Penn Healthcare Review Fall 2017

Where Business Meets Healthcare Editor-In-Chief Alisa Feldman

Editorial Aaron Lai (Managing Editor) Sophia Bussacca Grace Mock Vaishnavi Sharma Jason Grosz Elaine Ma

Strategy and Design Judy Choi, Co-director Chloe Le, Co-director Elaine Ma Alexis Megibow Sarah Nam

Business Catherine Ruan, Manager Saurabh Vasil, Manager Interested in writing for Penn Healthcare Review? Email wuhcpublications@gmail.com for more information.

Infographics except where indicated otherwise were designed by the Strategy and Design team members using Piktochart: “Easy to Use Infographic Maker.” Piktochart. https://piktochart. com/ Subscription to Pro Plan from 10/15/2017 to 11/14/2017.

Cover designed and graphically created by Chloe Le using Adobe Photoshop; image of the eye was photographed by Chloe Le then edited in Photoshop.

Dear Readers, It is with great excitement that I present to you the fourth issue of the Penn Healthcare Review.

The articles in this issue analyze a wide range of timely issues in health care, such as genetic testing, artificial intelligence, maternal and infant care, and much more. The featured articles elucidate the health implications of natural disasters and raise pressing questions about the medicalization of childbirth. We hope you will find these articles relevant and thought-provoking.

I want to thank all of the writers who wrote for this issue of Penn Healthcare Review, and our incredibly talented Editorial and Design Teams and Business Staff for helping bring this PHR issue to life.

Sincerely, Alisa Feldman Editor-in-Chief

C O N T E N T S WHARTON UNDERGRADUATE HEALTHCARE CLUB TECHNOLOGY & INNOVATION 4

HOW GENETIC TESTING RESEARCH AFFECTS 23ANDME AND ANCESTRY DNA CUSTOMERS

6

ARTIFICIAL INTELLIGENCE: HOW THE HEALTHCARE INDUSTRY IS EVOLVING

8

CRISPR: REVOLUTIONARY GENOME EDITING TECHNOLOGY

10

Grace Mock Hardi Patel Vraj Shroff

THE MICROFLUIDIC REVOLUTION: TECHNOLOGY THAT CAN REVOLUTIONIZE THE DIAGNOSTICS INDUSTRY Jason Grosz

12

FDA APPROVES THE FIRST IMMUNOTHERAPY, CAR-T Eric Shan

FEATURES 14

THE BIRTHING CRISIS Elaine Ma

OF NAUTRAL DISASTERS ON HUMAN HEALTH 16 THE CONSEQUENCES Sarah Nam

POLICY CHANGES 18

WHAT DOES REPEALING DACA MEAN FOR THE US’S HEALTH CARE SYSTEM? Arantza Rodriguez

OVERUSE: A DANGEROUS THREAT TO THE FUTURE OF HEALTHCARE 20 ANTIBIOTIC Karthik Prabhakaran

HEALTHCARE MANAGEMENT OF HEALTHCARE 22 PRIVATIZATION Gabrielle Ramirez PERSPECTIVES: FINANCING MATERNAL INFANT CARE IN SOUTH AFRICA 24 GLOBAL Sophia Busacca HEALTH MANAGEMENT 26 POPULATION Vaishnavi Sharma

FALL 2017 | PENN HEALTHCARE REVIEW | 3

TECHNOLOGY AND INNOVATION Title graphic designed by Chloe Le

A

s technology makes direct-to-consumer genetic testing easier, exhibited by the growth of popular brands 23andMe and Ancestry.com, the possibility of learning from DNA has allowed many to connect with their family and personal history in a unique way.

Customers can learn about their heritage and even connect with potential relatives online. However, the implications of genetic privacy in the digital age continue to concern many potential customers. This concern is amplified by the research done by major genetic testing companies and outside corporations with consumer genetic data.

When exploring the personal genome industry, 23andMe and AncestryDNA stand out as top products on the market. 23andMe differs from AncestryDNA in that 23andMe offers a Health and Ancestry option which expands beyond the ancestry search to also examine customers’ health data, including genetic health risks and carrier status for conditions such as Cystic Fibrosis for $199.1 23andMe and Ancestry.com offer a similar DNA ancestry test, priced at $99 2 and $79 3 respectively. These DNA tests are conducted through mail-in saliva samples taken through a painless mouth swab with results mailed back directly to the customer.

At 23andMe any genetic material submitted is stored at a secure biobank for at least one year and no more than ten years. ⁴ Once the saliva test is mailed in to Ancestry. com, it is stored in a third party lab without identifying information from customers, such as name or birthdate.⁵ Upon purchase customers must accept terms and conditions for the general DNA test, but both companies also provide an optional consent form for consumers to donate their genetic information to research through the companies 4 | PENN HEALTHCARE REVIEW | FALL 2017

after their ancestry report is made.⁶ Both 23andMe and Ancestry.com partner with a mix of academic, industry, and nonprofit groups to conduct genetic data research with the remaining banked saliva samples and resulting genetic database.⁷ 23andMe partners include the MRC Epidemiology Unit at Cambridge University, Broad Institute of MIT and Harvard, Pfizer, Genentech, Lupus Research Institute, the Michael J Fox Foundation, and National Parkinson Foundation.⁸ Notably, Biotech company Genentech purchased access to genetic data of customers with Parkinson’s for $10 million, demonstrating the potential for genetic testing companies to profit not only from test purchases but significant industry partnerships.9 Additionally, in 2016 23andMe opened a lab to start testing for treatment ideas based off their work in genetics research, hinting at an expansion into the pharmaceutical industry unprecedented for a DNA testing company.10 AncestryDNA also conducts genetic research, highlighting their Ancestry Human Diversity Project which partners with the USTAR Center for Genetic Discovery, the American Society of Human Genetics, Calico Life Sciences LLC, and the National Marrow Donor Program.11 Customers of both products are able to withdrawal from research at any time and opt for any remaining genetic material to be destroyed.12 Common research goals include furthering the study of history and migration and discovering links between genetic factors and human disease.13 Despite the guidelines for anonymous storage of genetic material by both companies, there is concern DNA can still be traced back to individuals as it is a

TECHNOLOGY AND INNOVATION

Infographic designed by Chloe Le

highly personal identifier. In 2014 Ancestry.com was subpoenaed by a New Orleans court to provide genetic data from one of their databases to evaluate a potential familial match of a suspect, causing concern for the use of stored genetic information in court cases.14 The genetic material obtained by the investigators resulted in clearing the suspect, but the use of the stored genetic material drew criticism in consequence. Additionally as government and healthcare hacking breaches become more common, the risk of insurance groups and employers gaining access to privileged genetic information concerns many. In case of a breach, the 2008 Genetic Information Nondisclosure Act (GINA) and 1996 Health Insurance Portability and Accountability Act (HIPAA) provide customers with certain protections.

Under GINA employers with more than 15 employees, including all federal agencies, cannot ask for or buy employee genetic information.15 GINA also prohibits US health insurance groups from using predictive genetic information to discriminate against those who carry genes for hereditary diseases, requesting genetic tests, restricting enrollment, or changing premiums based on potential

genetic information.16 The Omnibus Rule, added to HIPAA in 2013, classifies genetic information as protected health information, preventing its use in insurance plans, with the exceptions of life, disability, and long term care insurance.17 Overall, there are many benefits of using personal genome services for individuals and possibly even more for expanding the use of the genetic information to research for society. As genetic testing tools, and accompanying research initiatives advance, it is important that laws continue to prioritize genetic privacy. Customers must continue to remain informed about their option to engage or not engage in genetic research and decide if the privacy risks are worth the excitement of connecting with a new expanded personal history.

1.“Our Health + Ancestry DNA Service.” 23andMe. Accessed October 06, 2017. https://www.23andme.com/dna-health-ancestry/.

2. (“Our Health + Ancestry DNA Service.” 23andMe. Accessed October 06, 2017. https://www.23andme. com/dna-health-ancestry/.)

3. “DNA Tests for Ethnicity & Genealogy DNA Test.” AncestryDNA™ US. Accessed October 06, 2017. https:// www.ancestry.com/dna/.

4. 23andMe. “DNA Genetic Testing & Analysis.” 23andMe. Accessed October 06, 2017. https://www.23andme.com/about/biobanking/.

5. “Privacy for Your AncestryDNA Test.” Privacy for Your AncestryDNA Test. Accessed October 05, 2017. http://www.ancestry.com/cs/legal/PrivacyForAncestryDNATesting.)

6.“What Happens to Your Genetic Data When You Take a Commerical DNA Ancestry Test?” CitiGen. July 12, 2017. Accessed October 06, 2017. http://www.citigen.org/2017/07/12/what-happens-to-your-geneticdata-when-you-take-a-commercial-dna-ancestry-test/.)

7.“What Happens to Your Genetic Data When You Take a Commerical DNA Ancestry Test?” CitiGen. July 12, 2017. Accessed October 06, 2017. http://www.citigen.org/2017/07/12/what-happens-to-your-geneticdata-when-you-take-a-commercial-dna-ancestry-test/.)

8. 23andMe. “Becoming Part of Something Bigger.” Research - 23andMe. Accessed October 06, 2017. https://www.23andme.com/research/.

9.Regalado, Antonio. “23andMe Sells Data for Drug Search.” MIT Technology Review. July 08, 2016. Accessed October 06, 2017. https://www.technologyreview.com/s/601506/23andme-sells-data-for-drugsearch/.

10.Regalado, Antonio. “23andMe Sells Data for Drug Search.” MIT Technology Review. July 08, 2016.

Accessed October 06, 2017. https://www.technologyreview.com/s/601506/23andme-sells-data-for-drugsearch/.

11.“AncestryDNA Research and Collaboration.” AncestryDNA Research Collaborations. Accessed October 06, 2017. http://www.ancestry.com/cs/collaborations.

12. “What Happens to Your Genetic Data When You Take a Commercial DNA Ancestry Test?” CitiGen. July 12, 2017. Accessed October 06, 2017. http://www.citigen.org/2017/07/12/what-happens-to-your-geneticdata-when-you-take-a-commercial-dna-ancestry-test/ 13.“What Happens to Your Genetic Data When You Take a Commercial DNA Ancestry Test?” CitiGen. July 12, 2017. Accessed October 06, 2017. http://www.citigen.org/2017/07/12/what-happens-to-your-geneticdata-when-you-take-a-commercial-dna-ancestry-test/ 14.Mustian, Jim. “New Orleans Filmmaker Cleared in Cold-Case Murder; False Positive Highlights Limitations of Familial DNA Searching.” The Advocate. April 16, 2017. Accessed October 06, 2017. http://www. theadvocate.com/new_orleans/news/article_1b3a3f96-d574-59e0-9c6a-c3c7c0d2f166.html.

15. “Genetic Information Privacy.” Electronic Frontier Foundation. Accessed October 05, 2017. https:// www.eff.org/issues/genetic-information-privacy.

16. “What Is GINA?” 23andMe Customer Care. Accessed October 06, 2017. https://customercare.23andme.com/hc/en-us/articles/202907820-What-is-GINA-.

17. “Genetic Information Privacy.” Electronic Frontier Foundation. Accessed October 05, 2017. https:// www.eff.org/issues/genetic-information-privacy.

FALL 2017 | PENN HEALTHCARE REVIEW | 5

TECHNOLOGY AND INNOVATION

Title graphic designed by Sarah Nam

A

rtificial intelligence (AI) is dominating the healthcare industry. This statement should come off as no surprise since technology continues to pervade the healthcare sector, affecting how hospitals demonstrate care. However, as technology burgeons, a cloud of skepticism transcends technological advancement as people fear the loss of jobs that come with the expense of using robots. Nowadays, AI can solve a variety of specialized problems, in some cases even better than humans, but there is yet to emerge a single solution for AI to solve all problems simultaneously. This should comfort the skeptics of AI because industries that are digitized and inundated with rote work can only be subjugated to domination. The health industry is far from this description because each case of medicine is unique and individualized, says Andrew Ng, a Stanford University professor and former AI scientist at Alphabet Inc.’s Google who sat down with The Wall Street Journal’s global technology editor, Jason Dean, to explain why they believe the opportunities associated with this technology far outweigh the bad.1 Initially, artificial intelligence was introduced as a concept to mimic the human brain. AI largely enables the capacity to store and process copious amounts of data in a manner which translates information into functional tools.2 Since its inception in the healthcare sector, AI has been deployed to increase efficiency and enhance problem solving in specific areas where risk prediction is involved.

Now, the utilization of AI allows for better diagnosis, cure and treatment of debilitating conditions, according to Prasanna Vadhana Kannan who is a Research Analyst with Frost & Sullivan.2 According to the new market research report 6 | PENN HEALTHCARE REVIEW | FALL 2017

launched by Inkwood Research, the global artificial intelligence in healthcare market was valued at $1.21 billion in 2016 and is estimated to generate a net revenue of approximately $25.16 billion by 2025.3 The surge of global artificial intelligence in the healthcare market is primarily driven by growing investment by private firms. According to the world economic forum, in the year 2016 around 200 artificial intelligence based companies collectively invested in AI, which is valued at nearly $1.5 billion globally.3 Moreover, advancements in big data capabilities along with exponentially increasing healthcare expenditures are fueling the market globally.

Recent advances in the field of AI that are applicable to the health sector are drug discoveries, medical imaging and diagnostics, and patient data and risk analysis.

The world’s leading pharmaceutical companies are turning to artificial intelligence to improve the hitand- miss business of finding new drugs. Pharmaceutical giants, such as Merck & Co, Johnson & Johnson and Sanofi are exploring the use of AI to help streamline the drug discovery process.⁴ Their aim is to harness machine learning systems and databases of neural processes to predict how molecules will behave when treated with a drug, thereby saving time and money on unnecessary tests.⁴ AI enhances medical imaging and diagnostics.

Machine learning software is in place to assist medical professionals augment their approach in combating sickness. At the 2017 Health Information and Management Systems Society (HIMSS) annual conference in February, IBM/Merge, Philips, Agfa and Siemens demonstrated an integration of AI into their medical imaging software

TECHNOLOGY AND INNOVATION

systems.⁵ They showed how predictive analytics software can be used to limit unnecessary information (extensive history, past illnesses, etc.) that may be irrelevant to the case at hand when someone calls in sick, or if patient volumes increase.⁵ Others have equipped AI to quickly sift through massive amounts of big data or offer immediate clinical decision support for appropriate use criteria, the best test or imaging to make a diagnosis or even offer differential diagnoses.⁵ Patient risk analysis becomes more accurate with artificial intelligence. With technology in place that can measure patient symptoms and abnormalities that may not be evident to the naked eye, the detection of diseases

has become more detailed and profound.⁵ Doctors are able to detect early stage cancers and other life compromising illnesses with such technology, thus improving the chances of survival significantly.⁵ The use of AI is already becoming extensive in the healthcare industry, but its application is yet to be streamlined in all hospital settings. The U.S. Government has been preoccupied with health care reform, but this only involves discussion regarding insurance access and coverage. To truly improve our healthcare industry, discussion should shift to innovation with artificial intelligence leading the forefront.

Infographic designed by Sarah Nam 1. Andrew Ng, “The Optimistic Promise of Artificial Intelligence,” The Wall Street Journal, 13 June 2017, https://www.wsj.com/articles/the-optimistic-promise-of-artificial-intelligence-1497374822.

2. Prasanna Vadhana Kannan, “Artificial Intelligence Applications in Healthcare,” Asian Hospital & Healthcare Management, 6 October 2017, https://www.asianhhm.com/technology-equipment/artificial-intelligence 3. “Global Artificial Intelligence in Healthcare Market Forecast 2017-2025,” Inkwood Research, 6 October 2017, https://www.inkwoodresearch.com/reports/global-artificial-intelligence-in-healthcare-market-forecast-2017-2025/ 4. Ben Hirschler, “Big Pharma Turns to Artificial Intelligence to Speed Drug Discovery, GSK Signs Deal,” Yahoo! News, 1 July 2017, https://ca.news.yahoo.com/big-pharma-turns-artificial-intelligence-speed-drug-discovery-025733105--finance.html 5. Dave Fornell, “How Artificial Intelligence Will Change Medical Imaging,” Imaging Technology News,

24 February 2017, https://www.itnonline.com/article/how-artificial-intelligence-will-change-medical-imaging

FALL 2017 | PENN HEALTHCARE REVIEW | 7

TECHNOLOGY AND INNOVATION

Title graphic designed by Alexis Megibow

H

umans. A word that is synonymous with amelioration and hope is, on a deeper thought, also an implication of limitations. The history of human race is nothing but a race to be better: both from others and from our own selves. And to our credit, we have done pretty well -- we went from using stone for fires to finding water on intergalactic stone.1 However, we continue to face many problems worldwide: ischaemic heart disease and stroke cause 15 million deaths annually; cancer kills additional 8.2 million people, and dozens of other diseases wipe out millions of people every year.2 Additionally, every now and then a new virus will become active and threaten to wipe out the already struggling human race. The tussle of the human race, till this day, continues.3 This enduring struggle brings us to the core of this article -- CRISPR. WHAT IS CRISPR? CRISPR stands for Clustered Regularly Interspaced Short Palindromic Repeat.⁴ It refers to the unique organization of short, partially palindromic repeated DNA sequences found in the genomes of bacteria and other microorganisms. This immune system protects bacterial cells from invaders like viruses by destroying their genome.⁵ CRISPR has revolutionized the world in just over a decade.⁶ Within only a few years, research labs worldwide have adopted this new technology that facilitates making specific changes in the DNA of humans, other animals, and plants. In comparison to older laboratory techniques of modifying DNA, CRISPR is a lot more efficient.⁷ CRISPR is soon to be the gold standard of gene editing due to its 8 | PENN HEALTHCARE REVIEW | FALL 2017

highly sophisticated technique which allows researchers to even edit one single base pair.⁸ HOW WAS IT FOUND? In 1993, Francisco Mojica, from the University of Alicante in Spain, was the first to recognize autoimmune characteristics of CRISPR. Almost a decade later, in 2005, Alexander Bolotin from French National Institute for Agricultural Research discovered the Cas 9 protein and the characteristic sequence of DNA for every spacer, a sequence homologous to invader (viral) DNA, at one of the ends for target recognition. Later, thanks to numerous scientists, the technology kept up with the high hopes of the scientific community. Finally in 2003, a researcher at the Broad Institute and McGovern Institute for Brain Research of MIT and Harvard, Feng Zhang, became the first scientist to successfully adapt CRISPR-Cas9 system for genome editing in eukaryotic cells.⁹ HOW DOES CRISPR WORK? Interspersed beween the short DNA repeats of bacterial CRISPRs are short variable sequences called spacers, derived from DNA of previous invaders of the host bacterium. Thus, spacers serve as a genetic memory of previous infections. If the same virus attacks again, the CRISPR defense system will cut up any viral DNA sequence matching the spacer sequence and protect the bacterium from the attack. If a previously unseen virus attacks, a new spacer is made and added to the chain of spacers. Then the usual immune response proceeds to protect the host cells.10

TECHNOLOGY AND INNOVATION

Infographic designed by Alexis Megibow

The CRISPR immune system is a three-step process: • Acclimation -- DNA from an invading virus is cut into short segments that are inserted into the CRISPR sequence as new spacers.

• Formation -- Spacers undergo transcription, making short pieces called CRISPR ribonucleic acids.

• Destruction -- CRISPR RNAs guided molecular processes destroy the invader.11 Final words CRISPR is a new toy in the hands of curious scientists. It is immensely revolutionary and has great potential to help millions of people. It can be THE answer to every medical question.12 We can edit our genome to fix ourselves. We can make food disease resistant, eliminating starvation and malnutrition. We can replace mutations with functional DNA sequences. We can make ourselves stronger, smarter, more attractive, better...and we just hit the slippery slope. Greed can make the partition between fixing ourselves and improving ourselves quite porous.

Hypothetically, if some combination of the genome is incorporated within us for better characteristics, but we aren’t aware of its potential side effects, then it could put the entire gene pool at risk. Not only that, this can decrease our diversity as a whole, making us more prone to pandemics. Hence, CRISPR is a double-sided sword: it can make us better while posing an existential threat to (wo)mankind as well. Many ethical issues have been raised

regarding the unregulated use of the CRISPR technology.

The U.S. government and the international scientific community should take strict actions to keep an eye out on such research. If it makes sense that not everyone should have access to nuclear weapons then so should this.

Otherwise, we are just inviting extinction to the supper.13, 14

1. Culotta, Elizabeth, and Andrew Sugden. “Human Evolution.” Science | AAAS. July 26, 2017. Accessed November 06, 2017. http://www.sciencemag.org/topic/human-evolution.

2. National Cancer Institute. “Cancer Statistics.” National Cancer Institute. National Cancer Institute, n.d. Web. https://www.cancer.gov/about-cancer/understanding/statistics 3. World Health Organization. “The Top 10 Causes of Death.” World Health Organization. World Health Organization, n.d. Web. http://www.who.int/mediacentre/factsheets/fs310/en 4. Ibtissem Grissa, Gilles Vergnaud, and Christine Pourcel, “Clustered Regularly Interspaced Short Palindromic Repeats (CRISPRs) for the Genotyping of Bacterial Pathogens,” Methods in Molecular Biology Molecular Epidemiology of Microorganisms, 2009, , doi:10.1007/978-1-60327-999-4_9.

5. Richter, Corinna, James T. Chang, and Peter C. Fineran. “Function and Regulation of Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) / CRISPR Associated (Cas) Systems.” Viruses 4, no. 12 (October 19, 2012): 2291-311. doi:10.3390/v4102291.

6, 9. Broad Institute. “CRISPR Timeline.” Broad Institute. Broad Institute, 06 Jan. 2017. Web. https:// www.broadinstitute.org/what-broad/areas-focus/project-spotlight/crispr-timeline 7, 10, 11. Pak, Ekaterina. “CRISPR: A Game-changing Genetic Engineering Technique.” Science in the News. The Harvard University, 31 July 2014. Web. http://sitn.hms.harvard.edu/flash/2014/crispr-a-game-changing-genetic-engineering-technique 8. “New genome editing technique can target single letters of DNA sequence – LA Times.” Los Angeles Times. April 21, 2016. Accessed November 06, 2017. http://www.latimes.com/science/sciencenow/lasci-sn-a-crispr-base-editing-20160420-story.html.

12. Patterson, Thom, and Rachel Crane. “If it works, CRISPR gene editing will change our lives.”

CNN. October 30, 2015. Accessed November 06, 2017. http://www.cnn.com/2015/10/30/health/pioneers-crispr-dna-genome-editing/index.html.

13. “CRISPR gene editing can cause hundreds of unintended mutations.” Phys.org - News and Articles on Science and Technology. May 29, 2017. Accessed November 06, 2017. https://phys.org/ news/2017-05-crispr-gene-hundreds-unintended-mutations.html.

14. “Engineering Extinction: CRISPR, Gene Drives and Genetically-Modified Mosquitoes.” Bioethics Program. Accessed November 06, 2017. https://bioethics.las.iastate.edu/2016/09/20/engineering-extinction-crispr-gene-drives-and-genetically-modified-mosquitoes/.

FALL 2017 | PENN HEALTHCARE REVIEW | 9

TECHNOLOGY AND INNOVATION Title graphic designed by Elaine Ma

M

any of the breakthroughs in healthcare and medicine that reach the realm of popular culture focus on cures. Advances in cancer immunotherapy and anti-retroviral therapy dominate the scientific headlines and excite everyone from experts to laymen.1 For many ailments, however, treatment is not the only concern that doctors and scientists face. Sometimes, diagnosing a disease is just as hard if not harder than treating it; Tuberculosis is a prime example of this. The cure for Tuberculosis, for instance, is well-known amongst scientists and physicians.2 The TB treatment requires a cocktail of antibiotics such as rifampicin and isoniazid, and patients who finish their course of antibiotics are regularly cured.3 That being said, making cost effective TB diagnostics for developing countries continues to stump the scientific community.4 Microfluidics is a newly emerging technology that has the potential to revolutionize the diagnostics industry.5 Microfluidic chips consist of a series of channels and chambers that enable sub-milliliter volumes of fluid, such as blood or urine, to be precisely controlled.6 As fluid is directed through the chip, it comes into contact with devices and reagents that facilitate highly sensitive detection of biomarkers and disease indicators.7 Since they are cheap, self-contained, and easy to use, microfluidic chips often replace the need for trained medical personnel to conduct laboratory assays, such as ELISA and PCR, for diagnostic purposes.8 These advantages make microfluidics ideal for point-of-care use everywhere from cutting-edge hospitals in the United States to resource limited clinics in sub-Saharan Africa.9 One innovative application of microfluidics is in the detection of circulating tumor cells (CTCs) in the bloodstream of patients with cancer. CTCs are valuable for characterizing tumor type, enumerating metastatic progression, and monitoring relapse, but they are difficult to detect because they are exceedingly rare in the bloodstream.10 Studies estimate 10 | PENN HEALTHCARE REVIEW | FALL 2017

that for most types of cancer, there are only 1-100 CTCs per milliliter of blood.11 New research, including some from the University of Pennsylvania’s Issadore Lab, has demonstrated the ability of microfluidic chips to label CTCs with magnetic nanoparticles conjugated to tumor targeting antibodies.

Since the rest of the blood is naturally non-magnetic, once the CTCs are magnetically labelled, detectors similar to those in a computer’s hard drive can sensitively detect their presence.12 The ability to use different antibodies for different types of cancer enables this system to be a powerful and modular method for screening and monitoring different types of cancer.13 Microfluidic technologies are also transforming the way infectious diseases are diagnosed in the developing world.14 One example is in the diagnosis of Tuberculosis. Currently, TB is difficult to diagnose in settings where the disease burden is high.15 This is because PPD skin tests, which are the gold standard in the United States, do not directly detect TB bacteria- they detect antibodies for TB.16 In places like West Africa where TB prevalence is high, infants are given TB vaccinations that cause false positives on PPD tests.17 Other forms of diagnosing TB, such as cell culture and smear microscopy, are slow, rely on scarce laboratory personnel, and require reliable electricity and refrigeration. Research from Stanford University has demonstrated a promising way that microfluidics can replace these inefficient diagnostic procedures. They made a point-of-care that can accurately count TB cells present in a fluid sample without sophisticated laboratory infrastructure. The device does so by splitting the sample into droplets that contain one TB cell each. These droplets also contain a substrate that fluoresces in the presence of enzyme naturally produced by the TB cells.18 Fluorescence is then measured using photodetectors. One major advantage of this technology is that it digitalizes a process that is normally analog by only including one cell per droplet. This allows for more accurate measurements of cell number than

TECHNOLOGY AND INNOVATION

traditional spectroscopy. Similar microfluidic methods are also being used to diagnose other infectious diseases in the developing world, such as HIV/AIDS and malaria.19 In addition to their potential diagnostic capabilities, microfluidic technologies are also poised to revolutionize precision medicine and the drug development and regulatory processes. This is due to the emergence of organ-on-achip systems, which model organs such as the lungs and liver by seeding cells into microfluidic channels. The interface between the cells and the microfluidic channels can be used to model a range of cellular mechanisms, such as gas exchange in the lungs and antigen responses of immune cells.20 These organ-on-a-chip systems can be used in precision medicine by culturing a patient’s own cells on the chip to predict his/

her response to various treatments. They can also be used by large pharmaceutical companies for preliminary drug toxicity and efficacy testing. Going forward, the FDA will have to decide whether organs-on-a-chip can partially replace animal models in Phase I clinical trials and preclinical studies.21 Despite its recent development, microfluidics is an emerging technology that promises to reinvent how society approaches diagnostics, drug discovery, and disease modeling. Its power lies in the fact that microfluidic devices are small, self-contained, and cheap. Only the future can tell what impact they’ll have, but one thing is for sure: its impact will be far reaching, ranging from cancer to TB, from the U.S. to West Africa.22

Infographic designed by Elaine Ma 1. “Immunotherapy.” Popular Science. 2017. https://www.popsci.com/tags/immunotherapy.

2 .“Tuberculosis: Diagnosis and Treatment.” Mayo Clinic. 2017. Accessed November 7, 2017.

3 .“Treatment for TB Disease.” Centers for Disease Control and Prevention (CDC). August 11, 2016.

4.“Tuberculosis Fact Sheet.” World Health Organization. October 2017. Accessed November 7, 2017.

5. Whitesides, George. “The origins and the future of microfluidics.” Nature 442 (July 27, 2006).

6. Ibid.

7. Ibid.

8. Teh, Shia-Yen, Robert Lin, Lung-Hsin Hung, and Abraham Lee. “Droplet Microfluidics.” Lab on a Chip, no.

2 (January 11, 2008).

9. Ibid.

10. Krebs, Matthew G., Jian-Mei Hou, Tim H. Ward, and Fiona H. Blackhall. “Circulating tumour cells: their utility in cancer management and predicting outcomes.” Therapeutic Advances in Medical Oncology 2, no.

6 (November 2010): 351-65.

11. Li, Peng, Zackary S. Stratton, Ming Dao, Jerome Ritz, and Tony Jun Huang. “Probing circulating tumor cells in microfluidics.” Lab on a Chip 13, no. 4 (February 21, 2013): 602-09.

12. Issadore, D., J. Chung, H. Shao, M. Liong, AA Ghazani, CM Castro, R. Weissleder, and H. Lee. “Ultrasensitive clinical enumeration of rare cells ex vivo using a micro-hall detector.” Science Translational Medicine 4, no. 141 (July 4, 2012).

13. Ibid.

14. Chin, Curtis et al. “Microfluidics-based diagnostics of infectious diseases in the developing world.”

Nature Medicine 17 (February 3, 2011).

15. ”Tuberculosis Fact Sheet.” World Health Organization. October 2017. Accessed November 7, 2017.

16. “Tuberculin Skin Testing.” CDC TB Fact Sheets. May 11, 2016. Accessed November 7, 2017.

17. Ibid.

18. Rosenfeld, Liat, Yunfeng Cheng, Jianghong Rao, and Sindy Tang. “Rapid detection of tuberculosis using droplet-based microfluidics.” Proceedings of the Society of Photographic Instrumentation Engineers 8976 (March 6, 2014).

19. Tay, Andy, Andrea Pavesi, Saeed Yazdi, Chwee Lim, and Majid Warkiani. “Advances in microfluidics in combating infectious diseases.” Biotechnology Advances 34, no. 4 (July & aug. 2016): 404-21.

20. Bhatia, Sangeeta, and Donald Ingber. “Microfluidic organs-on-chips.” Nature Biotechnology 32 (August 5, 2014): 760-72.

21. Kang, Lifeng, Bong Chung, Robert Langer, and Ali Khademhosseini. “Microfluidics for Drug Discovery and Development: From Target Selection to Product Lifecycle Management.” Drug Discovery Today 13 (January 2008): 1-13.

22. Whitesides, George. “The origins and the future of microfluidics.” Nature 442 (July 27, 2006).

FALL 2017 | PENN HEALTHCARE REVIEW | 11

TECHNOLOGY AND INNOVATION

O

n August 30, 2017, Novartis made history when its treatment became the first gene therapy approved by the FDA in the United States. Kymriah (tisagenlecleucel) was developed in collaboration with scientists at the University of Pennsylvania. It aims to treat young patients with B-cell precursor acute lymphoblastic leukemia (ALL), an aggressive type of cancer.1,5,6,8 B-cells are a type of white blood cell that help provide immunity to the body. Patients with ALL have a buildup of abnormal bone marrow cells that prevents the production of other necessary types of cells or of platelets.8 This therapy may be effective for patients whose cancer has resisted conventional therapy, or they have relapsed.1,5,6,8 Kymriah makes use of a specific kind of the patient’s own immune cells called T-cells. T-cells are part of our body’s immune system and can have killing function. T-cells typically circulate around our bodies and recognize foreign particles, such as those that are associated with disease.4,12 When these cells recognize the foreign particle, they can release granules that form holes in the membrane of the target and destroy important proteins in the inside of the infected cell.12

12 | PENN HEALTHCARE REVIEW | FALL 2017

Title graphic designed by Judy Choi

T-cells are extracted from the patient and genetically modified to express a chimeric antigen receptor (CAR). This directs the T-cell towards the leukemia cells. The lab grows the genetically modified T-cells so they can then be infused back into the patient’s body. They act as missiles to target a protein marker on cancerous cells. When the cells interact with the target protein marker, they become activated. What makes this drug unique is that the cells can persist in the body and thus create long-term remissions.1,2,5 These CAR-T cells target CD19, a protein on the surface of B-cells. CD19 is a great target because it is highly expressed in B cell malignancies. Thus, these CAR-T cells will also kill normal B-cells, resulting in a B-cell deficient condition called B cell aplasia.3,7 In the immune system, B-cells are typically used to produce antibodies. Antibodies are proteins that help defend against foreign particles.9 Without B-cells, the body will not be able to produce antibodies and thus be at higher risk of infection. However, research has shown this problem can be managed by administering antibodies intravenously into the patient.3,5,7 A more significant downfall of this treatment is cyto-

TECHNOLOGY AND INNOVATION

Infographic designed by Judy Choi

kine-release syndrome (CRS), which occurs as these infused cells interact with their targets and become “activated,” releasing large amounts of cytokines. This may cause symptoms like a high fever and low blood pressure, and CRS can be life-threatening.3,5 However, to combat CRS, the FDA has also expanded the approval of Actemra (tocilizumab). This has resulted in complete resolution for the majority of patients. Moreover, the FDA is requiring providers of Kymriah to be trained in recognizing and dealing with CRS.3,5 This treatment is priced at 475,000 dollars for a onetime administration. However, the manufacturer has said that it will only receive payment if the patient responds to it within the first month of administration via its outcome-based pricing model. This innovative model represents a shift away from rewarding based on number of doses administered and towards rewarding based on a successful cure. Under this model, drug companies are incentivized to develop new cures and find further applications for already existing drugs.

In addition, on the payer’s end, there is less risk of having to undergo multiple iterations of a treatment which builds up costs. Medical professionals expect this approach will enhance competition and lower prices.10 Moreover, this seemingly steep price tag is actually considered reasonable or even undervalued by some analysts, especially when compared to other therapies that may not work as well. For instance, stem cell transplants also costs hundreds of thousands.10,11

Novartis has introduced a novel therapy and a corresponding pricing model that is both effective and innovative.10 There are still issues and concerns with the therapy, but researchers are making significant progress towards improving all aspects of the CAR-T cell.2 This form of therapy has the potential to be applied to other types of cancer and can revolutionize the way we tackle the disease.2 1. Kaiser, Jocelyn. “Modified T cells that attack leukemia become first gene therapy approved in the United States.” Science | AAAS. August 30, 2017. Accessed October 08, 2017. http://www.sciencemag.org/ news/2017/08/modified-t-cells-attack-leukemia-become-first-gene-therapy-approved-united-states.

2. ”CAR T Cells: Engineering Patients’ Immune Cells to Treat Their Cancer.” National Cancer Institute. Accessed October 08, 2017. https://www.cancer.gov/about-cancer/treatment/research/car-t-cells.

3. Chimeric Antigen Receptor (CAR) T-Cell Therapy Facts. PDF. Leukemia & Lymphoma Society.

4. “Beginners Guide to T cells.” T-cell Modulation Group. Accessed November 04, 2017. http://www.tcells. org/beginners/tcells/.

5. ”FDA approval brings first gene therapy to the United States.” US Food and Drug Administration. August 30, 2017. Accessed October 08, 2017. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm574058.htm.

6. Grady, Denise. “F.D.A. Approves First Gene-Altering Leukemia Treatment, Costing $475,000.” The New York Times. August 30, 2017. Accessed October 08, 2017. https://www.nytimes.com/2017/08/30/health/ gene-therapy-cancer.html.

7. Lim, Wendell A., and Carl H. June. “The Principles of Engineering Immune Cells to Treat Cancer.”

Cell168, no. 4 (February 9, 2017): 724-40. Accessed October 8, 2017. doi:https://doi.org/10.1016/j. cell.2017.01.016.

8. ”Novartis receives first ever FDA approval for a CAR-T cell therapy, Kymriah(TM) (CTL019), for children and young adults with B-cell ALL that is refractory or has relapsed at least twice.” Novartis. August 30, 2017.

Accessed October 08, 2017. https://www.novartis.com/news/media-releases/novartis-receives-first-ever-fda-approval-car-t-cell-therapy-kymriahtm-ctl019.

9. ”What is an Antibody? (Immunoglobulin).” Bio-Rad. Accessed October 08, 2017. https://www.bio-rad-antibodies.com/immunoglobulin-antibody.html.

10. Agus, David, and Dana Goldman. “Innovative Drugs Deserve Innovative Pricing.” Fortune. August 31, 2017. Accessed October 29, 2017. http://fortune.com/2017/08/31/novartis-gene-therapy-kymriah-cancer-treatment/.

11. Mukherjee, Sy. “Is $475,000 Too High a Price for Novartis’s ‘Historic’ Cancer Gene Therapy?” Fortune. August 31, 2017. Accessed October 29, 2017. http://fortune.com/2017/08/31/novartis-kymriah-car-t-cms-price/.

12. Wissinger, Erika. “CD8 T Cells.” British Society for Immunology. Accessed November 04, 2017. https:// www.immunology.org/public-information/bitesized-immunology/cells/cd8-t-cells.

FALL 2017 | PENN HEALTHCARE REVIEW | 13

FEATURES

I

n a 2011 whirlwind of tabloids and internet jabber, the famous ex-Spice Girl, Victoria Beckham, was depicted with phrases like “Too Posh To Push?” after delivering her fourth baby.6 Beckham has fully exercised her right to an elective C-section, much like a sleuth of other celebrities.

When a blasé attitude toward this surgery is reinforced repeatedly in the media, the perception of childbirth is shifted, along with its consequences. It is almost advertised as an easy, mess-free alternative to vaginal birth for the elite.6 Despite the normalization of such a serious, invasive procedure, is it really in the best interest of the woman and her child?

C-sections can be a necessary, life-saving procedure for certain cases. However, from a medical perspective, only a small minority of women actually needs it. The majority of delivering women are healthy and normal. For those that do not need it, it can actually do more harm than good with its numerous risks. An example of the pitfalls of excessive C- section utilization can be seen in Brazil, where a staggering 85% of births in private hospitals are through Cesarean.2 This is not because women are averse to natural births, but rather intimidation and misinformation. Performing a C-section is quicker and more profitable than vaginal birth for the obstetrician, so they often pressure women into opting for the lucrative option. Women often leave the hospital feeling disempowered and abused. While rates in the U.S. have not reached Brazil’s level of absurdity, we are still relatively high at around 32% compared to other developed nations.5 Among Western nations, the U.S. is one of the only nations that has had a rise in maternal mortality since 2000.1 The countries that see far better numbers in the health and safety of deliveries largely deliver babies through midwives at home, rather than in the hospital.5 In our modern healthcare system, overuse is a pervasive issue in most domains of hospital hospital care and childbirth is no exception.3 14 | PENN HEALTHCARE REVIEW | FALL 2017

So why does our country treat childbirth as a pathology?

There are several repercussions for perceiving child delivery as a medical issue that needs to be resolved in the hospital.

Through the advent of technological intervention, the 20 th century gave rise to dramatic changes in how we deliver babies.4 Delivery was shifted from midwives in the home to obstetricians in the hospital. Birth was no longer regarded as a natural, spiritual phenomenon. However, evidence has shown that midwifery is the optimal route for the majority of pregnancies, which are low-risk and normal. It can lower rates of C-section, complications, and the use of forceps.2 Compared to hospital deliveries, it is more holistic as it includes psychosocial care and pre/post-natal education. It is critical that the mother is well informed, as a homebirth is more independent and self-reliant. Perhaps the solution to our country’s lackluster statistics on birth outcomes could be improved by emphasizing the importance of fully educating women on the risks of medical interventions, which they are often kept in the dark about.2 There are still many health professionals that consider C-section to be equivalent to vaginal birth. Unfortunately, large-scale research on this issue does not have the means to be conducted. The U.S. is one of the few Western nations that do not have national records on maternal deaths. Maternal health experts must volunteer their own time to go through thousands of death certificates to piecemeal statistics.1 Many studies are conducted with fragmented administrative data, which cannot accurately depict a patient’s situation.2 Proper, evidence-based research is essential in exposing the deep issues within our practices. Nevertheless; the foremost basis of decision-making should be left to the mother. She should be given the full, unobstructed right to not only a natural birth, but also a C-section if she so chooses. The problem lies in the fact that our current society offers little empowerment for women who would prefer the natural, non-medicalized path.

Women are not given the respect they deserve to be confident

FEATURES

Title graphic designed by Elaine Ma

Infographic designed by Elaine Ma

in their innate abilities as life-givers. She should be given the full, unobstructed right to not only a natural birth, but also a C-section if she so chooses. The problem lies in the fact that our current society offers little empowerment for women who would prefer the natural, non-medicalized path. Women are not given the respect they deserve to be confident in their innate abilities as life-givers.

1. Ballesteros, Carlos. “Nobody Knows How Many Women Die In Childbirth.” Newsweek. October 23, 2017. Accessed October 27, 2017. http://www.newsweek.com/maternal-mortality-childbirth- 691026.

2. “Brazil Caesareans: Battle for natural childbirth”. BBC News. October 11, 2015. Accessed October 01, 2017. http://www.bbc.com/news/world-latin- america-34464268.

3. Kozhimannil et al (2013) “Cesarean Delivery Rates Vary Tenfold among US Hospitals” 4. McCool and Simeone (2002) “Birth in the United States: an overview of trends past and present” 5. “National Reports.” Birth By The Numbers. Accessed October 01, 2017. http://www.birthbythenumbers.org/united-states/national/.

6. Song, Sora. “Too Posh To Push?” Time. April 11, 2004. Accessed September 27, 2017. http://content. time.com/time/magazine/article/0,9171,610086,00.html.

FALL 2017 | PENN HEALTHCARE REVIEW | 15

FEATURES

I

n the past year, the world has witnessed nature’s most formidable forces at work. Causing mass destruction around the world, earthquakes, floods, and hurricanes have served as humbling reminders of nature’s immense power. Barreling through Houston and Florida, Hurricanes Harvey and Irma paved a trail of destruction that left many with physical injuries and grief-stricken hearts.1 The earthquakes in Mexico razed buildings and took many lives.2 Rescue teams, medics and countless unsung heroes worked tirelessly to care for those affected. People from different cities came together to help pick up the broken pieces.

Through pictures and videos, the devastation wrought by the earthquakes and hurricanes is clear.3 Seeing the flooded homes and toppled buildings, we are filled with horror and grief. However, it is equally important to recognize and address the damage that is at first, unseen to the eyes. What are the internal consequences that those affected face and how can they be overcome? This issue becomes more pressing as “studies of severe natural disasters show that 50% or more of those affected suffer from clinically significant distress or psychopathology.”4 The detrimental consequences that may arise from Harvey and Irma are reflected in past incidents. In previous segments, CNN has discussed the psychological distress that people faced after Hurricanes Katrina and Sandy.5 For example, suicidal thoughts of people living in Alabama, Louisiana and Mississippi significantly increased.6 Children were also more likely to engage in smoking and drinking and were more at risk for obesity, depression and cancer in the future.7 This indicates that the consequences of natural disasters persist throughout one’s life. Although houses 16 | PENN HEALTHCARE REVIEW | FALL 2017

may be rebuilt, the recovery of a person’s mental health takes much longer. These studies also revealed that children must be especially cared for. The National Center for PTSD emphasizesthis by stating that “children generally exhibit more severe distress after disasters than do adults.”8 Initially, this did not make sense to me because I thought that surely, the parents were under much greater pressure to rebuild their own and their children’s lives. However, after reading these studies, I was forced to consider the perspective of a child whose life is turned upside down after witnessing a horrific calamity. These children undergo a severe shock, in which everything they thought they knew about security and serenity is wiped clean.

People should therefore ensure that children are protected and taken care of.9 These deteriorating mental health trends are prevalent and their outcomes are far-reaching. It was stated in the New York Times that after the floods in Thailand and South Korea, those who underwent particularly devastating experiences were four times more likely to show symptoms of PTSD and depression. 10 In addition, the Centers for Disease Control and Prevention conducted studies and discovered that “onefifth to one-quarter of New Orleans police officers had symptoms of P.T.S.D. or depression three months after [Hurricane Katrina].” 11 Here, one can see that there is a strong correlation between natural disasters and deteriorating mental health outcomes over time, and that this trajectory is for the most part, universal. It has persisted across time in different countries and has affected multitudes of people, civilians and police officers alike.12 To address this issue, it is important to consider the underlying mechanisms that give rise to stress or depression in individuals who experience natural disasters. The National

FEATURES

Title graphic designed by Sarah Nam

Center for PTSD outlines several risk factors including the severity of exposure, minimal social support, and gender and familial variables.13 Athugh theseHowever, the story does not end here. Although these heavy psychological burdens intensify the damage of natural disasters, there have been numerous instances in which people have overcome stress and anxiety. In fact, in post-traumatic growth, “some people find they’ve grown as a person whether it be they feel stronger or they feel they can see new possibilities in their lives, or their relationships got better, or they have a stronger connection with God or spirituality.”14 With the ability to push through their shock and anxiety, some people are able to recover over time.15 However, the fact remains that there are some people who cannot handle the trauma of natural disasters. Fortunately, there are ways to support and alleviate their anxiety.

The National Center for PTSD suggests that strong social groups are able to bolster the resilience factor in an individual.16 People should also ask for help and place their mental health as one of their priorities; it is unfortunate that “people who normally [do] not experience mental health difficulties [are] very quick to dismiss their symptoms.”17 We should therefore not only provide resources, but also encourage their use.18 In addition to the physical destruction that natural disasters bring, it is important to consider the emotional and psychological damage that they inflict. It is difficult to acknowledge that people’s psychological states may be broken, in addition to cities, homes, and lives. However, we need to be cognizant of this so that mending can take place.

1. Johnson, David. “Is This the Worst Hurricane Season Ever? Here’s How It Compares.” Time. Accessed November 6, 2017. http://time.com/4952628/hurricane-season- harvey-irma- josemaria/.

2. “Huge Quake Kills More than 200 in Mexico.” BBC News, September 20, 2017, sec. Latin America & Caribbean. http://www.bbc.com/news/world-latin- america-41327593.

3. Johnson, David. “Is This the Worst Hurricane Season Ever? Here’s How It Compares.” Time. Accessed November 6, 2017. http://time.com/4952628/hurricane-season- harvey-irma- josemaria/.

4. “Mental Health Effects Following Disaster: Risk and Resilience Factors - PTSD: National Center for PTSD.” General Information. Accessed October 4, 2017. https://www.ptsd.va.gov/professional/pages/effects-disasters- mental-health.asp.

5. Susan Scutti. “The Psychological Aftermath of Hurricanes.” CNN. Accessed October 4, 2017. http://www. cnn.com/2017/09/19/health/psychological-aftermath- hurricanes-harvey-irma/index.html.

6. Susan Scutti. “The Psychological Aftermath of Hurricanes.” CNN. Accessed October 4, 2017. http://www. cnn.com/2017/09/19/health/psychological-aftermath- hurricanes-harvey-irma/index.html.

7. “Mental Health Effects Following Disaster: Risk and Resilience Factors - PTSD: National Center for PTSD.” General Information. Accessed October 4, 2017.

8. Susan Scutti. “The Psychological Aftermath of Hurricanes.” CNN. Accessed October 4, 2017. http://www. cnn.com/2017/09/19/health/psychological-aftermath- hurricanes-harvey-irma/index.html.

9. “Mental Health Effects Following Disaster: Risk and Resilience Factors - PTSD: National Center for PTSD.” General Information. Accessed October 4, 2017.

10. Carroll, Aaron E., and Austin Frakt. “The Long-Term Health Consequences of Hurricane Harvey.” The New York Times, August 31, 2017, sec. The Upshot. https://www.nytimes.com/2017/08/31/upshot/thelong- term-health- consequences-of- hurricane-harvey.html.

11. Carroll, Aaron E., and Austin Frakt. “The Long-Term Health Consequences of Hurricane Harvey.” The New York Times, August 31, 2017, sec. The Upshot. https://www.nytimes.com/2017/08/31/ upshot/the-long-term- health-consequences- of-hurricane-harvey.html.

12. Carroll, Aaron E., and Austin Frakt. “The Long-Term Health Consequences of Hurricane Harvey.” The New York Times, August 31, 2017, sec. The Upshot. https://www.nytimes.com/2017/08/31/upshot/thelong- term-health- consequences-of- hurricaneharvey.html.

13. “Mental Health Effects Following Disaster: Risk and Resilience Factors - PTSD: National Center for PTSD.” General Information. Accessed October 4, 2017. https://www.ptsd.va.gov/professional/pages/effects-disasters- mental-health.asp.

14. Susan Scutti. “The Psychological Aftermath of Hurricanes.” CNN. Accessed October 4, 2017. http://www. cnn.com/2017/09/19/health/psychological-aftermath- hurricanes-harvey-irma/index.html.

15. Susan Scutti. “The Psychological Aftermath of Hurricanes.” CNN. Accessed October 4, 2017. http://www. cnn.com/2017/09/19/health/psychological-aftermath- hurricanes-harvey-irma/index.html.

16. “Mental Health Effects Following Disaster: Risk and Resilience Factors - PTSD: National Center for PTSD.” General Information. Accessed October 4, 2017. https://www.ptsd.va.gov/professional/pages/ effects-disasters- mental-health.asp.

17. Susan Scutti. “The Psychological Aftermath of Hurricanes.” CNN. Accessed October 4, 2017. http://www. cnn.com/2017/09/19/health/psychological-aftermath- hurricanes-harvey-irma/index.html.

18. Susan Scutti. “The Psychological Aftermath of Hurricanes.” CNN. Accessed October 4, 2017. http://www. cnn.com/2017/09/19/health/psychological-aftermath- hurricanes-harvey-irma/index.html.

FALL 2017 | PENN HEALTHCARE REVIEW | 17

POLICY CHANGES

Title graphic designed by Judy Choi

T

he Deferred Action for Childhood Arrivals (DACA) program was established on June 15, 2012 by the Obama administration. It granted children who had arrived to the United States before their 16th birthday as undocumented immigrants, and met several other conditions, the right to request consideration for deferred action for two years and a work authorization status.1 Recently, United States president Donald Trump has announced the end of such program within the next six months, leaving the fate of more than 800,000 undocumented immigrants, the so called “Dreamers” in the United States unclear. 2 But who are these so called “Dreamers”? As former president of the United States, Barack Obama said when he first announced the program, “These are young people who study in our schools, they play in our neighborhoods, they’re friends with our kids, they pledge allegiance to our flag. They are Americans in their heart, in their minds, in every single way but one: on paper.” 3 The National UnDACAmented Research Project (NURP) is a longitudinal mixed-methods study that analyzes the impact of DACA on different fields such as education, labor market, health, among others. It draws data from a national survey of 1,402 people ages 18-31 who received DACA approval by June 2013. The study finds that receiving DACA improved the recipient’s economic and social standing. 94% of respondents said they would apply for U.S. citizenship if possible, which shows a strong desire for nearly all Dreamers to be a part of America. 49% of respondents say they worry about the deportation of friends and family almost all the time, and almost ⅔ of them know someone who has been deported.

In this survey, almost ⅔ of the study’s participants come from Mexico. Results from this study show that DACA 18 | PENN HEALTHCARE REVIEW | FALL 2017

has allowed undocumented immigrants to work and improve their economic standing. And it has also opened doors for them towards education and progress. 4 But now, all of that progress is in danger of fading away. Donald Trump’s decision to end DACA appears to be motivated by the idea that deporting undocumented immigrants will improve labor opportunities for American citizens. However, the economic consequences of such actions are estimated to be a $460 billion loss in GDP over the next decade caused by the decrease in revenue from DACA recipients. 5 In particular when talking about health care, it is estimated that almost 20,000 DACA recipients currently work in the health care industry. 6 It is in the best interest of health care industry leaders to diversify the workforce. This is important because a study found out that physicians who are under-represented minorities (Blacks, Hispanics, Asians, among others) play an essential role in providing health care for underserved populations. 7 This is relevant for DACA recipients because most of them are Hispanics from Mexico, El Salvador, Guatemala among others. 8 In addition, around 9,000 DACA recipients work as “Health Care practitioners or Technicians.”9 The repeal of DACA would have an impact on the future of the US health care workforce. For example, the Pre-Health Dreamers is composed of over 800 undocumented students located across 42 different states of the country who are in the process of working towards a career in the health care field. 10 If DACA is repealed, a great majority of such students would be impacted, and their career path would be damaged. According to Nakae and colleagues, 65 DACA recipients matriculated to medical school in 2016, and the number of medical school applicants with DACA continues to increase. 11 Taking a look into a specific case we have Bryan, an undergraduate student at the University of California. He volun-

POLICY CHANGES

Infographic designed by Judy Choi

teers as an interpreter at a free clinic in his community and is pursuing a pre-medical path. He came to the US when he was only 2 years old, and he dreams of becoming a physician and working for his community. 12 According to Talamantes and colleagues, if DACA were to be repealed, and students such as Bryan were to be deported, the US health care system would lose exceptional students who are willing to work towards improving access to health care for underserved communities, improving cultural awareness, and working towards extinguishing health care disparities and reaching a more equitable health care system. DACA has played a key role in guiding these young individuals towards better educational opportunities which have led them to better employment opportunities and a greater ability to contribute to their communities. 13 So what does the repeal of DACA mean for the United States health care industry? It means the loss of valuable students and future doctors that would most likely work for underserved communities and/or populations. It means the loss of about 9,000 Health Care Practitioners and Technicians.14 The end of DACA means a step backwards from a more equal and better health care in America.

1. “Deferred Action for Childhood Arrivals (DACA).” Deferred Action for Childhood Arrivals (DACA) | Homeland Security. Accessed October 05, 2017. https://www.dhs.gov/topic/deferred-action-childhood-arrivals-daca.

2. Capps R, Fix M, Zong J. The education and work profiles of the DACA population. 2017. Available at: www.migrationpolicy.org/research/education-and-work-profiles-daca-population. Accessed September 8, 2Capps R, Fix M, Zong J. The education and work profiles of the DACA population. 2017. Available at: www.migrationpolicy.org/research/education-and-work-profiles-daca-population. Accessed September 8, 2017 3. “Remarks by the President on Immigration.” National Archives and Records Administration. Accessed October 06, 2017. https://obamawhitehouse.archives.gov/the-press-office/2012/06/15/remarks-president-immigration.

4. Gonzales, Roberto G., and Veronica Terriquez. “Preliminary Findings from the National UnDACAmented Research Project.” Immigration Policy Center, Washington, DC (2013): 33-58.

5. Svajlenka NP, Jawetz T, Bautista-Chavez A. A new threat to DACA could cost states billions of dollars.

2017. Available at: https://www.americanprogress.org/issues/immigration/news/2017/07/21/436419/ new-threat-daca-cost-states-billions-dollars/. Accessed November 6, 2017 6. Capps R, Fix M, Zong J. The education and work profiles of the DACA population. 2017. Available at: www.migrationpolicy.org/research/education-and-work-profiles-daca-population. Accessed September 8, 2017 7. Komaromy, Miriam, Kevin Grumbach, Michael Drake, Karen Vranizan, Nicole Lurie, Dennis Keane, and Andrew B. Bindman. “The role of black and Hispanic physicians in providing health care for underserved populations.” New England Journal of Medicine334, no. 20 (1996): 1305-1310.

8. Hipsman, Faye, Bárbara Gómez-Aguiñaga, and Randy Capps. “DACA at four: Participation in the Deferred Action program and impacts on recipients.” Notes 1, no. 398,000 (2016): 228-000.

9. Capps R, Fix M, Zong J. The education and work profiles of the DACA population. 2017. Available at: www.migrationpolicy.org/research/education-and-work-profiles-daca-population. Accessed September 8, 2017 10. Pre-Health Dreamers. About us. http://www.phdreamers.org/about-us/. Accessed October 20, 2017.

11. Poll-Hunter, Norma I., Geoffrey H. Young, and Matthew Shick. “Values Guide Us in Times of Uncertainty.” Academic Medicine 92, no. 11 (2017): 1512-514. doi:10.1097/acm.0000000000001732.

12. Talamantes, Efrain, and Sergio Aguilar-Gaxiola. “Perspective: POTUS Trump’s Executive Orders - Implications for Immigrants and Health Care.” Ethnicity & Disease 27, no. 2 (2017): 121. doi:10.18865/ ed.27.2.121.

13. Gonzales, R.G., Murillo, M.A., Lacomba, C. and Brant, K., Taking Giant Leaps Forward.

Vancouver 14. Capps R, Fix M, Zong J. The education and work profiles of the DACA population. 2017. Available at: www.migrationpolicy.org/research/education-and-work-profiles-daca-population. Accessed September 8, 2017

FALL 2017 | PENN HEALTHCARE REVIEW | 19

POLICY CHANGES

Title graphic designed by Alexis Megibow

U

nnecessary antibiotic use in healthcare and animal agriculture has led to many severe consequences, such as increases in the cost of medical care and the risk of adverse reactions to antibiotics. 1 However, the most threatening consequence of the flagrant overuse and misuse of antibiotics in these two industries is undoubtedly the propagation of antibiotic resistance.

2 Antibiotic resistance is one of the most pressing threats to global public health. 3 Although the threat of antibiotic resistance could be greatly lessened by simply restricting the use of antibiotics to treating bacterial infections when necessary, progress on this front has alarmingly stalled due to the difficulties involved in implementing these restrictions. 4 The conception of antibiotics and the subsequent widespread use of antibiotics substantially advanced the capabilities of medicine.

2 Antibiotics in conjunction with vaccination have greatly lowered the prevalence of most bacterially-infectious diseases in developed countries and saved millions of lives. 2 In fact, the use of antibiotics is estimated to have increased the average life expectancy in developing countries by approximately 20 years. 2 Unfortunately, the more we use antibiotics, the greater the chance that their efficacies in killing bacteria decline due to antibiotic resistance. 5 Antibiotic resistance, as defined by the Centers for Disease Control and Prevention (CDC) is “the ability of bacteria to resist the effects of an antibiotic [and it occurs] 20 | PENN HEALTHCARE REVIEW | FALL 2017

when bacteria change in a way that reduces the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections. The bacteria survive and continue to multiply, causing more harm.” 5 The obvious threats that antibiotic resistance poses are 1) common illnesses caused by antibiotic-resistant bacteria may not be treatable except for expensive and dangerous treatments and 2) more severe illnesses caused by antibiotic-resistant bacteria may not be treatable at all. 5 Every time an antibiotic is used, there is a chance that the specific bacteria it is designated to kill will develop antibiotic resistance. 2 The prudent and appropriate use of antibiotics is treating people and animals who have been afflicted by bacterial infections with the potential to cause severe symptoms and bodily damage. 2 Antibiotic misuse and overuse can be attributed to two specific practices: 1) physicians and hospitals overprescribing antibiotics Infographic designed by Alexis Megibow unnecessarily and 2) food companies and farmers feeding antibiotics to their farm animals as a substitute for sanitary living conditions. 2 Figure 2 shows how antibiotic resistance spreads from these practices.

Physicians and hospitals face a complex decision when considering when to prescribe antibiotics for patients because they must consider two factors, patient health and economic value (profit-seeking), that often are at odds with each other.

While patient health and profit-seeking are not mutually exclusive in every case, profit-seeking often supersedes patient health in healthcare. Many physicians end up overprescribing

POLICY CHANGES

antibiotics for profit-seeking or out of unfounded concern of have proven to be incredibly difficult to enforce on individpreventing bacterial complications from arising in addition ual farms. 9 The overuse and misuse of antibiotics in animal to the current illness. 4 agriculture are the single greatest contributor to the propagaOverprescribing antibiotics for profit-seeking relates to tion of antibiotic resistance. 9 physicians trying to satisfy the patient enough for them to While the causes behind the propagation of antibiotic 6 continue having a financial relationship. Patients generally resistance are clear, public health officials are still working want immediate relief from their symptoms and sometimes to curb antibiotic overuse. Overprescribing antibiotics can are set on receiving antibiotics, so physicians sometimes potentially be solved with medical education focusing on prescribe antithis issue and biotics to satoversight of isfy their client physicians. The to maintain the overuse of anfinancial relatibiotics in anitionship for the mal agriculture future. 7 Overcan potentially prescribing anbe solved with tibiotics out of stricter regulaunfounded contions on anticerns of further biotic use with complications more stringent relates to medtesting of food ical education products. Aland a lack of though some oversight by a agricultural governing body. companies and 4 Although medical asthis is an area sociations arwith ambiguity, gue that there medical profesis insufficient sionals generevidence to ally agree that impose regulaover prescribtions on antibiing antibiotics otic use in these “Examples of How Antibiotic Resistance Spreads” from the CDC could be drastirespective incally curbed. 4 Dame Sally C. Davies, the Chief Medical Of- dustries, most global and national governmental entities reficer for England, writes, “Antibiotics are not recommended gard antibiotic overuse as a major threat and have adopted for patients with coughs, colds, and viral sore throats. How- resolutions and plans to institute such reforms.4Antibiotics ever, in a recent survey of antibiotic prescribing in UK gener- are critical for society’s collective health. Instead of allowing al practice, half of all patients consulting for these conditions antibiotics to be squandered needlessly and propagating anwere prescribed an antibiotic.” 4 Restricting and ultimately tibiotic resistance, as Dame Sally C. Davies says, “we must eliminating antibiotic overuse and misuse in healthcare is of value them accordingly.” 4 vital importance, as this is a major step towards addressing antibiotic resistance. 4 The other practice where antibiotic misuse and overuse is observed is animal agriculture. It is astounding to hear, but 80% of the antibiotics used in the U.S. are not used on sick 1. Laura J. Shallcross and Dame Sally C. Davies, “Antibiotic overuse: a key driver of antimicrobial resistance,” The British Journal of General Practice 64, no. 629 (2014): 604-605. humans but are instead used on healthy farm animals.8 Food 2. Shallcross and Davies, “Antibiotic overuse,” 604. corporations and farmers feed their animals (pigs, cows, 3. “Antibiotic Resistance Questions and Answers,” Centers for Disease Control and Prevention, last modified April 17, 2015, https://www.cdc.gov/getsmart/community/about/antibiotic-resistance-faqs.html. chickens, fish, and more) antibiotics to stave off infections 4. Shallcross and Davies, “Antibiotic overuse,” 605.

Centers for Disease Control and Prevention, “Antibiotic Resistance” https://www.cdc.gov/drugresisin crowded and unsanitary conditions. Although this saves 5.tance/about.html them a great deal of money, antibiotics are being used for **Infographic was NOT designed by Penn Healthcare Review 6. Dhruv Kullar and Anupam Jena, “Do incentives nudge physicians to prescribe opioids for pain?” Stat, nonessential purposes in mass numbers. Public health offi- August 18, 2016, https://www.statnews.com/2016/08/18/opioids-pain-prescribing-physicians/ cials in Europe have tried establishing stringent regulations 7. Kullar and Jena, “Incentives,” Stat.

8. Kendra Pierre-Louis, “To fight antibiotic resistance, we need higher taxes—or fewer meat eaters,” Popular on antibiotic use in animal agriculture, but these regulations Science, September 28, 2017, https://www.popsci.com/antibiotic-resistance-meat-farming-tax.

5

9. Pierre-Louis, “To fight antibiotic resistance,” Popular Science.

FALL 2017 | PENN HEALTHCARE REVIEW | 21

HEALTHCARE MANAGEMENT

S

ince the early 20th century, liberals and conservatives agree that every American should have the right to access to healthcare. 1 However, they differ in their methods of accomplishing this goal.

Liberals advocate that healthcare is a human right, while conservatives believe that healthcare is a commodity. 2 Their ideologies reflect on their healthcare proposals: liberals talk about moving towards a single-payer universal healthcare system and conservatives push for the privatization of healthcare. 3 Healthcare is now a political issue. To have a better perspective on this issue, we—as college students—need to examine both sides of the debate. We are familiar with a public healthcare model through the enactment of the Affordable Care Act. Now, it is time to consider the idea of a privatized healthcare system. 2 The Swiss Model Let’s look at the Swiss health system. Under the 1996 Federal Health Insurance Law, Swiss citizens are mandated to take out a health insurance policy. 4 They can choose from nearly 100 different private insurance companies.

There is no employer-sponsored insurance, nor government-funded insurance. The government plays only two roles in the healthcare system. It offers subsidies to those who use more than 10% of their income to pay for health insurance. Also, it enforces a minimum benefits mandate.5 The results are promising. In 2003, 42% of Swiss citizens chose high-deductible plans. Even more shocking is that, in 2013, 99.5% of Swiss citizens had health insurance.5 This is significantly better compared to the United States in 2013; only 86.6% of Americans had health insurance for all or part of the year. 6 Coverage Privatized healthcare would still have minimum

22 | PENN HEALTHCARE REVIEW | FALL 2017

Title graphic designed by Judy Choi

benefits. Under the Swiss model, the Federal Department of Home Affairs (FDHA) defines the mandatory health benefits. These include general practitioner and specialist services, pharmaceuticals, medical devices, home health care, preventative care, hospital services, among others.

These benefits are similar to “minimum essential benefits” (a set of services health insurance plans must cover, such as emergency services) found in state exchanges. However, unlike American Qualified Health Plans, all Swiss insurance plans are mandated to have these minimum benefits. 7 Insured persons would be more responsible for cost-sharing and out-of-pocket spending. For example, Swiss insurers are required to offer minimum annual deductibles of about $219. Insured persons have the freedom to opt for a higher deductible and a lower premium plan, which happens to be the more popular option. In addition to deductibles, insured persons pay 10% coinsurance with a cap of $511 annually. With each service, there is a copayment. 4 It may seem like Swiss citizens are paying an unfair amount of their healthcare, but a system that places most of financial responsibility on the people reduces moral hazard—a common problem in which insured people engage in more risky behavior. In the United States, a prevalent example is when insured people with high cholesterol continue to eat high-fat foods despite knowing that this type of behavior worsens their condition. 8 This is not to say a private healthcare system is unsympathetic. The Swiss system has a safety net in place.

The government fully covers maternity care and some preventative services. Additionally, minors do not pay deductibles or copayments for inpatient care. As mentioned earlier, the federal government provides subsidies to those who cannot afford to pay for premiums. In 2013, 28% of citizens benefited from these subsidies. 4

HEALTHCARE MANAGEMENT

Delivery Privatized healthcare is not the same as managed care. A managed care plan would mandate insured people to register with a general practitioner. Though managed care can be introduced into a privatized healthcare system, it is not necessary. More importantly, under a privatized system, insured people have the freedom to choose their doctor—the foundation of the Swiss healthcare system. 4 To promote capitalism, physicians would be paid through fee-for-service. In Switzerland, both general practitioners and specialists are paid according to a national fee-for-service scale called TARMED. The scale does not permit physicians to charge above the fee schedule, but offers incentives for “less resource-intensive” delivery of care. 4 Hospitals would be just like any other industry.

They would be private and forced to compete against other hospital networks, thus lowering hospital costs.

All hospitals would be paid like those under the Medicare system: based on a diagnostic related group (DRG) payment system. 9 Except, there wouldn’t be a national DRG system. Instead, depending on which side has the most bargaining power, either the hospital or insurers competes against other companies in its industry to offer the best DRG payment plans.

Cost containment and Quality Just like any healthcare system, there are problems of cost and quality of care. However, privatization has the potential to reduce cost through its innate capitalistic nature. As for quality of care, the federal government can continue to encourage innovators to develop quality improvement plans. Regardless, “managers in the private sector” are “more accountable” because they are “often subject” to their “stockholders.” 10 The Future After considering privatized healthcare and its benefits, it is tempting to implement certain ideas.

Yet, history has engraved public social insurance into our current healthcare system. This does not mean, though, that we cannot incorporate features of privatized healthcare. We are already doing so (i.e. state marketplaces). Despite this, there is potential for more privatization in the United States. If we do choose to move in this direction, then we can reap the same benefits as Swiss citizens: increased competition in the private sector encouraging the public sector to become more cost conscious, increased efficiency with less government regulation, and increased public resources for other non-healthcare government programs. 11 Reasonably, we cannot simply “flip” the healthcare system. However, we can start slow: vouchers, placing more responsibility on Americans, and encouraging competition. 10 We should remember that our country was founded on capitalistic values. 12 The healthcare system is no exception.

1. Linda Gordon, “What is “Welfare”?” in Pitied but not entitled: single mothers and the history of welfare, 1890 – 1935 (Cambridge, MA: Harvard Univ. Press, 1999).

2. Michael Nolan, “Why The U.S. Should Privatize Health Care,” Daily Wire, May 26, 2017, accessed October 01, 2017, http://www.dailywire.com/news/16895/why-us-should-privatizehealth-care-michael-nolan#.

3. ”Conservative vs. Liberal Beliefs,” Student News Daily, accessed October 01, 2017, https:// www.student newsdaily.com/conservative-vs-liberal-beliefs/.

4. Elias Mossialos et al., 2015 International Profiles of Health Care Systems, PDF, The Commonwealth Fund, January 2016.

5. Avik Roy, “Why Switzerland Has the World’s Best Health Care System,” Forbes, June 17, 2013, accessed October 01, 2017, https://www.forbes.com/sites/theapothecary/2011/04/29/why-switzerland-has-the-worlds-best-health-care-system/#6fdea8c77d74.

6. Jessica C. Smith Carla Medalia, “Health Insurance Coverage in the United States: 2013,” Census.gov, September 16, 2014, accessed October 01, 2017, https://www.census.gov/uat/ facets-publications/2014/demo/p60-250.html.

7. “Qualified Health Plan - HealthCare.gov Glossary,” HealthCare.gov, accessed October 01, 2017, https://www.healthcare.gov/glossary/qualified-health-plan/.

8. Ezekiel J. Emanuel, Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System (New York: PublicAffairs, 2014), 39-40.

9. Ezekiel J. Emanuel, Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System, 70.

10. Fevzi Akinci, “Privatization in Health Care: Theoretical Considerations and Real Outcomes,” Journal of Economics and Economic Education Research, 2002, 68, accessed October 01, 2017, http://www.alliedacademies.org/articles/privatization-in-health-care-theoretical-considerations-and-real-outcomes.pdf.

11. Fevzi Akinci, “Privatization in Health Care: Theoretical Considerations and Real Outcomes,” 69.

12. Steve Straub, “9 Quotes From Founding Fathers About Economics & Capitalism,” The Federalist Papers, June 17, 2014, accessed October 01, 2017, http://thefederalistpapers.org/founders/9-quotes-from-the-founding-fathers-about-economics-capitalism-and-banking.

FALL 2017 | PENN HEALTHCARE REVIEW | 23

HEALTHCARE MANAGEMENT

Title graphic designed by Chloe Le

“Cha-la, Cha-la, Cha-la” sang out the midwife, which in the tongue-clicking language of Xhosa means, “push.” This was the beginning of the first birth I assisted with at Khayelitsha Health Clinic Site B, which is located in a township outside of Cape Town, South Africa. The clinic lacks proper resources and is not well funded or staffed. The birth I was helping with quickly went into crisis mode. The baby’s cord was wrapped around its’ neck and its’ APGAR score at one minute (APGAR is a quick assessment performed on the baby at one minute and five minutes to assess the initial health of the infant; 0 is the worst score, and 9-10 are healthy scores) 1 was a 0. Juli, my fellow University of Pennsylvania Nursing student, and I clasped hands and held our breathes while the midwife rubbed a towel against the baby’s back and suctioned its’ mouth. The baby went from no pulse and blue to crying and breathing. It was one of the scariest, most beautiful, and incredible events I have had the opportunity to witness.

Moments like those at Site B allowed me to see the ramifications of the global nursing shortage and lack of policy and financing in healthcare clinics in rural South Africa. 2 Before I came to South Africa, I completed my medical-surgical rotation for nursing school in Brisbane, Australia at the Mater Adult Public Hospital on a surgical unit. 3 After studying in Australia, I continued my abroad experience and interned in Cape Town, South Africa at Site B in the Emergency Room and the Mother and Baby clinic. 4 I never expected to see or do what I did in South Africa, but with my previous experience on a surgical unit I was able to apply my skill set to the patient population I was working with in South Africa.

South African History and Politics It is important to recognize that many of South Africa’s health policy issues are rooted in its’ history. The apartheid ended in 1991 and though it no longer exists, when you drive into the city from the airport, it is easy to tell that it still pervades the quality of life of many South Africans. 5 According to the World Bank, as of 2011, the Gini coefficient, or income gap, is 0.63.

This number indicates a high-income disparity. 6 The high-income gap is historically rooted and can be traced to when the Dutch colonized South Africa and established the Dutch East Indies Trading Company in 1652 and traded Africans as slaves.

7

The income gap and the ratio of poor to wealthy house24 | PENN HEALTHCARE REVIEW | FALL 2017

holds greatly impacts healthcare in South Africa. While 86% of healthcare coverage is provided by the public system, the government only expends 50% of the money. 8 The private sector is small and is a resource limited to middle and higher income individuals and families. South Africa implemented universal coverage so everyone at the township clinic had coverage through the public sector. A tax revenue pool of funds finances the universal healthcare and healthcare accounts for 8.8% of South Africa’s GDP. 9 Khayelitsha Health Clinic Site B While interning on the Labor and Delivery Floor at Site B, Juli and I reminisced about our Obstetrics rotation at Penn.

Compared to Hospital of the University of Pennsylvania and Lankenau Hospital, we were in an extremely rural environment and the township clinic had an insufficient supply of medications, clothing, sheets, beds, space, and healthcare providers.

The township clinic had multiple floors including a 24-hour Emergency Room and daytime facilities that included a pharmacy, optometry, pediatrics, dentistry, Ubuntu ward for TB and HIV patients, and the Mother and Baby clinic. Each day the clinic spilled over with patients seeking care, and I was told that the Western Cape, where I was staffed has better healthcare than the Eastern Cape. 10 This shocked me, because Site B was cramped and there was a lot of demand and little resources.

How much worse could the clinics on the other side of South Africa be than Site B? At the Mother and Baby Clinic at Site B there were a lot of services offered including a Postpartum, Antepartum, Well Baby visits, and Labor and Delivery.

The Labor and Delivery Floor I am going to focus on the Labor and Delivery Floor and how the funding influences the health of the babies.

On the Labor and Delivery floor there were three beds, little patient privacy, and a lack of basic supplies like clean clothes, food and water, pain medication, and anti-hemorrhaging medication. The midwives, EMT students, and interns were the healthcare providers and delivered the babies.

There was one fetal heart rate machine and one blood pressure cuff that the midwives would have us use to check the delivering moms and assess if they were ready to push. There was no access to an emergency C-Section if the baby’s heart

HEALTHCARE MANAGEMENT

rate was decelerating or accelerating, whereas in this case in the United States, a baby with a fast or slow heart rate would be rushed to the Operating Room so the mom could have an emergency C-Section. In the township, the equivalent of an “emergency visit to the OR” was oxytocin and the magic of a midwife.

11 I saw this in the first birth where the baby had its’ cord around its’ neck. Normally, a cord being wrapped around the neck can be detected because the baby’s heart rate will decelerate and the mom will have an emergency C-Section to get the baby out fast.

12

Infographic designed by Chloe Le

The moms had no access to pain medication, and there was neither a contraction nor fetal heart rate monitor hooked up to the moms’ bellies, plus the mom would have no fresh gown or sheets provided. This is opposite to our rotations at HUP where most moms delivering naturally had an epidural, fetal heart rate and contraction machines hooked up to their bellies, and were in a clean hospital gown on fancy bed made specifically for delivery.

The mothers would sit silently enduring the pains of labor.

When it was time to push the midwife would shout out “Cha-la, Cha-la, Cha-la” and the mothers would push on demand. The midwives had no sympathy for the pain the mothers endured.

As soon as the baby was out, Juli and I would deliver the placenta, clamp the placenta, inject Vitamin K and apply Erythromycin (Chloromax) eye ointment to the baby, and then place the baby on the mother to begin breast-feeding. This occurred simultaneously as the Midwife sutured the mother to prevent hemorrhage. 13 If the Mothers’ status began to decline she would have to go to a hospital that was about 30 minutes by ambulance since there was only a first-line drug available on the floor to prevent Moms’ from hemorrhaging.

As for the baby, there was one GE Giraffe Incubator, if the baby had a declining status. Otherwise, the baby and mother would stay for six hours to be monitored and then sent home, whereas in the United States most mothers stay at least a day to be monitored unless they are absolutely healthy.14 All of these babies were tiny and typically would be placed in the NICU in the United States. Of the twenty-two births I witnessed and helped with, I never saw a baby over 2500 grams.

Converted to pounds, 2500 grams is a little over 5.5 pounds…

so the babies were very, very tiny. For a baby to qualify for the NICU with public insurance in South Africa, it has to be less than 28 weeks gestation AND weigh less than 1000 grams (a little over 2 pounds). 15 To put that in perspective, I am a triplet. I was born at 32 weeks gestation out of a recommended 40 weeks. My brother, sister, and I each weighed a little over 3 pounds. We were tiny and we were each in the NICU. My sister was in the NICU for a two and half weeks, my brother was in it for four weeks, and I was there for three weeks. We were healthy, little babies, but it was because of the hard work of our NICU nurses, doctors, and medical care to ensure that we did the rest of our developing that should have been done in-utero. If I were living in South Africa and relying on the public insurance system, I am not sure the three of us would be as healthy as we are today.

There are so many players in healthcare from policy-makers, lawyers, politicians, businessmen, tech companies, and providers. Ultimately, the goal of healthcare is to promote well-being and health, and that all starts with providing at the beginning of life. 16 Educating women and providing for women throughout pregnancy and the birth process is extremely critical for community health. 17 We need all of the sectors involved in pregnancy, pre-natal care, and childbirth to become passionate about understanding this process so it can be better financed. 18 This will allow women in rural clinics in South Africa, the United States, and all over the world to have the opportunity to have a healthy birth and healthy baby. 18 Ultimately this will lead to more stable populations with fewer long-term health issues and the ability to thrive physically and economically. 19 1. Medline Plus (August 2017). APGAR Score. Retrieved from: https://medlineplus.gov/ency/article/003402.htm 2. International Council of Nurses (2013). The Global Nursing Shortage: Priority Areas for Intervention. The Global Nursing Review Initiative (1-64).

3. Mater Hospital Brisbane. Retrieved from: http://www.mater.org.au/Home/Hospitals/Mater-Hospital-Brisbane 4. Western Cape Government. Retrieved from: https://www.westerncape.gov.za/facility/khayelitsha-site-b-community-health-clinic 5. South African History Online (2017). A History of Apartheid in South Africa. Retrieved from: http://www. sahistory.org.za/article/history-apartheid-south-africa 6. The World Bank (2017). GINI Index (World Bank Estimate). Retrieved from: https://data.worldbank.org/ indicator/SI.POV.GINI?locations=ZA 7. South African History Online (2017). History of Slavery and early colonization in South Africa. Retrieved from: http://www.sahistory.org.za/article/history-slavery-and-early-colonisation-south-africa 8. Health Financing Profile. (May 2016). South Africa. Retrieved from: https://www.healthpolicyproject. com/pubs/7887/SouthAfrica_HFP.pdf 9. McIntyre, Diane, Doherty, Jane, and Ataguba, John. (December 2014). Universal Health Coverage Assessment South Africa. Global Network for Health Equity.

10. Inside Story on Emergencies (2013). Healthcare in South Africa’s Eastern Cape Collapses. Retrieved from: http://www.irinnews.org/analysis/2013/09/23 11. Nordqvist, Christian (2011). The Shocking Truth About Giving Birth in South Africa. Medical News Today. Retrieved from: https://www.medicalnewstoday.com/articles/232413.php 12. Healthline Editorial Team and Dr. Steven King (2015). Fetal Heart Rate Monitoring: What is Normal, What is Not? Retrieved from: https://www.healthline.com/health/pregnancy/abnormal-fetal-heart-tracings#overview1 13. Medscape (2017). Postpartum Hemorrhage. Retrieved from: https://emedicine.medscape.com/article/275038-overview 14. American College of Obstetrics and Gynecologists. Your pregnancy and birth. 4th ed. Washington, DC: ACOG; 2005.

15. Department of Pediatrics (June 2007) Neonatal Guidelines Referral Criteria for Sick Neonates. Cape Town, South Africa. Province of Kwazulu-Natal Health Services.

16. Mahesh VC (2016). Who are the key players in the healthcare industry? Retrieved from: http://www. mahesh-vc.com/blog/understanding-whos-paying-for-what-in-the-healthcare-industry 17. Cook, K., & Loomis, C. (2012). The Impact of Choice and Control on Women’s Childbirth Experiences.

The Journal of Perinatal Education, 21(3), 158–168. http://doi.org/10.1891/1058-1243.21.3.158 18. Kalu-Umeh, N. N., Sambo, M. N., Idris, S. H., & Kurfi, A. M. (2013). Costs and Patterns of Financing Maternal Health Care Services in Rural Communities in Northern Nigeria: Evidence for Designing National Fee Exemption Policy. International Journal of MCH and AIDS, 2(1), 163–172.

19. World Health Organization (2010). Taking Stock of Maternal, Newborn, and Child Survival. Retrieved from: http://www.who.int/pmnch/topics/child/countdownreportpage36-45.pdf

FALL 2017 | PENN HEALTHCARE REVIEW | 25

HEALTHCARE MANAGEMENT

POPULATION HEALTH MANAGEMENT BY: VAISHNAVI SHARMA Title graphic designed by Judy Choi Title by Judy Choi

Introduction Population Health Management (PMH) is the process and system of collecting patient and healthcare system data, analyzing it thoroughly, and using it to improve clinical and financial outcomes.1 Healthcare data is difficult to use due to its large volume; even for a single patient, there is a lot of data ranging from vitals and hospital visits to lab results to procedure/surgery details. Often times PHM programs will use intelligence tools to collect, analyze, and provide a summary of the data for each patient.1 This data, along with the analysis of financial and operational data of health systems, will then determine what steps need to be taken to eliminate any problem areas or care gaps.

Why PHM is Important According to a study from the Commonwealth Fund, despite spending more on healthcare than any other high-income nation, the United States had overall lower health outcomes, characterized by a shorter life expectancy and a higher level of chronic conditions. The U.S. had the third highest amount of public healthcare spending, regardless of the fact that only 34% of residents were supported with public programs and universal healthcare was provided.2 The

26 | PENN HEALTHCARE REVIEW | FALL 2017

reason for such lackluster results is ineffective spending. Other countries, such as France, Germany, and Norway, may be spending less money than the United States, however they make sure that the money is spent effectively and used to improve outcomes.2 To be able to spend effectively, the first step is to know specific weaknesses in clinical or operational aspects of the healthcare system.2 The second step is to determine, specifically, what would limit those issues. This can be achieved through PHM programs.3

Steps Towards Successful PHM Programs The foremost necessity for a PHM program is acquiring all required information to properly analyze a healthcare system holistically. The U.S. is lacking in this first step. Even though the CDC has detailed information on the social determinants of health, such social determinants are often not taken into account and focused on by individual health systems. Focusing on such data would help hospitals know how to better serve those in their community. Another set of data that would be helpful is patient-reported health outcomes.3 This would comprise of not just looking at what labs were conducted on a patient but how the results affected the patient and the patient’s input.4 For example, if a patient received a lab result stating that

HEALTHCARE MANAGEMENT

their condition had worsened, how would this result affect their hospital stay, their job, or those around them? This data set could be used to improve patient experience and thus patient outcomes. First, health systems need to determine what sets of data they have and what they need to collect to best analyze and improve their health systems. Health systems can then invest in intelligence tools to scan through the information and hire an officer or team to form a plan of action based on the results. This would limit hospital spending by cutting unnecessary, unproductive expenditures, while also increasing outcomes since care gaps would immediately be able to be determined and addressed.1

An Example St. Vincent’s Health Partners, Inc. (SVHP) is a Connecticut based physician-hospital organization.

They needed to better manage the health of their community and decided to take the help of a population health management program. The organization took the change one step at a time. They first focused on trying to connect all of the data that was often stored in different systems across the care network.

They then worked on analyzing that data, intervening when a problem was apparent, improving patient engagement in the PHM process by taking input from them, and seeking support for implementing needed change. They noticed that after investing in and implementing the PHM program, SVHP, they were able

to maximize care by improving patient outcomes, decrease out-of-network care, and see lower expenses in several areas.5 All these improvements were possible because they were receiving real-time analysis and feedback on their practice. They were also able to better coordinate care across the organization since the program helped to streamline the many practices across the organization relating to care and data storage.5

Summary American healthcare is not on par with other high-income countries despite matching and often exceeding them in spending.3 This is partially due to ineffective spending practices which could be limited if PHM programs were implemented.2 These programs would analyze the workings of a healthcare system and pinpoint areas that need attention. All American healthcare systems implementing such programs could significantly improve national healthcare outcomes.1 1. ”What is Population Health Management?” Philips Wellcentive. Accessed October 06, 2017. https://www.wellcentive.com/what-is-population-health-management/.

2. Squires, David, and Chloe Anderson. “U.S. Health Care from a Global Perspective.” The Commonwealth Fund. October 08, 2015. Accessed October 06, 2017. http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective.

3. “Population Health Management Solutions and Strategies.” Health Catalyst. Accessed October 06, 2017. https://www.healthcatalyst.com/population-health/.

4. Deshpande, Prasannar, Blakshmi Sudeepthi, Surulivel Rajan, and Cp Abdul Nazir. “Patient-reported outcomes: A new era in clinical research.” Perspectives in Clinical Research2, no. 4 (2011):137. Accessed November 6, 2017. doi:10.4103/2229-3485.86879.

5. Niloff, Jonathan. “5 steps to population health management.” Healthcare IT News. February 11, 2015. Accessed October 06, 2017. http://www.healthcareitnews.com/blog/5-steps-population-health-management.

FALL 2017 | PENN HEALTHCARE REVIEW | 27

ADVERTISEMENTS

28 | PENN HEALTHCARE REVIEW | FALL 2017

ADVERTISEMENTS

(661) 326 – 1747 2031 24th Street | Bakersfield, CA 93301 | 661.326.1747 www.MySecureSystems.com License #613136 • ACO 2943 FALL 2017 | PENN HEALTHCARE REVIEW | 29

WHARTON UNDERGRADUATE HEALTHCARE CLUB This is a student-led initiative; all articles were written and edited by Penn undergraduates and therefore do not reflect the opinions of WUHC or the University of Pennsylvania.

30 | PENN HEALTHCARE REVIEW | FALL 2017