HURJ Volume 24 :: 2019-2020 by The HURJ

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HURJ hopkins undergraduate research journal • spring 2020 •

TABLE OF CONTENTS

TABLE OF

LETTER FROM THE EDITORS

STEM & TECHNOLOGY

HOPSITAL-ASSOCIATED INFECTSIONS: WHY ARE THEY STILL A PROBLEM? Ana Rosu

TAU PROTEIN AND COGNITIVE AGING IN ALZHEIMERâ&#x20AC;&#x2122;S DISEASE

Junyao Li

SURPRISE ENHANCED LEARNING IN INFANCY Mikayla R. Bisignani

SYNTHESIS AND CHARACTERIZATION OF NOVEL POLY (PRO-CURCUMIN) MATERIALS AS SPINAL CORD INJURY THERAPEUTICS

24 4

Sneha Kamada

THE DYNAMIC NUCELOSOME Ejlal Elalaoui

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CONTENTS HUMANITIES & SOCIAL SCIENCES

HUMANITARIANISM IN THE LATE CHAD BASIN: DILEMMAS OF WORKING AT THE INTERSECTION OF CLIMATE CHANGE, AUTOCRACY, POVERTY, AND BOKO HARAM Jordan Jain

A LITERATURE REVIEW OF GOVERNMENT NUTRITIONAL PROGRAMS AND THEIR EFFECT ON CHILDHOOD MALNUTRITION IN SOUTH ASIA

Amith Umesh, Varun Mahadevan

DOES SELF ESTEEM MATTER IN REGARD TO RELIGIOSITY AND DEGREE OF SECURE ATTACHMENT? Alexia Cilia

TRANSITION: AN ECONOMIC ANALYSIS OF TRANSGENDER BEHAVIOR

Julia Aurelia Glass

COMPUTATIONAL ANALYSIS ON THE RELATIONSHIP BETWEEN STATE POLITICAL PARTY DOMINANCE AND LACK OF HEALTH INSURANCE Daniel Habib

THE MODERN IMMIGRATION REGIME: PUBLIC CHARGE, TRAVEL BANDS AND ASYLUM FEES Daniel Mathew

HURJ EDITORIAL BOARD

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LETTER

from the

EDITORS

Hopkins Undergraduate Research Journal (HURJ) is the first undergraduate interdisciplinary research journal. Since its inception in 2001, every issue of HURJ evolved to better encompass and reflect the diverse interests of the students on the Homewood campus. In the following pages, you will encounter a sample of incredible research in the sciences, humanities, social sciences, and engineering which the undergraduates of the Johns Hopkins University engaged in. For each issue of HURJ, the editorial staff select from numerous article submissions, highlighting the passion and dedication of the Hopkins undergraduate community. We are confident that this publication is a testament to the boundless academic and intellectual talents of our peers. As you read each article presented in this issue, it is our hope that you will partake in honoring their work with us. Each issue of HURJ is only possible with the diligence, dedication, and cooperation of our staff and the contributing authors. We would like to extend a special thanks to them, which allowed for this issue the success it has become. We welcome all thoughtful ideas, comments, and questions. We hope that this journal serves as an inspiration for you to partake in the contribution and celebration the intellectual growth of this community. Sincerely,

Senyoung and Lina Co-Editors-in-chief

Senyoung Kim Co-Editor-in-chief â&#x20AC;˘ President

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Lina Oh Co-Editor-in-chief â&#x20AC;˘ Head of Layout

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Hospital Associated Infections:Why are They Still a Problem? Ana Rosu A B S T R A C T

There have been both government and hospital-led policy-based initiatives to

prevent HAIs, with limited success due to lack of consistency when implementing proper sanitary procedures. Since most HAIs are caused by transmission of pathogens on the surface of a medical device, several large-scale companies and startups have attempted to create medical devices with antimicrobial surfaces. However, these technological solutions have had their challenges in clinical trials and implementation. HAIs are an issue in any country and, to properly address them, there should be an increased push and support for technological solutions from both the financial and political perspectives.

INTRODUCTION

Hospital-associated infections (HAIs) were first reported in 1846 by Hungarian doctor Ignaz Semmelweis. Semmelweis realized that doctors in his hospital were spreading puerperal fever to women giving birth because they were not washing their hands after dissecting infected cadavers (Cavaillon et al.). Since then, HAIs continue to be associated with a variety of unsanitary practices in hospitals: improper sterilization in surgeries, catheter insertions, and ventilators are just a few examples. One in thirty-one patients will be infected by pathogens in hospitals after being admitted for treatment of another disease (Magill et al.). Most often, these HAIs will be transmitted when patients are catheterized with central lines or urinary catheters. Central line-associated bloodstream infections (CLABSI) have the highest mortality rate and monetary cost: the average CLABSI case has an 18 percent chance of death and costs 46,000 dollars. Other common HAIs include ventilator-associated pneumonia (VAP) and surgical site infections (SSI) (Zimlichman et al.). In 2013, it was estimated that the total annual costs 8

for HAIs was 9.8 billion dollars, with SSIs contributing most to overall costs, then VAPs and catheter-associated HAIs. Unfortunately, today, a patient’s likelihood of getting infected during their hospital stay is highly dependent upon how well their nurse or doctor follows proper sanitary procedure (“2018 National and State HealthcareAssociated Infections Progress Report”).

HOSPITAL ASSOCIATED I N F E C T I O N S (H A I S) CAUSES HAIs are commonly caused by C. difficile, S. aureus MRSA (multidrug resistant staphylococcus aureus), E. Coli., and norovirus. MRSA is best known for its high mortality rate and resistance to drugs like penicillin, oxacillin, methicillin, and amoxicillin. In extreme cases, HAIs can lead to severe sepsis, causing organs to dysfunction. In those cases, one in four patients will die (Mayr et al.). While some HAIs are deadly, many other HAI-causing pathogens do not necessarily cause death but increase hospital stay and inhibit patient recovery from the original disease.

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Catheter-associated HAIs are caused when pathogens crawl from the catheter’s insertion site to the tip of the catheter inside of the patient’s body. Once inside the body, these pathogens begin to colonize and form a biofilm, a layer of bacteria that covers itself in extracellular polymeric substances (EPS), which help pathogens adhere to the catheter and each other (Safdar et al.). Research has found that the EPS of biofilms protects bacteria from many common drugs, making the infection harder to treat (Costerton et al.; Drenkard et al.). Surgical site infections (SSI) are caused when pathogens infect a surgical wound through contact with a contaminated surgical instrument or caregiver or spread from the air into a newly made surgical wound. Because surgeries are invasive, infections can occur at different levels within the body: superficial (skin and subcutaneous tissue), deep incisional (fascia and muscular layers), and organ or space (any part of the body opened or manipulated during the procedure that is not skin, subcutaneous tissue, fascia, or muscular layers). Although more than half of SSIs are preventable by evidence-based guidelines,

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approximately 160,000-300,000 SSIs occur each year in the United States, accounting for 20 percent of all HAIs in hospitalized patients (Anderson et al.). Ventilator-associated pneumonia (VAP) is specific to patients that are mechanically ventilated. Clinical surveys suggest that VAP occurs in 5-15 percent of ventilated patients, causing between 250,000 and 300,000 cases per year in the United States (Klompas et al.). It’s suspected that VAP occurs when ventilators are improperly sterilized or placed in the supine position in patients. Another potential cause is the inhalation of bacteria through the ventilator circuit (Koenig et al.).

PREVENTING HAIS WITH POLICY

In 2008, the United States government enacted policies that penalized hospitals with high rates of HAIs. The Centers for Medicare and Medicaid Services denied payment for HAIs but restricted patients from having to pay more if their stay or treatment was increased because of HAIs, forcing hospitals to pay from their own budget. In response, hospitals implemented various programs to bring down HAI rates (Stone et al.). Many used the Comprehensive Unit-based Safety Program (CUSP) developed by Johns Hopkins Hospital, which was tested iwn 100 Michigan intensive care units and resulted in a 41 percent reduction in the rate of CLABSI (“Eliminating CLABSI, A National Patient Safety Imperative”). CUSP requires special training and ensures regular use of checklists for the most common procedures associated with HAIs. These checklists include simple steps such as washing hands, sanitizing patients’ skin with antiseptic, and wearing sterile masks, hats, gowns, and gloves. Some hospitals implemented individualized programs responding to HAI patterns specific to their institution. The Haukeland University Hospital in Norway performed a 17year study analyzing the results of their systematic infection control program, which included training healthcare workers and introducing evidencebased checklists, and found that they

were able to reduce their HAI rate from 8.3 percent in 1994 to 7.1 percent in 2010 (Koch et al.). The University of Mississippi Medical Center was able to reduce HAIs in neonatal intensive care units through coaching initiatives where colleagues privately tell one another to wash hands, rotating groups of employees secretly observing hand hygiene practices of their coworkers, and repeated training (Norwood, 2016). In the United States, due to the implementation of both nationwide and individual hospital policies, HAI rates have gone down significantly. In the case of CLABSI, in the period between 2006 and 2016, the rate of infection almost halved (“Data Summary of HAIs in the US: Assessing Progress 2006-2016”). However, despite this, there are many instances of both medical professionals and hospitals ignoring the designated checklists and training, due to overcrowded hospitals and too little time. Thus, due to human error, HAIs remain a persistent problem. To address this, both small and large companies have developed technological solutions to HAIs in the form of antimicrobial catheters, countertops, dialysis machines, and more.

PREVENTING HAIS WITH ANTIMICROBIAL MEDICAL DEVICES

Although HAIs happen when medical professionals do not properly follow sterilization and sanitation procedures, there are points in the infection chain where the spread of bacteria can be prevented through technology. Most solutions to HAIs are based on making medical devices or surfaces where HAI-causing bacteria typically colonize antimicrobial. To keep biofilms from adhering to catheters, companies such as Bard, Arrow International, and Cook Critical Care produce antibiotic-coated and antiseptic catheters. Cook Critical Care’s catheters use a combination of the antibiotics rifampin and minocycline to create an antimicrobial surface that kills bacteria before they can adhere and colonize (Zenios,

2009). Rifampin and minocycline inhibit protein synthesis: minocycline binds to the 30S subunit of bacterial ribosomes, preventing translation of RNA to proteins, and rifampin binds to beta subunits of DNA-dependent RNA polymerase, preventing the creation of RNA (Ye et al.; Deck, 2015). Unfortunately, rifampin/minocycline catheters can unintentionally select for bacteria that have ribosomal and RNA polymerase subunit designs resistant to binding, creating drugresistant bacterial strains. Studies have shown minocycline/rifampin catheters to be ineffective against new strains of S. Epidermis and Candida species (Raad et al.; Bonne et al.). Arrow International impregnates catheter surfaces with chlorhexidinesilver sulfadiazine, making them antiseptic. Silver sulfadiazine releases silver ions that bind to microbial DNA, allowing sulfadiazine to interfere with microbial metabolic processes (Gallagher, 2012). Chlorhexidine, a positively charged molecule, binds with the negatively charged phospholipids that comprise bacterial cell walls, causing them to rupture (Mangram et al.). In the lab, chlorhexidine and silver sulfadiazine work synergistically to create a slightly hydrophobic surface on catheters that is toxic to fungi and bacteria, prevents bacterial adhesion, and inhibits bacterial colony growth (Monzillo et al.). However, in clinical practice, numerous studies have found chlorhexidine silver sulfadiazine impregnated catheters to be ineffective, and in a few cases, toxic to patients (Wassil et al.). In a discussion with the Chief of Infection Prevention Control, at a Midwestern Hospital, it was revealed that hospitals avoid using current antimicrobial catheters at a large scale because of unconvincing clinical data of their efficacy and their increased cost (Susan Ruwe, personal communication, March 13, 2019). Light Line Medical (originally Veritas Medical LLC), a startup company founded by researchers at the University of Utah, is developing a set of catheters that utilize electromagnetic light therapy to eliminate bacterial colonies. A conductive line transfers light with a wavelength of 405 nm

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from an electromagnetic power source throughout the whole catheter (Rhodes et al.). Light Line Medical urinary catheters, respiratory catheters, and central lines have been expected to achieve FDA/ CE clearance for hospital use by 2018, 2020, and 2022, respectively. One Johns Hopkins-based startup, Relavo, has come up with a novel way to sterilize dialysis machines. They are particularly common in patients receiving at-home dialysis treatment. By changing the structure of the dialysis machine, Relavo forces patients and medical professionals to follow sanitary procedure, preventing infection (Hub staff report, 2019; Tantibanchachai, 2019). Last of all, some hospitals like Memorial Sloan Kettering have replaced steel countertops, armrests, and doorknobs in with copper, a well-known antimicrobial metal. After implementation, HAI rates were reduced by 58 percent (Salgado et al.).

hospital is, the time that nurses have for each patient, how much experience the medical professional has, etc.). A seemingly more convenient alternative to addressing HAIs would be coming up with medical devices that can prevent infection—either through the material they are made out of, their length of use, or their forced alteration of procedure. However, as with the development of any technological solution to a problem, for an ideal technology to appear, there must be adequate funding and desire for it. Unfortunately, many hospitals are understandably reluctant to admit that they have issues with infection control, which inhibits the rate at which new technological solutions to HAIs are implemented. In addition, because at the national level in comparison with other health problems, the number of reported deaths due to HAIs is less, it does not make the research and development of new technologies a priority for funding.

“Approximately 160,000-300,000 SSIs occur each year in the United States, accounting for 20 percent of all HAIs in hospitalized patients.” Unfortunately, not many technological solutions have been developed to prevent SSI and VAP, primarily because of the large number of potential factors influencing infection rates and lack of specific understanding of how exactly infection is caused, respectively.

CONCLUSION

While there have been attempts to address HAIs with both hospital and nationwide policy, as well as new technologies, each approach has its own drawbacks. Although proper training and procedure checklists are essential, their efficacy will always be limited by the attention and time medical professionals give them, which depends on many factors that cannot always be controlled (how crowded a 10

Thus, HAIs—preventable infections that have had a known cause since the 1800s—are still a common problem in hospitals. However, HAIs are not only a national problem. In poor countries developing and implementing policies for sanitization is much more challenging than in western countries. New technological solutions could offer solutions to be easily delivered and implemented worldwide.

REFERENCES

1. Cavaillon J, Chretien F. From septicemia to sepsis 3.0 – from Ignaz Semmelweis to Louis Pasteur. Nature Genes & Immunity. 2019 Mar 22; 20:371-82. 2. Magill S, O’Leary E, Janelle S, Thompson D and Edwards J, et al. Changes in prevalence of health 3. Zimlichman E, Henderson D, Tamir O, Franz C, Bates D, et al. Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Internal Medicine. 2013 Dec 9; 173(22):2039-46.

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4. United States. CDC. 2018 National and State Healthcare-Associated Infections Progress Report. 2018. 5. Mayr F, Yende S, Angus D. Epidemiology of severe sepsis. Virulence. 2014 Jan 1; 5(1):4-11. 6. Safdar N, Maki D. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med. 2004; 30: 62-67. 7. Costerton J, Stewart P, Greenberg E. Bacterial biofilms: A common cause of persistent infections. Science. 1999 May 21; 284(5418):1318-22. 8. Drenkard E, Ausubel F. Pseudomonas biofilm formation and antibiotic resistance are linked to phenotypic variation. Nature. 2002 Apr 18; 416:740-43. 9. Anderson D, Podgorny K, Berrios-Torres S, Bratzler D, Kaye K, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology. 2014 Jun; 35(6):605-27. 10. Klompas M, Branson R, Eichenwald E, Greene L, Berenholtz S, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals” 2014 update. Infection Control and Hospital Epidemiology. 2014 Aug; 35(8):915-36. 11. Koenig S, Truwit J. Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. Clinical Microbiology Reviews. 2006 Oct; 19(4):637-57. 12. Stone P, Glied S, McNair P, Matthes N, Larson E, et al. CMS changes in reimbursement for HAIs: Setting a research agenda. Med Care. 2010 May; 48(5):433-39. 13. Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality & Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality. “Eliminating CLABSI, A National Patient Safety Imperative: Final Report on the National On the CUSP: Stop BSI Project.” 2012 Oct. 14. Koch A, Nilsen R, Dalheim A, Cox R, Harthug S. Need for more targeted measures – Only less severe hospital-associated declined after introduction of an infection control program. Journal of Infection and Public Health. 2015 May 1; 8(3): 282-90. 15. Norwood, A. (2016, Oct 13). UMMC washes away alarmingly high number of hospital infections. Mississippi Today. Retrieved from https://mississippitoday. org/2016/10/13/ummc-washes-awayalarmingly-high-number-of-hospital-infections/ 16. United States. CDC. Data Summary of HAIs in the US: Assessing Progress 2006-2016. 2016. 17. Zenios S, Makower J, Yock P, Brinton J, Krummel T, et al. Biodesign: The process of innovating medical technologies. Cambridge University Press; 2009. 18. Ye Z, Li C, Zhai S. Guidelines for therapeutic drug monitoring of vancomycin: A systemic review. Plos ONE. 2014 Jun 16; 9(6): e99044. 19. Deck D, Winston L. Basic and Clinical Phamacology. 13th ed. McGraw-Hill: Lange; 2015. 20. Raad I, Darouiche R, Dupuis J, Abi-Said D, Ericsson C, et al. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: A randomized, double-blind trial. Annals of Int. Med. 1997 Aug 15; 127(4): 267-74. 21. Bonne S, Mazuski J, Sona C, Schallom M, Schuerer D, et al. Effectiveness of minocycline and rifampin vs chlorhexidine and silver sulfadiazine-impregnated central venous catheters in preventing central line-associated bloodstream infection in a high-volume

STEM & TECHNOLOGY academic intensive care unit: A before and after trial. J Am Coll Surg. 2015 Sep; 221(3): 739-47. 22. Gallagher J, Branski L, Williams-Bouyer N, Villarreal C, Herndon D. Total Burn Care. 4th ed. Saunders Elsevier; 2012. 23. Mangram A, Horan T, Pearson M, Silver L, and Jarvis W. United States. CDC. Guideline for prevention of surgical site infection. 1999 Aug 13. 24. Monzillo V, Corona S, Lanzarini P, Dalla Valle C, Marone P. Chlorhexidine-silver sulfadiazineimpregnated central venous catheters: in vitro antibacterial activity and impact on bacterial adhesion. New Microbiol. 2012 Apr; 35(2): 175-82. 25. Wassil S, Crill C, Phelps S. Antimicrobial impregnated catheters in the prevention of catheter-related bloodstream infection in hospitalized patients. J Pediatr Pharmacol Ther. 2007 Apr-Jun; 12(2): 77-90. 26. Ruwe, S. (2019, March 13). Personal interview 27. Rhodes N, Bracken A, Presa M, Poursaid A, Coil R, Barneck M, Allen J. U.S. Patent No. 20130267888 A1. Washington, DC: U.S. Patent and Trademark. 2013. 28. Hub staff report. (2019, Apr 12). Team develops device that reduces infection risk during at-home dialysis. JHU Hub. 29. Tantibanchachai. (2019, Oct 29). Student engineers design a solution to address common dialysis complication. JHU Hub. Retrieved from https://hub.jhu.edu/2019/10/29/ relavo-collegiate-inventors-competition/. 30. Salgado C, Sepkowitz K, John J, Cantey J, Schmidt M, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013 May; 34(5): 479-86.

ANA ROSU Class of 2023. Ana is a freshman from Champaign, Illinois majoring in Biomedical Engineering. Her research interests include translational sciences as well as tissue and immunoengineering. She hopes to pursue a career in clinical research.

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Ta u p r o t e i n a n d Cognitive Aging in Alzheimer’s Disease Junyao Li INTRODUCTION

Alzheimer’s Disease (AD) is an age-associated neurodegenerative disease. The prominent symptoms include loss of memory and the ability to acquire new knowledge and skills, as well as decreased executive function (National Institute on Aging). Research on AD has traced the genetic and biochemical basis of familial AD. In particular, genetic mutations associated with processing of APP (amyloid precursor protein) drive elevated production of amyloidß(Aß) peptide. Amyloid-ß(Aß) peptide aggregation into plaques is one of the hallmarks of AD with the other being neurofibrillary tangles (NFTs) (Herrup, 2015). Many drugs were developed targeting the synthesis and aggregation of Aß. However, none of the completed human clinical trials on Aß directed treatment have been successful in improving cognition. Furthermore, research has found that the correlation between density of Aß plaques and severity of AD is weak (Herrup, 2015). Given the indefinite relationship between Aß and AD, researchers have shifted their attentions to investigation of NFT, the other hallmark of AD. NFT is a pathological manifestation of aggregated protein, tau. Tau is a microtubule-assembly-activator protein that promotes the assembly of tubulin into microtubules and stabilizes their structures. In the AD brain, tau protein is hyperphosphorylated and it prevents, rather than facilitates, the formation of microtubules. Hyperphosphorylated tau protein 12

(p-tau) monomers tend to aggregate into NFT in neuronal soma or manifest as neuropil threads in neurites and as dystrophic neurites surrounding an amyloid-beta (AB) core in neuritic plaques (Khatoon et. al. 1992). However, how tau affects cognitive changes is not clear. Although familial AD caused by gene mutations has driven research priorities, most cases of AD are late onse and sporadic cases with no known genetic determinant. For these cases, aging is the greatest risk factor. Data has shown loss of synapses between the entorhinal cortex (EC) and hippocampus in aged brains. Further, p-tau, which contributes to the loss of neurites, is shown to accumulate before formation of NFT and onset of AD (Bancher et. al. 1989). The goal of our lab, then, is to investigate whether changes in tau levels or phosphorylation are an agedependent component of this disease.

are also observed in an aged population of Long Evans Rats (Haberman, 2017), which was selected as the model organism for our investigation of the aged-dependent differential cognitive impairment and its relationship with tau protein expression. Research has shown that NFTs are first seen in the lateral entorhinal cortex (LEC) (Braak & Braak, 1995). However, the reasons for this regional specificity in the onset of tau accumulation are unclear. Thus, we decided to begin our investigation in the LEC in an aged rat model in which individual differences in memory performance at old age include both impaired and unimpaired performance. We were able to quantify the tau mRNA expression levels of aged rats with intact memory (AU) and aged rats with memory impairment (AI). The results found an upregulation of mRNA in the AU compared to the AI. A correlational analysis between mRNA expression and a learning index (LI)

“When normal tau protein is hyperphosphorylated and aggregates into NFTs, there is a net decrease in functional tau protein and results in a deficit in memory...” Human have heterogeneity in memory and cognitive function performance as they age. In particular, aging human populations can have either declined cognitive function or preserved cognitive function (performance within the range of young rats) (Haberman, 2017). Such variations

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that measures memory function shows that lower tau mRNA level occurs with a worse learning index, i.e. a higher cognitive deficit. With that, we decided to quantify the tau protein expression level in LEC to see if a similar correlation can be found between tau protein and memory function.

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METHODS

Aged (24 months) and young (6 months) male Long Evans rats were used for this experiment. All rats were characterized on a standardized water maze task (Gallagher et. al. 1993). A learning index was used to measure the memory function and cognitive ability of rats, with a higher scoring learning index indicative of greater cognitive impairment (Haberman, 2017). The learning index was then used to categorize rats into Young, AU, and AI, with the AU rats performing within the range of Young rats and the AI rats performing outside the range of Young rats (Haberman, 2017). Protein was first extracted from dissected rat LEC tissue of young, AU and AI populations. Tissue was homogenized by a pestle followed with sonication in RIPA buffer with protease inhibitors. Protein concentration was determined using BCA protein assay. Then, tau protein expression level in LEC of AU and AI rats was quantified using Western Blot. Specifically, samples were prepared using proteins extract from LEC of AU and AI rats, mixed with 2X sample buffer and TBS. 10 micrograms of protein extracts were run in a 4-12% Bis-Tris Gel using MOPS buffer at 200V for 50 mins. Then, the proteins were transferred from the gel to a nitrocellulose membrane at 30V for 1 hour. Mouse IgG1 anti-tau 189-195; Biolegend Cat# 814302 was our primary antibody, and Goat antimouse IgG1 488 was our secondary antibody. Primary antibody and secondary antibody were incubated in 5% non-fat dry milk in TBS-T at 1:3000 ratio and 1:1000 ratio, respectively. Primary antibody was incubated at 4Â°C overnight and the fluorescently tagged secondary antibody was incubated at room temperature for one hour. After incubation, proteins were visualized with a Typhoon laser scanner to detect the fluorescent signal. Tubulin protein was a building block for the ubiquitous microtubule structure and was used as the control for our experiment. Expression of tubulin protein was detected and imaged using tubulin-specific antibodies. Bands for tau and tubulin were quantified with ImageQuant and Students T-test was used to test for significant differences.

RESULTS

A total of 27 protein samples from Young, AU and AI rats were loaded and the results of the Western Blot with tau-specific antibody are shown (Figure 1). To focus on cognitiondependent differences, the data analysis included only on AU and AI rats Analysis of total tau protein expression normalized to tubulin control as well as middle band tau isoform protein expression normalized to tubulin control are presented respectively (Figure 2; Figure 3). Note that there is no significant difference in total protein expression between AU and AI rats. However, statistical differences are observed between AU and AI rats when isolating the middle band tau isoform protein or the two of the tau protein isoforms with intermediate molecular weights.

DISCUSSION

Our investigation used a rat model to study aging. It is an ideal model organism because there are individual cognitive ability differences among healthy young and aged rats. Learning index scores, a reliable measure of spatial memory, between young and aged rats show not only inter-group differences but also intragroup differences within the aged rats. Some aged rats have retained cognitive capability while others have undergone memory loss. (Gallagher et. al. 2006) Since loss of memory is an early symptom of AD and aging, this rat model is chosen for our investigation. Results of our Western Blot are not ideal. As seen in (Figure 1A), there is a smearing of the signal in lane 4 and 5, which may due to a failure of proper protein transfer from the gel to the membrane. Similar mishaps can be observed in lane 9 (Figure 1B) and lanes 8 and 10 of Figure 1C. We suspect the problematic image is a result of improper transfer. Nonetheless, we were able to quantify the tau protein expression levels in AU and AI rats. Total tau analysis shows no significant difference between AU and AI rats (Figure 2). However, tau isoform expression levels seem to vary between AU and AI, though the results are only statistically

significant when the two outlier samples are excluded (Figure 3). The adjusted protein expression level trend seems to indicate similar results as the mRNA expression. A previous study has demonstrated that higher tau mRNA levels correlate with a better score in learning index, and worse performance on the memory task is associated with lower tau. Thus, it is plausible that increased tau protein expression may be related to the minimal cognitive deficit in AU rats, and we hope that a modified protocol will address issues noted above and improve results. An acute tau knockout experiment has shown that tau protein plays an important and necessary role in hippocampal-dependent memory function (Velazquez, 2018). In particular, tau plays an essential role in the long-term depression (LTD) of the hippocampus, a key synaptic process involved in motor learning and memory function (Kimura, 2014). Thus, when normal tau protein is hyperphosphorylated and aggregates into NFTs, there is a net decrease in functional tau protein and results in a deficit in memory and cognitive function. The retained cognitive and memory function in AU rats may be supported by the relatively high level of tau protein. As mentioned, problematic transfer during the Western Blot experiment resulted in poor imaging. To obtain better results, we will repeat our experiments on total tau protein concentration in young, AU and AI rats using Polyvinylidene fluoride (PVDF) membrane instead of nitrocellulose mimpfectane. We would also like to further examine the role of phosphorylated tau and cognitive aging. Previous research has demonstrated a difference in tau phosphorylation level between aged rats with unimpaired cognitive function and aged rats with impaired cognitive function (Stranahan et. al. 2010). Examination of phosphorylated tau in LEC would help strengthen our findings about the tau protein expression level and its function in memory and cognitive functiovn in young, AU and AI rat cohorts.

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REFERENCES

1. Anoop, A et al. “CSF Biomarkers for Alzheimer’s Disease Diagnosis.” International journal of Alzheimer’s disease vol. 2010 606802. 23 Jun. 2010, doi:10.4061/2010/606802 2.Bancher, C., et al. “Accumulation of abnormally phosphorylated τ precedes the formation of neurofibrillary tangles in Alzheimer’s disease.” Brain research 477.1-2 (1989): 90-99. 3. Doody, Rachelle S., et al. “Phase 3 trials of solanezumab for mild-to-moderate Alzheimer’s disease.” New England Journal of Medicine 370.4 (2014): 311-321. 4. Ge, Yuan et al. “Hippocampal long-term depression is required for the consolidation of spatial memory.” Proceedings of the National Academy of Sciences of the United States of America vol. 107,38 (2010): 16697-702. 5. Gallagher, Michela, et al. “Individual differences in neurocognitive aging of the medial temporal lobe.” Age 28.3 (2006): 221-233. 6. Haberman, Rebecca P., et al. “Heightened Cortical Excitability in Aged Rodents with Memory Impairment.” Neurobiology of Aging, vol. 54, 2017, pp. 144–151., doi:10.1016/j.neurobiolaging. 2016.12.021. 7. Herrup, Karl. “The case for rejecting the amyloid cascade hypothesis.” Nature neuroscience 18.6 (2015): 794. 8.Iqbal, Khalid, Fei Liu, and Cheng-Xin Gong. “Tau and neurodegenerative disease: the story so far.” Nature Reviews Neurology 12.1 (2016): 15. 9. Khatoon, Sabiha, Inge Grundke‐Iqbal, and Khalid Iqbal. “Brain levels of microtubule‐ associated protein τ are elevated in Alzheimer’s disease: A radioimmuno‐slot‐blot assay for nanograms of the protein.” Journal of neurochemistry 59.2 (1992): 750-753. 10. Kimura T et al. 2014 Microtubuleassociated protein tau is essential for long-term depression in the hippocampus. Phil. Trans. R. Soc. B 369: 20130144. 11. Velazquez, Ramon, et al. “Acute Tau Knockdown in the Hippocampus of Adult Mice Causes Learning and Memory Deficits.” Aging Cell, vol. 17, no. 4, Oct. 2018, doi:10.1111/acel.12775. 12. “What Are the Signs of Alzheimer’s Disease?” National Institute on Aging, U.S. Department of Health and Human Services, www.nia.nih.gov/ health/what-are-signs-alzheimers-disease. 13. Pooler, Amy M., et al. “Propagation of tau pathology in Alzheimer’s disease: identification of novel therapeutic targets.” Alzheimer’s research & therapy 5.5 (2013): 49. 14. Roberson, Erik D., et al. “Reducing endogenous tau ameliorates amyloid ß-induced deficits in an Alzheimer’s disease mouse model.” Science 316.5825 (2007): 750-754. 15.Stranahan, Alexis M., Rebecca P. Haberman, and Michela Gallagher. “Cognitive decline is associated with reduced reelin expression in the entorhinal cortex of aged rats.” Cerebral Cortex 21.2 (2010): 392-400.

FIGURES

Figure 1. Western Blot for Tau in LEC: lan 1 (protein ladder); lanes 2-10 (rats’ protein samples).

Figure 2. Tau protein expression levels in AU and AI rats.

Figure 3. Tau isoform expression levels in AU and AI rats.

JUNYAO LI Class of 2021. Junyao is a junior from Guangzhou, China. He majors in neuroscience and plans to attend medical school. He learned a lot about learning and memory from his previous classes, which piqued his interest in Alzheimer’s Disease research.

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Surprise Enhanced Learning in Infancy Mikayla R. Bisignani INTRODUCTION

The complexity of the human mind and the vast extent of what it can accomplish are products of human’s ability to learn and reason to acquire knowledge. An important aspect of learning involves incorporating new information into one’s pre-existing knowledge of the world. Therefore, it is easy to assume that information learned in such a way cannot be obtained until mature stages of development where this knowledge of the world can be verbally expressed. However, much of this pre-existing knowledge is present innately and is observed even in infancy. Previous research has revealed that young children possess an abundance of knowledge about the physical world around them, have expectations of its natural behavior, and are surprised when these expectations are violated. This surprise is indicated by longer looking time at surprising events or objects. Further research suggests that this aspect of surprise can play an instrumental role in enhancing young children’s learning. Thus, opening the door to characterize and explore what contributes to this phenomenon. What about surprise drives children to participate in learning enhancing behaviors? What are infants looking for during these longer interactions with the surprising object? Many theories had been proposed in the early field of developmental science to explain the learning mechanisms of the human mind and its development. Spelke and Kinzler (2007) ultimately fine-tuned theories originating from Piaget (1954), Locke (1689), Hume (1748), and even Darwin (1871). Spelke and Kinzler suggested

that humans evolutionarily possess four systems of core knowledge, present in infancy and persisting through development into adulthood. These systems include primitive representations of objects, actions, number, and space, that are then built on by all subsequent learning. has been the most extensively studied and is the primary focus of the presented study. Core knowledge of objects is important for humans’ everyday learning of the physical world, but how exactly this process occurs in infancy is still undetermined. Perhaps this core knowledge indicates on which aspects of the world to focus our learning. This idea stems from the observation that infants are surprised by, and hence look longer at, objects that violate these fundamental expectations. By focusing on the visual attention of infants, one can gain insight to the development of physical knowledge. A series of studies concluded that infants tend to look longer at novel rather than familiar stimuli suggesting that infants are able to perceive the event as new or novel compared to the familiar event (Fagan, 1970, 1971; Friedman, 1972; Fantz, 1964, Kellman & Spelke,1983; Kotovsky & Baillargeon, 1994; Leslie & Keeble, 1987). Further experiments presented infants with both a possible and impossible event. The impossible, or surprising event, involved an object violating expectations of support, continuity, or solidity, such as a toy floating or passing through a wall. It was found that infants tended to look longer at the impossible event than the possible event. This preference confirms that infants possess physical knowledge of

the world and are surprised when an impossible event occurs (Baillargeon, 1986; Baillargeon, Spelke, & Wasserman, 1985; Spelke, Breinlinger, Macomber, & Jacobson, 1992). An example of such an experiment by Spelke and colleagues (1992), tested whether or not 2.5-month-old infants can comprehend objects’ solidity and that they exist continuously. This question was tested by showing infants both a possible and impossible event and recording looking times. The possible event consisted of a ball moving from left to right along a platform and disappearing behind an occluding screen. A tall box was visible behind the screen, and when the occluder was removed, the ball had appeared to be stopped by the tall box, as depicted in Figure 1a. In the impossible condition, when the occluder was removed, the ball had seemingly gone through the tall box and rested at the end of the platform, as depicted in Figure 1b. Results from this experiment revealed that infants looked longer at the impossible event compared to the possible event. This suggested that infants were able to follow the intended path of the object, expected it to be stopped by the tall box, and were surprised when the ball violated this expectation. Several researchers have performed similar experiments extending these findings to support infant’s surprise when objects violate basic physical properties (e.g. Stahl & Feigenson, 2015). Furthermore, findings such as these begin to suggest that this surprise could be an integral part in infant’s learning. Stahl and Feigenson (2015) replicated Spelke and colleagues’

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findings and expanded upon them. They reconfirmed infant’s preference to look at objects that performed actions violating their expectations, as opposed to objects that performed as expected. An additional component of this study, however, focused on whether infants engage in explanation seeking behavior and learn better following surprising events. Previous research by Schultz and Bonawitz (2007) and Leagare, Gellman, and Wellman (2010) suggests that following a surprising or inconsistent event, older children are motivated to explore the surprising entity. These exploratory behaviors are presumably performed in an attempt to explain the mechanisms behind the surprising event. These studies suggest that children can generate explanations for these surprising events as a result of this exploratory behavior. However, the children in these studies were much older, three- to five-yearsold, than the infants targeted in this study. Stahl and Feigenson (2015)’s findings were of the first to suggest that even preverbal infants engage in these explanation seeking behavior following surprise. This experiment involved testing ten to twelve-month-old infants in one of two conditions. In both conditions, infants watched a toy ball or truck roll down a ramp and become hidden behind an occluding screen. In one condition, the ball behaved accordingly and was stopped by a visible wall. However, in the other condition, the ball seemingly passed through the solid wall, violating the expectation of solidity. Then infants were provided the opportunity to explore the object that just completed either the expected or surprising event along with a second distractor object, irrelevant to the event previously seen. The results of this part of the experiment revealed that infants in the expected condition preferred to explore the novel distractor object, whereas infants in the surprising condition preferred to explore the object that violated their expectations. Furthermore, Stahl and Feigenson (2015) characterized the actions that the infants performed while exploring the objects and found that infants tended to engage in exploratory behavior consistent with the type of 16

violation observed. This exploratory behavior was classified as hypothesis testing behavior because it seemed as if infants were attempting to figure out a reason or explanation for how the surprising event they witnessed had occurred (i.e. banging the object as if to test whether it was solid). Furthermore, this study proposed one of the first suggestions that surprise can enhance learning in infants. During one of the experiments in this study,

highly suggested by previous research, is to further confirm the notion that surprise enhances learning. The second question is when young infants are surprised, do they seek resolution? This is suggested through the hypothesis testing behaviors observed by Stahl and Feigenson (2015), but whether infants engage in hypothesis testing behavior because they seek explanatory information is unknown. The third main question is if children

“...enhanced learning [is] in service of explanation-seeking, and when an explanation is provided, ... learning [is] diminished.” an infant was again shown either an expected or unexpected event, and then taught to associate a particular novel sound with the observed object. Then the sound would be played in the presence of the observed object as well as a novel distractor object. If infants had witnessed the object behave surprisingly, they looked at that familiar object more than the novel object, and more than their peers in the expected condition when the target sound was played. In summary, they learned better. This was further validated by trying to teach infants to associate a novel sound with an object that did not undergo a surprising event in which this enhanced learning was not observed (Stahl & Feigenson, 2015). Similar surprise enhanced learning has also been demonstrated in older children (Stahl & Feigenson 2017). Older children display the tendency to learn nouns and verbs associated with surprising outcomes more effectively than non-surprising or expected outcomes (Stahl and Feigensen, 2017). Convergence between these results and previous research show that surprise enhanced learning can occur across several core knowledge domains and in various environments. The current study seeks to enhance existing research by further exploring the motivation for infants’ explanation seeking behavior following surprise. There are three main research questions examined throughout this project. The first, although already

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are looking for a resolution, then do the hypothesis testing behaviors and enhanced learning diminish when one is provided? We predict that infants do seek a resolution following surprise; therefore, if provided with one, infants will not engage in explanation seeking behaviors and will not demonstrate enhanced learning. Answers to these questions have valuable applications in the education field and may contribute to clinical approaches to assessing development.

METHOD Participants

This study is currently in progress, so the following numbers represent the participants run to date. The current sample consists of 23 infants between 16 and 19-months of age (Mage= 17.91 months, SEM= .24) from the Greater Baltimore Area. Participants were recruited by phone, email, brochures, and local in-person tabling events. The No Explanation condition consists of four females and six males. The Explanation condition consists of five females and eight males.

Design This study used a between subjects design, randomly assigning participants to either the No Explanation, or Explanation condition at the first part of the longitudinal design (when participants are 10- to 13-monthsold). The testing room consists of a puppet show stage with wall to wall

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curtain, behind which the experimenter stood. The participant sat in either a high chair or on a parent/guardian’s lap three feet away from the stage. There were two cameras set up in the room to record participants during the study. One camera provided an aerial view while the other was discreetly hidden in the stage at approximately eye level of the participants.

Procedure Upon arrival to a scheduled appointment, participants underwent the consent process- parents or guardians were instructed to remain as noninfluential to the child’s actions as possible. Participants and his or her parent/guardian were then taken into the previously set up room and placed into the high chair. The parent/ guardian sat in a chair approximately five feet behind the high chair and to the left. If the participant was not comfortable in the high chair, it was replaced the parent or guardian’s chair, and the participant sat on his or her lap. The researcher then went behind the puppet stage where she could not be seen by the participant. (A) Surprise phase The curtain lifted on the stage to reveal an object present in center front on top of a block in front of an occluder screen. The object was either a cylindrical orange toy or a spherical green toy. The toy used as the familiar object was counterbalanced among participants. The researcher then said “(Participant’s name) look at this, look at this,” and pointed to the object, and further encouraged the participant to look at the object. The researcher then let the curtain down and set up for the next scene. When the curtain was raised again, participants saw an identical object now on the right side of the stage. Unbeknownst to the infant, the object was slightly altered to be attached to the back wall of the stage (Figure 2.A1; 2.B1). In both conditions, the researcher pointed to the object again, stating for the participant to look at the object then moved it into the center of the of the stage over the occluder (Figure 2.A2; 2.B2) and waited for ten seconds. The experimenter moved the object so that it appeared to be lifted and repositioned but was actually sliding

along the back wall to which it was affixed. Next, the experimenter moved the second block out from behind the occluder to the left side of the stage (Figure 2.A3; 2.B3) and waited for ten seconds. Then the researcher removed the occluder (Figure 2.A4; 2.B4) and waited 20 seconds. (i) No Explanation Condition This condition revealed to show that the sliver of block that could be seen from behind the occluder was not supporting the object, but rather the object was floating. (ii) Explanation Condition This condition revealed to show the block that had appeared to be floating was actually resting on the top of a third block that was hidden behind the occluder. (B) Teaching phase 20 seconds after the occluder was removed, the researcher pointed to the object and said, “this is a toma, yeah a toma, that’s a toma,” and waited fifteen seconds. Then the curtain was lowered, and all blocks were removed from the stage. (i) Novel Label Test 1 The original object and a new novel object (e.g. the orange or green toy that was not used during the puppet show) were placed on opposite sides of the stage in designated spots. Which side the objects were placed, was counterbalanced among participants. The curtain was then lifted up and the experimenter stated for the participant to look and then waited five seconds before she said, “(Participant’s name) where’s the toma? Look at the toma, where’s the toma?” Then after 20 seconds, the researcher lowered the curtain. (C) Exploration phase Then the researcher brought the familiar and novel object to the child and placed them on the high chair tray table in front of the child. Again, counterbalancing was used to determine which side each object was placed. The experimenter stepped out of view and waited thirty seconds before taking back the toys. (i) Novel Label Test 2. The experimenter placed the familiar and novel objects back on the stage on opposite sides of each other and opposite from novel label

test 1. The researcher then raised the curtain and after five seconds said, “(Participant’s name), where’s the toma? Look at the toma, where’s the toma?” The researcher waited 20 seconds before bringing the curtain down and instructing the parent and child that the experiment was finished. Participants and their guardian were then debriefed, and the child was provided with a certificate of achievement for completing the study. The child was also permitted to pick out a prize amongst a laboratory t-shirt, book, or stuffed animal.

RESULTS

The video recordings of each participant were stored in a collective database so that they could be later examined and coded by multiple researchers. The videos were analyzed using the program DataVyu. The sections of video in which measurements were made included the initial surprise phase, the no explanation and/or explanation phase, the exploration phase, and both novel label test phases. In the no explanation and/or explanation phase, several looking times were recorded. Coders recorded when the participant was looking at the stage during the first ten seconds after the object was moved into the center of the stage (Figure 2.A2; 2.B2), the first ten seconds after the block was moved (Figure 2.A3; 2.B3), and the first 20 seconds after the occluder was removed (Figure 2.A4; 2.B4). The exploration phase coding consisted of the thirty seconds after the objects were placed in front of the participant and the researcher was out of the video frame. In this segment, coders reported the times when the participant was looking at and when the participant was touching the novel object, the familiar object, or both objects. Most of these results have yet to be looked into further as they are intended to make comparisons within a longitudinal study not discussed in this paper. The most important measure from these segments was the looking time after the explanation was provided. The novel label test results revealed important information supporting

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the hypothesis. In this segment, first coders recorded the baseline looking tendencies of each participant. This was done by reporting the times when participants looked at either the novel object or the familiar object for the first five seconds after the curtain was lifted in the novel label test 1. This baseline measurement served as an indicator of whether infants had a preference to look at one object or the other before learning was assessed. Coders then recorded the looking tendencies for the participant for the ten seconds immediately after the “t” was aspirated in the word “toma,” when the researcher first said, “(Participant’s name), where’s the toma?” This was repeated for the novel label test 2. The results suggest that the longer participants detected the violation, with no subsequent explanation, the more they learned the correct object labels and the better they performed at the label test (n = 10; r = .32; Figure 3a). However, when the infants were provided an explanation, this correlation between looking time and learning score disappeared (n = 13; r = .06; Figure 3b). These results extend previous findings that witnessing unexpected events enhances early learning, further demonstrating that the presence or absence of an explanation for such events modulates infants’ behavior. Similar to the continuum observed in violation detection time, infants varied in time spent looking at the explanation. Importantly, the longer the participant looked at the explanation, the less they looked to the correct object at test (n = 13, r = .21; Figure 4). These findings show that explanations diminish surprise-induced learning.

DISCUSSION

This study replicates previous research demonstrating that surprise enhances learning. However, critically, this study demonstrates that infants look longer and learn better because they are seeking explanations; when one is provided, learning is hindered. Because children learned less efficiently when an explanation was provided, these findings are in agreement with results from part one of this longitudinal 18

design, suggesting the consequences of surprise: exploration and enhanced learning are in service of explanationseeking, and when an explanation is provided, exploration and learning are diminished.

FUTURE DIRECTIONS

This study is one part of a threepart longitudinal study evaluating the dissociability and consistency of the cognitive components that are engaged in surprised-induced learning. The first part looks at children when they are 11-months-old, then they are asked to return for this study a few months later. Participants of this study are placed into the same condition to which they were randomly assigned in the first experiment. The last part of this longitudinal study will take place when children who participated in part one and in this currently discussed part two of the longitudinal studies are 31to 33-months-old. This final study seeks to address whether surprise and/or explanation recognition are stable, independent cognitive processes and whether they predict performance on problem solving, curiosity, working memory, and inhibition control measures in toddlerhood. The current findings leave open the possibility that individual differences are stable throughout early childhood and also whether these differences are predictive of other cognitive outcomes. For example, perhaps infants who look long at violations are also very curious or persistent when problem solving or perhaps instead infants who look long at explanatory information are more curious and better problem solvers. None of the remarkable achievements that humans are able to attain would be possible without the ability to learn. Insights into this process, how it works as well as the origins of its development, can serve to enhance learning across several disciplines. This study provides a further understanding into why surprise enhances learning and exploration, demonstrating that the consequences following surprise may represent infants’ search for explanations early in life.

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REFERENCES

1. Baillargeon, R. (1998). Infants’ understanding of the physical world. Journal of the Neurological Sciences, 143, 199. 2. Baillargeon, R. (1986). Representing the existence and the location of hidden objects: Object permanence in 6-and 8-month-old infants. Cognition, 23, 21-41. 3. Baillargeon, R., Spelke, E. S., & Wasserman, S. (1985). Object permanence in five-monthold infants. Cognition, 20, 191-208. 4. Darwin, C. (1871). The descent of man, and selection in relation to sex. London, UK: J. Murray. 5. Fagan, J. F. (1970). Memory in the infant. Journal of Experimental Child Psychology, 9, 217-226. 6. Fagan, J. F. (1971). Infants’ recognition memory for a series of visual stimuli. Journal of Experimental Child Psychology, 11, 244-250. 7. Fantz, R. L. (1964). Visual experience in infants: Decreased attention to familiar patterns relative to novel ones. Science, 146, 668-670. 8. Friedman, S. (1972). Newborn visual attention to repeated exposure of redundant vs “novel” targets. Perception & Psychophysics, 12, 291-294. 9. Hume, D. (1748). An enquiry concerning human understanding. L.A. Selby-Bigge & P.H. Nidditch (Eds.), (1975 edn.). Oxford, UK: Clarendon Press. 10. Kellman, P. J., & Spelke, E. S. (1983). Perception of partly occluded objects in infancy. Cognitive psychology, 15, 483-524. 11. Kotovsky, L., & Baillargeon, R. (1994). Calibrationbased reasoning about collision events in 11-month-old infants. Cognition, 51, 107-129. 12. Leslie, A. M., & Keeble, S. (1987). Do six-month-old infants perceive causality? Cognition, 25, 265-288. 13. Locke, J. (1689). An essay concerning human understanding. Available through L.A. SelbyBigge (Ed.), Project Gutenberg, LA, 2006. 14. Piaget, J. (1954). The construction of reality in the child. New York, NY: Routlege. 15. Spelke, E. S., Breinlinger, K., Macomber, J., & Jacobson, K. (1992). Origins of knowledge. Psychological review, 99, 605. 16. Spelke, E. S., & Kinzler, K. D. (2007). Core knowledge. Developmental science, 10(1), 89-96. 17. Stahl, A. E., & Feigenson, L. (2015). Observing the unexpected enhances infants’ learning and exploration. Science, 348, 91-94. 18. Stahl, A. E., & Feigenson, L. (2017). Expectancy violations promote learning in young children. Cognition, 163, 1-14.

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FIGURES

Figure 1A. Possible event presented to infants.

Figure 2A.

Figure 3A. Infants’ viewing times with explanation.

Figure 1B. Impossible event presented to infants.

Figure 2B.

Figure 3B. Infants’ viewing times without explanation.

Figure 4. Infants’ viewing times with explanation recognition.

MIKAYLA R. BISIGNANI Class of 2021. Mikayla is a junior majoring in Molecular and Cellular Biology. She is from Latrobe, PA. On campus, Mikayla is a member of the Varsity Swimming and Track and Field teams. In addition, she works as a research assistant in the Lab for Child Development. She hopes to pursue a career in pediatric medicine! Hopkins Undergraduate Research Journal

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Synthesis and Characterization of Novel Poly(pro-Curcumin) Materials as Spinal Cord Injury Therapeutics

Sneha Kamada

A B S T R A C T Curcumin has been used as an anti-inflammatory and antioxidant compound in Ayurvedic medicine for centuries in India. Recently curcumin has been investigated for its potential use in biomedical applications1, although it is limited by poor solubility and instability, as well as unfavorable biodistribution in vivo1. For this reason, chemically modified curcumin analogs known as â&#x20AC;&#x153;pro-drugâ&#x20AC;? materials are currently of interest. In particular, controlled release of drugs from biopolymer scaffolds is a promising route in spinal cord injury (SCI) where highly oriented polymer fibers guide neurite outgrowth and assist in repair of scar tissue at the lesion site2. Since curcumin is an excellent anti-inflammatory compound, the goal was to develop biomaterial scaffolds that would release this molecule slowly over time. To that end, a polymeric pro-drug strategy was developed. In this work, a novel polyester was synthesized out of curcumin, pentenoic acid, and triethylene glycol dithiol. Following the creation of the curcumin polymer, an antioxidant activity test confirmed that the curcumin polymer was a potent antioxidant platform. The first extension of this project will be to synthesize a longer polymeric chain to maximize molecular weight. Furthermore, once the polymer is extended, its anti-inflammatory properties will be tested through cell trials as well as investigating the mechanical properties. For future applications, this polymer can be electrospun into fibers, crosslinked into injectable hydrogels, or painted as a coating on medical implants to aid in the recovery and discomfort of surgery.

INTRODUCTION

Spinal cord injury (SCI) is any trauma to the spinal cord that results in a loss of communication between the damaged portion and the rest of the body (3). According to the World Health Organization (WHO), between 250,000-500,000 people suffer an SCI annually (4). Overall, only about 0.8% of patients make a full functional recovery following SCI (5). Unlike many injuries, SCIs have a much slower rate of healing and drastically alter the quality of life for a patient (3). SCIs differ from other types of injuries in that nerve cells are unable to regenerate quickly like other cells in the body (3). Once scar tissues form, the nerve cells cannot grow over the lesion site and the spinal cord is irreversibly damaged. Therefore, most of the treatment administered following the injury is to either prevent 20

further damage or alleviate secondary symptoms (6). However, studies have shown that nerve cells can potentially grow into the lesion site if they are given mechanical guidance cues by oriented fibers in a biomaterial scaffold, thereby potentially reducing paralysis (7). Biopolymer scaffolds provide a highly promising strategy for guiding nerve cell regrowth (7). They provide the same structural benefits of other scaffold materials but are also biodegradable which can prevent extraction surgeries and control the rate of regeneration. With nerve cell regeneration, the problem arises with scar tissue, which often develops before the nerves can finish healing and once scar tissue forms, growth will be stalled. A biopolymer scaffold made of a molecule that would improve nerve

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growth at the lesion site. Turmeric, an Indian spice, has been used for anti-inflammatory applications in Ayurvedic medicine for centuries (1). Curcumin is an active component of turmeric with both anti-inflammatory and antioxidant properties (1). When synthesized into a polymer and spun into fibers, it can be used as a support system in SCI repair. The antioxidant properties would benefit the newly healed tissues while the anti-inflammatory properties would decrease swelling and pain in the incision site and the overall injury. Alternatively, it could be used as a hydrogel or surface coating for any type of internal implant to provide the same benefits. In this study, a novel monomer and polymer were synthesized out of pure curcumin and then characterized

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to show the presence of antioxidant activity. A Steglich Esterification synthesis was conducted to synthesize the curcumin diester monomer. After running a series of washes to obtain the utmost purity, a polymerization procedure was performed. To characterize the curcumin polymer, hydrogen-nuclear magnetic resonance (1H-NMR) spectra, gel permeation chromatography (GPC), and antioxidant tests were run.

Curcumin diester Activation A three neck flask in a N2 atmosphere with a stir bar was placed on a stir plate. Pure curcumin powder (4.0 g.) was combined with DMAP (1.08 g.) in the flask and immediately sealed to contain the N2. Tetrahydrofuran (THF) as the solvent was added to the flask on the stir plate in order to prepare a homogenous solution. A needle was purged with the N2 atmosphere and used to

“Since curcumin is an excellent anti-inflammatory compound, the goal was to develop biomaterial scaffolds that would release this molecule slowly over time.” PURPOSE

The purpose of this study is to synthesize a novel curcumin polymer for use in reducing inflammation in spinal cord injury.

EXPERIMENTAL PROCEDURES Materials Pure curcumin purchased from Sigma Aldrich was used to synthesize the monomer. Pentenoic acid purchased from Sigma Aldrich was used to prepare the pure curcumin for linking during the polymerization. 4-Dimethylaminopyridine (DMAP) purchased from Sigma Aldrich was used as a catalyst in the curcumin diester activation. N,N’Diisopropylcarbodiimide (DIC) purchased from Sigma Aldrich was used as an activator in the curcumin diester activation. Tetrahydrofuran (THF) purchased from Sigma Aldrich was used to dissolve all the components of the monomer synthesis. Triethylene glycol dithiol purchased from Sigma Aldrich was used as a linker between curcumin monomers. 2,2-Dimethoxy2-phenylacetophenone purchased from Sigma Aldrich was used as a photoinitiator in the polymerization procedure. 2,2-diphenyl-1picrylhydrazyl (DPPH) purchased from Sigma Aldrich was used as a photoindicator in the antioxidant activity test.

inject pentenoic acid (6.8 g.) into the mixture. A secondary needle was also purged with the N2 atmosphere and used to slowly insert DIC (5.2 mL.) at a rate of approximately 0.2 ml. every 20 minutes. The flask was placed in an ice bath in order to ensure the mixture did not overheat while the DIC was added into the flask. After the DIC was completely added, the flask was left to stir overnight outside of the ice bath. Purification of Curcumin Monomer (A) Filtration of Precipitate A filtration was set up by placing a funnel with fluted filter paper into a beaker. The filter paper was then wet with ethyl acetate and the crude curcumin diester was poured into the center. The filter paper was rinsed with ethyl acetate three separate times to separate the impurities from the pure curcumin monomer. The crystalline byproduct of the reaction (diisopropyl urea), was removed and disposed of along with the filter paper and the liquid crude product solution was reserved. (B) Aqueous Workup The crude curcumin diester was placed in a separatory funnel to remove any impurities. Sodium hydroxide (0.1 M) was poured into a separatory funnel and shaken to combine both liquids. The phases were allowed to separate and then the aqueous phase was removed into a waste beaker. The same process was repeated with pure water, 0.1 M hydrochloric acid and brine.

(C) Recrystallization of Product The crude curcumin monomer was dissolved in acetone within a beaker. Hexanes were then poured on top of the acetone solution to form two distinct layers and the beaker was refrigerated overnight. A filtration procedure was set up the next day with fluted filter paper inside a funnel on top of a beaker. The filter paper was wet with cold hexanes and then the monomer solution was poured into the funnel. The paper was rinsed three times with cold hexanes and then stored as pure monomer in a vial. Curcumin diester Polymerization THF solvent was used to dissolve triethylene glycol dithiol (0.1466 g.) and DMPA (0.0021 g.) in a vial. The solution was then added to the pure curcumin monomer (0.4282 g.) and shaken to combine. The vial containing the solution was placed on the rotovap to remove the maximum amount of THF possible while still maintaining a liquid within the vial. A stir bar was placed into the vial and the cap was replaced with a cap that could be punctured with a needle. The vial was filled with a N2 atmosphere and placed on a stir plate. A UV lamp was set up on the stir plate to be able to shine through the entire vial overnight. The stir plate was turned on and the UV lamp was turned on to long-wave UV light and left overnight. Curcumin Polymer Characterization To confirm that the polymerization was successful, 1H-NMR was run on a sample of the polymer and pure chloroform combined. Following confirmation, GPC was run on the sample to determine molecular weight. Finally, an antioxidant activity test was run to determine retention of the antioxidant properties of pure curcumin. To run the test, a sample of the polymer was combined with methanol and placed in cuvettes along with DPPH. The cuvettes were inserted into a photospectrometer to measure the number of photons in the sample. The values received from the experimental and control cuvettes were placed into the antioxidant activity equation to calculate percentages of antioxidant activity.

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RESULTS AND DISCUSSION Monomer Synthesis

Successful monomer synthesis was confirmed by 1H-NMR. To ensure the reaction was fully complete in an inert atmosphere, the synthesis was run overnight. Following the synthesis, the waste product, urea, was removed through a simple filtration procedure that can be applied to any amount of sample. Prior to analysis by 1H-NMR, the expected product structure was drawn using ChemDraw software (Figure 1). The 1H-NMR spectra of the obtained product (Figure 2) is in perfect agreement with the proposed chemical structure of the product molecule Figure 1). Each peak in the spectra represents the magnetic chemical environment of the protons in the molecule. The chemical shift, multiplicity, and integrated areas of each peak are correlated to the number of magnetically indistinguishable protons in the predicted structure (Figure 1) to confirm successful monomer synthesis. Polymer Synthesis The curcumin monomer was purified by recrystallization from acetone/hexanes to obtain the highest possible purity, and the polymerization procedure was performed on these purified crystals of pro-curcumin monomer. After the polymerization was completed, ChemDraw was used to create a predicted chemical formula Figure 3) for the targeted curcumin polymer. The resulting products were then analyzed by 1H-NMR (Figure 4) in deuterated chloroform. The 1H-NMR indicated that approximately 50% conversion from monomer to polymer. The crude reaction product from the attempted polymerization was also analyzed by GPC to determine the molecular weight (Figure 5). The GPC method separates components of the polydisperse mixture based on a size-exclusion effect, in which smaller molecules will elute more slowly from the column whereas larger molecules permeate faster. By GPC, a peak ~2000 g/mol at approximately 25 minutes suggests some polymer was formed in agreement with the 1H-NMR. Antioxidant Activity 22

The values from the photospectrometer were placed into the antioxidant activity equation to determine percentage of antioxidant activity. It was seen that the initial antioxidant activity value was approximately 18% but over the course of 30 minutes the antioxidant activity increased to over 90% (Figure 6). Along with the quantitative analysis of the antioxidant activity of the oligomer, a qualitative analysis was done based on the color of the DPPH indicator as time passed. The dark purple of the indicator (Figure 7a) fading into the yellow of the polymer (Figure 7b) indicated qualitatively that there was antioxidant activity.

CONCLUSION

A curcumin monomer was successfully synthesized through an activation procedure. The monomer was fully reacted to form a curcumin diester molecule where each pure curcumin molecule was bonded to a triethylene glycol molecule on either end. The creation of the molecule was confirmed through 1H-NMR and then purified through recrystallization. The polymerization was successful as well, resulting in a polymer with a molecular weight of ~2000 g/mol, and was confirmed through 1H-NMR and GPC. Following the polymerization procedure, it was seen through an antioxidant activity test that the polymer retained over 90% of the antioxidant activity present in the pure curcumin molecules over the course of 30 minutes. In the future, the first objective will be to increase the length of the polymer. The next objective would be to further characterize the polymer by testing its mechanical and antiinflammatory properties. The final objective would be to spin the polymer into fibers and construct a biopolymer scaffold. An alternative final objective would be to create a polymer coating to be used on general medical implants. The curcumin polymer can easily be produced using a larger mass of curcumin, resulting in more polymer to build a longer or bigger biopolymer scaffold. Its ability to degrade in the body makes it suitable for implantation because there would be no need to

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reopen the surgical incision to remove the scaffold later. However, because it is a biopolymer, the degradation would not harm the body because it is made of biological components. A curcumin biopolymer scaffold could prevent permanent spinal cord injury as it can help guide nerve cell regeneration as well as reduce inflammation in the wounded area during the recovery period. A curcumin polymer coating could serve as an anti-inflammatory mechanism as well but can be more generally applied to any surgical area.

LITERATURE CITED

1. Jurenka, J.S. Anti-inflammatory Properties of Curcumin, a Major Constituent of Curcuma longa: A Review of Preclinical and Clinical Research. Alternative Medicine Review Volume 14, Number 2 2009. 2. Velema J., Kaplan D. (2006) BiopolymerBased Biomaterials as Scaffolds for Tissue Engineering. In: Lee K., Kaplan D. (eds) Tissue Engineering I. Advances in Biochemical Engineering/Biotechnology, vol 102. Springer, Berlin, Heidelberg. 3. Brodwin, M. G.; Siu, F. W.; Howard, J.; Brodwin, E. R. Medical, Psychosocial, and Vocational Aspects of Disability Third Edition 2009. Elliot and Fitzpatrick, Inc., p 299. 4. “Spinal Cord Injury.” World Health Organization, World Health Organization, 19 Nov. 2013, www.who.int/news-room/ fact-sheets/detail/spinal-cord-injury. 5. National Spinal Cord Injury Statistical Center, Facts and Figures at a Glance. Birmingham, AL: University of Alabama at Birmingham, 2018. 6. “Spinal Cord Injury.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 19 Dec. 2017, www.mayoclinic. org/diseases-conditions/spinal-cordinjury/diagnosis-treatment/drc-20377895. 7. Tang, Huadong, et al. “Curcumin Polymers as Anticancer Conjugates.” Biomaterials, Elsevier, 29 June 2010, www.sciencedirect. com/science/article/pii/S0142961210007398.

STEM & TECHNOLOGY

FIGURES

Figure 1. Predicted chemical structure of pure curcumin monomer Figure 6. Equation for antioxidant activity

Figure 2. 1H-NMR of pure curcumin monomer

Figure 7. Qualitative analysis of antioxidant activity using DPPH indicator: (a) initial appearance of indicator at t = 0, (b) final appearance of indicator at t = 30.

Figure 3. Predicted chemical structure of pure curcumin polymer

Figure 4. 1H-NMR of pure curcumin polymer

SNEHA KAMADA

Figure 5. GPC of curcumin polymer

Class of 2023. Sneha is an aspiring doctor from Poughkeepsie, New York, majoring in Biomedical Engineering. She is interested in biomaterials and tissue regeneration research. She is a dedicated member of her design team on campus and competes as a Bollywood dancer. Hopkins Undergraduate Research Journal

STEM & TECHNOLOGY

The Dynamic Nucleosome Ejlal Elalaoui

KEY ACRONYMS

NFR: Nucleosome-free region ATP: Adenosine triphosphate AA nucleosome: Nucleosome with two H2A-H2B dimers AZ nucleosome: Nucleosome w/ one H2A-H2B and one H2AZ-H2B dimer ZZ nucleosome: : Nucleosome with two H2AZ-H2B dimers PIC: Pre-initiation complex TBP: TATA-binding protein TFIID: Transcription factor IID RNA pol II: RNA polymerase II GTF: General transcription factor TSS: Transcription start site HP: Heterochromatin-binding protein

INTRODUCTION

The eukaryotic nucleus contains DNA condensed by histone proteins to form chromatin. Until 1974, the exact mode of association of histones and DNA in chromatin remained a controversial point. The field was transformed in 1974 when Roger Kornberg made the insightful proposal that eight histones form a kernel around which 200 base-pairs of DNA wrap.1 This unit of assembly was later named the nucleosome.2 The stoichiometry of the protein kernel was proposed to comprise two copies of the four core histone types H2A, H2B, H3, and H4.1 However, the overall organization of the histones in the kernel remained elusive.3 The precise mode of assembly of the octamer was reported in 1978 based on the results of several biochemical and biophysical techniques. These established that the histone octamer is a tripartite, reversibly associating equilibrium system.4 In 1991, 24

the atomic organization of the octamer was crystallographically resolved; it documented that a central H3-H4 tetramer is flanked by two H2A-H2B dimers, one on each side.5 These crystallographic studies also identified a common structural motif, the histone fold, among the four histones. However, there exist local primary-sequence variations of each core histone, responsible for a great repertoire of histone variants. One such variant, H2A.Z (H2AZ), is the focus of this paper. In yeast, H2AZ differs from H2A by forty percent in amino acid sequence as well as in patterns of modification.7 Nevertheless, it retains the capacity to form a dimer with the original H2B.6 Furthermore, it has been reported that H2AZ nucleosomes have reduced stability.9, 10 However, there remains some controversy over whether the interaction between the H2AZ-H2B dimer and (H3-H4)2 tetramer results in more stable nucleosome than a canonical nucleosome with H2A-H2B dimers.11

CHROMATIN REMODELER SWR1

In yeast, the promoter region before a gene is typically depleted of nucleosomes, hence its label nucleosome-free region or NFR. The nucleosomes that flank either side, downstream and upstream, of the NFR are designated the +1 and -1 nucleosomes, respectively. Saccharomyces cerevisiae (budding yeast) has approximately 5000 +1 nucleosomes of about 60000 total nucleosomes, a majority of which are

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H2AZ variants rather than canonical.12 The activity of SWR1, a fourteen-subunit chromatin remodeling complex in budding yeast, illustrates the dynamic nature of the +1 nucleosome.13, 14 One essential subunit of the complex is Swr1, an ATPase.14 The complex recognizes the stretch of naked DNA in the NFR and in an ATP-dependent reaction, incorporates an H2AZ-H2B dimer into the nucleosome instead of the original H2A-H2B.12 The replacement reaction relies on the delivery of an H2AZ-H2B dimer to SWR1 by a protein chaperone, and the binding of the dimer to the Swr1 subunit of the SWR1 complex. While the binding itself does not depend on ATP, the sequential removal of the H2A-H2B dimer then deposition of H2AZ-H2B requires it.7, 14 Before being affected by SWR1, the canonical nucleosome is denoted â&#x20AC;&#x153;AAâ&#x20AC;? meaning that both dimers around the (H3-H4)2 tetramer have histones H2AH2B in association. SWR1 replaces one or both of the histone H2A-H2B dimers to produce a nucleosome that is either heterotypic (AZ), with one canonical H2A-H2B dimer and one H2AZ-H2B, or homotypic (ZZ) in which both dimers contain the variant. AZ and ZZ nucleosomes are present genome-wide, especially at promoter-proximal loci. Interestingly, despite the prevalence of nucleosomes heterotypic or homotypic for the H2AZ variant, AA presence is also substantial at promoters. According to a reaction kinetic assay, SWR1 converts AA nucleosomes to AZ and ZZ in a stepwise fashion. During incubation with SWR1, H2AZH2B dimers, and ATP, immobilized

STEM & TECHNOLOGY

AA nucleosomes undergo distinct changes. After a temporary accretion of AZ nucleosomes, ZZ species increased until they comprised the majority of nucleosomes on the assay. Canonical AA nucleosomes, containing no H2AZ-H2B dimers, thus became a minor portion of the total population. Similar to the AA nucleosome, the AZ is a substrate for SWR1 activity; however, it is also an intermediate in the reaction for the ZZ end-product. Interestingly, the mechanism of replacement is unidirectional, meaning that the capacity of SWR1 does not include the replacement of nucleosomal H2AZH2B with free H2A-H2B dimers. In fact, required for the enzymatic activity of SWR1 is the presence of H2AZ-H2B dimers, as the AA nucleosome itself is not sufficient to stimulate H2A-H2B eviction.7

TRANSCRIPTION PRE–INITIATION COMPLEX

In chromatin architecture, the NFR is not solely delineated by H2AZ enriched +1 and -1 nucleosomes; it is also the site of PIC assembly. PIC assembly begins when TATA-binding protein (TBP) arrives at an 80-200 base-pair promoter region, accompanied by a multi-subunit transcription factor IID complex.15, 16 The formation of the PIC signals the recruitment of RNA polymerase (pol) II and associated general transcription factors (GTFs) to the transcription start site (TSS). Evidence suggests that the +1 nucleosome, shielding start sites in S.cerevisiae, engages and positions part of the transcription machinery at promoters.15 Thus, its disassembly is an anticipated outcome for transcription to proceed.16 Likewise, in other promoter regions where it occludes the TATA-box, the +1 nucleosome competes with PIC assembly. Hence, histone eviction likely precedes the PIC.15, 16 In budding yeast cells, removal of TBP which is required for PIC assembly, resulted in an enrichment of H2AZ variant nucleosomes flanking the promoters and a decrease in AA nucleosomes. This could be due to a role of PIC in H2AZ removal or due to enhanced recruitment of SWR1 in the

absence of PIC. However, the latter possibility was not observed by directly monitoring SWR1 binding to select gene promoters under conditions of PIC depletion. SWR1 levels were reduced upon PIC depletion and this likely reflects rapid dissociation of SWR1 from ZZ enriched +1 nucleosomes. Consistently, a lower affinity of SWR1 for ZZ nucleosomes compared to AA nucleosomes has been reported.16, 19 Additionally, the possibility was ruled out that histone eviction is a byproduct of chromatin remodeler INO80 activity. Inactivating the INO80 gene did not affect any significant change upon the concentration of H2AZ; a global increase in H2AZ would have been expected if indeed INO80 had the role of evicting H2AZ.16

to an H2AZ-H2B dimer, acts upon the +1 nucleosome and interchanges one canonical dimer with the variant version to produce a heterotypic AZ. Subsequently, SWR1 exchanges the second dimer for a variant, yielding a ZZ nucleosome. In the histone region that binds free H2AZ-H2B dimers to chaperones, there are prominent structural differences between H2A and H2AZ-containing nucleosomes.19, 16 The PIC assembles on the NFR and the adjacent +1 nucleosome, which occludes the TSS, must be disassembled for transcription to proceed. This likely occurs due to the PIC itself at an, as of yet, unspecified stage of initiation, elongation, or termination. After the PIC escapes the promoter, whether in elongation

“The tendency to view ... the nucleosome as a stationary structure is exceedingly useful in terms of simplification and instruction. However, it masks the remarkably dynamic nature of chromatin inside the cell nucleus.” The overall picture seems to indicate that nucleosome disassembly is a byproduct of transcriptional machinery rather than a process unrelated to pre-initiation complex assembly.16 For instance, the promoter for the Pho5 yeast gene undergoes a documented change in chromatin architecture upon transcription induction. Normally sealing the promoter under repressed condition, four nucleosomes at the promoter switch to an open configuration because of transcription machinery. The area upstream of the Pho5 gene contains H2AZ, indicating that the aforementioned dynamics affect the histone variant as well.18

APPARANT CYCLE

These various findings point to the existence of a possible histone cycle. Promoter regions attract SWR1 because of the long stretch of naked DNA of the NFR. The complex, upon binding

or unproductive disassociation, a canonical AA nucleosome reassembles at the +1 locus.16 Distinguishing between the stages of transcription may mean examining the role of machinery proteins specific to each stage. One technique investigated the effect of immobilized elongation complexes with RNA polymerase II attached, on adjacent nucleosomes in terms of transcriptional efficiency. Comparing the rate of transcription between naked DNA and nucleosomes, the latter presented a near absolute inhibition of RNA synthesis.20 However, increasing ionic strength in-vitro allowed transcription to proceed. Strikingly, a byproduct of RNA pol II procession was the loss of an H2A-H2B dimer from the octamer, resulting in a hexasome of DNA wrapped around six histones instead of eight.20 In the need to move nucleosomes, histone chaperone complexes such

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as FACT also enable elongation.21 However, the purposeful disassociation of nucleosomal subunits by specific proteins does not negate the natural movement of chromatin. Neither DNA nor histones are immobile inside the nucleus.22 Structurally, the H2A-H2B histones are on the surface of the octamer surrounding the (H3-H4)2 tetramer within and are especially motile as they are perpetually exchanged.23

IMPLICATIONS FOR GENE EXPRESSION AND DISEASE

The roles of SWR1 and the PIC demonstrate the active function of H2AZ in gene expression. The dynamics of H2AZ are an important part of how chromatin architecture changes, including the opening of tightly packed heterochromatin to allow for nuclear processes. Acetylation of H2AZ is important for maintaining chromatin in open conformation, called euchromatin. In order for transcription machinery to access DNA, it cannot be heterochromatic or tightly condensed around histone octamers.24, 26 A key aspect of histone variant dynamics also pertains to location on chromatin. For instance, CENP-A a eukaryotic variant of H3, is present in the centromeres of chromosomes and is essential for survival. Another H2A variant, H2AX, signals DNA damage and retains repair machinery when phosphorylated at double-strand breaks. Furthermore, in budding yeast, telomeres are heterochromatic regions and H2AZ is essential for blocking the spread of silenced genic regions.24 The significance of investigation into H2AZ dynamics is also revealed by its role in human diseases, particularly in cancer-related fields. In eukaryotes of higher order than yeast, two complexes, p400 and SRCAP which are derived from SWR1, spearhead H2AZ deposition.27 Vertebrates specifically have two versions of H2AZ: H2AZ.1 and H2A.Z.2. These versions have identical sequences barring three amino acids. Each version has a unique mechanistic role that reveals the function of H2AZ 26

in human disease. Overall, many cancer types display H2AZ overexpression; however, H2AZ.1 appears confined to genes that regulate immune response while H2AZ.2 affects the progression of cell cycle, particularly S-phase.27 Although H2AZ overexpression is best characterized in breast cancer, it has been linked to colorectal and genitourinary cancers as well. A recent study of H2AZ in prostate carcinoma cell lines suggests that H2AZ acetylation stimulates oncogene transcription. Analogously, H2AZ deacetylation appears to be prevalent on nucleosomes alongside the TSS and affects tumor suppressor genes by decreasing the rate of their expression.25

CONCLUSION

The tendency to view DNA as a fixed line or the nucleosome as a stationary structure is exceedingly useful in terms of simplification and instruction. However, it masks the remarkably dynamic nature of chromatin inside the cell nucleus. Regulation of gene expression and accessibility to DNA depends on constant changes to both the nucleic acid and protein components of chromatin. Indeed, chromatin remodelers, chaperones, and other regulatory proteins alter the composition of the histone octamers as well as the position of nucleosomes at defined genomic loci. This energetic environment allows for epigenetic response to external stimuli in addition to the nucleic acid processes of transcription and replication. Recent advances in technology, such as singlemolecule imaging, have made the study of these essential phenomena possible.13 Undoubtedly, further exploration of this field is crucial as nucleosome dynamics are integral to gene expression, and therefore, may be the key to elucidating countless diseases.

ACKNOWLEDGEâ&#x20AC;&#x201C; MENTS I wish to express my deepest gratitude to Dr. Evangelos Moudrianakis, Dr. Anand Ranjan, and Dr. Carl Wu for their help and advice

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regarding this paper. I would also like to thank all the members of the Wu Lab for their support.

REFERENCES

1. Kornberg, R. D., & Thomas, J. O. (1974). Chromatin structure: Oligomers of the histones. Science, 184, 865. Retrieved from http://search. ebscohost.com/login.aspx?direct=true&db=rg r&AN=523842976&site=ehost-live&scope=site 2. Oudet, P., Gross-Bellard, M., & Chambon, P. (1975). Electron microscopic and biochemical evidence that chromatin structure is a repeating unit. Cell, 4(4), 281. Retrieved from http://search. ebscohost.com/login.aspx?direct=true&db=cm edm&AN=1122558&site=ehost-live&scope=site 3. Thomas, J. O., & Kornberg, R. D. (1975). An octamer of histones in chromatin and free in solution. Proceedings of the National Academy of Sciences of the United States of America, 72(7), 2626. Retrieved from http://search. ebscohost.com/login.aspx?direct=true&db=cm edm&AN=241077&site=ehost-live&scope=site 4. Eickbush, T. H., & Moudrianakis, E. N. (1978). The histone core complex: An octamer assembled by two sets of protein-protein interactions. Biochemistry, 17(23), 4955. Retrieved from http://search.ebscohost. com/login.aspx?direct=true&db=cmedm &AN=718868&site=ehost-live&scope=site 5. Arents, G., Burlingame, R. W., Wang, B. C., Love, W. E., & Moudrianakis, E. N. (1991). The nucleosomal core histone octamer at 3.1 A resolution: A tripartite protein assembly and a left-handed superhelix. Proceedings of the National Academy of Sciences of the United States of America, 88(22), 10148. Retrieved from http://search. ebscohost.com/login.aspx?direct=true&db=cm edm&AN=1946434&site=ehost-live&scope=site 6. Hatch, C. L., Bonner, W. M., & Moudrianakis, E. N. (1983). Minor histone 2A variants and ubiquinated forms in the native H2A:H2B dimer. Science, 221(4609), 468. 7. Luk, E., Ranjan, A., Fitzgerald, P. C., Mizuguchi, G., Huang, Y., Wei, D., & Wu, C. (2010). Stepwise histone replacement by SWR1 requires dual activation with histone H2A.Z and canonical nucleosome. Cell, 143(5), 725. 8. Placek, B. J., Harrison, L. N., Villers, B. M., & Gloss, L. M. (2005). The H2A.Z/H2B dimer is unstable compared to the dimer containing the major H2A isoform. Protein Science: A Publication of the Protein Society, 14(2), 514. Retrieved from http://search.ebscohost. com/login.aspx?direct=true&db=cmedm& AN=15632282&site=ehost-live&scope=site 9. Abbott, D. W., Ivanova, V. S., Wang, X., Bonner, W. M., & AusiĂł, J. (2001). Characterization of the stability and folding of H2A.Z chromatin particles: Implications for transcriptional activation. The Journal of Biological Chemistry, 276(45), 41945. Retrieved from http://search. ebscohost.com/login.aspx?direct=true&db=cm edm&AN=11551971&site=ehost-live&scope=site 10. Suto, R. K., Clarkson, M. J., Tremethick, D. J., & Luger, K. (2000). Crystal structure of a nucleosome core particle containing the variant histone H2A.Z. Nature Structural Biology, 7(12), 1121. 11. Park, Y. J., Dyer, P. N., Tremethick, D. J., & Luger, K. (2004). A new fluorescence resonance energy transfer approach demonstrates that

STEM & TECHNOLOGY the histone variant H2AZ stabilizes the histone octamer within the nucleosome. The Journal of Biological Chemistry, 279(23), 24274. 12. Yen, K., Vinayachandran, V., & Pugh, B. F. (2013). SWR-C and INO80 chromatin remodelers recognize nucleosome-free regions near +1 nucleosomes. Cell, 154(6), 1246. 13. Lai, W. K. M., & Pugh, B. F. (2017). Understanding nucleosome dynamics and their links to gene expression and DNA replication. Nature Reviews.Molecular Cell Biology, 18(9), 548. 14. Wu, W. H., Wu, C. H., Ladurner, A., Mizuguchi, G., Wei, D., Xiao, H., . . . Wu, C. (2009). N terminus of Swr1 binds to histone H2AZ and provides a platform for subunit assembly in the chromatin remodeling complex. The Journal of Biological Chemistry, 284(10), 6200. 15. Rhee, H. S., & Pugh, B. F. (2012). Genomewide structure and organization of eukaryotic pre-initiation complexes. Nature, 483(7389), 295. 16. Tramantano, M., Sun, L., Au, C., Labuz, D., Liu, Z., Chou, M., . . . Luk, E. (2016). Constitutive turnover of histone H2A.Z at yeast promoters requires the preinitiation complex. Elife, 5 17. Papamichos-Chronakis, M., Watanabe, S., Rando, O. J., & Peterson, C. L. (2011). Global regulation of H2A.Z localization by the INO80 chromatin-remodeling enzyme is essential for genome integrity. Cell, 144(2), 200. 18. Santisteban, M. S., Kalashnikova, T., & Smith, M. M. (2000). Histone H2A.Z regulates transcription and is partially redundant with nucleosome remodeling complexes. Cell, 103(3), 411. 19. Ranjan, A., Mizuguchi, G., FitzGerald, P. C., Wei, D., Wang, F., Huang, Y., . . . Wu, C. (2013). Nucleosome-free region dominates histone acetylation in targeting SWR1 to promoters for H2A.Z replacement. Cell, 154(6), 1232. 20. Kireeva, M. L., Walter, W., Tchernajenko, V., Bondarenko, V., Kashlev, M., & Studitsky, V. M. (2002). Nucleosome remodeling induced by RNA polymerase II: Loss of the H2A/H2B dimer during transcription. Molecular Cell, 9(3), 541. 21. Orphanides, G., & Reinberg, D. (2000). RNA polymerase II elongation through chromatin. Nature, 407(6803), 471. 22. Jackson, V. (1990). In vivo studies on the dynamics of histone-DNA interaction: Evidence for nucleosome dissolution during replication and transcription and a low level of dissolution independent of both. Biochemistry, 29(3), 719. 23. Kimura, H., & Cook, P. R. (2001). Kinetics of core histones in living human cells: Little exchange of H3 and H4 and some rapid exchange of H2B. The Journal of Cell Biology, 153(7), 1341. 24. Babiarz, J. E., Halley, J. E., & Rine, J. (2006). Telomeric heterochromatin boundaries require NuA4-dependent acetylation of histone variant H2A.Z in saccharomyces cerevisiae. Genes & Development, 20(6), 700. 25. Monteiro, F. L., Baptista, T., Amado, F., Vitorino, R., Jerรณnimo, C., & Helguero, L. A. (2014). Expression and functionality of histone H2A variants in cancer. Oncotarget, 5(11), 3428. 26. Ausiรณ, J. (2006). Histone variant--the structure behind the function. Briefings in Functional Genomics & Proteomics, 5(3), 228. 27. Zink, L. M., & Hake, S. B. (2016). Histone variants: Nuclear function and disease. Current Opinion in Genetics & Development, 37, 82. variants: Nuclear function and disease. Current Opinion in Genetics & Development, 37, 82.

FIGURES

Figure 1: A model of promoter-proximal histone dynamics

EJLAL ELALAOUI Class of 2020. Ejlal Elalaoui is a senior Molecular and Cellular Biology major from Kissimmee, Florida. After graduation, she plans to pursue an MD-PhD dual degree. Stemming from her passion for microscopy, her research interest lies in live-cell single-molecule fluorescence imaging of nuclear protein dynamics. She uses this approach to study chromatin architecture and gain insight on gene regulation.

artwork by @MimiPrints Hopkins Undergraduate Research Journal

HUMANITIES & SOCIAL SCIENCES

Humanitarianism in the Lake Chad Basin:the Intersection of Autocracy, Poverty, and Boko Haram Lake Chad is the principal source of life for the Sahel, an area of land where the Sahara desert to the North meets the savannahs to the South. Located where Chad, Nigeria, Cameroon, and Niger meet, it provides water for over 30 million people (Ross, 2018). The Lake Chad basin has historically been an oasis in an otherwise arid region, occupying a vital role in trans-Saharan trade. Even the ancient Romans admired its significance after sending expeditions across the Sahara (King, 2018). Up until recently, Lake Chad acted as a cultural and socioeconomic hub, with thriving cross-border trade between the lake islands and the mainland in agricultural products, fish, and other vital goods. However, since the 1960s the lake, once the size of New Jersey, has shrunk by nearly 95% (Taub, 2017). Due to a combination of factors including climate change, overpopulation, overuse, and irrigation issues, the Lake Chad basin is becoming increasingly uninhabitable.

STATE ABANDONMENT

The plight of this once vibrant region has gone largely unrecognized by the central governments of Chad, Nigeria, Niger, and Cameroon. On the Nigerian side of the basin, the northeastern state of Borno has a literacy rate of just 46% for boys and 34% for girls, while some southern Nigerian states have literacy above 98% for both boys and girls (Matfess, 2016). Since Nigeria began producing oil, it has neglected the non-oil producing regions near Lake Chad, marginalizing it economically and failing to offer proper social services, such as health and education

Jordan N. Jain (Matfess, 2016). Similarly, the neighboring states of Niger and Chad, countries that rank among the lowest in Human Development, have central governments which are incapable and largely uninterested in the Lake Chad region’s development. Famed historian Sam Nolutshungu notes that Chad has been an “aberrant, marginal, a fictive state” for decades. It was a country that existed “even in its peaceful moments, alternately under a cloud of contingent

networks to provide social services in a region deprived of government support (Matfess, 2016). These groups filled a state vacuum by facilitating commerce, helping provide income, and supporting the unemployed, widows, and children. This movement would eventually become what is now known as Boko Haram. In addition to offering social services and group identity in an area of state absence, the group revived a tradition of jihad

"The plight of this once vibrant region has gone largely unrecognized by the central governments of Chad, Nigeria, Niger, and Cameroon.” anarchy or tyranny” (Nolutshungu, 1996). Niger, Nigeria, Cameroon, and Chad have all seen frequent transitions from democracy to military or authoritarian rule. Consequently, inhabitants of the Lake Chad region have deep grievances towards central authorities and their security forces, seeing them as corrupt and unconcerned with alleviating social and economic disparities (Vivekananda, 2018).

BOKO HARAM

In the early 2000s, a young Salafi spiritual leader in Northeastern Nigeria named Mohammed Yusuf began capitalizing on these grievances, utilizing anti-colonial and anti-elite rhetoric to appeal to local marginalized youth. He and his followers railed against corruption and inequalities, advocating for locally led self-help

that goes back hundreds of years (Taub, 2017). Boko Haram saw national governments as illegitimate and carried out violent paramilitary incursions around the Lake Chad basin. Since 2009, Boko Haram has become more radical and violent, notably involved in the 2014 abduction of 276 girls from their school in Chibok, Nigeria. Since then, the movement has spread across borders, with over 20,000 killed and 2.2 million displaced around Lake Chad, exacerbating fragile environmental and socioeconomic conditions (Mercy Corps, 2016).

HUMANITARIANISM The Boko Haram insurgency alarmed the international community and illuminated existing issues of climatic fragility and socioeconomic disparities of the Lake Chad basin. In

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HUMANITIES & SOCIAL SCIENCES

an effort to stabilize the region, many Western donor countries and NGOs insisted on providing humanitarian assistance to local populations. This paper proposes that these interventions pose a problematic dilemma. NGOs and other humanitarian organizations risk becoming parastatal, operating parallel to the state and encroaching on areas which should be the responsibility of governments. Beyond this, humanitarianism in Lake Chad presents a particularly unique predicament because in providing much-needed health/social services and economic support, NGOs are indirectly supporting the continuation of autocratic regimes. Governments are relieved of their responsibilities and are able to further direct funds into their militaries, consolidate power, and monopolize violence, perpetuating the conditions that led people to take up arms in the first place. As journalist Ben Taub (2017) noted while investigating the region: “[In Lake Chad,] the international community ends up fulfilling the unwanted obligations of statehood. The regime reaps the benefit: the threats that arise from its failure to govern are mitigated, and its leader is left to focus on the task of strengthening the security apparatus that keeps him in power.” In recent years, hundreds of NGOs, foreign governments, and institutions have been involved in humanitarian work around Lake Chad. In Maiduguri alone (the largest town on the Nigerian side of the basin), there are over 150 NGOs involved in humanitarianism, stabilization, and development (Oloio, 2019). On the Chadian side in Baga Sola, the city is said to have increased in size threefold since NGOs and international institutions moved in (Taub, 2017). In 2017, despite it only being 62% of the UN funding goal, $912 million flooded into humanitarian and stabilization programs in the Lake Chad basin (OCHA, 2018). NGOs have set up widespread operations in towns around the basin, with displacement sites providing social services such as basic education, healthcare, clean 30

water, and mental health support to people who fled from the Lake Chad islands to the mainland (OCHA, 2018). In a region seemingly abandoned by states, the provision of basic social services at displacement sites by NGOs was welcomed. In an interview, CARE Chad Country Director stressed the need for governments to assume responsibility for providing these services. When CARE volunteers asked people at displacement sites if they wanted to return to the Lake Chad islands, a frequent response was: “no, because we know now what school and health care is” (Chadwick, 2018). Although quite basic, in an area of state neglect, displacement sites offer an improvement over life in and around the Lake Chad Basin.

MILITARIZATION OF LAKE CHAD

While NGOs are providing services which should be within the purview of states, central governments in the region seem to have directed their attention to securitized strategies for dealing with the crises of the Lake Chad basin. Along with military funding from the US and other Western countries, the Sahelian countries have invested hundreds of millions of government funds into their security forces (Taub, 2017). All four countries around the lake have supplied thousands of soldiers to join an effort called the Multi-National Joint Task Force, whose goal is to eradicate Boko Haram. Other government strategies included sweeping changes which ignored local contexts. The Chadian government banned the use of boats on Lake Chad, since some Boko Haram militants had used them to attack the islands (Taub, 2017). As a result, many fishermen had their livelihoods destroyed, and communities which relied on fishing were left with insufficient food. The governments of the region have continued to neglect and socioeconomically marginalize populations of the Lake Chad basin, while simultaneously pursuing a securitized strategy that perpetuates distrust in central authorities. For instance, take the story of a local twelve-year old boy of the Boudouma

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tribe in Niger: “One day, airplanes came and bombed all the huts. A piece of shrapnel pierced Aboudou’s shoulder. He had fifteen friends on the island, but when the attack was over all of them were dead. After that, his family fled to Chad, where they were detained by the military. He was much more afraid of the uniformed soldiers than he was of Boko Haram” (Taub, 2017). Even the UN has criticized governments’ responses, arguing that a military victory alone is not enough to create stability and improve conditions. Rather, security strategies often violate human rights and further alienate locals of Lake Chad (UNDP, 2018). While a militarized approach to the crises of the Lake Chad basin may be short-sighted and counterproductive, from the perspective of an autocrat, it is instrumental in keeping them in power. For example, in Chad, the Déby regime has relied on a strong national security apparatus to bolster the regime’s legitimacy. Déby surrounds himself with a strong military elite who remain loyal to the president rather than the republic (Nickels & Shorey, 2015). Chadian security forces frequently crackdown on opposition and protests. Likewise, in neighboring countries of Nigeria, Niger, and Cameroon, funding for the military is often given priority over state-led development projects for the Lake Chad basin. A proposal was sent to governments in the region for building the Transaqua canal, which would transfer water from the tributaries of the Congo River to the Chari River basin to revitalize Lake Chad. The response from ministers was a “deafening silence” (Ross, 2018).

A PARADOX?

NGOs and the international community have enabled the state to pursue a militarized approach by relieving it of its social responsibilities to citizens. Governments in the region do not feel pressured to pursue development projects or provide basic social services. Rather, in a way, they want Boko Haram to be

HUMANITIES & SOCIAL SCIENCES

a distant manageable threat, as it keeps autocrats in power and allows humanitarian emergency funds to continue flowing in (Taub, 2017). As Linda Polman notes in her book The Crisis Caravan, “If you use enough violence, aid will arrive, and if you use even more violence, even more aid will arrive” (Polman, 2018). It can be argued that since NGOs and international institutions indirectly strengthen autocratic regimes, allowing them to strengthen their security apparatuses, NGOs and international institutions perpetuate the conditions that initially led people to violently rebel.

have certainly created an environment which alleviates socioeconomic marginalization and gives people a reason to turn away from Boko Haram and its toxic ideology. While the quotes from the Chadian government official certainly resonate and have truth to them, it is hard not to see the irony of those statements. The government official praises humanitarians for providing the basic social services which should be the responsibility of his government to provide to the people. While humanitarian projects at displacement sites around the basin are having a positive impact in the

“NGOs ... enabled the state to pursue a militarized approach by relieving it of its social responsibilities to citizens.” Many would disagree with this line of thought, arguing that humanitarians are involved with crucial lifesaving work. Max Chevalier (2018), a representative from Handicap International, challenged Linda Polman: “Yes, but, good grief, should we just do nothing at all then?” Chevalier certainly has a point. Around the Lake Chad basin, humanitarian organizations are providing vital services for populations that otherwise would be neglected by their governments. In 2017, NGOs reached more than six million people and helped avert a famine in Borno state, Nigeria (Chadwick, 2018). A Chadian government official applauded the work of humanitarians in the country since they encouraged defections from Boko Haram: “Those who had left to join Boko Haram learned that the humanitarian community is here, giving people food to eat, giving people money”. He encourages local boys to call their friends in Boko Haram and tell them, “We’re O.K. We have food. We have shelter. The humanitarians have given us blankets”. The official concluded: “When someone is no longer hungry, he is no longer dangerous” (Taub, 2017). It is hard to deny the positive stabilization and life-saving projects that NGOs and humanitarians have undertaken in the Lake Chad basin. They

short-term, they are far from a longterm solution to the consequences of environmental degradation, social marginalization, poverty, and violence. In other words, NGOs’ presence is fleeting. Once the perceived emergency subsides, humanitarian funds will move to other crises around the world. In the end, it must be the state which takes responsibility for protecting and caring for its people based on their rights as citizens. In conclusion, the Lake Chad basin crisis presents a unique challenge to humanitarian organizations – in a way creating a paradox. By providing basic social services to those fleeing violence and depravation, NGOs and international institutions assume state responsibilities, allowing the state to focus on strengthening its security apparatus and perpetuating autocracy. The violence and neglect arising from autocracy were the foundational problems which led to environmental neglect, socioeconomic marginalization, and the subsequent rise of groups such as Boko Haram in the first place. The challenges of the Lake Chad basin crisis certainly have no easy solutions, however, illuminating this paradox highlights the need to pressure states to provide basic social services and ensure national wealth is equitably distributed.

BIBLIOGRAPHY

1. “2018 Humanitarian Needs and Requirement Overview: Lake Chad Basin Emergency.” OCHA. www. reliefweb.int/sites/reliefweb.int/files/resources/LCB_ HNRO_21022018_EN_Final.pdf 2. Apard, Elodie. “The Words of Boko Haram: Understanding Speeches by Mohammed Yusuf and Abubakar Shekau.” Afrique Contemporaine 3, no. 255 (2015): 41-69. 3. Awosusi, AE. “Aftermath of Boko Haram violence in the Lake Chad Basin: a neglected global health threat.” BMJ global heal. 2, 1 (2017). 4. Chadwick, Vince. “Lake Chad meeting to take on humanitarian-development nexus.” Devex. Last modified August 17, 2018. www.devex.com/news/lakechad-meeting-to-take-on-humanitarian-developmentnexus-93305. 5. Harsch, Ernest. “Strengthening bonds in the Sahel.” UN Africa Renewal. www.un.org/africarenewal/ magazine/august-november-2018/strengtheningbonds-sahel. 6. King, Arienne. “The Roman Empire in West Africa.” Ancient History Encyclopedia. March 7, 2018. 7. Matfess, Hilary. “Here’s why so many people join Boko Haram, despite its notorious violence.” Washington Post. Last modified April 26, 2016. www.washingtonpost. com/news/monkey-cage/wp/2016/04/26/hereswhy-so-many-people-join-boko-haram-despite-itsnotorious-violence/?utm_term=.2a2c55c91bcf. 8. “Motivations and Empty Promises: Voices of Former Boko Haram Combatants and Nigerian Youth .” Mercy Corps. Last modified April , 2016. 9. Nickels, B. P., and Shorey, M., “Chad: A Precarious Counterterrorism Partner.” Combatting Terrorism Ctr. Sentinel. Vol. 8:4 (04/2015): 7-10. 10. Nolutshungu,S.C. Limits of Anarchy: Intervention & State Formation in Chad. Charlottesville, VA: University of Virginia Press, 1996. 11. Olojo, A. “Humanitarian aid in Nigeria’s north-east: helping or hurting?.” Inst. for Security Stu. Last modified July 31, 2019. issafrica.org/iss-today/humanitarian-aidin-nigerias-north-east-helping-or-hurting. 12. Polman, L. The crisis caravan: what’s wrong with humanitarian aid? Metropolitan Books, 2010. 13. “Resilience for Sustainable Development in the Lake Chad Basin.” UNDP & OCHA. Last modified August , 2018. www.undp.org/content/dam/rba/docs/UNDPOCHA-Lake-Chad-%20Resilience_spreads-EN.pdf. 14.Ross, Will. “Lake Chad: Can the vanishing lake be saved?.” BBC Africa. Last modified March 31, 2018. www.bbc.com/news/world-africa-43500314. 15. Taub, Ben. “Lake Chad: The World’s Most Complex Humanitarian Disaster.” The New Yorker. Last modified November 27, 2017. www.newyorker.com/ magazine/2017/12/04/lake-chad-the-worlds-mostcomplex-humanitarian-disaster. 16. Vivekananda, Janani, Martin Wall, and Susanne Wolfmaier. “Lake Chad: A Climate of Fragility.” E-International Relations. Last modified May 20, 2018. www.e-ir.info/2018/05/20/lake-chad-a-climate-offragility/.

JORDAN N. JAIN Class of 2021. Jordan is a junior majoring in International Studies & Sociology with a minor in Islamic Studies. He is originally from New Jersey but attended secondary school in the UK before coming to Hopkins. His research paper shows his interests in international development, human rights, and global social change.

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A Literature Review of Government Nutritional Program and Their Effect on Childhood Nutrition A m i t h U m e s h & Va r u n M a h a d e v a n INTRODUCTION

Malnutrition is a silent crisis in South Asia. Without adequate resources to ensure proper health education nor to purchase life-saving treatments, many South Asian countries, such as India and Bangladesh often fail to even recognize that malnutrition afflicts its children. India, specifically, is burdened by a large proportion of malnutrition in South Asia. In fact, more than one-third of the worldâ&#x20AC;&#x2122;s malnourished children are located in India. Every year, almost half of children in India suffer from malnutrition and nearly a million children die before surpassing one month of age.1 About 60 million Indian children are underweight, about 45 million are stunted, 20% are wasted, and 57% are Vitamin-A deficient.1 Stunting is defined as a low height for weight whereas wasting is defined as having a low weight for age.2 Despite growing to the sixth largest economy by GDP in the latter half of the 20th century, India has experienced growth in rates of malnutrition, especially in its most impoverished states.1 However, governmental work on malnutrition throughout South Asian countries has bolstered in the last 30 years. For example, Bangladesh has implemented a national nutrition policy, pledging to control and prevent malnutrition.3 The government of Pakistan also has programs such as the Micronutrient Initiative and the School Health Programme, which are focused efforts of larger development schemes to improve the health and economy 32

of its country.4 Specifically, these programs are aimed at delivering healthy food options to children and mothers in order to prevent and treat malnutrition. The most cohesive of these schemes, the Integrated Child Development Services Program (ICDS), was developed by the government of India. It provides health check- ups, vaccinations, food and preschool education to children up to six years of age.5 Furthermore, nutritional rehabilitation centers provide primary care inpatient services to children who are severely malnourished.5, 6 Admitted children receive energy-dense supplementary feedings, micronutrient supplementation, and consultation with dietitians to develop long-term health goals.5 Although literature has examined the broad efficacy of these governmental initiatives, often in terms of education delivery or referral services, a rigorous and focused inspection of nutritional delivery, such as supplementary feeding, through governmental institutions is lacking. Furthermore, many systematic reviews on nutritional feeding strategies for malnourished children have studied delivery through non-governmental organizations such as United Nations Childrenâ&#x20AC;&#x2122;s Fund (UNICEF) or the World Health Organization (WHO). We seek to understand whether the long-term prevention and solution to malnutrition in South Asia involves the cohesive integration of supplemental nutrition delivery with governmental institutions

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to reach the greater population burdened with malnutrition. To this end, a focused examination of past successes and failures of such an integration is paramount to guiding future efforts in alleviating this crisis. Therefore, in this review, we aim to examine the relationship between government programs that deliver nutrition in South Asia and malnutrition in their beneficiary children.

METHODS

Eligibility Criteria All reviewed articles examined the effect government deliveries of nutrition on how children responded to these treatments. Responsiveness was measured using anthropometric changes in measures such as weight and height. Eligibility criteria included the type of program, specifically government nutritional intervention programs, including those delivered in conjunction with non-profit organizations that played a non-primary role in delivery of program. Childhood malnutrition as an outcome was another eligibility criterion screened for. The age range was restricted to studies examining participants under 18, and the type of malnutrition examined by studies included the following: moderately (<2SD) or severely (<3SD) undernourished, and stunted (low height-for-age), wasted (low weightfor-height), and underweight (low weight-for-age) in the WHO Anthro Survey Analyzer, which includes globally agreed upon normal weight distribution among children under five.2

HUMANITIES & SOCIAL SCIENCES

Study Quality Assessment The method used to assess the strength of the study design was the abridged version of the Downs and Black tool.10 Quality for each study was determined by analyzing whether the Downs and Black criteria were met for each study. The criteria evaluate the quality of each study by using a ten-question scale that assesses study quality, external validity, study bias, confounding and selection bias, and study power. The denominator for the Downs and Black tool is eight for experiments, and six for nonexperiments.

RESULTS

Study Characteristics Of the eight articles reviewed, seven were from Karnataka, Maharashtra, Kerala, West Bengal, Madhya Pradesh, Uttar Pradesh. 6, 8â&#x20AC;&#x201C;13, and the remaining article were in Bangladesh.14 The population of all studies included children that were malnourished to some degree, as defined by undernourishment, wasting, or stunting. Furthermore, some studies assessed all children (both healthy and malnourished), but others only sampled malnourished children. The age range also varied between studies. For example, some selected for school children specifically between the ages of six to ten years old while others chose for children between six months and 59 months.11, 13 Four of the studies were experiments, three of which were controlled trials, 8,10,14 and the remaining experiment was a quasiexperimental trial.9 The remaining four studies used a cross-sectional study design.6,11â&#x20AC;&#x201C;13 All studies included programs that delivered nutritive foods either fortified with micronutrients or high in fat content. All studies measured anthropometric measures such as height and weight. These were then converted to formal indices for malnutrition such as height for age z-scores, weight for age z-scores, body mass index z-scores, or composite index of anthropometric failure, generally using the online WHO Anthro Survey Analyzer. These indices were then used to classify children into levels of malnutrition such as wasted,

stunted, severely malnourished or moderately malnourished. Additionally, one study measured biochemical values of micronutrients such as vitamin levels.14 Only one study measured mortality of children.6 Synthesis Seven of the eight studies showed significant improvements in either weight or height gain, and subsequent recovery from malnutrition as a byproduct for all the subjects.6,8â&#x20AC;&#x201C;11,13,14 A range of 40% to 50% growth in weight was observed in all these studies. The one study that administered fortified biscuits and measured micronutrients observed statistically significant levels of increase in micronutrients and hemoglobin. Although Devara et. al reported decreases in the proportion of underweight children compared to baseline, no statistical significance was observed between the intervention and control group. Of the eight studies, Jayalakshmi et. al reported no benefits from government intervention for child malnutrition as none of the outcomes differed between treatment and control group, showing the ICDS government program was not sufficient in bringing children out of malnutrition.

DISCUSSION

In this review, we sought to elucidate the nature of the relationship between government nutritional intervention programs and childhood malnutrition in South Asian countries. We found that the delivery of nutritional interventions through governmental programs in South Asian countries, specifically, India and Bangladesh, was successful in alleviating malnutrition in children as compared to their baseline status or compared to control groups. This finding was consistent with nearly all studies (seven out of eight), especially since all of them scored highly on the Downs and Black scale due to their strength in generalizability. Reviewed studies indicate that governmental nutrition programs provide a source for both primary prevention (for children at high risk for malnutrition) and secondary prevention (for malnourished children) of childhood malnutrition. The strength of these

government programs comes from their extensive reach into communities and a general sense of trust from the community in the programs.15 With regular attendance at the programs, children can receive a consistent supplemental feeding.15 Although spot- feeding services of meals or take-home rations are also employed by non-governmental organizations or community-based management programs, the aforementioned strengths of the governmental programs give them an advantage in mobilizing these supplemental feeding schemes.15 We found differential seasonality to be a prominent contributor to confounding in the assessed studies. Large variabilities in seasons in South Asia, primarily observed from monsoons, that affect farming and availability of food can significantly affect weight gain or loss in children.16 None of the reviewed studies specifically controlled for this confounder. Therefore, future studies should aim to procure anthropometric measurements during the same season or account for seasonality. This may include allocating case and control groups to multiple seasons to be run in a parallel manner. Furthermore, only one of the eight studies specifically assessed biochemical measures such as micronutrient levels. Although assessing weight gain serves as a broad marker of malnutrition, changes in micronutrient levels are critically important to proper biological function and should be addressed in future studies. Additionally, varying age ranges for participants were included across reviewed studies: 6 months to 59 months, zero to six years old, 6 to 11 years old, 10 to 14 years old, 15 to 18 years old. Although recruiting participants in such constrained age ranges allow researchers to derive specific conclusions to that age group, literature in the field of malnutrition lack a comprehensive review of programs that range the entirety of childhood from birth to 18 years. This may be the result of either a lack of government programs or a limitation of studies to recruit participants from a wide age range. However, efforts to analyze outcomes from government

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programs that provide such continuity of care is critically important to understanding their long-term efficacy and susceptibility to relapse for different populations and thus should be a focus of future studies and policy development.

CONCLUSION

Our review sought to uncover the effects of governmental nutrition programs in South Asian countries on childhood malnutrition. Although our review faces limitations in only assessing a small number of studies from a single database (PubMed), it is the first review to examine how governmental nutritional delivery programs in South Asia affect childhood malnutrition. Previous reviews have assessed the broad effectiveness of governmental programs on malnutrition (i.e. maternal advising, primary care support, and preschool education), but none have focused, specifically, on the efficacy of supplemental nutrition to alleviate childhood malnutrition through these programs. Another strength of our review is that it utilizes a highly refined search strategy. Developing the search strategy was a rigorously iterative process that aimed to capture a large pool of articles while keeping the topic of inquiry in focus. On average, we found that these programs were effective in decreasing wasting or stunting, or both, in children by supplementing their regular diets with additional nutrition. Overall, as a result, children recovered from wasting or stunting. However, future programs can better their services by aiming to assess micronutrient malnutrition and providing continuity of care until beneficiaries reach adulthood. Nevertheless, the success of these government programs as points of access for supplemental nutrition to malnourished children are indicative of a long-term solution to the crisis of malnutrition in South Asia.

REFERENCES

1. Motedayen M, Dousti M, Sayehmiri F, Pourmahmoudi AA. An Investigation of the Prevalence and Causes of Malnutrition in Iran: a Review Article and Meta-analysis. Clin Nutr Res. 2019;8(2):101-118. 2. Helping India Combat Persistently High Rates

of Malnutrition. https://www.worldbank.org/ en/news/feature/2013/05/13/helping-india-combat-persistently-high-rates-of-malnutrition. Accessed November 22, 2019. 3. Akhtar S. Malnutrition in South Asia-A Critical Reappraisal. Crit Rev Food Sci Nutr. 2016;56(14):2320-2330. 4. UNICEF Helps Malnourished Children With Ready-to-Use-Therapeutic Food | UNICEF USA. https://www.unicefusa.org/stories/whatready-use-therapeutic-food/32481. Accessed November 22, 2019. 5. Bazzano AN, Potts KS, Bazzano LA, Mason JB. The Life Course Implications of Ready to Use Therapeutic Food for Children in Low-Income Countries.Â Int J Environ Res Public Health. 2017;14(4):403. Published 2017 Apr 11. 6. Segre J, Liu G, Komrska J. Local versus offshore production of ready-to-use therapeutic foods and small quantity lipid-based nutrient supplements. Matern Child Nutr. 2017;13(4). 7. Borg B, Mihrshahi S, Laillou A, et al. Development and testing of locally-produced ready-touse therapeutic and supplementary foods (RUTFs and RUSFs) in Cambodia: lessons learned. BMC Public Health. 2019;19(1):1200. 8. Wali N, Agho K, Renzaho AMN. Past drivers of and priorities for child undernutrition in South Asia: a mixed methods systematic review protocol. Syst Rev. 2019;8(1):189. 9. Schoonees A, Lombard MJ, Musekiwa A, Nel E, Volmink J. Ready-to-use therapeutic food (RUTF) for home-based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age. Cochrane database Syst Rev. 2019;5:CD009000. 10. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377 LP - 384. 11. WHO | Severe Acute Malnutrition. WHO. 2009. 12. Hudson JI, Pope HGJ, Glynn RJ. The cross-sectional cohort study: an underutilized design. Epidemiology. 2005;16(3):355-359. doi:10.1097/01. 13. Ministry of Women & Child Development, India https://icds-wcd.nic.in/. Accessed November 22, 2019. 14. Jadhav AR, Karnik P, Fernandes L, Fernandes S, Shah N, Manglani M. Indigenously Prepared Ready-to-use Therapeutic Food (RUTF) in Children with Severe Acute Malnutrition. Indian Pediatr. 2019;56(4):287-293. 15. Sigh S, Roos N, Chamnan C, Laillou A, Prak S, Wieringa FT. Effectiveness of a Locally Produced, Fish-Based Food Product on Weight Gain among Cambodian Children in the Treatment of Acute Malnutrition: A Randomized Controlled Trial. Nutrients. 2018;10(7):909. 16. Thapa BR, Goyal P, Menon J, Sharma A. Acceptability and Efficacy of Locally Produced Ready-to-Use Therapeutic Food Nutreal in the Management of Severe Acute Malnutrition in Comparison With Defined Food: A Randomized Control Trial. Food Nutr Bull. 2017;38(1):18-26. 17. Bhandari N, Mohan SB, Bose A, et al. Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India. BMJ Glob Heal. 2016;1(4):e000144. 18. Bashir A, Zaman S. Effectiveness And Acceptability Of Ready-To-Use Therapuetic Foods

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Among Malnourished Children In A Tertiary Care Hospital. J Ayub Med Coll Abbottabad. 2016;28(3):501-505. 19. Shewade HD, Patro BK, Bharti B, Soundappan K, Kaur A, Taneja N. Effectiveness of Indigenous Ready-to-Use Therapeutic Food in Community-based Management of Uncomplicated Severe Acute Malnutrition: a Randomized Controlled Trial from India. J Trop Pediatr. 2013;59(5):393-398. 20. Thakur GS, Singh HP, Patel C. Locally-prepared ready-to-use therapeutic food for children with severe acute malnutrition: A controlled trial. Indian Pediatr. 2013;50(3):295-299. 21. Singh AS, Kang G, Ramachandran A, Sarkar R, Peter P, Bose A. Locally made ready to use therapeutic food for treatment of malnutrition a randomized controlled trial. Indian Pediatr. 2010;47(8):679-686. 22. Ireen S, Raihan MJ, Choudhury N, et al. Challenges and opportunities of integration of community based Management of Acute Malnutrition into the government health system in Bangladesh: a qualitative study. BMC Health Serv Res. 2018;18(1):256. 23. Schulz KF, Grimes DA. Blinding in randomised trials: hiding who got what. Lancet (London, England). 2002;359(9307):696-700.

VARUN MAHADEVAN Class of 2021. Varun is a junior from Oakland, California, studying biophysics. Varun is interested in domestic as well as global healthcare inequities. He hopes to pursue a medical degree to address these inequities in clinical settings. Additionally, he is involved in nutrition research with a focus on Indiaâ&#x20AC;&#x2122;s malnutrition crisis.

AMITH UMESH Class of 2020. Amith is a senior majoring in biophysics. Born in India, Amith has a strong interest in global health. Additionally, he is working to pursue pediatric medicine. His research stems from his experience working in the non-profit organization he founded in 2018, where he helped develop lowcost supplementary food for malnurished children in India.

HUMANITIES & SOCIAL SCIENCES

Does Self Esteem Matter in Regard to Religiosity and Degree of Secure Alexa Cillia Attachment? INTRODUCTION

Background on Adult Attachment Over the past four decades, attachment theory has become one of the most highly regarded and influential theories for social-emotional development and has significantly contributed to the understanding of interpersonal functioning. Attachment Theory was developed by Bowlby (1973) and colleagues with additions to the theory from Ainsworth (Ainsworth, Blehar & Wall, 1978) who assigned attachment styles through analyzing individual attachment patterns. Attachment theory states a working internal model of relationships and self is formed through the quality of relationship between an infant and caregiver (Bowlby, 1973). The applications of attachment theory extend into adult relationships with the theory proposing “that the nature and quality of relationships in adult life are influenced by affective experiences that took place during childhood” (Collins & Read, 1990). The working model of attachment incorporates content such as emotion regulation (Crugnola et al., 2011) and is crucial to understand how individuals manage stress/distress (Mikulincer, Dolev & Shaver, 2004). This serves as a model in the development of subsequent relationships between figures of importance and self (such as friends, significant others, authority figures, etc.) and dictates the level of proximity an individual seeks from others when their attachment system is activated (Mikulincer & Shaver, 2007). Stability of Attachment Style Waters, Merrick, Trebous, Crowell

& Albersheim (2000) found people’s attachment style are relatively stable over time through a 20year longitudinal study. Attachment style has also shown to be relatively stable over significant life changes— for example, within the two years following becoming a new mother (Stern, Fraley, Jones, Gross, Shaver, & Cassidy 2018). However, research has revealed “attachment is malleable, such that, with new experiences (e.g., adult trauma, psychotherapy),” an individual can move between attachment styles, becoming more or less secure over time (Tasca, Ritchie & Balfour, L. 2011; BakermansKranenburg & vanIjzendoorn, 2009; Waters et al., 2000). Attachment and Self-esteem Here we describe self-esteem as a person’s general negative or positive attitude towards themselves (Rosenberg, 1965). A child’s environment and relationship with caregivers has been shown to have a deep and permanent effect on the development of their self-esteem (Verschueren and Marcoen 1999, Orth 2018). Bowlby (1985, 1989) outlined that the processes which are linked in establishing an individual’s sense of “self” and attachment style are similar to those responsible for developing an individual’s attitude towards what they perceive as their “self.” However, research by Çevik (2018) has shown levels of self-esteem to be linked with fearful and dismissive attachment styles but not to secure nor preoccupied. Further, Nanu (2015) demonstrated a positive relationship between secure attachment and self-esteem as well as a negative

relationship between insecure attachments and self-esteem, insecure attachment referring to all attachment styles aside from secure. As detailed above, research on the nature of the relationship between attachment and self-esteem has not been conclusively determined. Religiosity and Self-esteem There are mixed findings linking religiosity and self-esteem. In general, religiosity is often examined with the distinction of internal versus external religiosity. Generally, internal religiosity provides individuals with a motivation for life through religion, and they see religion as giving life ultimate significance. In contrast, in extrinsic religiosity, religion is used as a tool for gaining other extrinsic goals such as sociability, security, and status. Unless otherwise noted, religiosity is composed as a combination of both intrinsic and extrinsic. In 2006, Jonas & Fischer found self-esteem negatively correlated with intrinsic religiosity. Additionally, Stern & Wright (2017) found religiosity to have a negative relationship with selfesteem. However, religiosity has also been positively linked to self-esteem (Khaledian, 2013). Additionally, Waldron, Scarpa, & Kim-Spoon (2018) found an individual’s view of God affects the relationship between religiosity and self-esteem. Waldron, et all., (2018) found abuse victims who viewed God as negative experience a negative relationship with religiosity and self-esteem while those who view God positively experience a positive relationship with religiosity. Religiosity and Attachment Prior research has shown a positive

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relationship between religious views and secure attachment styles as well as a negative relationship between religious attitudes and a preoccupied attachment style (Baghteyfouni, Sogolitappeh, Baghteyfouni, Raaei, F & Sharbafzadeh 2015). However, the empirical support for this relationship is sparse with few published studies on the subject. Attachment, Religiosity, Self-esteem on Wellbeing Involvement in a religion has been linked with a higher level of wellbeing and life satisfaction (You & Lim, 2019; Yang, 2010). Prior research has also shown life satisfaction/wellbeing has a positive relationship with secure attachment and a negative relationship with anxious attachment styles as well as insecure attachment styles in general (Nanu, 2015; Li, X., & Zheng, X. 2014). Literature has also shown a positive relationship between self-esteem and life satisfaction (Yang, Q., et al. 2018; Li, X., & Zheng, X. 2014). There is weak evidence of the relationship between religiosity and secure attachment. However, both attachment and religiosity are related to similar constructs such as wellbeing and self-esteem. Further, both religiosity and attachment style have been independently, positively linked to self-esteem indicating the possibility of a moderation relationship. Shedding light on the relationship between religiosity and secure attachment (as well as self-esteem) could uncover the mechanisms behind their role in wellbeing/life satisfaction and lead to interventions for effectively improving both a person’s attachment style in becoming more secure and their wellbeing/life satisfaction. Current Study This study’s goal is to explore the mechanisms behind the relationship between religiosity, self-esteem, and secure attachment. We seek to explore whether a person’s level of religiosity and degree of secure attachment (DSA) are significantly related. Further, if this relationship exists, we investigate whether it is moderated by self-esteem (Figure 1). That is to say, whether a person’s religiosity is linked to their DSA, with their level of self36

esteem affecting the strength of this relationship. Through this data collection and analysis, we expect to find a significant positive relationship between religiosity and DSA. Additionally, we expect this relationship to be moderated by their level of self-esteem, with lower selfesteem weakening this relationship.

METHOD

Participants The participants were recruited through convenience sampling with Johns Hopkins University SONA portal for research credit in AS.200.201 or extra credit in an eligible class if not enrolled in AS.200.20. A total of 104 participants were recorded and consented to the use of their data in this analysis 69% female; 39% White, 27% Asian - including South and Eastern Asian, and 11% Black; additionally. All participants were between the ages of 18 and 22, with an average of 19. This sample generalizes to the population of educated young adults. Design This study is correlational featuring two predictor variables (self-esteem and religiosity) as well as an outcome variable (DSA), all of which are continuous and on an interval scale. A multiple regression analysis controls for self-esteem during the analysis of the direct relationship between religiosity and DSA. Additionally, each measure within the survey is randomized to control for priming effects, and the administration of the survey is consistent for all participants. No manipulation checks were included due to the limited procedures available for inclusion in the survey. Materials Here levels of religiosity, level of self-esteem, and DSA score were measured through the Duke University Religion Index (Koenig, 2010; DUREL), Rosenberg Self-esteem Scale (Rosenberg, 1965; RSES), and The Attachment Style Questionnaire (Van Oudenhoven, Hofstra, & Bakker, 2003; ASQ), respectively. All of these measures are self-report surveys which utilize Likert scales (1-4; 1-5; 1-6) and are interval measures. These

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surveys are considered reliable and valid in collecting data with regards to religiosity, level of self-esteem and attachment style, respectively. The DUREL is a popular multidimensional measure of religiosity and in 2018, Lace & Handal confirmed the Tripartite Structure of the DUREL and its validity for use in English speaking university student contexts. The DUREL consists of five items: it specifically measures overt (item 1), non-overt (item 2), and intrinsic religiosity (items 3 – 5). Items measuring overt and nonovert religiosity are measured through a 6-point Likert Scale while intrinsic religiosity is measured through a 5-point Likert scale. Prior research frequently uses the RSES and it is regarded as adequately valid and reliable. However, Gnambs, Scharl & Schroeders (2018) found cultural differences between participants affects the validity of the scale due to differing interpretations of the items when compared across countries. However, the participants are all located in America and should not experience the same variability as was shown across more vs. less individualistic countries. Additionally, Xu & Leung, (2018) found the RSES is reliable with a higher point Likert Scale (compared to a 4-point), unfortunately because of the scoring dictated by the project we were unable to account for this and administered the RSES with a 4-point Likert Scale with all ten items. The ASQ consists of 22 items measured on a 5-point Likert Scale, this survey measures secure, preoccupied, fearful and dismissive attachment. The ASQ has been frequently used as a reliable measure of attachment style in these four categories. However, development in attachment research has also produced the Experiences in Close Relationship Scale (ECR; Brennan, Clark, & Shaver, 1998). This scale measures attachment style based on two dimensions: avoidance and anxiety. The different combinations of the scales of avoidance and anxiety roughly map onto the four attachment styles determined by the ASQ. Much of the literature connecting attachment to well-being and life satisfaction—as well as that between

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attachment and religiosity, and attachment and self-esteem—has utilized the categorical model of secure, preoccupied, fearful, dismissive attachment. Therefore, it would make sense to use the ASQ when investigating the relationship between attachment and these variables. Procedure Students logged into the SONA online portal and had the option to choose to participate in a number of research studies on the Johns Hopkins Campus. Once the student had enrolled to participate in this study, they were presented with a link to the online survey. This survey could be taken at any location and any time of the day; the student was made aware of this. The first page of the survey presented a consent form. After filling out the consent form the participant was taken through the rest of the survey, which took an average of 8 minutes to complete. At the end of the survey, the SONA database automatically assigned the student research credit or extra credit depending on their preference. There was no component of deception present in this study.

RESULTS

We hypothesized the score on The Rosenberg Self-esteem Scale (Rosenberg, 1965) would predict the score on The Duke University Religion Index (Koenig, 2010) with a higher score on one predicting a higher score on the other. Additionally, we hypothesized this relationship would weaken depending on the score on the Secure Attachment subsection in the full Attachment Style Questionnaire (ASQ; Van Oudenhoven, Hofstra, & Bakker, 2003). The Rosenberg Self-esteem Scale (Rosenberg, 1965) was scored such that items 2, 5, 6, 8, and 9 were reverse scored (these response scores were subtracted from the highest possible response score + 1), then the average of the responses (1 – 4 scale) across the 10 items was taken. Higher values reflected greater self-esteem. To score The Duke University Religion Index (Koenig, 2010) the (summed) raw score for items 1 – 5 was assigned as the participants’ Religiosity Score. This combines the overt, non-overt,

and intrinsic religiosity sub-scales. The full Attachment Style Questionnaire (ASQ; Van Oudenhoven, Hofstra, & Bakker, 2003) was scored such that the items 3, 7, 15 were reverse scored (these responses were subtracted from the highest possible score + 1), then the average of the secure sub-scale items (secure = items 1, 3, 7, 9, 12, 13, 16, 20) were averaged and assigned as the DSA. The averages of each sub-scale item category (fearful = 2, 4, 18, 21; preoccupied = 6, 8, 10, 15, 19, 22; dismissing = 5, 11, 14, 17) were assigned as the Fearful

Main Effects Separate exploratory bivariate linear regressions were conducted between self-esteem and each attachment style. A bivariate linear regression was appropriate as there was one predictor variable (selfesteem) and one outcome variable (an attachment style) per linear regression. Additionally, there was only one set of data for each of the analysis due to the between-subjects design of the study. An F-test was conducted within each bivariate linear regression to determine the significance of the bivariate linear

“A child’s environment and relationship with caregivers have shown to have a deep and permanent effect on the development of their self-esteem.” Attachment Score, Preoccupied Attachment Score, and Dismissive Attachment Score, respectively. The scores from the ASQ scale are quantitative and on an interval scale. A bivariate linear regression was performed on religiosity (predictor variable) and DSA (outcome variable) to test the hypothesis of a significant relationship between the two variables. A bivariate linear regression was appropriate because the variables were continuous. Within the bivariate linear regression, an F-test was used to test the significance of the bivariate linear regression. The bivariate linear regression (and included F-test) found the relationship between these two variables as non-significant (see Table 1) [F(1,101) = 1.86, p = .176]. A multiple linear regression was not performed to determine the moderation effect of self-esteem on the relationship between religiosity and DSA, as the relationship between the two was determined nonsignificant, leaving no possibility of a moderation effect by self-esteem. There was no relationship between religiosity and DSA, therefore, self-esteem could not weaken the relationship. Overall, there was no relationship between religiosity, DSA, and/or self-esteem present in the data.

regression. Main effects between self-esteem and all attachment styles (measured through bivariate linear regressions) were found significant (see Figure 2). The bivariate linear regression (and included F-test) found significant relationships between self-esteem and DSA (degree of secure attachment) [F(1, 101) = 8.445, p = 0.004499, R2 = .07716], preoccupied attachment [F(1, 101) = 62.69, p = 3.239e-12, R2 = .383], fearful attachment [F(1, 101) = 15.4, p = .0001, R2 = .132], and dismissive attachment [F(1, 101) = 18.43, p = 4.054e-05, R2 = .154]. In other words, there was a significant positive relationship between self-esteem and DSA as well as self-esteewwm and dismissive attachment. There was also a significant negative relationship between self-esteem and preoccupied attachment as well as self-esteem and fearful attachment (see Figure 2).

DISCUSSION

This study seeks to identify if there is a relationship between religiosity and DSA and further, if this relationship is affected (moderated) by selfesteem. We did not find a significant relationship between religiosity and

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DSA; further, self-esteem was not a moderator as moderators affect existing relationships between variables. However, exploratory tests showed a significant positive relationship between high selfesteem and secure attachment as well as dismissive attachment. They also showed a significant negative relationship between high self-esteem and preoccupied attachment as well as fearful attachment. Data on the nature of the relationship between religiosity and DSA was mostly absent from literature, additionally, no prior research had looked at the relationship between religiosity, DSA, and self-esteem prior to this study. These results are significant in that they shed light on the relationship between key variables associated with well-being/life satisfaction. There is conflicting prior research on the relationship between each attachment style and self-esteem, with various studies finding different relationships as well as non-significant relationship between different attachment styles. Our results contribute to that research area finding significant relationships between all attachment styles and self-esteem, as well as the specific type of relationships. Additionally, our results provide support for the categorization of attachment styles by dimensions of anxiety and avoidance (see Figure 3). Overall, our findings show a significant difference between attachment styles and self-esteem, which relate to levels of anxiety (negative view of self). Our study found attachment styles corresponding to a negative view of self (higher anxiety) were also linked with lower self-esteem. Conversely, attachment styles not associated with negative view of self (lower anxiety) were linked with higher self-esteem. Prior research and our findings support the possibility of a clinical application of the relationship between attachment style and selfesteem. While the exact nature of their relationship is not known, through addressing either attachment style or self-esteem in treatment, a patient’s non-addressed trait, either self-esteem 38

or style) may be able to improve/move to be more secure. Limitations As with any study that utilizes self-report measures, there is an uncertainty as to the accuracy and reliability of the responses collected from each individual. This is due to both uncertainty of the participant in questions requiring emotional clarity to the participant purposefully choosing a more socially acceptable answer. To combat this, the participant was notified their answers were confidential. Additionally, all participants were recruited through the Johns Hopkins University SONA portal meaning all participants were undergraduate students at Johns Hopkins University (located in Baltimore, Maryland), between the ages of 18 -22, and participants were most likely enrolled in a Psychology course at the university (these are the classes which take SONA credit for extra credit). This convenience sampling has resulted in participants belonging to a population that may not be representative of all Americans. Participant data on religiosity was extremely right skewed the data set collected, meaning most participants scored low on religiosity. This non-normal distribution could have contributed to the non-significant relationship between religiosity and DSA. A conventional method of correction should be applied in the future Prior research shows the RSES reliability is significantly increased with the use of an 11- point scale instead of a 4-point scale (Xu & Leung, 2018). Unfortunately, given scoring restraints the RSES was administered with a 4-point scale although an 11-point scale is recommended going forward. Additionally, the RSES has shown to have limited validity due to cultural differences between participants affecting the interpretations of the items (Gnambs, et al., 2018). While the study was administered in English in the United States, international student responses were not controlled for – this should be controlled for going forward. Future Directions In order to improve upon the reliability of the self-report measures, future studies should explore the possibility of behavioral measures

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to operationalize the self-report measures for all variables. Given the non-normal distribution of religiosity scores, a replication is recommended. Additionally, future studies should explore the causality of self-esteem and attachment styles in order to better understand their relationship and improve the potential for application in a clinical setting.

CONCLUSION

A significant relationship between religiosity and DSA was not found, signifying a moderation effect by selfesteem could not have been present. However, significant relationships between all attachment styles and self-esteem were determined and provide support for the dimensional (anxiety and avoidance) approach to mapping attachment styles (Figure 3). Additionally, the relationship between attachment styles and self-esteem should be explored further for application in a clinical setting (such as therapy, psychiatry).

REFERENCES

Ainsworth, M. D., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum. Baghteyfouni, T. K., Sogolitappeh, F. N., Baghteyfouni, Z. K., Raaei, F., & Sharbafzadeh, A. (2015). The Relationship between Attachment Lifestyle with religious attitudes and anxiety. International Journal of Scientific Management & Development, 3(3), 993–997. Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2009). The first 10,000 adult attachment interviews: Distributions of adult attachment representations in clinical and non-clinical groups. Attachment and Human Development, 11, 223–263. Bowlby, J. (1973). Attachment and loss: Separation: Anxiety, and anger (Vol. 19). New York: Basic Books. Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult attachment: An integrative overview. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships (pp. 46–76). New York: Guilford. Çevik, G. B. (2018). The roles of attachment styles, anxiety, and communication skills in the prediction of self esteem in university students. Journal of Educational Sciences & Psychology, 8(1), 90–103. Cho, Y. Y., & Choi, B. D. (2017). The effects of intrinsic extrinsic religious orientation on meaning of life, and well-being focusing on the mediating effect of university students’ recognition of death. Studies in Religion, 77(3), 67–92. Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship

HUMANITIES & SOCIAL SCIENCES quality in dating couples. Journal of Personality and Social Psychology,58(4), 644-663. Crugnola, C. R., Tambelli, R., Spinelli, M., Gazzotti, S., Caprin, C., & Albizzati, A. (2011). Attachment patterns and emotion regulation strategies in the second year. Infant Behavior and Development,34(1), 136-151. Gnambs, T., Scharl, A., & Schroeders, U. (2018). The structure of the Rosenberg Self-esteem Scale: A cross-cultural meta-analysis. Zeitschrift Für Psychologie, 226(1), 14–29.(Supplemental) Jonas, E., & Fischer, P. (2006). Terror management and religion: Evidence that intrinsic religiousness mitigates worldview defense following mortality salience. Journal of Personality and Social Psychology, 91(3), 553–567. Lace, J. W., & Handal, P. J. (2018). Confirming the Tripartite Structure of the Duke University Religion Index: A Methodological Approach. Journal of Religion & Health, 57(2), 704–716. Li, X., & Zheng, X. (2014). Adult Attachment Orientations and Subjective Well-Being: Emotional Intelligence and Self-esteem as Moderators. Social Behavior and Personality: An International Journal,42(8), 1257-1265. Mikulincer, M., Dolev, T., & Shaver, P. R. (2004). Attachment-Related Strategies During Thought Suppression: Ironic Rebounds and Vulnerable Self-Representations. Journal of Personality and Social Psychology, 87(6), 940–956. ht Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood. New York, NY: Guilford Press. Nanu, D. E. (2015). The Attachment Relationship with Emotional Intelligence and Well-Being. Journal of Experiential Psychotherapy / Revista de PSIHOterapie Experientiala, 18(2), 20–27. Khaledian, M., Moradi, S., Tavhidi, A., & Shaikhzekariaee, V. (2013). The Relationship between Attachment Lifestyle with Depression and Anxiety of the Political Students. Open Journal of Social Science Research, 1(5), 115. Koenig, H. G., & Büssing, A. (2010). The Duke University Religion Index (DUREL): A Five-Item Measure for Use in Epidemological Studies. Religions, 1(1), 78-85. Orth, U. (2018). The family environment in early childhood has a long-term effect on self-esteem: A longitudinal study from birth to age 27 years. Journal of Personality and Social Psychology, 114(4), 637-655. Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press. Stern, S., & Wright, A. J. (2017). Discrete Effects of Religiosity and Spirituality on Gay Identity and Self-esteem. Journal of Homosexuality,65(8), 1071-1092. Tasca, G. A., Ritchie, K., & Balfour, L. (2011). Implications of attachment theory & research for the assessment and treatment of eating disorders.Psychotherapy, 48(3), 249-259. Developmental Processes across the First Two Years of Parenthood: Stability and Change in Adult Attachment Style. Developmental Psychology, 54(5), 975–988. Verschueren, K., & Marcoen, A. (1999). Representation of self and socioemotional competence in kindergartners: Differential and combined effects of attachment to mother and father. Child Development, 70(1), 183–201. Waldron, J. C., Scarpa, A., & Kim-Spoon, J. (2018). Religiosity and interpersonal problems explain individual differences in self esteem

among young adults with child maltreatment experiences. Child Abuse & Neglect,80, 277-284. Waters, E., Merrick, S., Treboux, D., Crowell, J., & Albersheim, L. (2000). Attachment security in infancy and early adulthood: A 20-year longitudinal study. Child Development, 71, 684–689. Xu, M. L. and Leung, S. O. (2018), Effects of varying numbers of Likert scale points on factor structure of the Rosenberg Self‐ Esteem Scale. Asian J Soc Psychol, 21: 119-128. Yang, J. Y. (2010). The relationship among orientations to happiness, religiosity and subjective well‐being in adolescents. (Master’s thesis). Myongji University, Seoul, Korea. Yang, Q., Tian, L., Huebner, E. S., & Zhu, X. (2018). Relations among academic achievement, self-esteem, and subjective well-being in school among elementary school students: A longitudinal mediation model. School Psychology Quarterly. (Supplemental) You, S., & Lim, S. A. (2019). Religious Orientation and Subjective Well-being: The Mediating Role of Meaning in Life. Journal of Psychology & Theology, 47(1), 34–47.

ALEXA M. CILLIA Class of 2021. Alexa is majoring in Psychology and Spanish. She currently works as a research assistant in Dr. Papadakis’ Clinical Psychology Lab, which studies the association between co-rumination, depression, and friendship closeness. She intends to pursue a PhD in Clinical Psychology and is interested in studying the effects of violence exposure in children and corresponding protective and risk factors.

FIGURES

Table 1. Bivariate Linear Regression Figure 1. Hypothesized relationship

between Predictor Variables and Outcome Variable.

between variables Religiosity and DSA outlined above. The Relationship is not significant with [F (1,101) = 1.86, p = .176].

Figure 2. Scatterplots demonstrating bivariate linear regression models between at-

tachment styles and self-esteem. Not: DSA = secure att., the descriptor ‘low self-esteem’ indicates a low score as higher self-esteem and a high schore as lower self-esteem. Hopkins Undergraduate Research Journal

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TRANSITION:An Economic Analysis of Tr a n s g e n d e r B e h a v i o r Julia Aurelia Glass ABSTRACT

This paper uses an economic decision-making framework of dynamic optimization to model the

transition behavior of transgender people. Although medical guidelines imply that people either need to transition or not, a continuum of gender dysphoria likely reflects reality more accurately. When approached from this perspective, analyzing the transition decision reveals the existence of the “marginal transgender person” who may face higher costs than benefits from transitioning. I also explore the role of information asymmetries in the transition decision.

INTRODUCTION

Despite growing public awareness of transgender people, the decision-making process that results in a transition — the process of reintegrating oneself into society in one’s preferred gender role — remains poorly understood. Decades of misguided or nonexistent research leave health care providers with inadequate or incorrect knowledge, although many organizations such as the World Association for Transgender Health strive to combat this information gap. Rigorous application of decisionmaking theory to the reality of transgender peoples’ lives could shed light on the real benefits people can expect from transition and the real costs they will incur, but no such research exists. In this paper, I will use an economic model of dynamic optimization to analyze conventional wisdom about transition benefits. Gender dysphoria is defined as distress caused by a difference between the gender one identifies with and the gender one is treated as, and medical literature currently approaches gender dysphoria as binary. It follows that only a change in gender role can alleviate dysphoria (American -Psychiatric Association 2013). A decision-making framework models this assumption as a binary variable, by which one either 40

receives a great deal of benefit from transitioning, or does not. However, medical literature also acknowledges the possibility that gender dysphoria may actually exist on a spectrum, and individuals may suffer from varying degrees of gender dysphoria, with correspondingly varying benefits from transitioning. Under this alternative assumption, the binary variable becomes continuous. Transitioning unfortunately has its associated costs, and it follows under the continuous assumption that some individuals face expected benefits nearly equal to costs. These individuals, who I refer to as “marginal transgender people,” are ignored under the binary assumption. If the continuous assumption holds true, marginal transgender people may suffer inefficiencies, or loss of benefit, under policies made with a binary assumption. The binary assumption lumps all transgender people into a single group and assumes that nearly all enjoy large benefits that outweigh the costs of transition. However, marginal transgender people do not enjoy such uniformly large benefits, introducing the possibility that those benefits fail to outweigh their costs under current transition procedures. The binary assumption obscures these reduced benefits, exacerbated by the difficulty of knowing one’s true transition costs and benefits. The

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results could also suggest the necessity of improved policies to enhance transgender welfare and serve the marginal transgender person.

DYNAMIC OPTIMIZATION INTRODUCTION Transition costs and benefits.

Transition has the potential to bring enormous benefits, both through improved overall happiness and the knock-on effects of better health. The American Psychiatric Association (2013) associates gender dysphoria with a range of negative consequences, from damaged relationships to social stigma and even interference with routine life. Transition consists of interventions that reduce or eliminate the often extreme negative feelings associated with living in the wrong gender role by targeting specific differences between oneself and oneself as the opposite gender. For instance, an early survey of patients who received gender-confirmation surgery as part of their transition revealed high satisfaction rates, from 87% among those who transitioned from a male to female role, and 97% among those who transition from female to male (Green & Fleming 1990). Satisfied patients feel free to pursue more natural sexual roles, wear more gender-appropriate clothing, and enjoy life in their bodies

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without the dissonance of having the incorrect genitalia. However, transition, unfortunately, carries both financial and social costs. Transitioning can be extremely expensive; transgender people must not only pay for costly medical procedures but also new clothing, new identification documents, and a myriad of other procedures. Social costs stem directly from the hostility and ignorance many transgender people encounter, in part due to lack of awareness — only 16% of Americans could even claim to personally know a transgender person as recently as 2015 (Adam & Goodman 2015). Transgender people can undergo the insecurity of maintaining their pre-transition social networks, and the very first Supreme Court case touching on transgender rights concerns whether they must fear losing their jobs after transitioning. Transition incurs opportunity costs as well, since transitioning requires a great deal of time, often years. The dynamic optimization framework. To model transitioning, we need to take timeframe into account, since some costs impose themselves immediately while others remain over time, and benefits take time to accrue but last the lifetime of an individual. Economists approach such problems with a dynamic optimization model, under which an individual makes a choice, , that carries a probability of affecting a state variable in the future. The binary choice variable represents whether a person transitions ( = 1) or not ( = 0). We refer to as “health capital,” and use this binary variable to represent the overall “healthiness” of a person. When a person is in the “high” health state ( = 1), they will have a benefit relative to the “low” health state ( = 0), due to increased physical well-being or earning potential. We would like to isolate the impact of transition on this increase, and so a high health state should be understood as the health state of a person living in their preferred gender role. Thus, a transgender person will probably start in the low health state but move to the high following transition. The decision to transition could carry associated costs however. The current-period utility given by Equation 1 represents

the difference between the benefits of an improved health state, , and the cost of transition, , depending on an individual’s health state and transition choice at the given moment; both and are always greater than zero. Since transition brings benefits and costs now and into the future, this utility must be considered both in the present period and in subsequent periods in a person’s life. Equation 2 reflects this optimization over time. A person seeks the highest utility given their health state and so chooses a = 0 or 1 that maximizes the sum total of their utility in the current period, , and in every future period. The value 0 < < 1 discounts future utility, because people uniformly value future benefits less highly than present benefits. A person’s choice of will have a certain probability of moving them to either the high or low health states in the next period, given by and, respectively, thus maximizing.

model accommodates this assumption through the choice-dependent probabilities of moving between health states. We introduce a binary variable that represents transition propensity. This variable takes a value of one if a person meets the medical definition of transgender, and zero if that person does not. A transgender person should definitely move to the high health state if they transition, and definitely remain in the low health state if they do not; in other words, when = 1, = 1 and = 0. Conversely a non-transgender person should move to the low health state by transitioning, so when = 0, = 0 and = 1. Therefore, the probabilities of moving between health states given transition choice can be rewritten in terms of . To analyze behavior of transgender and non-transgender individuals, we refer to the condition under which a person transitions, given by Equation 3 where utility of transitioning must exceed the utility of not doing so.

“it is my hope that the theoretical framework I developed encourages future economics research on transgender decision making with sincerity and sensitivity. The binary assumption. Medical literature implicitly assumes a binary distribution of transgender people by focusing on a diagnosis of gender dysphoria. Under the standards set in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, widely trusted as criteria for diagnosis, gender dysphoria revolves very specifically around the discrepancy between assigned gender and “experienced/expressed” gender. The language of experience and expression defines transition, since transgender people only realistically express or experience their desired gender role through concerted effort to live that role. Under the binary assumption, realistically nontransgender people should never meet these criteria for gender dysphoria, and the population can be segregated along gender dysphoric lines. Our binary dynamic optimization

When the terms from Equation 2 are rewritten in terms of and substituted into Equation 3, the transition condition becomes Equation 4 where expected utility, described by the discounted improvement in utility due to health state improvement in the future, must outweigh the upfront cost of transitioning given by . Binary transition propensity results in clear behavior: when = 0, the left-hand term is and cannot exceed transition cost, so non-transgender people will never transition. However, when = 1, a transgender person will transition as long as costs are low compared to future-discounted utility improvement . Only transgender individuals, with a propensity of = 1, can expect a uniformly high positive utility from transition, whereas non-transgender individuals would not achieve any sort of increase in utility from transition (Figure 1). Among transgender

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individuals — those in the upper half of the graph of Figure 2 — costs still play a role; only individuals who fall in the shaded quadrant, with a transition propensity of one but costs lower than, should transition, while those to the right face such astronomically high costs they should not. This behavior is consistent with the medical necessity theory, whereby only transgender individuals should invariably transition under sufficiently low costs. The continuous assumption. A binary distribution on transition propensity glosses over the wildly varying degrees of distress suffered by gender dysphoric people. Gender dysphoria might manifest itself in isolated ways, or entirely cripple one’s ability to function in society. It follows that alleviation of this dysphoria might bring minor benefits or radically improve one’s happiness. Thus a transition propensity variable continuously distributed on the interval [0,1], , reflects the existence of individuals with a partial inclination towards living in the opposite gender role. Taking this continuous transition propensity to represent the probabilities that a person moves between health states after transitioning, can be substituted directly for in Equation 2. The condition under which a person transitions now becomes Equation 5 where every individual in the population should transition so long as their expected utility exceeds cost . Benefits now follow a linear distribution dependent on transition propensity (Figure 3). The effects of transition propensity on benefits (Figure 3) allow the population to be separated into transgender and nontransgender individuals, with positive (> 0.5) and negative expected utilities (< 0.5) from transition respectively. A transgender individual contemplating transition must weigh their own transition propensity along with costs, and varying expected utilities among the transgender population split the transgender population into two parts (Figure 4). Transgender people in the shaded region still see an expected utility from transition greater than cost, and will transition. Additionally, some transgender people face higher transition costs than benefits; this group 42

falls in the upper-right-hand quadrant. However, there must exist transgender people who face bearable costs, but due to a low (but still greater than 0.5) transition propensity receive an expected payoff too low (although still positive) to justify those costs. These people fall in the unshaded region of the upper-left-hand quadrant, and we refer to them as marginal transgender individuals.

MARGINAL TRANSGENDER PEOPLE & IMPERFECT INFORMATION

If the continuous assumption holds true, many marginal transgender people would have greater costs than benefits from transitioning, despite being encouraged to do so under the binary assumption. Healthcare providers associate gender dysphoria with an ultimate goal of transition, due to the diagnostic criteria’s foundations under the binary assumption, linking diagnoses to the maximal improvement expected by people with high transition propensities. However, if transition propensity does indeed vary continuously, the cost of transitioning may need to be taken into account. If transgender people knew their transition propensities with perfect clarity, they would avoid this outcome, but the routes through which people learn about transition makes this challenging at best. Transgender individuals lack access to perfect information regarding both their transition propensities and the costs of transition. Transgender people invariably describe a great deal of uncertainty regarding their desire to live in the opposite gender role when faced with the daunting prospect of transition. Difficulty in ascertaining transition propensity can make it challenging to accurately predict the expected utility from transition. The costs as well vary markedly between individuals. Even financial costs change depending on the amount of treatment needed to life comfortably in a new gender role, desired lifestyle, and access to insurance coverage.

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Non-concrete costs, such as social rejection, isolation, or discrimination, remain cloudier still. This imperfect information can lead to inefficiencies for marginal transgender people. Regardless of the distribution of transition propensity, uncertainty regarding costs can lead to inefficiencies for transgender people close to the cost threshold, seen along the vertical line (Figure 2,4). For individuals whose actual cost falls to the left of this line, an overestimate of cost will discourage transition, while they would in fact reap benefits from living in a new gender role. Conversely, those to the right who underestimate costs may transition when costs actually exceed benefits.

CONCLUSION

In this paper, I used a model of dynamic optimization to reveal potential inefficiencies suffered by marginal transgender people under prevailing assumptions about transition behavior. This economic decision-making model revealed different behaviors depending on the assumptions made about the benefits people enjoy from transition. I interpreted existing medical literature under this framework using a binary distribution of transition benefits, where some people gain highly from transition, while the rest do not, and compared behavior to an alternate assumption whereby the benefits of transition vary continuously throughout the population. If that continuous model holds true, there exist marginal transgender people who might transition under the binary assumption but end up with a net loss. This model suggests policies could improve transgender welfare either by improving net benefits or reducing the inefficiencies suffered by marginal transgender people. Doubtless, advances in public acceptance of transgender people and advocates who push for reductions to transition cost improve the welfare of the transgender population. Financial burden reductions, such as enhanced insurance coverage for transition treatments, and a more welcoming social environment either increase net benefit for those who wish to transition

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or encourage some to transition who would have failed to do so in the past. Already a great deal of effort has gone into improving this aspect of the transition experiences, such as a widespread adoption of transition expense coverage under Medicaid (Movement Advancement Project 2019). Although financial costs can never be reduced completely, many of the costs associated with transition are purely social in nature, which can be overcome. As long as discrimination against transgender people in housing and employment, in interpersonal and romantic relationships, as children and as parents, continues to discourage marginal transgender people from seeking a fulfilling life in their desired gender role, such people needlessly suffer and leave society deprived of their potential contribution. Greater acceptance of the lives of transgender people brings benefits to everyone. The theoretical approach developed in this paper suggests new research should focus on the real distribution of transgender people throughout the population. I built the model and considered assumptions regarding transition propensities based solely on my observations that medical literature tends towards segregating gender dysphoric people from the rest, the transition process carries an enormous degree of uncertainty, and transgender people transition ultimately to live better, happier lives in their preferred gender role. Nevertheless, the validity of the binary and continuous assumptions cannot be ascertained without real data on people who attempt to transition. Having lived in fear for so long, transgender people remain cautious about sharing their experiences, resulting in little high-quality data on their behavior, and it is my hope that the theoretical framework I developed encourages future economics research on transgender decision making with sincerity and sensitivity.

ACKNOWLEDGE– MENTS I would like to thank Professor Nicholas Papageorge at Johns Hopkins

University, who not only taught me the economics principles used in this paper but also inspired me to consider my experiences in a new light.

EQUATIONS Equation 1. u(H,T) = θΗΗ - θΤΤ Equation 2. V(H) = maxTu(H,T) + β[P(H,T)V(1) + P(0 | H, T)V(0)] Equation 3. V(H)T=1 > V(H)T=0 Equation 4. β(2ω – 1)[V(1) – V(0)] > θT Equation 5. β(2Ω – 1)[V(1) – V(0)] > θT

FIGURES

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Julia Aurelia Glass Class of 2020. Aurelia is a graduating senior from Miami, Florida double majoring in Engineering Mechanics. She is involved in a range of activities, such as Kappa Alpha Theta, Alumni Student Ambassadors, and Hopkins Taekwondo. Aurelia’s unique experiences as a transgender woman lead her to explore the economic implications of this topic in depth. She plans on exploring more within the field at the School of Advanced International Studies at Johns Hopkins University. Hopkins Undergraduate Research Journal

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Computational Analysis on the Relationship Between State Political Party Dominance and Lack of Health Insurance Daniel Habib BACKGROUND

Healthcare in the United States has recently gained a greater foothold in the political sphere, especially with Obamacare on the verge of repeal since the election of Donald Trump. Although President Trump has not been successful in completely eradicating the Affordable Care Act, he has been chipping away at it. President Trump signed in 2017 and enacted in January 2019 the Tax Cuts and Jobs Act to repeal the Obamacare individual mandate that puts a punitive tax on citizens in certain socioeconomic groups if they do not have health insurance. According to Reuters, the Congressional Budget Office estimates that this repeal will increase the number of uninsured Americans by a staggering 13 million (1). With no financial incentive to continue paying for premiums, fewer young, and hence typically healthy, people feel inclined to pay for insurance. Health insurance providers with a greater proportion of sick people and surging costs would be forced to increase premiums, further widening the healthcare gap. As a result of unaffordable health insurance, utilizing preventative care may even more frequently take a back seat in favor of risking sporadic, expensive emergency room visits when preventable, 44

progressively worsening health issues suddenly become urgent. Knowledge of insurance disparities takes us one step closer to ensuring assistance for the uninsured. Current research initiatives, such as SToP Glaucoma of the Wilmer Eye Institute of Johns Hopkins Hospital, are aimed at determining optimal methods of providing health services to the uninsured and would benefit from insurance demographic research. Understanding which states fall above and below the national average rate of uninsured Americans is key in properly addressing the issue of healthcare in the United States on a case-bycase basis. A shift away from a one-size-fits-all mentality may be useful when supplementing public insurance with region-specific programs, which take into account both political party dominance as well as exceptional local disparities. For example, regions with lower rates of uninsured citizens may benefit more from small scale free clinics, while areas with higher uninsured rates may require a more comprehensive approach to keep pace with demand. Matlab-generated analysis of raw data retrieved from the United States Census Bureau and Gallup compares the uninsured rate of each region to the national

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average in order to evaluate the relationship between uninsured rates and regional political party dominance in 2017, the year the Tax Cuts and Jobs Act was signed (2-3).

METHODS

Data of uninsured rates with error margins of each state, the District of Colombia, and the United States as a whole were obtained from the 2017 census conducted by the USCB (2). Data of political party dominance in 2017 were obtained from Gallup (3). Another raw data set from the USCB was used to compare the poverty rate in Democrat and Republican states (4). Analysis and computation were conducted using the MATLABÂŽ 2017 version, MATLAB_R2017b (Figure 1). The bar graphs of uninsured population discrepancy with the national average were color coded according to which political party affiliation was dominant in each respective region in 2017. Solid regions had a ten or higher percentage point advantage, lean regions had only a five to nine-point advantage, and competitive regions had a dominant party discrepancy below five percentage points. In this paper, lean and solid democrat classifications were consolidated into just democrat regions, and lean and solid republican classifications were consolidated into republican

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regions for an adequate number of regions in each category on which more accurate statistical analysis could be conducted. Figure 1; Table 1

RESULTS

Figure 2; Figure 3 No significant correlation was found between poverty rate and the rate of uninsured residents in each state. Hence, the policies in Republicandominant states, rather than the poverty rates alone, are responsible for higher rates of uninsurance and do not adequately address the needs of the states’ impoverished and uninsured residents.

DISCUSSION

Unified action in solving America’s health insurance crisis seems further from reach as candidates at every level of government are pressured to the poles of the political spectrum. Many Republican states refuse to implement the federally sponsored Medicaid expansion offered by the Affordable Care Act of 2010, better known as Obamacare, due to its association with a Democratic president. On the other end of the spectrum, more radical Democrats want to overhaul Obamacare in favor of a singlepayer healthcare system. Partisan participation in what should be a bipartisan approach cannot solve the healthcare problem. Of the 15 states that opted against Medicaid expansion (Table 1), 14 have above-average rates of uninsurance and 10 are Republican (4-5). Competitive Wisconsin is the only exception to the trend, while the uninsurance rates of Republicandominant Oklahoma, Wyoming, and Mississippi are notably higher than the national average (4-5). A potential confounding factor is that some Republican states that opt out of Medicaid expansion, such

as Mississippi, are very poor (4). This may account for higher rates of uninsured residents. Hoever, the below-average poverty rates of Wyovming, Utah, and Missouri fail to corroborate this theory (4). Moreover, three more of the ten Republican states have poverty rates from the national average by less than one percent (4). The four remaining Republican states, which show more significant differences, may implicate poverty in higher uninsurance but fail to explain it

"People with little financial leeway are not so much making a choice as they are prioritizing basic necessities.” entirely (4). For example, Alabama has the second highest poverty rate of the ten Republican states, which refuse to expand Medicaid, yet has one of the lowest rates of uninsurance of these states (4). The possibility of an increase in the uninsurance rate, rapidly increasing premiums, and a shift away from preventative care raises the question of how to tackle the national crisis of uninsured Americans. Although a number of states prominently stood out from the trend, the majority of predominantly democrat areas have lower rates of people without insurance (Figure 2).

CONCLUSION

Considering political party allegiance is founded more times than not, though a shift away from the mentality of one size fits all is justifiable in supplementing public insurance with region-specific

programs, which take into account both political party dominance as well as other underlying disparities. The trend demonstrated by the graphs highlights the failure of Republican states to implement more accessible and effective healthcare. People with little financial leeway are not so much making a choice as they are prioritizing basic necessities, such as housing and food, over investing without immediate payoff. Obviously, an individual voter’s political affiliation does not directly affect that person’s ability to get insurance. Nevertheless, the refusal of several Republican states to participate in the Obamacare expansion of Medicaid to adults living under 138% of the federal poverty line has profound consequences (5). Small-scale health clinics may be more feasible in Democrat dominant regions since the demands are likely to be lower proportional to those in republican areas, which would require more expansive political reforms to account for the greater percentage of uninsured people.

REFERENCES 1.

Abutaleb Y. (2017, November 8). Repeal of individual mandate would increase uninsured, premiums: CBO. Reuters, Politics. Retrieved from https:// www.reuters.com/article/us-usa-taxhealthcare/repeal-of-individual-mandate-would-increase-uninsured-premiums-cbo-idUSKBN1D820Q. 2. Berchick ER et al. (2018, September 12). Health Insurance Coverage in the United States: 2017. United States Census Bureau, Report No. P60-264. Washington, DC: U.S. Government Printing Office. 3. Gallup (2017). 2017 U.S. Party Affiliation by State. Retrieved from https://news. gallup.com/poll/226643/2017-party-affiliation-state.aspx. 4. Fontenot K et al. (2018, September 12). Income and Poverty in the United States: 2017. United States Census Bureau, Report No. P60-263. Washington, DC: U.S. Government Printing Office. 5. MACPAC (2019). Medicaid expansion to the new adult group. Retrieved from https://www.macpac.gov/subtopic/ medicaid-expansion/.

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FIGURES

Figure 1. (A) Calculation of signed discrepancy between the national uninsured rate and the uninsured percentage of each region. (B) Error calculation of each regionâ&#x20AC;&#x2122;s discrepancy. (C) Calculation of average discrepancy by political party dominance. N represents the number of values. (D) Error propagation of average signed discrepancies.

Table 1. Uninsurance and Poverty Rate Comparison of the 15 states that opted against Medicaid expansion (2-5). Figure 2. (Left) Average Signed Discrepancy between Percent of U.S. Uninsured Population Ntionwide and Percent of Uninsured Population by Political Party Dominance in 2017. Discrepancies of each region were compared, allowing for cross referencing with respect to each regionâ&#x20AC;&#x2122;s dominant political party affiliation (23). The line y = 0 represents the national uninsured rate, and the distance from this line to the end of each column represents the signed discrepancy between the uninsured rate of each region to the national uninsured rate. Figure 3. (Bottom) Signed Discrepancy between Percent of U.S. Uninsured Population Ntionwide and Percent of Uninsured Population by Political Party Dominance in 2017. The discrepancies of each region were averaged according to political party dominance and plotted in a separate figure to make more conspicuous the correlation between political party dominance and rate of uninsured people (2-3). The average signed discrepancy between the national uninsured rate and that of competitive, democrat, and republican states were found to be 0.04%, -2.70%, and 1.33% respectively.

DANIEL HABIB Class of 2022. Daniel Habib is a sophomore on the pre-medical track majoring in biophysics and minoring in bioethics. He is a teaching assistant for organic chemistry lab, cancer research assistant, hospice volunteer, and a discussion leader for MEDPanel. He is a Hippocrates Med Review contributor, focusing on topics at the intersection of bioethics, politics, and medicine. He believes that any obstacle can be overcome with people dedicated to making a difference. 46

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The Modern Immigration R e g i m e : P u b l i c C h a r g e , Tr a v e l Bans, and Asylum Fees Daniel G. Matthew INTRODUCTION

Since the early months of 2019, administrators in the Department of Homeland Security and United States Citizenship and Immigration Services have proposed an onslaught of rules and executive orders issued by Washington that aim to curb the inflow of family-based migration through policies that specifically target low-income immigrants and deny them access to work visas on the grounds that they would pose an undue burden on the American welfare system. The latest of a series of such rules forwarded by the White House is a proposal issued by the Department of Homeland Security to double the fee for the U.S. citizenship application, along with initiating other price hikes for legal immigrants in the new tentative fee schedule (Hackman, 2019). These laws disproportionately affect migrants from the Global South, where adjusted per capita incomes tend to be lower than in the rest of the world, and are designed to alter the demographic composition of immigrants to the United States to favor merit-based immigration and reduce chain migration. However, such policies are nothing new. The ascriptive modern immigration regime engineered by the current administration is a point of continuity in a long history of U.S. immigration laws based on deeply inegalitarian and illiberal ideas about citizenship based on race and nationality, supporting a “multiple traditions” view of American political culture. This article explores the extensive historical precedent that supports this analysis, examining in turn the arguments for open and closed immigration regimes, the history of immigration law with a focus on the major developments that have led to the current system, and

specific immigration laws that have been enacted or proposed since the election of Donald Trump in 2016.

OPEN IMMIGRATI– O N SYSTEM

An assessment of the character of the modern American immigration regime and the extent to which it is a protraction of historically illiberal policies would be inadequate without first defining the parameters of liberal and ascriptive immigration regimes. A liberal immigration regime is one whose policies reflect a certain openness and acceptance toward people born outside a country’s borders. Douglas Nelson, a professor at Tulane University, describes the core elements of a liberal immigration regime as including “individual freedom to make migration choices, protection of property rights in labor and enforcement of legitimate contracts, and protection of [individual] rights” (Nelson). In effect, his definition implies a guarantee of some degree of autonomy for individuals to decide whether to enter or exit a country, as well as protection of individual and property rights, as requisite to classifying an immigration regime as liberal. Another article entitled “Political Theories of Migration” published in the Annual Review of Political Science by Sarah Song discusses the characteristics of open immigration regimes in terms of John Rawls’s liberal egalitarian theory of justice. In his 1971 book entitled “A Theory of Justice,” philosopher John Rawls attempted to theorize a utilitarian justification of a democratic political order centered around the concept of justice as fairness. He imagined a hypothetical position, called the original position, from

which a group of rational individuals in a closed society would have no knowledge of their economic or social circumstances— including facts about their race, sex, religion, education, intelligence, or skills— in their future lives and would be asked to decide what general principles should govern the political institutions under which they live (“Democratic Ideas”). From behind this “veil of ignorance,” rational individuals would adopt rules that guarantee all citizens a maximum and equal degree of liberty, establish equal opportunity, and distribute wealth such that those that are least well-off would be better-off than they would be in any other distribution. Song then references the work of another author, Joseph Carens, to illustrate how the device of the original position could be revised to adopt a global standpoint from which individuals would select principles of justice that apply to everyone in the world, not just to fellow citizens. From their position behind this expanded veil of ignorance, people would not know which country they would be citizens of and would therefore conceivably add “freedom of international movement” to the list of basic liberties that all individuals are entitled to. An article by The Intelligencer presents the features of a liberal immigration regime in more concrete terms: the article describes the paradigmatic liberal immigration regime as one that provides a pathway to citizenship for law-abiding undocumented citizens, prioritizes the unification of families, and objects to internal migration enforcement such as workplace raids.

CLOSED IMMIGRA– TION SYSTEM

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An ascriptive immigration system, on the other hand, is one that associates citizenship with some misconceived notion of ethnic or national identity, utilizing devices such as national origin-based quotas and literacy tests or, more recently, travel bans and increased citizenship fees to alter the ethnic composition of the inflow of migrants into a country. It produces policies motivated by “racial animosity” as described in Roger Smith’s “Beyond Tocqueville, Myrdal, and Hartz: The Multiple Traditions in America,” often creating a hierarchy that arbitrarily places different racial groups in a particular social status (Smith, 1993).

ASCRIPTIVE IMM– IGRATION POLICI– ES IN HISTORICAL PRECE DENT

The history of the American immigration system is marked by a centuries-old tradition of racially prejudiced legislation. We begin with a review of the 1882 Chinese Exclusion Act, considered the first significant law restricting immigration into the United States. Chinese workers began migrating to the U.S. in the 1850s to work in gold mines, agriculture, and factories. They came to the United States in order to avail themselves of the relative strength of the U.S. dollar and send money back to China to support their families. They also needed to repay their loans to the Chinese merchants who paid their passage to America. These financial pressures forced them to accept work for whatever wages they could, making them less expensive to hire than American workers who required higher wages to support their families in the U.S. (“Chinese Immigration”). Caving to domestic pressures to reduce competition in the labor market, the California state government passed a series of measures aimed at Chinese residents, ranging from requiring special licenses for Chinese businesses or workers to preventing naturalization outright. The legislation suspended Chinese immigration for 10 years and required every Chinese person traveling in or out of the U.S. to carry a certificate identifying his or her status as a laborer, scholar, 48

diplomat, or merchant. Six years later, the Scott Act made reentry to the U.S. after a visit to China impossible. The Chinese Exclusion Act thus represents an early instance of the U.S. government infringing on immigrants’ rights under the pretext of serving American interests, a precedent mirrored in recent immigration policies such as the Muslim ban of 2017.Another federal law enacted to restrict immigrants’ ability to enter the U.S. was the Immigration Act of 1924. The law limited the

that prevailed at its founding.” Instead, Smith argues, America has not always held true to such ideals but rather exhibited a more complex pattern of apparently inconsistent combinations of liberalism, republicanism, and ascriptive Americanism. The Immigration and Naturalization Act of 1965, for example, sidestepped tradition and abolished the previous system based on national origin. It established a new immigration policy based on reuniting immigrant families and attracting skilled labor to

“... history of the American immigration system is marked by a centuriesold tradition of racially prejudiced legislation.” number of immigrants allowed entry into the U.S. through a national-origins quota which restricted the number of annually available visas to two percent of the total number of people of each nationality in the United States as of the 1890 national census (“The Immigration Act of 1924”). Legislators chose the 1890 census in particular because it favored immigration from northern and western Europe and reinforced the “Asiatic Barred Zone” created by the Immigration Act of 1917, which extended the exclusion originally targeted at the Chinese to much of East Asia, the Pacific Islands, Turkey, Saudi Arabia, and the Polynesian Islands.

LIBERAL IMMIGR– ATION POLICIES IN HISTORICAL PRE– CEDENT However, racial prejudice against immigrants from the Global South has not motivated all federal immigration laws suggesting the validity of Roger Smith’s proposed multiple traditions view of American political culture. The multiple traditions thesis challenges the central claim of Alexis de Tocqueville’s magnum opus “Democracy in America,” that “America has been shaped by the unusually free and egalitarian ideas and material conditions

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the United States and brought about an increase in immigration from Asia, Africa, and Latin America. Similarly, the Immigration Act of 1990 established a “lottery system” that granted visas to qualified applicants randomly to replace the previous system that granted visas based on country of origin and increased the number of annually available visas threefold (“Immigration Act of 1990”). The legislation reflected characteristics of a liberal immigration regime, corroborating the view that American immigration has displayed multiple traditions in its policies, even if one tradition— ascriptive Americanism— has predominated. It might be tempting to look at the evidence and predict a line of best fit that charts a positive trend in immigration policy liberalization across time. To some extent this is true, inasmuch as later laws were spurred by contemporaneous movements that emphasized civil rights at home and international human rights abroad, as in the case of the Immigration Act of 1965. However, a number of counter examples refute this idea — the Immigration Act of 1986, for example, enabled workplace abuses such as discriminatory profiling and failed to deal with over two million illegal immigrants despite its focus on resolving the growing issue of illegal immigration in the 1980s (Moffett, 2019). And the more recent immigration pol-

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icies, such as those proposed or enacted since early 2019, would certainly defy this trend.

THE MODERN IMM– G R A T I O N R E G I M E: RECENT IMMIGRA– TION POLICIES Over the past three years, the Trump administration has tightened its grasp on the immigration system, pushing legislation that has targeted low-income immigrants and disproportionately affected individuals from Latin America, Africa, and Asia. The aforementioned new rule proposed by the Department of Homeland Security which proposes to double the filing fee for the Form N-400 application for naturalization, for instance, specifically targets the economic vulnerability of immigrants from the Global South where adjusted per capita incomes tend to be lower than in the rest of the world. Under the new fee schedule proposed by the rule, the naturalization application processing fee would increase a hefty 83% to a total price of $1170, DACA grantees would have to pay $275 fee to renew their legal-status permits, fee waivers to applicants with incomes below the federal poverty line would be eliminated, and asylum seekers to America would be asked to pay a $50 application fee for the first time (Hackman et al., 2019). The rule to increase citizenship fees proposed by the DHS violates the spirit of a liberal immigration regime by pricing out estimated thousands of lower-income immigrants most of them family members of native or naturalized U.S. citizens. The rule also contains a provision that would transfer money raised through the new fee schedule to Immigration and Customs Enforcement, the agency responsible for workplace raids, which further illustrates the illiberal nature of the proposed rule. As one critic describes it, the proposed rule amounts to a “wealth tax” on becoming a U.S. citizen (Hackman et al., 2019). In a similar vein, the White House released a proclamation in October stating that future immigrants would be required to prove they will obtain health insurance within thirty days of

entering the country or are able to cover “reasonably foreseeable” medical costs in order to be eligible to apply for visas (“Trump Proclamation Could”). A federal court recently blocked this rule, which came on the tail of the new “public charge” policy giving U.S. officials the authority to deny permanent legal status to immigrants who use public benefits (Hackman, 2019). The new health insurance requirement was projected to bar up to 65% of wouldbe green card holders, according to the Migration Policy Institute (Pierce, 2018). The rule— and the intentions underlying it— betrays a broader lack of commitment to the American ideals of liberalism and opportunity for those willing to work hard. Defending the policy by reasoning that “[i]mmigrants who enter this country should not further saddle our healthcare system, and subsequently American taxpayers, with higher costs,” President Trump circumvented Congress and the public by tapping executive power to expand the definition of “public charge” in a long-standing provision of existing immigration law (Hauslohner, 2019). Both the new health care requirement and the separate but related “public charge” rule are intended to shift the composition of migration inflows to increase merit-based migration and decrease family or “chain migration.”

clopædia Britannica, Encyclopædia Britannica, Inc., 18 Nov. 2019, Hackman, Michelle, and Alicia A. Caldwell. “Trump Administration Proposes Increasing Fee for U.S. Citizenship Application.” The Wall Street Journal, Dow Jones & Company, 9 Nov. 2019, www.wsj.com/articles/trump-administration-proposes-increasing-fee-for-u-s-citizenship-application-11573255094. Hackman, Michelle. “Judge Blocks Trump Administration’s Health-Care Requirement for New Immigrants.” The Wall Street Journal, Dow Jones & Company, 3 Nov. 2019, www.wsj.com/articles/ judge-blocks-trump-administrations-health-carerequirement-for-new-immigrants-11572746016. Hauslohner, Abigail, et al. “Trump Officials Move to Deny Green Cards, Path to Citizenship for Poor Immigrants.” The Washington Post, WP Company, 12 Aug. 2019, www.washingtonpost.com/immigration/trump-administration-aims-to-make-citizenship-more-difficult-for-immigrants-who-rely-on-public-assistance/2019/08/12/ fe3f8162-b565-11e9-8949-5f36ff92706e_story.html. “The Immigration Act of 1924” U.S. Department of State, U.S. Department of State, www.history.state. gov/milestones/1921-1936/immigration-act. Moffett, Dan. “Legacy of the Immigration Reform and Control Act of 1986.” ThoughtCo, ThoughtCo, 3 July 2019, www.thoughtco.com/immigration-reform-and-control-act-1986-1951972. Nelson, Douglas. On the Sustainability of A Liberal Immigration Regime. www.un.org/en/development/desa/population/events/pdf/other/turin/ NELSON.pdf. Pierce, Sarah, and Andrew Selee. “Immigration under Trump: A Review of Policy Shifts in the Year Since the Election.” Migrationpolicy.org, 22 Jan. 2018, www.migrationpolicy.org/research/immigration-under-trump-review-policy-shifts. Smith, Rogers M. “Beyond Tocqueville, Myrdal, and Hartz: The Multiple Traditions in America.” American Political Science Review, vol. 87, no. 3, 1993, pp. 549– 566., “Trump Proclamation Could Bar an Estimated Two-Thirds of Legal Immigrants.” U.S. News & World Report, U.S. News & World Report, www.usnews. com/news/national-news/articles/2019-10-07/ trump-proclamation-could-bar-an-estimated-twothirds-of-legal-immigrants.

CONCLUSION

All in all, although the ascriptive modern immigration regime finds precedent in a long history of ascriptive policies designed to keep out “undesirable” groups. The history of immigration law is replete with examples of legislation that have manifest anti-immigrant sentiment, along with comparatively short intervening moments of inclusive federal policies. This combination of traditions in immigration suggests the validity of the multiple traditions view of American political culture. As America moves into the future, the issue of immigration will likely find itself a battleground for the soul of the nation.

BIBLIOGRAPHY

“Chinese Immigration and the Chinese Exclusion Acts” U.S. Dept. of State, U.S. Dept. of State, accessed November 9, 2019. “Democratic Ideas from Pericles to Rawls.” Ency-

DANIEL G. MATTHEW Class of 2022. Daniel is a sophomore from southern California majoring in International Studies and Economics. As a member of Hopkins’ undergraduate pre-law community, he holds leadership roles as the president of the Financial Analysts Club, director of programming of JHU Law Review, and head leader of Economics PILOT program. His research intere`sts include immigration policy and migrant advocacy, inspired by his internship experience at Global Immigration Partners. He is currently working to establish HopHaven, JHU’s first student-run immigration clinic providing immigration assistance in Baltimore.

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DOES SELF ESTEEM MATTER IN REGARD TO RELIGIOSITY AND DEGREE OF SECURE ATTACHMENT?

27

HOPSITAL-ASSOCIATED INFECTSIONS: WHY ARE THEY STILL A PROBLEM?