, including cirrhosis of the liver and alcohol poisoning.1,8 When other alcohol-related deaths are taken into account, such as accidents, homicides, suicides, and poisoning from bootleg or

YALE GLOBAL HEALTH REVIEW


non-beverage alcohol, this number more than doubles to 1.2 million, making alcohol the second leading cause of death in Russia after cardiovascular disease.12 Alcoholism presents a curious problem, because the deeply-ingrained drinking culture in Russia is characterized by a few key differences from other developed countries.13 Russia’s consumption of spirits is unique; elsewhere, softer drinks such as beer and wine prevail.9,14,15 Wine, for example, was largely reserved for the aristocracy during the tsarist era, and beer was not widespread.10 Now, drinking has ingrained itself into every kind of social gathering, and drinking distilled alcohol to intoxication is commonplace.9 It is considered normal to binge drink for days, and solitary drinking, a particularly troublesome phenomenon from a health perspective, is common among Russian men.9,15,16 This drinking culture is not a new development. In fact, it has been noted for centuries.9 From the 16th through the 20th centuries, state policies failed to discourage excessive drinking and, when politically expedient, actually encouraged alcohol consumption.10 A huge proportion of state revenue has historically come from vodka sales, and the series of authoritarian states have actually created policies to encourage drinking in order to keep the population docile.10,17

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Excessive drinking in Russia has historically been correlated to the stability of the country, with changes in alcohol consumption leading to huge fluctuations in the death rates.17,18 Russian men born between 1950 and 1970 maintained a relatively stable quality of life, with education, housing, and employment guaranteed by the government. During the decline of the Soviet regime, when stability decreased and resources grew scarce, alcoholism increased.9 To respond to this phenomenon, then-President Gorbachev instituted an anti-alcoholism campaign from 1985 to 1988, during which he closed numerous distilleries across the country and limited the sale of alcohol.10 Gorbachev’s campaign actually succeeded, to an extent, and appreciably increased the life expectancy in Russia for a short period.9,18,19 By the early 1990s, however, deregulation of the market, which resulted in cheaper vodka and greater instability, led to increasing alcohol consumption and related illnesses.10 This trend continued until the early 2000s, when the rise of Vladimir Putin, increased oil prices, and greater stability caused alcohol consumption to mostly level off.9 In 2005, progressive regulation was introduced to limit alcohol pro-

duction, which had a noted, albeit limited, benefit.8,9,14 Plummeting oil prices and economic sanctions have been accompanied by an increase in alcohol consumption since 2013, especially among young people.20,21 Despite the modest but apparent positive effects of the 2005 alcohol policies, in early 2015, President Putin made the critical—and questionable—decision to cut the minimum price of vodka.22,23 Russian

Russians – especially working age men – have for some time been drinking themselves to death.

rulers, all the way back to the tsars, have used the tactic of reducing alcohol prices as a method of controlling the population and gaining popularity.17 Cynical measures, such as lowering vodka prices to placate the masses, helped leaders maintain power despite the decrease in the overall mortality rate that accompanies increases in vodka prices.18 In August 2015, less than a year after Putin slashed vodka prices, Russia’s Health Minister reported that mortality rates had already risen among young people, ages 30 to 45, and that 70% of autopsies revealed alcohol in the decedents’ blood.20 HIV, DRUG USE & TUBERCULOSIS Russia also faces additional public health crises. Around 1 million people in Russia have been diagnosed as HIV positive.24 The WHO estimates another million HIV-positive Russians remain undiagnosed. Even more disturbing is the fact that 80% of those who are HIV-positive are under age 30, indicating that, unlike alcoholism, HIV/ AIDS is a modern epidemic.12 According to a 2013 United Nations estimate, HIV diagnoses rose 30% during each of the three previous years.25 It was also estimated that, in 2013, 98% of new infections occurred in intravenous drug users.12 Further complicating the dismal health outlook of the epidemic is the fact that enormous numbers of Russians suffer from opioid addiction, a problem deeply intertwined with HIV. Indeed, the HIV epidemic was jump-started by infections among opioid users. In 2008, 80% of all HIV infections were associated with injection drug use, and in 2010, the

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World Drug Report suggested that approximately 1.6 million Russians regularly use opioids.26 This problem is exacerbated by the fact that opioids remain cheap in Russia, since the country is the preferred route for heroin trafficked from central Asia to Europe.7 Recently, the HIV epidemic has spread beyond traditional risk groups into the general population. Since 2013, the proportion infected by IV drug use has fallen to 50%, and 42% of new infections occur as a result of heterosexual contact.27 In some ways, the emerging HIV and opioid “dual epidemic” perfectly represents the failure of Russia’s healthcare system. First, the combined epidemic demonstrates the grave lack of education among healthcare workers: many healthcare workers report fearing that the casual contact involved in the treatment of people with HIV/AIDS would infect them with the disease and one in four nursing students in their last year of training believe that all homosexuals have AIDS.28,29 These misconceptions go handin-hand with deep-seated social stigma surrounding HIV and the LGBT community in Russia. In a healthcare context, stigma leads to confidentiality breaches, refusal of care, and humiliating practices, among other issues.28,29,30 This stigma also leads people to avoid seeking treatment for fear of themselves or their family being ostracized.28 The rising prevalence of HIV has also resulted in the recent resurgence of tuberculosis (TB) in Russia. Russia has historically struggled with high rates of TB, as evidenced by the government policy enacted after the October Revolution of 1917 that mandated TB screening and access to treatment.31 This program achieved some success throughout the Soviet era, and by the collapse of the Soviet Union in 1991, Russia had achieved a steady rate of just under 50 cases per 100,000 people per year.32 Unfortunately, with the fall of the Soviet Union, these programs fell into chaos, and TB returned with a vengeance.31 By 2005, the number of TB cases had tripled to almost 150 per 100,000 people per year, largely resulting from an ongoing epidemic in Russia’s notorious prisons. A policy enacted in 2005 helped initiate a decline in TB incidence, but a new and even more daunting problem emerged: multidrug-resistant tuberculosis (MDR-TB). Although overall TB incidence has diminished to 75 cases per 100,000 people, MDR-TB is becoming more prominent, representing 21.4% of new cases in 2013.32 Furthermore, a HIV-positive patient is more likely to develop MDR-TB than a patient without

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A patient with MDR-TB receives care from a Russian doctor.

HIV, so the increase in prevalence is likely tied to the emerging HIV epidemic.33 Thus, as the HIV epidemic continues to worsen, MDR-TB will likely grow, as well. RUSSIA IN PERSPECTIVE Even chronic health problems typically shared by all developed countries are substantially more prevalent and deadly in Russia. The most common cause of death in Russia, for instance, is cardiovascular disease, which accounts for 57% of all deaths. The main driver of cardiovascular disease is high blood pressure and an estimated 39.7% of Russian adults suffer from hypertension, as compared to 29% of American adults.34 Institutional failure contributes significantly to this disparity. The Russian healthcare system tends to allocate most of its attention and resources to acute issues, rather than to effective long-term treatment of chronic disease.18 Hypertension is difficult to treat due to poor adherence to medication, comorbidities such as obesity and smoking, and failure to execute recommended lifestyle changes. Instead of providing long-term treatment after a severe cardiovascular event or allowing people to die, it would be more effective to divert funds to programs such as smoking cessation interventions and nutritional counseling. It is estimated that improved hy-

pertension treatment alone could increase life expectancy in Russia by 0.93 years.34 Russia also leads the world in tobacco use. At 60% of the male adult population, and 39% of the entire adult population, Russia has the highest prevalence of smokers in the world.35 Approximately a third of all cancers worldwide result from tobacco use, and that number grows even higher in Russia.36 Smoking causes an estimated 332,000 deaths in Russia each year, accounting for up to 30% of all male deaths. Not only does smoking cost Russian lives, but smoking also demands more than 125 billion rubles (1.9 billion USD) from Russia’s health system each year. The World Health Organization (WHO) recommends higher taxes, smoke-free laws to reduce the risk of secondhand smoke, a ban on advertising, and provision of cessation programs to reduce smoking in Eastern Europe. Until 2010, no law to limit smoking had been proposed. As late as 2008, the Duma actually acted to prevent the WHO from providing its own programs to reduce tobacco use. Finally, in 2010, Putin mandated that the Duma pass regulation to limit public smoking, but due to industry opposition, including that of members of the Duma who represent key figures in the tobacco industry, this effort met significant resistance.35 It took three years for any regulation to pass,

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and even then, the legislation was minimal: smoking was banned in schools, hospitals, government institutions, train stations, and airports.36 Even more discouraging is the fact that an estimated quarter of all Russian youths smoke. Another obstacle to an effective anti-tobacco policy is the popular view, even among healthcare workers, that smoking is a psychiatric disorder, with no physiological component. The main treatments offered to assist people in quitting rely on hypnosis, acupuncture, and cognitive behavioral therapies. Additionally, most addiction treatment centers are inundated with alcoholics and IV drug users, so treating smokers remains a low priority.35

Russia’s shortsightedness. Most doctors worldwide classify opioid addiction as a chronic, relapsing mental disorder. The Russian medical system, however, focuses on the acute symptoms of drug use, and largely ignores the rest. The most effective treatment centers are largely funded by international donors, and state-funded hospitals and clinics tend to fall short in comparison. Furthermore, Russia’s stovepiped system of treatment promotes the comorbidity of opioid addiction and HIV.7 Opioid addiction is treated in one specialized medical center, and HIV in another, so it can be nearly impossible to receive treatment for both at the same time.

With the system already struggling and ineffective, it is hard to imagine a justification for further reductions in care.

The government under Putin has done little to address the failings in its health care system and, in many ways, has made matters worse. Putin himself has exacerbated the stigma surrounding HIV with his support for Russia’s “anti-propaganda” bill in 2013, which banned teaching minors about “non-traditional relationships” or ever communicating about homosexual relations in a positive context.37,38 Laws such as these effectively prevent the education necessary to reduce transmission, and increase the stigma among healthcare workers and the general population.38 Additionally, the health of marginalized groups remains a very low priority for government funding. It is difficult to know exact numbers because historically, Russia’s Health Services Ministry has misrepresented health data, but, as of 2011, only an estimated 5% of people with HIV were receiving lifesaving antiretroviral therapy (ART).25 In large part, this small percentage resulted from the high cost of ART in Russia as compared to other countries and, because of the chronic underfunding of hospitals, the full cost of treatment often falls upon those with the disease.39 The insufficiency of policies to combat opioid addiction further demonstrates

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Worse still is that, in spite of the rampant health issues facing the population, Putin has enacted policies that reward downsizing the healthcare system. This “optimization” officially began in 2013, but the effort to cut healthcare costs began well before that. Between 2005 and 2013, the number of healthcare providers was cut from 8,249 to 2,085, and in rural areas fell from 2,631 to 124.40 As a result, mortality rates continue to climb. In 2014, overall mortality increased 2.6% from the 2013 rate. In the first two months of 2015 alone, mortality climbed 2.2% above that of the same period in 2014.41 These mortality increases likely result directly from downsizing. Health care workers are being laid off in droves, despite a severe shortage.5,41 There are now 64,900 doctors in Russia, and, if the plan is followed, there will be only 50,800 by 2018.42 With the system already struggling and ineffective, it is hard to imagine a justification for further reductions in care. Given plunging oil prices and economic sanctions against Russia, the government claims that cutbacks in healthcare spending are necessary. Indeed, the Russian economy is predicted to contract by 4% this year.43 Another driver for these cuts, however, is the dramatic increase in military spending and intervention.44 The gov-

ernment’s military spending has reached record high levels, at 3.1 trillion rubles per year, or about 50 billion USD.45 Military spending makes up 4.4% of Russia’s GDP, an increase from 2.6% in 2012, when Putin assumed the presidency, and now drains 34% of Russia’s total federal budget.40,46 Meanwhile, since the beginning of 2015 alone, the number of people below the poverty line has increased 3.1 million to 22.9 million, meaning that one in five Russian adults is now considered officially “poor.”47 The average man in Russia dies before he reaches the age of 65, whereas the average American man lives to the age of 76 or above. If Russia wants to bridge this gap, it must adopt effective policies to prevent chronic disease and improve patient care. Vodka and tobacco sales need increased regulation and higher prices. Homophobia and the resulting HIV stigma must be addressed, or HIV will become Russia’s most significant health issue. Russia needs to reduce corruption within its medical system, and policies must be enacted to ensure higher standards for both doctors and nurses. Hospitals should be streamlined, rather than compartmentalized. And, most important, funding to the hospitals needs to be increased. Russia is in the midst of a massive, largely ignored public health crisis. Although considered a superpower due to its vast natural resources and military spending, Russia stands out for its overwhelmingly poor health as well. Many preexisting societal circumstances have contributed to the emergence of disease, but negligent and corrupt government actions have exacerbated problems, allowing them to become endemic. These missteps have already caused life expectancy in Russia to fall thirteen years below that of any other developed nation, and the consequences will only increase if Russia’s leaders continue to enact policies that ignore the best interests of its populace.

www Chaney is a sophomore in Davenport College planning to major in Molecular Biophysics and Biochemistry. She is working at the Ko Lab at Yale researching the environmental communication mechanism of leptospirosis, a neglected tropical disease. She is also a member of the Varsity Women’s Field Hockey team and involved with Engineers Without Borders. She can be contacted at chaney.kalinich@ yale.edu.

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AMERICAN HEALTH INEQUITIES

AMERICA'S FORGOTTEN CITIES:

Public Health Crises in the Texas Colonias By Eli Rami

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T

exas is the second most populous state in the US. An economic powerhouse of the United States, if Texas were a sovereign nation it would rank as the fourteenth largest economy in the world.1 With a gross state product of over 1.6 trillion dollars in 2014, Texas has the second largest state economy in the US. Large agricultural and oil-related industries support the state economy. Home to gleaming cities, expansive ranches, and picturesque deserts, Texas’ economic and cultural importance remains unquestionable today. However, unimaginable landscapes exist just to the south of its largest cities. The state of Texas is home to nearly three thousand colonias, informal settlements strung along the US-Mexico border.2 Colonias exist throughout the Southwest, but the most populous settlements are found in Texas. Here, over five hundred thousand people call the colonias home.2

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• Over 400,000 people live in about 2,300 exisiting colonia commnities • Around 65% of residents are US citizens • Up to 60% of residents are unemployed Nearly all colonias sit on undeveloped land that sold at far-below market prices to low-income Mexican immigrants looking for affordable housing in the 1950s and 60s. During this period, the rise of the maquiladora industry in border counties attracted immigrants, and Mexican textile factories that sat directly on the border employed low-wage workers living in border communities. The small supply of worker housing in Texas could not accommodate the state’s swelling population. Land developers viewed the demand for cheap housing as an opportunity to divide relatively isolated and worthless areas of land into properties comprised of small lots. Quickly, people began to settle into these plots, which they purchased at below-market rates. They built their homes from whatever materials they could find; colonia housing materials today typically include plywood, cardboard and tarps.3 Most communities lack access to basic services such as electricity and running water. A majority of colonia residents are low-income, impoverished Hispanics, nearly 65 percent of whom are US citizens.4 Nearly half of all residents live below the US poverty line—$23,850 for a family of four.4 Due to Texas’ tax and regulation systems, the state did not control or manage the growth of most colonia settlements as they grew in popularity; in unincorporated counties of Texas, local governments have very little regulatory power. Since the colonias sit on unincorporated land, workers may legally construct unregulated structures that do not comply with state building or health codes. Due to these exemptions for colonia buildings, nontraditional homes populate the colonias—a combination of two RV vehicles may form one house, another may add on rooms only supported by cinderblocks, and homes may have extension cords that run outside, increasing the danger of fire and electrical shocks.5 New colonia construction continues to this day. A Texas realtor currently sells half-acre plots for $25,000 with a twenty-year financing scheme that only requires a $500 down payment.7 Because the median price of a home in Houston is over $220,000, and housing costs in many other cities are prohibitive,

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many low-wage Hispanic workers in Texas have been forced to buy land in these undeveloped areas. As many residents have neither the credit history nor the resources to qualify for traditional home financing methods, majority of colonia land plots are purchased via “contracts for deed,” a financing arrangement in which land ownership remains with the seller until the total purchase price is paid.6 Colonia communities lack basic services such as clean water and sewage systems, electricity, and paved roads. While many households are equipped with septic tanks, the tanks frequently overflow, creating rivers of stinking sewage on the unpaved streets and roadsides. Residents often collect rainwater for drinking and bathing with buckets that sit outside or from stagnant wells. The improper and nonexistent sanitation infrastructure has enabled hepatitis A, a virus usually spread by consuming food or water contaminated with fecal matters, to become ubiquitous in the colonias. Most hepatitis A infections travel by way of improper drinking sources and toilet facilities.3 In addition, due to the lack of municipal garbage collection, colonia residents often must burn their waste. This practice, combined with mold and cockroaches inside homes, leads to high rates of asthma, rashes and lice infestations.5 Residents of colonia communities also suffer from tuberculosis at three times the national rate due to poor sanitary conditions.3 Given the high incidence of disease, access to healthcare remains the most dire health issue facing the colonias today. Across the Texas colonias, anywhere from fifty to eighty percent of residents do not have health insurance.7 While most residents qualify for Medicaid, many do not use the service for myriad reasons, such as distrust of the program, confusion over how to register for the services, and fear that any contact with government officials or agencies will lead to deportation.5 Insurance rates are so low that community activists have reported instances of residents pulling out their own teeth because they could not afford to visit a dentist. While

colonia population has increased dramatically in recent years, the quality and availability of healthcare has not risen to meet the demand. Despite the severity of health issues that plague the colonias, a glimmer of hope for healthcare in these communities exists in volunteer organizations, which strive to fill the gap left by government healthcare systems. One of the most successful healthcare interventions are promotoras, Spanish-speaking volunteer nurses who walk door-to-door in the colonias and distribute free healthcare advice. They advise residents on a variety of topics, ranging from teaching new mothers about breastfeeding to notifying community members about public health screenings.3 In addition, the large-scale Operation Lone Star, a medical training exercise jointly run by state agencies, the Texas State Guard and the National Guard, operates once a year for two weeks. Residents wait in line for hours for their chance to receive free basic medical and dental care.5 Colonia communities rarely receive media attention outside Texas, despite the fact that hundreds of thousands of people live and work in these areas. While there have been some state interventions in the form of electricity cabling and paved roads for some colonias, ensuring that quality of life in the colonias rises to match living standards in the broader US requires much more work. The main barrier to infrastructural and sanitary improvements lies in the high state costs of reform—Texas and other states with large colonia populations will need to spend billions of dollars in order to improve wellbeing in these communities. While the future of colonias remains uncertain, grassroots efforts from local residents have made strides toward giving their communities the standard of living that they deserve. www Eli is a sophomore in Ezra Stiles college. His major is undecided. He can be contacted at elijah.rami@yale.edu.

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1. E, González, personal communication, April 5, 2016. 2. Depression. (2016). American Psychological Association. Retrieved from http:// www.apa.org/topics/depress/. 3. American Psychiatric Association. (2013). Diagnostic and Statistical manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. 4. Fonagy, P., Cottrell, D., Phillips, J., Bevington, D., Glaser, D., & Allison, E. (2015). What works for whom? A critical review of treatments for children and adolescents. New York, NY: The Guilford Press. 5. Collins, P., Patel, V., Joestl, S., March, D., Insel, T., & Daar, A. (2011). Grand challenges in global mental health. Nature, 475(7354), 27-30. 6. Hatcher-Kay, C., & King, C. (2003). Depression and suicide. Pediatrics in review, 24(11), 363-371. 7. Ruiz, L., Colin, R., Corlay, I., Lara, M., & Dueñas, H. (2007). Trastorno depresivo mayor en México: La relación entre la intensidad de la depresión, los síntomas físicos dolorosos y la calidad de vida. Salud Mental, 30(2), 25-32. 8. Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyer, I. (2011). Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). American Journal of Psychiatry, 168(5), 495-5019. 9. Luby, J. et al. (2003). The clinical picture of depression in preschool children. Journal of the American Academy of Child & Adolescent Psychiatry, 42(3), 340-348. 10. Costello, E. et al. (2002). Development and natural history of mood disorders. Biological Psychiatry, 52(6), 529-542. 11. Costello, E. et al. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60(8), 837-844. 12. Brodbeck, J., Abbott, R., Goodyer, I., & Croudace, T. (2011). General and specific components of depression and anxiety in an adolescent population. BMC Psychiatry, 11(1), 1-12. 13. 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From childhood to adult age: 18-year longitudinal results and prediction of the course of mental disorders in the community. Social Psychiatry and Psychiatric Epidemiology, 44(9), 792-803. 18. Fombonne, E., Wostear, G., Cooper, V., Harrington, R., & Rutter, M. (2001). The Maudsley long-term follow-up of child and adolescent depression. The British Journal of Psychiatry, 179(3), 210-217. 19. Johnson, J., Cohen, P., Skodol, A., Oldham, J., Kasen, S., & Brook, J. (1999). Personality disorders in adolescence and risk of major mental disorders and suicidality during adulthood. Archives of General Psychiatry, 56(9), 805-811. 20. Lewinsohn, P., Petit, J., Joiner Jr, T., & Seeley, J. (2003). The symptomatic expression of major depressive disorder in adolescents and young adults. Journal of Abnormal Psychology, 112(2), 244. 21. Richmond, T. K., & Rosen, D. S. (2005). The treatment of adolescent depression in the era of the black box warning. Current Opinion in Pediatrics, 17(4), 466-472. 22. Rao, U. M. A. et al. (1995). Unipolar depression in adolescents: clinical outcome in adulthood. Journal of the American Academy of Child & Adolescent Psychiatry, 34(5), 566-578. 23. Rohde, P., Lewinsohn, P. M., & Seeley, J. R. (1994). Are adolescents changed by an episode of major depression? Journal of the American Academy of Child & Adolescent Psychiatry, 33(9), 1289-1298. 24. Curry, J. et al. (2011). Recovery and recurrence following treatment for adolescent major depression. Archives of General Psychiatry, 68(3), 263-269. 25. Lewinsohn, P. M. et al. (1994). Adolescent psychopathology: II. Psychosocial risk factors for depression. Journal of Abnormal Psychology, 103(2), 302. 26. Angold, A., Erkanli, A., Silberg, J., Eaves, L., & Costello, E. J. (2002). Depression scale scores in 8–17‐year‐olds: effects of age and gender. Journal of Child Psychology and Psychiatry, 43(8), 1052-1063. 27. Kuehner, C. (2003). 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29. Estadísticas de Mortalidad, Consulta Interactiva de Datos. (n.d.). National Institute of Statistics and Geography. Retrieved from http://www.inegi.org.mx/ est/lista_cubos/consulta.aspx?p=adm&c=4. 30. GBD Compare, Viz-Hub. (n.d.). Institute for Health Metrics and Evaluation. Retrieved from http://vizhub.healthdata.org/gbd-compare/. 31. Metrics: Disability-Adjusted Life Year (DALY). (n.d.). World Health Organization. Retrieved from http://www.who.int/healthinfo/global_burden_disease/ metrics_daly/en/ 32. Medina-Mora, M. et al. (2005). Prevalence, service use, and demographic correlates of 12-month DSM-IV psychiatric disorders in Mexico: results from the Mexican National Comorbidity Survey. Psychological Medicine, 35, 1773–1783. 33. National Institute of Statistics and Geography. (n.d.) Estadísticas a propósito del día internacional de las personas de edad (1 de octubre). Retrieved from http:// www.inegi.org.mx/saladeprensa/aproposito/2014/adultos0.pdf. 34. Garcia-Peña, C. et al. (2008). Depressive symptoms among older adults in Mexico City. Journal of General Internal Medicine, 23(12), 1973-1980. 35. Weller, S., Baer, R., Garcia de Alba, J., Salcedo, A. (2008). Susto and nervios: Expressions for stress and depression. Culture, Medicine, and Psychiatry, 32(3), 406-420. 36. Mexico City’s Ministry of Health. (n.d). Mitos y realidades acerca de la Salud Mental. Retrieved from http://www.salud.df.gob.mx/portal/images/portal/ inicio/general/archivo_pdf/INFORMACIO%CC%81N%20DE%20INTERE%CC%81S.pdf. 37. Mexico City’s Ministry of Health. (n.d.). Programas y Acciones. Salud Mental. Retrieved from http://www.salud.df.gob.mx/portal/index.php/programas-y-acciones/84-ssp/pp0o0orogramas/309-sm. 38. Berenzon, S., Saavedra, N., Medina-Mora, M., Aparicio, V., & Galván, J. (2013). Evaluación del sistema de salud mental en México: ¿hacia dónde encaminar la atención? Rev. Panam Salud Pública, 33(4), 252-8. 39. MhGAP Intervention Guide from mental, neurological and substance use disorders in non-specialized health settings. (n.d.). World Health Organization. Retrieved from http://apps.who.int/iris/bitstre am/10665/44406/1/9789241548069_eng.pdf 40. Khan, F. (2016). Why depression screenings should be part of routine check-ups. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2016/02/depression-screening-primary-care/462933/?utm_source=SFFB. 41. Grade definitions. (n.d.). US Preventive Services Task Force. Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Name/gradedefinitions. 42. Medina-Mora, M. (2015). Mexico: Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz. Informe anual de autoevaluación 2014: Enero-Diciembre. 43. Organizacion Mundial de la Salud, Organizacion Panamericana de la Salud, & Secretaria de Salud de Mexico. (2011). IESM-OMS Informe sobre sistema de salud mental en Mexico. Mexico. FOOD INSECURITY in the “Salad Bowl of America” by Claire Chang (p. 17) 1. Lauritzen, E. (2014) Monterey County 2014 Crop Report. Monterey County Agricultural Commissioner. Retrieved from: https://www.co.monterey.ca.us/ home/showdocument?id=1581. 2. Anderson, S. A. (1990). Core indicators of nutritional state for difficult-to-sample populations. The Journal of Nutrition, 120(11), 1557-1599. 3. Coleman-Jensen, A., Gregory, C., & Singh, A. (2014). Household food security in the United States in 2013. USDA-ERS Economic Research Report, (173). 4. Kresge, L., & Eastman, C. (2010). Increasing food security among agricultural workers in California’s Salinas Valley. Davis, CA: California Institute for Rural Studies. 5. Dinour, L. M., Bergen, D., & Yeh, M. C. (2007). The food insecurity–obesity paradox: A review of the literature and the role food stamps may play. Journal of the American Dietetic Association, 107(11), 1952-1961. 6. Wirth, C., Strochlic, R., & Getz, C. (2007). Hunger in the fields: Food insecurity among farmworkers in Fresno County. California Institute for Rural Studies. 7. Calavita, K. (1994). US immigration and policy responses: The limits of legislation. Controlling Immigration: A Global Perspective, 55-82. 8. Brown, S., & Getz, C. (2011). Farmworker food insecurity and the production of hunger in California. Cultivating food justice: Race, class, and sustainability, 121-146. 9. Villarejo, D. (2003). The health of US hired farmworkers. Annual Review of Public Health, 24(1), 175-193. 10. Borre, K., Ertle, L., & Graff, M. (2010). Working to eat: Vulnerability, food insecurity, and obesity among migrant and seasonal farmworker families. American Journal of Industrial Medicine, 53(4), 443-462. 11. Cook, J. T., et al. (2004). Food insecurity is associated with adverse health outcomes among human infants and toddlers. The Journal of Nutrition, 134(6), 1432-1438. 12. Seligman, H. K., Bindman, A. B., Vittinghoff, E., Kanaya, A. M.,

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& Kushel, M. B. (2007). Food insecurity is associated with diabetes mellitus: results from the National Health Examination and Nutrition Examination Survey (NHANES) 1999–2002. Journal of General Internal Medicine, 22(7), 1018-1023. 13. Gundersen, C., & Ziliak, J. P. (2015). Food insecurity and health outcomes. Health Affairs, 34(11), 1830-1839. 14. Townsend, M. S., Peerson, J., Love, B., Achterberg, C., & Murphy, S. P. (2001). Food insecurity is positively related to overweight in women. The Journal of Nutrition, 131(6), 1738-1745. 15. Dinour, L. M., Bergen, D., & Yeh, M. C. (2007). The food insecurty–obesity paradox: A review of the literature and the role food stamps may play. Journal of the American Dietetic Association, 107(11), 1952-1961. 16. Minkoff-Zern, L. A. (2014). Hunger amidst plenty: Farmworker food insecurity and coping strategies in California. Local Environment, 19(2), 204-219. IRELAND: Restrictions on Abortion by Ariela Zebede (p. 19) 1. Taylor, C. (2015). Ireland ranked as one of the best in terms of reputation. The Irish Times. Retrieved from: http://www.irishtimes.com/business/economy/ ireland-ranked-as-one-of-the-best-in-terms-of-reputation-1.2287594. 2. Schwab, K. et al. (2015). The global gender gap report 2015. World Economic Forum. Retrieved from http://www3.weforum.org/docs/GGGR2015/cover.pdf. 3. She is not a criminal—the impact of Ireland’s abortion law. (2015). Amnesty International. Retrieved from http://www.amnestyusa.org/pdfs/Ireland_She_ Is_Not_A_Criminal.pdf. 4. Implementation of the protection of life during pregnancy act 2013 (2014). Ann Roinn Slainte Department of Health. Retrieved from http://cdn.thejournal.ie/ media/2014/08/doctor-guidance1.pdf. 5. Facts and information about sexual violence and rape. (2016). Dublin Rape Crisis Center. Retrieved from http://www.drcc.ie/get-help-and-information/ facts-and-info-about-sexual-violence-and-rape/. 6. Convention against torture and other cruel, inhuman or degrading treatment or punishment [PDF]. (2011). United Nations. Retrieved from http:// www2.ohchr.org/english/bodies/cat/docs/CAT.C.PRY.CO.4-6_en.pdf. 7. Abortion statistics, England and Wales: 2014. (2015). UK Department of Health. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/433437/2014_Commentary__5_.pdf. 8. Abandoned and stigmatized: the impact of the Irish abortion law on women. (2014). Center for Reproductive Rights. Retrieved from http://tbinternet. ohchr.org/Treaties/CCPR/Shared%20Documents/IRL/INT_CCPR_CSS_ IRL_17442_E.pdf. 9. Protection of life during pregnancy act 2013. (2013). Retrieved from http:// www.irishstatutebook.ie/eli/2013/act/35/enacted/en/pdf. 10. Consistent poverty rates. (n.d.). European Anti-Poverty Network Ireland. Retrieved from http://www.eapn.ie/eapn/training/consistent-poverty-rates. 11. Ireland at the UN: we have ‘no solution’ for women who can’t afford to travel for an abortion. (2014). Thejournal.ie. Retrieved from http://www.thejournal.ie/ireland-unhrc-day-twp-1572161-Jul2014/. 12. Healthy mothers, healthy babies: South Carolina’s plan to reduce infant mortality and premature births. (2013). DHEC. Retrieved from https://www. scdhec.gov/library/cr-010842.pdf. 13. The World Factbook. (n.d.). Central Intelligence Agency. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/rankorder/2004rank.html 14. Myth #6: Ireland, without abortion, is the safest place in the world for pregnant women. (2014). Abortion Rights Campaign. Retrieved from http:// www.abortionrightscampaign.ie/2014/03/06/myth-6-ireland-without-abortionhas-the-lowest-maternal-mortality-rate-in-the-world/. 15. Maternal mortality rates. (2016). Profile Campaign. Retrieved from http:// prolifecampaign.ie/main/maternal-mortality-statistics/. PAKISTAN & BRAZIL: The Current Narrative of Healthcare Reform by Mahrukh Shahid (p. 23) 1. Junaidi, I. (2016). PM launches health scheme for the poor. Dawn. Retrieved from http://www.dawn.com/news/1229970. 2. Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: history, advances, and challenges. Lancet, 377(9779), 1778-1797. 3. Nishtar, S. et al. (2013). Pakistan’s health system: performance and prospects after the 18th Constitutional Amendment. Lancet, 381(9884), 2193-2206. 4. Monteiro C, Cavalcante T, Moura E, Claro R, Szwarcwald C. (2007). Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989–2003). Bulletin of the World Health Organization, 85, 527–534. 5. Research shows BISP is ‘biased, misused’. (2014). Dawn. Retrieved from http://www.dawn.com/news/1112696. 6. Reproductive Healthcare and Rights Bill, S., 90th Cong. (2013). 7. Tax revenue (% of GDP). (2014). The World Bank. Retrieved from http://data.

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worldbank.org/indicator/GC.TAX.TOTL.GD.ZS. 8. Benazir Income Support Program. (n.d.). BISP. Retrieved from http://www. bisp.gov.pk THE UNSEEN CONSEQUENCES OF WAR: Responding to Sri Lanka’s Mental Health Burden by Ohvia Muraleetharan (p. 25) 1. Central Intelligence Agency. (2013). The World Factbook: Sri Lanka. Washington, DC. 2. Somasundaram, D., & Jamunanantha, C. (2002). Trauma, war, and violence: Public mental health in socio-cultural context (J. De Jong, Ed.). New York: Kluwer Academic/Plenum. 3. Bush, K. D., & Saltarelli, D. (2000). The two faces of education in ethnic conflict: Towards a peacebuilding education for children. Florence, Italy: UNICEF, United Nations Children’s Fund, Innocenti Research Centre. Retrieved from http:// www.unicef-irc.org/publications/ 4. Somasundaram, D. (2010). Parallel governments: living between terror and counter terror in Northern Lanka (1982--2009). Journal of Asian and African Studies, 45(5), 56-583. 5, UNICEF. (2004). The State of the World’s Children 2005: Childhood Under Threat. New York, NY: Bellamy, C. 6. K. Muraleetharan, personal communication, April 14, 2016. 7. Amnesty International. (1996). Sri Lanka: Wavering Commitment to Human Rights. London. 8. D. Sacco, personal communication, April 15, 2016. 9. Catani, C., Jacob, N., Schauer, E., Kohila, M., & Neuner, F. (2008). Family violence, war, and natural disasters: A study of the effect of extreme stress on children’s mental health in Sri Lanka. BMC Psychiatry, 8(1), 33. 10. Knipe, D., Metcalfe, C., & Gunnell, D. (2015). WHO suicide statistics – a cautionary tale. Ceylon Med. J. Ceylon Medical Journal, 60(1), 35. 11. Samarasekare, N., Davies, M. L., & Siribaddana, S. (2012). The stigma of mental illness in Sri Lanka: the perspectives of community mental health workers. Stigma Research and Action, 2(2), 93-99. 12. Elbert, T., Schauer, M., Schauer, E., Huschka, B., Hirth, M., & Neuner, F. (2009). Trauma-related impairment in children—a survey in Sri Lankan provinces affected by armed conflict. Child Abuse & Neglect, 33(4), 238-246. 13. Catani, C., Schauer, E., & Neuner, F. (2008). Beyond individual war trauma: domestic violence against children in Afghanistan and Sri Lanka. J Marital Family Therapy Journal of Marital and Family Therapy, 34(2), 165-176. 14, Yehuda, R., Halligan, S. L., & Grossman, R. (2001). Childhood trauma and risk for PTSD: Relationship to intergenerational effects of trauma, parental PTSD, and cortisol excretion. Develop. Psychopathol. Development and Psychopathology, 13(3), 733-753. 15. Catani, C. et al. (2009). Treating children traumatized by war and tsunami: a comparison between exposure therapy and meditation-relaxation in NorthEast Sri Lanka. BMC Psychiatry, 9(1), 22. 16. Sri Lanka Mental Health Directorate. (2005). The Mental Health Policy of Sri Lanka. Colombo: Ministry of Healthcare & Nutrition. 17. Zolnierek, C. D. (2008). Mental health policy and integrated care: global perspectives. Journal of Psychiatric and Mental Health Nursing, 15(7), 562-568. 18. World Health Organization. (2012). WHO country cooperation strategy, 20122017: Democratic Socialist Republic of Sri Lanka. New Delhi: Regional Office for South-East Asia. 19. World Health Organization. (2011). Mental Health Atlas 2011: Sri Lanka. Geneva: Department of Mental Health and Substance Abuse. AT THE HELM: United States Foreign Policy and Reproductive Rights by Aviva Rabin-Court (p. 33) 1. Roe v. Wade. Legal Information Institute. (n.d.). Retrieved from https://www. law.cornell.edu/supremecourt/text/410/113. 2. Barot, S. (2013). Abortion restrictions in US foreign aid: the history and harms of the Helms Amendment. Guttmacher Policy Review. Retrieved from https://www.guttmacher.org/pubs/gpr/16/3/gpr160309.html. 3. USAID’S family planning guiding principles and US legislative and policy requirements. (n.d.). USAID. Retrieved from https://www.usaid.gov/whatwe-do/global-health/family-planning/usaids-family-planning-guiding-principles-and-us. 4. Planned Parenthood of Southeastern Pennsylvania v. Casey. (n.d.). Case Briefs. Retrieved from http://www.casebriefs.com/blog/law/constitutional-law/ constitutional-law-keyed-to-stone/implied-fundamental-rights/planned-parenthood-of-southeastern-pennsylvania-v-casey-4/2/. 5. Whole Woman’s Health v. Hellerstedt. (n.d.) Center for Reproductive Rights. Retrieved from http://www.reproductiverights.org/case/whole-womans-health-v-hellerstedt. 6. Texas Omnibus Abortion Bill (HB2). (2013). Legislative Tracker. Retrieved from https://rewire.news/legislative-tracker/law/texas-omnibus-abortion-bill-hb-2-2013/ .

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7. Walden, K. (2014) Does looking at the ultrasound before an abortion change women’s minds? Slate. Retrieved from http://www.slate.com/blogs/xx_factor/2014/01/09/ultrasound_viewing_before_an_abortion_a_new_study_finds_ that_for_a_small.html. 8. Helms Amendment. (n.d.). Center for Health and Gender Equity. Retrieved from http://www.genderhealth.org/the_issues/us_foreign_policy/helms/. 9. Cohen, S. A. (2012). Access to safe abortion in the developing world: saving lives while advancing rights. Guttmacher Policy Review. Retrieved from https:// www.guttmacher.org/pubs/gpr/15/4/gpr150402.html. 10. Haddad, L. (2009). Unsafe abortion: unnecessary maternal mortality. Rev Obstet Gynecol. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2709326/. 11. Reproductive health. (n.d.). World Health Organization. Retrieved from http://www.who.int/topics/reproductive_health/en/. 12. Global and regional estimates of violence against women. (2013). World Health Organization. Retrieved from http://www.who.int/reproductivehealth/ publications/violence/9789241564625/en/. 13. Responding to intimate partner violence and sexual violence against women. (2013). World Health Organization. Retrieved from http://apps.who.int/iris/ bitstream/10665/85240/1/9789241548595_eng.pdf. 14. Searcey, D. (2016). Military victories over Boko Haram mean little to Nigerians. New York Times. Retrieved from http://www.nytimes.com/2016/01/16/ world/africa/boko-haram-nigeria.html. 15. Nossiter, A. (2015). Boko Haram militants raped hundreds of female captives in Nigeria. New York Times. Retrieved from http://www.nytimes. com/2015/05/19/world/africa/boko-haram-militants-raped-hundreds-of-female-captives-in-nigeria.html. LOW-COST DIAGNOSTICS: Advancements in Global Health by Wen Yi Low (p. 38) 1. Burgess, D. C. H., Wasserman, J., & Dahl, C. A. (2006). Global health diagnostics. Nature, 444, 1-2. 2. Kumar, A. A. et al. (2015). From the bench to the field in low‐cost diagnostics: two case studies. Angewandte Chemie International Edition, 54(20), 5836-5853. 3. Pitta, D. A., Guesalaga, R., & Marshall, P. (2008). The quest for the fortune at the bottom of the pyramid: potential and challenges. Journal of Consumer Marketing, 25(7), 393-401. 4. Mabey, D., Peeling, R. W., Ustianowski, A., & Perkins, M. D. (2004). Tropical infectious diseases: diagnostics for the developing world. Nature Reviews Microbiology, 2(3), 231-240. 5. Kettler, H., White, K., & Hawkes, S. (2004). Mapping the landscape of diagnostics for sexually transmitted infections: key findings and recommendations. World Health Organization. 6. Research low-cost diagnostics and tools for global health. (2011). Whitesides Research Group. Retrieved from http://gmwgroup.harvard.edu/research/index. php?page=24. 7. Scudellari, M. (2013). A dime a dozen. The Scientist. Retrieved from http:// www.the-scientist.com/?articles.view/articleNo/33761/title/A-Dime-a-Dozen/. 8. Martinez, A. W., Phillips, S. T., Whitesides, G. M., & Carrilho, E. (2009). Diagnostics for the developing world: microfluidic paper-based analytical devices. Analytical chemistry, 82(1), 3-10. 9. Chin, C. D., Linder, V., & Sia, S. K. (2012). Commercialization of microfluidic point-of-care diagnostic devices. Lab on a Chip, 12(12), 2118-2134. 10. Warren, A. D., Kwong, G. A., Wood, D. K., Lin, K. Y., & Bhatia, S. N. (2014). Point-of-care diagnostics for noncommunicable diseases using synthetic urinary biomarkers and paper microfluidics. Proceedings of the National Academy of Sciences, 111(10), 3671-3676. 11. Bwambok, D. K. et al. (n.d.). Adaptive use of bubble wrap for storing liquid samples and performing analytical assays. Analytical chemistry, 86(15), 7478-7485. 12. Nemiroski, A. et al. (2014). Universal mobile electrochemical detector designed for use in resource-limited applications. Proceedings of the National Academy of Sciences, 111(33), 11984-11989. 13. Leavitt, F. (2004). The real drug abusers. Rowman & Littlefield Publishers. RUSSIA: The Sickness of a Nation by Chaney Kalinich (p. 41) 1. Chelala, C. (2012, December 23). Russia’s demographic and public health crisis. Common Dreams. Retrieved from http://www.commondreams.org/ views/2012/12/23/russias-demographic%20-and-public-health-crisis. 2. Life expectancy at birth, Russian Federation (2013). World Health Organization. Retrieved from http://www.who.int/countries/rus/en/. 3. Danton, C. (2007). The health crisis in Russia. Topical Research Digest: Human Rights in Russia and the Former Soviet Republics, 43-50. Retrieved from http:// www.du.edu/korbel/hrhw/researchdigest/russia/russia.pdf. 4. Chirkunov, O. (2013). Management of motives in health care. Problems of

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