PHRM 485 Intercultural and Global Health Issues Spring 2018 by ckohknox

PHRM 48500 Intercultural and Global Health Issues Spring 2018

Compiled by Cynthia P. Koh-Knox, PharmD, RPh Purdue University College of Pharmacy

http://themeltingpot-pamela.blogspot.com/2011/01/interculturallanguage-barriers.html; www.gul.gu.se

Course description: This course is designed to meet the University Embedded Outcomes of Intercultural Knowledge, and Global Citizenship and Social Awareness. Students will discuss and develop presentations (verbal and written) about various intercultural and global health issues. Course goals: The goals of this course are to  increase awareness of cross-cultural and global health issues.  identify and recognize new perspectives, and articulate insights into own cultural rules and biases  interpret intercultural experiences from the perspectives of one and more than one worldview.  facilitate learning through discussion of current intercultural and global health issues.  enhance written and verbal communication skills.

Table of Contents Topic (Authors)

Page

Addiction (Remington Griswold and Katherine Halik) ........................................................................................... 1 Air pollution (Brandon Kim and Hyejin Kim).......................................................................................................... 5 Bipolar disorder (Victoria VanEtten and Andy Wang) ........................................................................................... 9 Black market organ trafficking (Natalie Cradeur and Audrey Tepe) ................................................................... 13 Cancer in the United States (Sarah McGinness and Vivian Miller)...................................................................... 17 Children’s health (Jeungeun Lee and Kirsten Lewis) ........................................................................................... 21 Diabetes (Jon Jones and Stella Jung) ................................................................................................................... 25 Female reproductive health (Mu Qui and Ellen Rothrock).................................................................................. 29 Food safety (Logan Cathro and Chris Blackwell) ................................................................................................. 33 Genetically modified organisms (GMOs) (Ethan Chau and Mark Choi) .............................................................. 37 Geriatric health (Siena Cooper and Amanda Graboski) ...................................................................................... 41 Heart disease (Angi Shao and Arthur Sima) ........................................................................................................ 45 Human trafficking (Avni Bhalgat and Madison McAteer).................................................................................... 49 Infectious diseases (Arbaaz Mukadam and Stephen Purdy) ............................................................................... 54 Medical errors: First do no harm? (Anthony St. John and Quinton Thompson) ................................................. 58 Mental illness (Julia Czarnik and Danielle Derosas)............................................................................................. 62 Mental illness (Zoe Harves and Karen Ho) .......................................................................................................... 66 Mycobacterium tuberculosis (Ami Lee and Joanne Lin) ...................................................................................... 70 Nutrition and health (Maddie Brown and Joanna Shao) ..................................................................................... 74 Pollution: a health crisis (Kai Gao) ....................................................................................................................... 78 Stem cell research (Allison Clifton and Jenna Dejoris) ........................................................................................ 83 Validity of alternative treatments (Nikki Kouknas and Jake LeClaire) ................................................................. 87 Water pollution (Jiayang Huang and Delaram Hojati) ......................................................................................... 91 Water pollution and its effects on human health (Jory Goff) ............................................................................. 95 Women’s health (Veronica Welch and Diana Zhang) .......................................................................................... 97

Remington Griswold Katherine Halik •

• • •

BSPS BSPS Spring 2018

The DSM-5 was the first Mental Health Handbook to recognize addiction as a mental health disorder o Acceptance of addiction as a mental health disorder can vary between cultures Addiction is not limited to substances but also includes behaviors Cultural acceptance may alter definitions of problem behaviors 21.5 million American adults (12 and older) had a substance use disorder in 2014

Tobacco

Image from: washingtonpost.com, smoking among U.S. adults

Chances of quitting smoking are low with some people attempting up to 20 times before they are successful Health Effects: 480,000 deaths per year due to different types of cancer, heart disease, stroke, etc.

With nicotine Replacement Therapy (NRT) chances of quitting increase by 5070%

The average age of first cigarette is 15.1 years old showing that cigarettes are easily accessible at a young age

Currently there are no effect NRTs for Chew/Dip

Patch

• Place on Body and remove before bed, then rotate application site next day

Microtabs

• Place and Dissolve under tongue

Lozenge

• Place between gum and cheek; similar to a cough drop

Inhaler Nasal Spray

Cultural Acceptance: The smoking rate has continued to drop every year since its peak in 1965 (42.4%) till 2014 (16.8%)

Juul/E-Cig Fad: These two products can be labeled as nicotine free or containing nicotine but without FDA approval there is no way of knowing for sure if there is nicotine or not and can lead to nicotine addiction

Gum

• Chew for 30 seconds and then place between gum and cheek

• Place capsule inside inhaler and inhale just like smoking a cigarette • Inhale into one nostril as needed for urges

Image from: tobaccofreelife.org, Nicotine replacement therapy

There are a variety of nicotine replacement therapies that can greatly increase the chances of quitting. Find the one that works best for you

Alcohol

Image from World Health Organization, Alcohol and Health

In the United States, the National Institute on Alcohol Abuse and Alcoholism estimates that 16

million people have an

Alcohol Use Disorder diagnosable by the DSM-5

When compared to treatment data, it is possible that as few as

10% of individuals

with an alcohol use disorder in the U.S. seek treatment.

Only 31% of countries have a national alcohol policy in place.

If you or a loved one show signs of an alcohol use disorder, we recommend not only seeking treatment but also assigning a friend to hold the individual accountable in continuing treatment.

Although alcohol is relatively easy to access, according to the World Health Organization, harmful use of alcohol leads to 3.3 million deaths every year. Long-term health consequences caused by alcohol abuse are outlined above. Globally, ATLAS-SU found that 1.5% of the world’s population suffers from weekly episodes of excessive drinking

Looking at alcohol use from a legal perspective, alcohol restrictions vary from country to country.

In the United States, a commonly known and culturally accepted treatment is Alcoholics Anonymous, but AA is actually an international organization that implements a 12 step program within a group setting. o There are more than

115,000 groups globally

10%

• of countries do not have any age restrictions for drinking.

• of countries deem alcohol illegal at any age. • These countries are predominantly muslim.

61%

• of countries have a minimum drinking age between 18-19 years old.

• of countries, including the United States, restrict drinking until the age of 21. 2

o Over 2 million members are either currently seeking treatment or have successfully completed the program.

o However, it is estimated that around 40% of participants drop out of the program after the first several meetings.

Opioids/Painkillers/Prescription Drugs

Opioid Prescriptions: Prescriptions numbers have quadrupled since 1999 and correlate with the increase in opioid overdoses. Major issue currently are Pill Mills which are Doctors that multiple patients use to get extreme amount of pain pills (Usually a Pain Clinic)

Narcotics Anonymous: A 2015 survey had around 23,000 responses and includes the ages ranging from under 21 to over 60 years old

Opioid Crisis: Leading to increased heroin use and death. There were 52,404 opioid overdose deaths in 2015 and have been increasing since 1999

Image from: NA.org

Naloxone (Narcan)/Suboxone Use: These drugs are used to someone from an opioid overdose and help with addiction treatment respectively. Naloxone is an opioid receptor antagonist and works by displacing the opioid from the receptor. Naloxone in particular is a hot topic right now, because many states have laws requiring EMTs and first responders to carry this drug and save someone from an opioid overdose. Image from: vitals.lifehacker.com, Naloxone

Naloxone is a great drug that can help prevent overdose deaths which should be carried by anyone that could come across an overdose Image from: hhs.gov, about the epidemic

Preventative Care Availability Advertising

Taxes

may be limited by legal constraints for purchase such as a minimum age requirement. to increase awareness of harms and side effects through campaigns or on the packaging of the product.

As prevention methods for addiction develop, continue to stay up to date on information and options available.

may also be limited through restrictions on refills for prescription drugs and painkillers. As of 2016, 105 countries now require graphic photo warnings on the packages of cigarettes to deter consumers from purchase.

An increase in taxes may be implemented to discourage the initial purchase of tobacco and alcohol.

Image from heroine.net, The State of Syringe Exchange

Naltrexone/Suboxone • Naltrexone, an opiate antagonist, can be used both for preventing opiate effects and also for decreasing a desire to take opioids. • Suboxone can be used to relieve symptoms associated with opioid withdrawal. • These can potentially be life saving when used in emergency situations.

Nicotine Replacements • There are various nicotine replacement therapies that can help a person quit their smoking addiction. • Examples of these include patches, gum, and lozenges. Drinkingage.procon.org. (2018). Minimum Legal Drinking Age in 190 Countries - Minimum Legal Drinking Age - ProCon.org. [online] Available at: https://drinkingage.procon.org/view.resource.php?resourceID=004294 Accessed 25 Feb. 2018. Martine. The Framework Convention Alliance for Tobacco Control. More than 100 countries / territories have required picture health warnings. http://www.fctc.org/publications/meeting-resources/cop7-bulletins/1485more-than-100-countries-territories-have-required-picture-health-warnings. Accessed February 22, 2018. Alcohol Use Disorder. National Institute on Alcohol Abuse and Alcoholism. https://www.niaaa.nih.gov/alcohol-health/overview-alcoholconsumption/alcohol-use-disorders. Accessed February 23, 2018. Alcohol. World Health Organization. http://www.who.int/mediacentre/factsheets/fs349/en/. Accessed February 22, 2018. Global Stats and Facts on Substance Abuse and Treatment. Rehab International. https://rehab-international.org/blog/global-stats-and-facts-onsubstance-abuse-and-treatment. Accessed February 23, 2018.

Needle exchange programs have increased in global prevalence, with an average of 90% return rate across 26 different studies. As shown in the figure below, the largest concentrations of needle exchange programs are in New Mexico, California, and New York, however there are still many states that do not offer needle exchanges. What Is the Success Rate of AA? American Addiction Centers. https://americanaddictioncenters.org/rehab-guide/12-step/whats-the-success-rate-of-aa/. Accessed February 22, 2018. Smoking & Tobacco Use. (2018, February 20). Retrieved February 21, 2018, from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm Chaiton, M. (2016, June 01). Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. Retrieved Feburary 21, 2018, from http://bmjopen.bmj.com/content/6/6/e011045 Overdoses & Deaths - Drug-Free World. (n.d.). Retrieved February 21, 2018, from http://www.drugfreeworld.org/drugfacts/prescription/abuse-international-statistics.html Opioid Addiction. (2016), Retrieved Feburary 21, 2018, from https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

Spring 2018 Authored by Brandon Kim and Hyejin Kim (BSPS Students)

AIR POLLUTION Background !!!!Air!pollution!is!a!major!problem!across!the!world! making!headlines!most!frequently!due!to!heavy! smog.!Not!only!does!it!cause!low!visibility!due!to!its! physical!property,!but!air!pollution!severely! threatens!our!health!as!well.!In!2013,!polluted!air! led!to!4.4!million!premature!deaths!with!China!and! India!accounting!for!1.6!and!1.4!million!respectively! according!to!an!OECD!report.!More!than!half!of! deaths!occur!in!two!of!the!worldâ&#x20AC;&#x2122;s!fastest!growing! economies,!China!and!India.!Air!pollution!is!the!4th! highest!risk!factor!for!death!worldwide,!contributing! heart!disease,!strokes,!lung!cancer,!and!other! conditions.!The!three!major!causes!are!burning!of! fossil!fuels,!exhaust!from!factories!and!industries,! and!indoor!air!pollution.!Especially!particulate! matter!(PM)!and!groundPlevel!ozone,!which!are! major!air!pollutants,!are!caused!by!emissions!from! things!like!power!generation,!transportation! agriculture,!burning!of!fossil!fuels,!and!household!air! ! pollution!like!smoking.!

Sourced!by!Global!Burden!of!Air!Pollution.!(2013).!Retrieved!April!01,!2018,!from! http://www.citationmachine.net/americanFmedicalFassociation/citeFaFwebsite!

Life Quality Issues !!!!Particulate!matters(PMs)!are!so!tiny!in!size!that!it!gets!into!everywhere.!First,! when!we!are!exposed!to!air!pollutants!such!as!CO,!NO2,!SO2,!and!PMs,!they!cause! irritation!or!even!inflammation!on!the!contact!spots!such!as!our!eyes,!nose,!and! the!respiratory!tract.!People!may!show!redness!and!feel!burning!sensation!in!the! eyes,!cough,!sneeze!or!feel!dryness!in!the!nose/throat!almost!instantly!once!they! are!exposed!to!the!polluted!area.!This!may!not!be!the!major!health!issue! immediately,!however,!it!can!develop!into!severe!symptoms!which!will!be! discussed!later!in!this!monograph.!This!irritation!and!inflammation!caused!by!air! pollutant!limit!our!outdoor!activity!from!exercising!outside!to!taking!a!short!walk.! Additionally,!PMs!are!very!tiny!so!it!can!easily!flow!into!the!houses!too.!This!makes! householders!in!the!polluted!area!reluctant!to!open!the!windows!because!doing!so! will!only!worsen!the!atmosphere!in!their!houses.!Especially!if!there!is!an!infant!or!a! child!in!the!house,!the!infiltration!of!PMs!is!a!bigger!issue!since!young!individuals! typically!have!not!fully!established!immune!system,!therefore!more!vulnerable!to! the!pollutants.!Hygroscopic!molecules!in!the!PM!can!cause!PM!haze!when!the! pollutants!are!met!with!high!humidity!and!low!temperature.!This!haze!typically! shows!yellow!color!due!to!sulfate!formation.!PM!haze!cause!low!visibility!and! cause!traffic!chaos!both!on!the!road!and!in!the!air.!For!instance,!on!November!8th,! 2017,!there!was!a!thick!haze!in!New!Delhi,!India!that!developed!from!air!pollution! at!the!presence!of!cold!weather!and!slow!wind,!and!this!haze!caused!18Pvehicle! pileup!due!to!low!visibility.!

Sourced!by! http://www.yonhapnews.co.kr/bulletin/2015/02/23 /0200000000AKR20150223096300004.HTML.! Published!February!23,!2015.!Accessed!April!1,!2018.!

Sourced!by!Marshall!J.!PM!2.5.!PNAS.! http://www.pnas.org/content/110/22/8756.! Published!May!28,!2013.!Accessed!April!1,!2018.!

Respiratory Issues

Sourced!by!Chapter!10!F!Respiratory!System.! http://www.ilocis.org/documents/chpt10e.htm.! Accessed!April!1,!2018.!

Sourced!by!Respiratory!Effects.! https://volcanoes.usgs.gov/volcanic_ash/respiratory_effects. html.!Accessed!April!1,!2018.! !

!!!!! !!!!The!first!entry!of!the!particulate!matter!to!our!biological!system! would!be!through!our!respiratory!tract.!We!breathe!all!the!time,!thus,! the!particles!flow!along!with!the!air!we!inhale.!These!particles!make! contacts!with!our!respiratory!system!in!four!different!ways!due!to! their!sizes;!interception,!impaction,!sedimentation,!and! diffusion.!!Interception!is!when!a!particle!makes!a!contact!with! mucous!membrane!in!our!straight!airway!and!gets!caught,!Impaction! is!when!a!particle!collides!and!stick!to!a!surface!in!the!particles!original! path!when!there!is!a!bend!in!the!airway!system.!Typically,!particles! greater!than!10!μm!are!deposited!in!the!nose!or!throat!by!interception! or!impaction.!Next,!sedimentation!is!when!gravitational!forces!and!air! resistance!overcome!the!buoyancy!of!the!particle!so!that!the!particle! settle!on!a!surface!in!the!airway.!Sedimentation!most!commonly! occurs!in!the!bronchi!and!bronchioles!and!typical!particle!size!is!0.5P10! μm.!Lastly,!diffusion!is!the!random!motion!of!particles!similar!to!that! of!gas!molecules,!hence!its!name.!Particles!smaller!than!0.5!μm!exhibit! this!activity!and!they!are!mostly!deposited!in!the!smaller!airways!and! alveoli.! ! ! !!!!The!deposition!of!particulate!matter!affects!our!health!of! respiratory!system.!A!report!from!the!last!century!illustrated!that! increased!PM!concentration!may!directly!lead!to!premature!death!of!a! population.!For!instance,!PM2.5!decreased!the!average!life!span!by!8.6! months!in!EU!countries!according!to!Orru!et!al!(2011).!However,!the! cause!and!route!of!exposure!that!lead!to!disease!and!death!is!often! complex!and!poorly!understood.!Deposition!of!particles!in!the!throat! and!upper!airway,!just!below!the!throat,!is!dealt!with!our!defense! system,!which!includes!coughing!and!sneezing.!This!can!cause! discomfort!in!daily!life!and!may!trigger!inflammation!at!the!contact! area!when!exposed!long!enough!and!untreated.!Breysse!et!al!found! that!every!10mg/m3!increase!in!indoor!PM2.5P10!concentration!led!to!a! 6%!increase!in!the!number!of!coughing,!wheezing,!or!chest!tightness! (2010).!Deeper!in!the!tract,!particulate!matters!are!often!responsible! for!tracheitis!and!bronchitis!which!describes!for!inflammation!in!the! deeper!respiratory!tract.!Even!further,!PM!smaller!than!2.5!μm!can! reach!into!alveoli!and!cause!adverse!response.!According!to!Analitis!et! al,!respiratory!mortality!increased!by!0.58%!for!every!10!μg/m3! increase!in!PM10!(2006).!In!addition,!Zanobetti!et!al!(2009)!and! Dominici!et!al!(2006)!found!that!prevalence!rate!of!respiratory!disease! increased!by!2.07%,!while!hospitalization!rate!increased!by!8%!for!10! μg/m3!increase!in!PM2.5.!This!effect!of!PM!on!our!health!can!cause! premature!death!of!people!due!to!asthma,!chronic!obstructive! pulmonary!disease,!and!many!more!respiratory!diseases.!!

! 6

Heart Issues !!!!LongPterm!exposure!to!air!pollution!has!been!linked!to!an! increased!risk!of!heart!disease,!but!the!biological!process!has! not!been!understood.!Why!air!pollution!also!cause!heart!disease! is!not!very!understood.!One!suggestion!is!that!tiny!particles!of! soot!migrate!through!the!lungs,!into!the!blood!stream!and! thence!to!the!walls!of!blood!vessels.!The!migration!of!pollutants! can!damage!the!blood!vessels.!Until!now,!this!has!remained! hypothetical.!However,!a!study!published!in!ACS!Nano,!by!Mark! Miller!of!Edinburgh!University,!suggests!not!only!that!it!is! correct,!but!also!that!those!particles!are!specifically!carried!to! parts!of!blood!vessels!where!they!will!do!maximum!damage!–! the!arterial!plaques!associated!with!cardiovascular!disease.! Moreover,!figure!5!shows!that!there!is!a!strong!link!between!air! pollution!exposure!and!cardiovascular!diseases!–!such!as!stroke! and!heart!disease!–!and!cancer.!!

Figure 1

Sourced!by!China's!clean!air!challenge:!The!health!impacts!of! transport!emissions.!(2015,!March!12).!Retrieved!April!01,!2018,!from! http://thecityfix.com/blog/chinaFcleanFairFchallengeFhealthFimpactsF transportFemissisionFpollutionFsustainableFsuFsong/!

Are Pollutants Related To Building Up Arterial Plaques? !!!!Particulate!matter!measuring!less!than!2.5!microns!(PM2.5),!which!is!one!of! major!air!pollutants,!has!been!widely!linked!to!heart!disease.!These!tiny! particles!of!dust,!soot,!and!smoke!accompany!emissions!from!power!plants! and!vehicle!exhaust,!and!lead!to!an!estimated!60,000!premature!deaths!per! year!in!the!United!States.!EPA!standards!limit!average!human!exposure!of! PM2.5!to!a!maximum!of!15!micrograms!per!cubic!meter.!Now!a!study! published!in!the!21!December!2005!issue!of!JAMA!shows!that!longPterm! exposure!to!PM2.5!even!at!levels!within!federal!standards!accelerates!the! development!of!atherosclerosis!in!laboratory!mice!by!increasing!plaque! development,!especially!when!the!mice!are!also!fed!a!highPfat!diet.!! !!!!Mice!do!not!naturally!develop!plaque,!a!fatty!deposit!on!the!inner!lining!of! arteries;!the!28!mice!used!in!the!study!were!genetically!modified!to!do!so.! The!animals!were!divided!into!two!subgroups,!one!fed!a!normal!diet,!the! other!fed!a!highPfat!diet.!Those!subgroups!were!then!divided!again,!with!half! breathing!air!containing!concentrated!PM2.5!at!levels!equivalent!to!15.2! micrograms!per!cubic!meter!and!the!other!half!breathing!particlePfree! filtered!air.!The!air!pollution!group!was!exposed!for!six!hours!per!day,!five! days!per!week,!for!six!months.! !!!!Researchers!found!measurable!changes!in!the!extent!and!severity!of! plaque!formation!in!the!aorta!as!well!as!artery!inflammation!and!reduced! function!of!the!arterial!lining.!In!animals!that!breathed!polluted!air!and!ate!a! highPfat!diet,!41.5%!of!the!arterial!interior!measured!was!filled!with!plaque,! compared!to!13.2%!in!animals!that!breathed!filtered!air!and!ate!a!normal! diet.!In!humans,!high!plaque!levels!can!lead!to!heart!attacks!and!strokes.!!

Sourced!by!Household!air!pollution!linked!to!higher!risk!of! heart!attacks,!death.!(2016,!June!13).!Retrieved!April!01,! 2018,!from!https://medicalxpress.com/news/2016F06F householdFairFpollutionFlinkedFhigher.html!

Sourced!by!Purohit,!B.!(2017,!February!04).!Air!pollution! can!break!your!heart.!Retrieved!April!01,!2018,!from! https://smartairfilters.com/en/blog/airFpollutionFcanF breakFyourFheart/!

Immune System Issues Air Pollution and Allergies: A connection? !!!!Allergies!are!a!number!of!conditions!caused!by!hypersensitivity!of!immune! system!to!the!environment.!Allergic!disease!is!more!common!in!urban!cities! and!less!common!in!rural!cities.!This!suggests!that!there!is!a!correlation! between!modern,!urban!life!and!allergy.!By!far!the!most!important!indoor! pollutant!is!tobacco!smoke,!which!is!strongly!associated!with!allergic! sensitization,!asthma,!and!other!respiratory!illness.!Exposure!to!smoke!results! in!the!body’s!enhanced!ability!to!produce!IgE!that!attaches!to!allergens.!The! IgE!response!is!a!key!trigger!of!allergic!reactions.!Parental!smoking!increases! the!risk!of!their!children!having!many!respiratory!illnesses.!Moreover,!the! increased!rates!of!allergy!and!asthma!in!city!and!in!those!living!close!to! highways!has!drawn!attention!to!the!role!of!outdoor!pollution.!Common!air! pollutants!probably!act!more!as!irritants!than!as!promoters!of!sensitization.! These!pollutants!have!been!shown!to!be!hazardous!to!people!with!asthma.! Recent!studies!suggest!that!prematurely!born!children!are!more!sensitive!to! the!respiratory!allergies!of!outdoor!pollution.!There!may!also!be!an!association! with!diesel!exhaust!particles!and!the!worldwide!increase!in!respiratory! allergies.!Diesel!exhaust!has!been!shown!to!enhance!the!ability!to!make!the! allergy!antibody,!IgE,!in!response!to!exposure!to!allergens.!

Sourced!by!Specific!molecular!events!that!could!explain! allergic!reactions!to!air!pollution.!(2016,!December!22).! Retrieved!April!01,!2018,!from! https://www.sciencedaily.com/releases/2016/12/16122 2094830.htm!

Professional Opinion Air!pollution!not!only!hampers!our!life!quality!but!does!harm!our!health!in!many!ways.!Governments!and! individuals!all!around!the!globe!should!endeavor!to!reduce!air!pollution!for!cleaner!environment!and!better!life!for! our!descendants.!We!think!air!pollution!regulation!should!be!reinforced!in!order!to!reduce!the!pollution.!For! instance,!installation!of!air!purification!system!at!factories!must!be!checked!and!regulated!by!government.!Due!to! its!maintenance!and!cost,!the!purification!system!if!often!neglected!unless!there!is!an!announced!investigation.!As! a!specific!example!the!EPA,!United!States!Environmental!Protection!Agency,!made!a!law!that!requires!EPA!to! establish!healthPbased!national!air!quality!standards!to!protect!people!with!an!“adequate!margin!of! safety.”!!Thermoelectric!power!plants!are!one!of!the!biggest!source!of!air!pollutants!too.!Switching!thermoelectric! power!plants!to!other!type!of!power!plants!will!help!reducing!the!generation!of!air!pollutant!as!well.!Lastly,! individuals!can!help!aid!air!pollution!as!well,!by!saving!energy!usage!or!carpooling!to!reduce!fuel!combustions.! Choosing!environmentPfriendly!products!will!also!help!reducing!air!pollutants!because!they!are!combusted!at! furnaces!after!use.!Likewise,!there!are!many!possible!ways!to!reduce!air!pollution!either!nationally!or!individually.! Therefore,!we!claim!that!though!air!purification!process!won’t!be!instantly!sensible,!if!we!keep!trying!to!aid!air! pollution,!there!will!be!cleaner!atmosphere!sooner!or!later.!Keep!in!mind!that!air!pollution!did!not!come!to!us!all!of! a!sudden!too.!

! ! References:!! 1. 2. 3. 4. 5.

Health!and!Environmental!Effects!of!Particulate!Matter!(PM).!(2016,!July!01).!Retrieved!April!01,!2018,!from!! Respiratory!Effects.!https://volcanoes.usgs.gov/volcanic_ash/respiratory_effects.html.!Accessed!April!1,!2018.! The!link!between!pollution!and!heart!disease.!(2017,!May!04).!Retrieved!April!01,!2018,!from!! Haynes,!R.!C.!(2006,!April).!Air!Pollution:!The!Plaque!of!the!Matter.!Retrieved!April!01,!2018,!from!! Albright,!J.!F.,!&!Goldstein,!R.!A.!(1996,!February).!Airborne!pollutants!and!the!immune!system.!Retrieved!April! 01,!2018,!from!

Bipolar Disorder Andy Wang, BSPS

Victoria VanEtten, BSPS

Spring 2018 Bipolar disorder (BD) is a mood disorder characterized by alternating periods of mania and depression. It currently affects 2.8% of adults and 2.9 % of children in the United States.

There are 4 types of BD: BD-I—1 or more manic episodes, mixed episodes, periods of depression, and extreme manic episodes BD-2—1 or more episodes of major depression and mild mania (hypomania) Cyclothymia—Mild cycles of mania and depression Subthreshold BD—Some symptoms, but not enough to qualify for full diagnosis

44.8% 62.9% ~75% of BD patients also suffer through behavior disorders.

of BD patients also suffer with anxiety disorders.

Of BD patients have an existing comorbid condition.

Globally, the United States (4.4%) and New Zealand (3.9) have the highest rates of BD while Japan (0.7%), Bulgaria (0.3%), and India (0.1%) have the lowest rates. 9

Life with Bipolar Disorder The Two Sides

Source: https://timedotcom.files.wordpress.com/2014/09/depression-treatment.jpg?w=1100&quality=85

Source:http://undepress.net/wp-content/uploads/2015/11/Matching-energy.jpg

Either you feel like you’re nothing… Depressive Phase

...Or you feel like you’re everything Manic Phase

Key Symptoms: Feeling down or sad, lethargic, loss of interest, thoughts of death, trouble concentrating, forgetful

Key Symptoms: Jumpy, touchy, emotional, hyperactive, overwhelming, feeling invincible, recklessness

What do patients feel during this phase?

“I’m tired all the time”

“I am SO happy”

“I just want to be with myself”

“I just feel like I can do anything and no one can stop me”

“I have people to talk to, but I still feel lonely, like no one cares”

“I want to do this, and this, and this, and this” “Death doesn’t scare me”

“if I was dead, I wouldn’t have to feel this way”

of patients with moderate or severe depressive episodes could not normally go through daily life.

attempt suicide.

have suicidal ideation.

of patients with moderate or severe manic episodes could not normally go through daily life.

Diagnosis and Misdiagnosis The Sad Truth BD is hard to diagnose because there is no medical test that confirms someone has BD. Diagnoses are made by trained professionals who listen and observe symptoms and come to a diagnosis based on their judgment. They can fail to diagnose properly due to missing symptoms during observation or poor judgment. About half the time, BD patients are asymptomatic, which may cause further confusion during follow up diagnosis appointments with a professional. Source: http://4.bp.blogspot.com/-zMKYXzYuyks/Tc1wIDUbIiI/AAAAAAAAJnA/jBT0TSJIJMU/s1600/bipolar+depressive.jpg

70% of patients with BD were incorrectly diagnosed in their first diagnosis, and more than 1/3 of these were incorrectly diagnosed for the next 10 years.

Treatments Efficacy and Cost

Average cost of treatment per patient per year:

There are 4 main ways BD is treated: Medication such as mood stabilizers, antipsychotics, antidepressants Talk therapy in conjunction with medications Electroconvulsive therapy for severely manic or depressed patients Stimulation such as vagus nerve stimulation and light therapy

Proportion Seeking Help (%)

Treatment Seeking by Country Income 80 70 60 50 40 30 20 10

Even in high income countries, only 75% of BD patients seek mental help.

Lower-Middle

Upper-Middle

High

Counry Income Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3486639/

$19,000 Average cost of treatment for all patients per year: $32,000,000,000 There is NO cure for BD. With optimal treatment, a bipolar patient can regain 7 years of life, 10 years of effective major activity, and 9 years of normal health which otherwise would have been lost due to the illness. With proper and prompt treatment, patients can reduce the time between episodes and eventually regain normal function.

Social Aspects of BD Culture, Awareness, Acceptance

References References

Sometimes, the best medication is support and understanding. Some of the best ways to spread awareness is talking about bipolar disorder. BPHope suggests that “society, in general, has a preconceived notion about how people with bipolar are supposed to be” indicating there is a stigma associated with the disorder. By raising awareness, BD patients will be able to gain greater acceptance and will be more likely to reach out for help.

3 Simple Ways to Raise Awareness about Bipolar Disorder | bpHope. bpHope - bp Magazine Community. https://www.bphope.com/ blog/3-simple-ways-to-raiseawareness-about-bipolardisorder/. Published October 8, 2015. Accessed April 2, 2018.

Bipolar Disorder. National Institute of Mental Health. https:// www.nimh.nih.gov/health/ publications/bipolar-disorder/ index.shtml. Accessed March 21, 2018.

Source: http://3.bp.blogspot.com/-PZTL3biAq2Y/UifYtNmQgyI/ AAAAAAAAARc/KBcg2a4WDq0/s1600/Green+Ribbon++Bipolar+Awareness+Angel.jpg

Surveys conducted by the South African Depression and Anxiety Group (SADAG in 2017 and by Dr. Long in 1998 indicated that: indicated BD has caused “severe” damage to their social lives.

experienced discrimination in the workplace.

were met with lack of understanding, disinterest, insults, prejudice, or hostility

indicated BD has caused “severe” damage to their job/career.

Cost for services. Mental Health Treatment. http:// mentalhealthtreatment.net/ bipolar-disorder/costs/. Accessed April 3, 2018.

Merikangas KR, Jin R, He J-P, et al. Prevalence and Correlates of Bipolar Spectrum Disorder in the World Mental Health Survey Initiative. Archives of general psychiatry. https:// www.ncbi.nlm.nih.gov/pmc/ articles/PMC3486639/. Published March 2011. Accessed April 3, 2018.

Singh T, Rajput M. Misdiagnosis of Bipolar Disorder. Psychiatry (Edgmont). https:// www.ncbi.nlm.nih.gov/pmc/ articles/PMC2945875/. Published October 2006. Accessed April 1, 2018.

Professional Opinion There have been many improvements to BD treatment, acceptance, etc. over the past decade, however more can be done. Symptom management is excellent, as many patients are able to gain a significant part of their life back with treatment. Our current aim should be to minimize side effects and develop curative therapies. Misdiagnosis represents a serious issue, as patients are being misdiagnosed far too often, resulting in delayed treatment and further damage. Improving diagnosis should be the priority. Socially, there have been movements to increase awareness and acceptance for BD. Statistics still show, however, that many BD patients are still being discriminated against and constantly struggle with their social and work lives. 12

Types of Bipolar Disorder. Secure2. http://www.dbsalliance.org/site/ PageServer? pagename=education_bipolar_types. Accessed April 3, 2018.

Understanding Bipolar Disorder -Treatment. WebMD. https:// www.webmd.com/bipolardisorder/guide/understandingbipolar-disorder-treatment#1. Accessed April 3, 2018.

Black Market Organ Trafficking Background:Every ten minutes, someone is added to the national transplant waiting list. On average, 20 people die each day while waiting for a transplant. The transplant list has grown an astounding rate of 8% in last 10 years. It was estimated that organ trafficking accounts for 5–10% of the kidney transplants performed annually throughout the world.

An Aging Population

As medicine and technology evolve, the lifespan of humans are increasing. This increase in life expectancy allows for more delayed diseases to take effect. A rise in cardiovascular disease can be seen as the heart must sustain the body for many more years. Due to this, an increase in organs are needed to help support the aging population.

Transplant Tourism Definition: Transplant Tourism is a phenomenon where patients travel abroad to purchase organs for transplants.

Hazards Of Transplant Tourism “Transplant Tourist” are traveling to established destinations to obtain accessible organs for transplantation, available from the poor of that destination country who sell kidneys. These tourist then return to the United States for follow-up care.

What Needs To Be Done? According to World Health Assembly “ We need to take measures to protect the poorest and vulnerable groups from transplant tourism and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissue and organs.

Example Advertisement

What is your kidney worth to you? A broker located in China openly advertised"Donate a kidney, buy a new iPad!"In addition, the donor would be compensated$4,000 and it could be harvested quickly and easily in as little as 10 days.

Stealing or Harvesting Organs The “Process”

Living Victim/Donor Receives ~ $5,000 ⬇ Organ Broker Receives ~ $100,000 ⬇ Organ Recipient Pays ~$150,00

Legalization of Sales Pros Saves Lives. The availability of more organs will save patients from dying waiting for a donor.

Saves Money. Transplants are cheaper than dialysis and will save the healthcare system millions of dollars.

Stops Black Market Sales. By making organ sales legal, the black market for organ sales will no longer be needed. This will increase safety by having medical professionals finding compatible matches and performing surgeries legally.

Fairness There will be an established price for each organ and an established price for each donation. This will promote equal and fair opportunities.

Cons Exploitation An organ market may benefit the wealthy but pressure the poor into sacrificing their health for money.

Ethical Dilemmas Family members may benefit by allowing a member to die in order to sell his/her organs for profit.

Violation of Human Rights Human rights are based on the principle of respect for the individual. Legalization can be seen as putting a price tag on life.

Feasibility of Regulation Some experts believe that regulation of legal organ sales would be impossible and promote transplant tourism.

CANCER IN THE UNITED STATES PHRM 485: Intercultural and Global Health Issues Sarah McGinness, BSPS Student;Vivian Miller, BSPS Student Spring 2018

BACKGROUND Cancer is a disease characterized by uncontrolled growth and spread of abnormal cells. Cancer can arise from almost anywhere in the body and can invade into nearby tissue. Some cancer cells are able to break off and metastasize to distant parts of the body. If left untreated, cancer can be fatal. There are many contributing factors to cancer, including lifestyle factors and nonmodifiable factors such as inherited genetic mutations. Cancer is caused by changes to genes that control how cells function. These genetic changes can be inherited or arise due to certain environmental exposures. Cancer in each person is a unique combination of these genetic changes, making it very difficult to treat. Genetic changes that drive cancer include activation of genes that enable cells to grow and survive inappropriately (oncogenes), inactivation of genes involved in regulation of cell growth and division (tumor suppressor genes), and mutations in genes involved in DNA repair. Combinations of these mutations could cause cells to become cancerous. There are more than 100 types of cancer depending on the site of origin and types of cells that are involved. Due to its complexity and high prevalence, research and development of novel cancer treatments is always ongoing.

Estimated numbers of new cancer cases for 2018, excluding basal cell and squamous cell skin cancers and in situ carcinomas except urinary bladder. Reprinted from Cancer Facts and Figures 2018. Available at https://www.cancer.org/content/dam/cancer -org/research/cancer-facts-andstatistics/annual-cancer-facts-andfigures/2018/cancer-facts-and-figures2018.pdf.

INCIDENCE AND MORTALITY RATES OF CANCER • About 1.7 million new cancer cases are expected to be diagnosed in 2018 • In the US, approximately 40 out of 100 men and 38 out of 100 women will develop cancer during their lifetime • About 609,640 Americans are expected to die of cancer in 2018, which translates to about 1,670 deaths per day. • Cancer is the second most common cause of death in the US

Cancer of any site is more common in older age populations. 87% of all cancers in the United States are diagnosed in people 50 years of age or older.

2017 Cancer Statistics New Cancer Cases: 1,688,780 Cancer Deaths: 600,920 The incidence and mortality rates of cancer have not significantly decreased over the past 40 years.

Cancer disparities are thought to reflect the interplay of socioeconomic factors, culture, diet, stress, the environment, and biology. All figures from this page are reprinted from Cancer Stat Facts. Available at https://seer.cancer.gov/statfacts/html/all.html.

PROFESSIONAL OPINION It is in our professional opinion that cancer is a serious disease that will eventually surpass heart disease as the number one cause of death in the United States. Despite numerous efforts, cancer incidence and mortality rates have not decreased significantly over the past 40 years, while the morbidity or heart disease has steadily decreased in the past decade. Cancer is difficult to treat due to high complexity, not only because it has multiple causes that compound upon each other, but also because it is highly dynamic. Cancer cells are highly liable to mutations which enable them to metastasize, reoccur after latent periods, evade the immune system,or become resistant to current therapies. New, innovative therapeutic strategies are required in order to keep up with cancer treatments. Cancer is also a highly expensive disease to treat and has become a 140-billion-dollar industry. Personalized medicine, cell therapies, and novel biotechnology keep medical bills high not only for the patient, but also for the taxpayer. Instead of trying to keep up with treating new cancer cases, more should be done in the line of prevention. Cancer can be influenced by the environment due to many epigenetic factors that play into cancer. Taking a preventative approach to cancer, could decrease cancer incidence and mortality. 18

C ANCER RISK FACTORS AND CANCER PREVENTION According to the American Cancer Society, at least 42% of newly diagnosed cancers in the US are potentially avoidable. One can decrease their risk of cancer by choosing healthy behaviors. Tobacco is closely related to cancer risk and causes 30% of all cancer deaths in the US.

Diet is important in cancer and by consuming a diet high in fruits and vegetables and limiting consumption of fats and meat, risk of certain cancers can be reduced.

Physical activity can reduce the risk of several types of cancer.

Increased body weight and obesity is associated with risks to several types of cancer and there is high association between obesity and worse prognosis and outcomes among some cancer patients, with excess body weight contributes to one in five cancer-related deaths in the US.

Several cancer risk factors have been targeted over years and there has been improvement in decreasing these risk factors. Preventative measures to cancer risks has been made in overall decreased use of tobacco products, increased physical activity, increase in sunscreen use, decreased use of indoor tanning beds, increasing HPV immunizations, and less environmental exposure to arsenic and radon. However there are certain preventative measures that are not improving or are getting worse such as the consumption of fruits and vegetables, increased alcohol consumption, increasing obesity, and lack of cancer screenings. Drug Inactivation: To acquire clinical efficacy many anticancer drugs must undergo metabolic activation, complex mechanisms of interactions between substances and proteins. The drug is activated by modifying, partially degrading, or making the drug more complex using other molecules or proteins. Down regulation or mutation of specific metabolic pathways can lead to decreased drug activation.

Drug Efflux: Multidrug resistance protein 1, Multidrug resistanceassociated protein 1, and breast cancer resistance protein are three transporters with broad substrate specificity and are able to efflux many xenobiotics from cells, thus protecting cancer cells from many first line chemotherapies.

Drug Target Alteration: A drugâ&#x20AC;&#x2122;s molecular target influences it efficacy. Alterations to said target, such as mutations and modification of expression levels, could alter the response of cancer cells to that drug.

Epigenetic modifications such as DNA methylation and histone modification via acetylation or methylation, regulate the expression of genes throughout the chromosome. In cancer, this normal regulation is broken. Epigenetic alterations, such as histone methylation and acetylation, may play a role in the development of drug resistance.

Apoptosis and autophagy are two important regulatory events that contribute to the death of a cell. Apoptosis has two established pathways, intrinsic and extrinsic, that merge through caspase3 activation down-stream, resulting in apoptosis of the cell. Inhibition of factors involved with either pathway can result in proliferation of cancer cells. Cancer cells that decrease lysosomal pH will cause autophagy, phagolysosomal death in an acidic lysosomal pH. Raising the pH inactivates the digestive enzymes in lysosomes thus inhibiting autophagy, leading to cancer cell survival.

DRUG RESISTANCE DNA Damage Repair:

Epigenetics:

Cell Death Inhibition:

Chemotherapy drugs can damage the DNA of cancer cells directly or indirectly, thus leading to cancer cell apoptosis. However, some cells have DNA damage response mechanisms that can reverse the drug-induced damage. 19

Cancer Cell Heterogeneity: The presence of drug resistant cancer calls within the heterogeneous cancer cell population will be enriched with medication therapy.

Epithelial-Mesenchymal Transition and Metastasis The epithelial to mesenchymal transition (EMT) is a mechanism by which solid tumors become metastatic. Several factors during EMT play significant roles in drug resistance development. Cancer cells may also develop resistance during the signaling processes of differentiation, which are essential for EMT

FINANCIAL BURDEN OF C ANCER The financial costs of cancer care are a burden to people diagnosed with cancer, their families, and society as a whole. Cancer costs will continue to rise at a rapid rate due to an aging population and high cancer prevalence among the elderly. Thus, even if cancer incidence rate remain constant or decrease, cancer prevalence will continue to increase among the aging population. Costs will continue to increase as novel and more technologically advanced treatments are adopted in the standard of care.

Care for cancer survivors accounted for an estimated 137.4 billion in medical care expenditures in the United States in 2010. Financial toxicity describes problems a cancer patient has related to the cost of treatment. Financial toxicity and financial distress describe the personal out-ofpocket costs that cause financial problems for a patient, including copayments, deductibles, and coinsurance. These costs typically are used for hospital stays, outpatient services, medical appointments, and prescription medications. Cancer patients and survivors are more likely to have financial distress than people without cancer. Cancer is one of the most expensive medical conditions to treat in the United States.

SOURCES • • • • • • • • • •

Reprinted from Projections of the cost of cancer care in the United States: 2010-2020. Available at https://academic.oup.com/jnci/article/103/2/117/2568866.

National expenditures were largest for female breast, colorectal, prostate, lymphoma, and lung cancers, reflecting prevalence of disease, treatment patterns, and costs for different types of care.

American Cancer Society, Cancer facts and figures 2018. Available at https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-andstatistics/annual-cancer-facts-and-figures/2018/cancer-facts-and-figures-2018.pdf. Accessed February 21, 2018. American Cancer Society. Diet and cancer, Available at https://www.cancer.org/cancer/cancer-causes/diet-physical-activity/diet-and-physicalactivity.html. Accessed February 21, 2018. American Cancer Society. Economic impact of cancer. Available at https://www.cancer.org/cancer/cancer-basics/economic-impact-of-cancer.html. Accessed February 21, 2018. Housman G, Byler S, Heerboth S, et al. Drug resistance in cancer: an overview. Cancers 2014, 6, 1769-1792. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. JNCI-J Natl Cancer I 2011;103:117-28. National Cancer Institute. Cancer disparities. Available at https://www.cancer.gov/about-cancer/understanding/disparities. Accessed February 21, 2018. National Cancer Institute. Financial toxicity and cancer treatment. Available at https://www.cancer.gov/about-cancer/managing-care/track-carecosts/financial-toxicity-pdq. Accessed February 21, 2018. National Cancer Institute. Cancer statistics. Available at https://www.cancer.gov/about-cancer/understanding/statistics. Accessed February 21, 2018. National Cancer Institute. Surveillance, epidemiology, and end results program. Available at https://seer.cancer.gov/statfacts/html/all.html. Accessed February 21, 2018. National Cancer Institute. Cancer trends progress report. Available at https://progressreport.cancer.gov/after/economic_burden. Accessed February 20 21, 2018.

Children’s Health The following information is health issues affecting and/or involving children. Children are their own population when it comes to health. There are some health treatments that only children receive. These treatments can affect children for the rest of their lives. Besides just treatments, there are some negative things that can happen to children that healthcare professionals need to be aware of because they can also impact the child’s health for the rest of his or her life. Another issue that will be addressed is healthcare for children.

Kirsten Lewis & Jeungeun Lee BSPS Students Spring 2018

sexual activity that the child cannot comprehend. It’s noteworthy to recognize that sexual abuse doesn’t always involve body contact. This includes acts like touching of a child’s breasts or genitalia, s o m e o n e exposing their genitalia to a child, fondling, oral-genital contact, and exhibitionism, voyeurism, and exposure to pornography.

Child Abuse and Neglect

Child neglect occurs when someone fails to provide the necessities or basic need of life to a child and is the most https://www.pinterest.com/pin/423760646158083077/ common form of Child abuse is defined in many states as any type maltreatment. This can include physical neglect, of cruelty inflicted upon a child, including physical such as not providing food, clothing, or shelter harm, verbal abuse, emotional abuse, and sexual and emotional neglect such as withholding love or abuse or exploitation. Neglect, also, is a type of comfort or medical neglect that is when medical abuse even though it is an example of inaction care is refused by parents. Sometimes, a parent that cause harm. According to some studies, one might be physically or mentally unable to care in four girls and one in eight boys are sexually for a child because of serious injury, untreated abused before the age of eighteen and about one depression, or anxiety. Parents might also be on in twenty children are physically abused each year. alcohol or drug which can weaken judgment and ability to take a good care of the child. Physical abuse involves non-accidental harming of a child by burning, beating, or breaking bones. Physical abuse might be the most visible type Many of the times parents abusing their child of abuse but other abuses like emotional abuse claim that their abusive act is a form of discipline, and neglect also leave deep scars that lasts but there are certainly conspicuous differences long throughout life of a child. Those effects between the two. Unpredictability of parents’ include lack of trust and relationship difficulties, abuse or absence of motivation to teach their Core feelings of being “worthless”, and trouble child or only using fear of children to control regulating emotions. Research also has found a their behaviors may be some of the elements of strong correlation between a history of abuse physical abuse. and a variety of adult problem behaviors, such as substance abuse, juvenile and adult crime, and Child sexual abuse includes exposure of a child to 21

methadone is used, but doctors try to use as little meds as possible. However, according to Dr. Jansson, the goal of therapies for NAS is to provide just enough medication so that the infant can eat, sleep and interact.

poor social adjustment. Also, Child abuse victims have tendency repeat the violent acts that they experienced on their own children, creating a vicious cycle of abuse. Professional Opinion: However, child abuse is preventable although it is not simple as it is not easy for abused child to speak up. There are community agencies and supportive services for families having trouble. Adults should pay careful attention on signs of abuse and act on suspicions.

The impact of NAS over a long period of time is difficult to define because there are too many other variables that could compromise the conclusion. Based on some observation, drug exposed infants have been found to exhibit increased, dysregulated motor patterns and decreased overall activity. These issues were present in toddlerhood and were associated with shorter attention spans and poor social engagement. Also theyâ&#x20AC;&#x2122;re at a

Children Born With Drug Addiction In 2012 nearly 22,000 babies were born drug dependent which one in every twenty-five minutes and as the opioid crisis has increased dramatically over the past five years in can be inferred that those numbers have increased. Consuming drugs and alcohol during pregnancy can lead to a number of health problems, like premature labor and fetal death. But in some cases, the motherâ&#x20AC;&#x2122;s addiction is passed on to her child via placenta, resulting in babies born addicted to those drugs.

https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome

Babies who are addicted to drugs suffer from the symptoms of neonatal abstinence syndrome (NAS) which is withdrawal symptoms that occurs shortly after birth (one to three days after birth). Babies go through number of different problems involved with autonomic nervous system which includes fever, vomiting, diarrhea, gagging, hiccupping, color changes, and fast breathing. They also have problems with movements such as tremors and jitteriness, leading to a difficulty in feeding, and unhealthy weight loss.

higher risk of negative co-habiting experiences like exposure to violence, poor nutrition, and continued maternal drug use. Professional Opinion: Most pregnant patients with substance disorders care for their children and hope for their childrenâ&#x20AC;&#x2122;s well-being. However, they often times constitute a vulnerable population that needs help. Supporting those patients may considerably reduce future expenses in health of children as well as their education and other social costs.

Babies can be treated either with or without the help of medication, and if medical interventions are needed, doctors usually use morphine for therapy. Sometimes other medications such as 22

Children’s Health Insurance Program (CHIP) The Children’s Health Insurance Program (CHIP) is a governmental health insurance program for children in families that earn too much money to qualify for Medicaid. However, these families do not make enough for private health insurance. It provides coverage for routine check-ups, immunizations, doctor visits, prescriptions, dental and vision care, inpatient and outpatient hospital care, laboratory and X-ray services, emergency services, and other services specific to states. CHIP provides free dental vists and “well child” doctor visits. Other services may require a copayment.5

those months of unceratinty, she considered selling her car and downsizing her house, so she could afford the health services that her children required. She considered stocking up on inhalers. Through CHIP, she pays $13 for each doctor’s visit. She would have to pay $40 dollors for each visit through private insurance.6

https://www.washingtonpost.com/politics/they-treated-my-kids-health-insurance-like-it-was-a-gamethe-battle-over-chip/2018/01/29/5ba12470-01dd-11e8-bb03-722769454f82_story.html?utm_term=.516f1bbbd783

Professional Opinion: The continuation of the CHIP program was a good thing that the US government did. Through this program, 9 million children are covered. Whether someone believes healthcare is a right or a privilege, children cannot control what their parents do. If their parents do not make enough money or make too little to afford private insurance, that should not prevent children from getting health insurance when they need it.

CHIP was authorized by Congress in 1997. This program allowed the number of uninsured children in Alabama to drop from 20% to 2%. Currently, CHIP provides coverage for 9 million children in the United States and 370,000 pregnant women.6 On Septemeber 30, 2017, the program expired. Alabama was planning on stopping enrollment in January 2018 and cutting 80,000 children from the program in February. It was refunded for an additional six years on January 22, 2018 with the end of the governent shutdown.6

Vaccines

During the months of uncertainty of whether this program would continue, parents were concerned about how their children would be covered. Some of the things that parents were considering included working more hours so that could afford more expensive health services and quiting their jobs, so that they would qualify for Medicaid due to a lowered income. Some parents did buy health insurance policies that they cannot afford for their children.6

One important aspect of medicine today is preventative care. A very important preventative care treatment for children is vaccines. Vaccines not only provide protection throughout children. They also provide protection in adulthood. However, this common practice seems to have a lot of controversy currently surrounding it. Vaccines do NOT cause autism. Vaccines causing autism is one of the most frequently given reason by parents for not or not wanting to vaccination their children. This controversy started due to the publication of an article in the scientific journal, Lancet, in 1998 that linked the measles-mumpsrubella (MMR) vaccine with autism. The data

One family that had this experience was the Meads (pictured). Varina Mead is a single mother that lives in Prattville, AL. She has two children, Ava and Gavin. Ava has asthma. Gavin has ADD. During 23

published in this article has been shown to be flawed and no one has been able to replicate the results. The initial interpretations of the findings have been retracted by nearly all of the authors.7

Most of these controversies are about a single person. However, vaccines are also benefical to society. This concept is know as herd immunity (pictured). Even if some people are immunized, a disease can easily spread through out a population. However, if most people are immunized, then a contagious disease will not spread. The theorized amount of immunization for herd immunity is 95% of the population. There are some populations that are unable to be vaccinated. An example of this are individuals fighting cancer. They considered immunocompromised and because of that, they cannot be immunized.10 Profesional Opinion: Vaccines are a medical prevention treatment that should be required. Vaccines will protect children from harmful diseases that are still present in the world and they will carry that protection with them throughout adulthood. Also, vaccines protect individuals in the community who are unable to be vaccinated, for example, because they are fighting cancer and are immunocompromised. If a person, wants to live in society, they should have to do things that will not cause harm them in order to protect others in society.

References

http://www.pbs.org/wgbh/nova/body/herd-immunity.html

Another controversy that some people believe is that some of these diseases that children are vaccinated against are no longer around, so there is no point in being vaccinated against them. Usually when this argument is given, the person means that the diseases are no longer around in the country they live in. All of the diseases that have a vaccines are still found in other countries. With the ease and frequency of travel nowadays, someone could pick up one of these disease and bring it back to their country, where it might not be found. If people are unvaccinated against that disease it could easily spread.8

3. 4. 5. 6.

The final controversy that will be addressed is overloading children’s immune systems with vaccines will weaken them. There is no scientific evidence that supports this claim. The evidence shows that simultaneously vaccinating with multiple vaccines has no adverse effects on children’s health. Also, everyday children are exposed to many foreign antigens and germs, and that does not cause their immune systems to weaken.9

10.

What Happens When a Baby Is Born Addicted to Drugs? The Science Explorer. http://thescienceexplorer.com/brain-and-body/what-happenswhen-baby-born-addicted-drugs. Accessed February 27, 2018. Aguilera-Hellweg Pby M. Babies Fall Victim to the Opioid Crisis. National Geographic. https://www.nationalgeographic.com/ magazine/2017/09/science-of-addiction-babies-opioids/. Published October 19, 2017. Accessed February 27, 2018. Child Abuse. Psychology Today. https://www.psychologytoday.com/ conditions/child-abuse. Published May 18, 2017. Accessed February 27, 2018. What Is Child Abuse and Neglect? Recognizing the Signs and Symptoms. Retrieved February 27, 2018, from https://www.childwelfare. gov/pubs/factsheets/whatiscan/ The children’s health insurance program (CHIP). Healthcare.gov. https://www.healthcare.gov/medicaid-chip/childrens-health-insuranceprogram/. Accessed February 26, 2018. Samuels, R. ‘They treated my kids’ health insurance like it was a game’: The battle over CHIP. The Washington Post. https://www. washingtonpost.com/politics/they-treated-my-kids-health-insurancelike-it-was-a-game-the-battle-over-chip/2018/01/29/5ba12470-01dd11e8-bb03-722769454f82_story.html?utm_term=.438229d4c11a. Published January 30, 2018. Accessed February 26, 2018. Bronfin DR. Childhood Immunization Controversies: What Are Parents Asking? The Ochsner Journal. 2008;8(3):151-156. Six common misconceptions about immunizations: Vaccinepreventable diseases have been virtually eliminated from my country, so there is no need for my child to be vaccinated. World Health Organization. http://www.who.int/vaccine_safety/initiative/detection/ immunization_misconceptions/en/index5.html. Accessed February 26, 2018. Six common misconceptions about immunizations: Giving a child multiple vaccinations for different diseases at the same time increases the risk of harmful side effects and can overload the immune system. World Health Organization. http://www.who.int/vaccine_safety/initiative/ detection/immunization_misconceptions/en/index6.html. Accessed February 26, 2018. Willingham E, Helft L. What is Herd Immunity? PBS. http://www.pbs.org/ wgbh/nova/body/herd-immunity.html. Published September 5, 2014. Accessed February 26, 2018.

Diabetes Spring 2018

Stella Jung, Jon Jones BSPS Students

Background Information Today, diabetes became a major global problem and more people are receiving treatments to alleviate its symptoms. Therefore, our group decided to choose diabetes as our topic. Four different issues of diabetes are the prevalence of diabetes in the US vs. in the world, current treatments of diabetes, treatments under development and lastly, costs associated with diabetes.

produced in beta-islet cells of pancreas and it regulates blood glucose in our body. There are two main types of diabetes and they are type I and type II diabetes. Patients with type I diabetes do not produce enough insulin in their body, while patientsâ&#x20AC;&#x2122; cells with type II diabetes do not react to insulin, which eventually cause insulin resistance. Common symptoms associated with diabetes are frequent urination, excessive thirst, hunger, weight loss and fatigue. However, diabetes also can cause detrimental effects in different parts of our bodies such as heart, blood vessels, kidney, eyes and nerves.

Diabetes is a group of metabolic diseases characterized by high blood sugar or glucose levels that result from defects in insulin or its action or both. Insulin is a hormone that is

Diabetes in the US vs. World 1. Currently, approximately 30.3 million have diabetes, which is 9.4% of the U.S. population. 2. 23.1 million people are diagnosed, while 7.2 million are undiagnosed. 3. Diabetes is currently the 7th leading cause of death and 382 million people are living with diabetes in the world. Moreover, almost 90% of all cases of diabetes worldwide suffer from type II diabetes and 90% of them are overweight. It shows a strong correlation between obesity and diabetes, which concerns peopleâ&#x20AC;&#x2122;s diet and exercise levels.

Figure 1. Prevalence of Diabetes in the US from http://www.businessinsider.com/map-of-diabetes-rates-inthe-us-2017-7

The study has shown that obese people are up to 80 times more likely to develop type II diabetes than those with a BMI (Body Mass Index) of less than 22. Obesity can stimulate changes in bodyâ&#x20AC;&#x2122;s metabolism and these lead adipose tissue to release fat molecules into the blood. Thus, it may influence insulin responsive cells and ultimately result into reduced insulin sensitivity.

Figure 2. Prevalence of Diabtes in the World from https://ifmsa.wordpress.com/2014/11/14/ifmsa-for-theworld-diabetes-day-2014/

Current Diagnosis Methods/Treatments When discussing the landscape of current treatments available for patients with diabetes, it is important to understand that treatment plans vary greatly from patient to patient and must be individualized to achieve the best results. The first step is to make a diagnosis of diabetes and to understand the severity of the diabetes present in a patient before developing a treatment plan.

glucose measured in the morning before they have eaten or drinken anything. Any result above 126 mg/dL for this test may indicate a status of diabetes. The second is an oral glucose tolerance test, where a beverage that is high in glucose content is consumed and then blood glucose levels in the patient tracked in 30 minute intervals for 3 hours afterward. If the patientâ&#x20AC;&#x2122;s blood glucose levels ever exceed ~200 mg/dL, then diabetes may be present. The final test is the A1c test. The A1c test can provide an average glucose level for approximately the last 3 months due to the fact that it measures the amount of glycated hemoglobin.

In order to diagnose diabetes and assess the severity, there are three tests that are used. The first is a basic fasting glucose test, where a patient fasts overnight and has their blood

Once diagnosing the type and severity of diabetes, a treatment plan can begin to be developed. In terms of type 1 diabetes, given the nature of the pathology of the disease with the body being unable to produce enough insulin due to the beta islet cells being attacked by the immune system, administration of insulin is quintessential. There are several different types of insulin, ranging from rapid acting within a matter of minutes to ultra long acting that can last several hours. Insulin can be administered in a variety of ways, one of the most common being the use of an insulin pump. An insulin pump will administer a continuous low level dose of insulin that the doctor will program to the specific needs of the patient. When a patient eats a meal, particularly one high in sugar, a calculation is done with assistance from the

Figure 3. Current Diabetes Treatment from https://www.walmart.com/ip/A1C-Now-Rapid-DiagnosticTest-Kit-Diabetes-Management-Box-of-20/116377383

insulin pump and using data entered by the patient in order to calculate a bolus dose in response to the glucose consumed. This is to prevent the patients blood glucose levels from spiking too high, but must be done carefully, because the administration of too much insulin can lower the blood glucose to unsafe levels and cause the patient to go hypoglycemic.

In type 2 diabetes, administration of insulin is sometimes used but is usually not needed. A patient with type 2 diabetes still produces insulin in their bodies, but is unable to produce enough or has developed a resistance to insulin that makes it insufficient leading to uncontrolled blood glucose levels. The first line of defense is diet and exercise, as living a healthier lifestyle lower in consumption of glucose can begin to reverse some of the symptoms of insulin resistance in patients with early forms of type 2 diabetes. In more severe cases, oral medications can be used to help the patientâ&#x20AC;&#x2122;s own body produce more insulin to meet the gap between what they are producing and the amount needed to compensate for the insulin resistance that has been developed.

Figure 4. Current Diabetes Treatment from https://www.accu-chek.com/

Treatments under Development In regard to treatments under development for diabetes, there are two schools of thought being applied in attempt to expand the treatment options. First, for 20+ years researchers have been attempting to develop an autonomous pancreas that can be employed to make up for the lack of homeostatic function in a patient with diabetes. The crux of this method would be constant communication between a continuous glucose monitor and a insulin pump, allowing the insulin pump to make mathematical models and calculations based on the data inputted from the continuous glucose meter as to how much insulin should be released in anticipation of meals and in response to variations. Unfortunately, the development of an autonomous pancreas has ran into significant difficulty, particularly in the realm of regulatory approvals in submissions. However, it is hopefully anticipated that such a device would be available and approved for market use within the ~5 years.

Figure 5. Future Treatments for Diabetes from https://www.thediabetescouncil.com/closed-loop-systemsfuture-treatment-for-diabetes/

The next school of thought being pursued is to replace the beta islet cells that are destroyed by the immune system within type 1 diabetes using stem cells. While replacing the cells using stem cells has been successfully completed using various techniques, the difficulty is to prevent the immune system from attacking the newly developed beta islet cells again, bringing the patient back to where they started pathophysiologically. Researchers at MIT have discovered a technique to â&#x20AC;&#x153;cloakâ&#x20AC;? these beta islet cells from immune system attack, and have proved its efficacy in mouse models, but this method is still years away from human testing. 27

Costs with Diabetes Due to increasing diagnosis of diabetes in the U.S., the costs associated with the disease are also increasing. Since the costs related with diabetes vary widely in different countries, our group has decided to focus on the costs in the U.S. only. Recently, the total costs of diagnosed diabetes in the US were approximately $245 billion. Based on that total cost, $176 billion were in direct cost area such as medical costs, while $69 million were in production costs due to decreased productivity of patients. Average patient cost is estimated to be $13,700 per year. However, the costs of diabetes keep increasing every year. By 2030, the total cost of diabetes will reach up to $622 billion and it is 3.3% of the overall U.S. GDP. Based on the current U.S. population, the cost will be $1,900 per person.

Figure 6. Different Types of Diabetes Treatments from http://chuyenkhoatimmach.com/diabetes-disease-causessymptoms-treatment-and-diet-plans-for-different-type

Professional Opinion Due high costs of the treatments, some patients are reluctant to receive treatments. It may lead to detrimental complications due to uncontrollable blood sugar level. Therefore, we think many researchers, pharmaceutical

companies and the U.S. government should consider what they can do to lower the costs of diabetes and seek for ways that can ease the financial burden of health care system and of the patient.

References: Diabetes Disease: Causes, Symptoms, Treatment and Diet Plans for different chuyenkhoatimmachcom. http://chuyenkhoatimmach.com/diabetes-disease-causes-symptoms-treatment-and-diet-plans-for-different-types/. Published December 12, 2016. Accessed April 2, 2018.

Types.

Gruber B. Care and Cure: Engineering the future of diabetes treatment. Reuters. https://www.reuters.com/article/us-usa-diabetes-research/care-andcure-engineering-the-future-of-diabetes-treatment-idUSKCN0VJ2MN. Published February 10, 2016. Accessed April 2, 2018. How is Diabetes Treated? Joslin Diabetes Center. http://www.joslin.org/info/How_is_Diabetes_Treated.html. Accessed April 2, 2018. IFMSA for the World Diabetes Day 2014. IFMSA's Official Blog. https://ifmsa.wordpress.com/2014/11/14/ifmsa-for-the-world-diabetes-day-2014/. Published November 14, 2014. Accessed April 2, 2018. Insulin, Medicines, & Other Diabetes Treatments. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/insulin-medicines-treatments. Published November 1, 2016. Accessed April 2, 2018. Ramsey L. The CDC mapped out where people with diabetes live in the US - here's what it found. Insider. http://www.businessinsider.com/map-of-diabetes-rates-in-the-us-2017-7. Published July 19, 2017. Accessed April 2, 2018.

Business

Statistics About Diabetes. American Diabetes Association. http://www.diabetes.org/diabetes-basics/statistics/?referrer=https://www.google.com/. Published July 19, 2017. Accessed April 2, 2018. Treatment & Care. American Diabetes Association. http://www.diabetes.org/living-with-diabetes/treatment-and-care/. Accessed April 2, 2018.

Female Reproductive Health Ellen Rothrock (BSPS student) & Mu Qiu (BSPS student) Spring 2018

Background

Approximately half of the world’s population is biologically female • There are a lot of misconceptions about female reproductive health • Sex education on female body can be limited, inaccurate or absent • There are a lot of problems with how the world as a whole is dealing with female reproductive health •

Sanitary Feminine Products

Feminine Hygiene Icon Set. Vecteezy. 2018. Available at: https://www.vecteezy.com/vector-art/100199feminine-hygiene-icon-set. Accessed March 30, 2018.

High costs and unavailability of menstrual products is the prime reason for women and girls not to use sanitary pads. Women who cannot afford menstrual products reported that they substitute with whatever they can find: toilet paper, paper towels, rags, even dirty socks. Without access to menstrual products, these women are at risk for reproductive health issues including infections, toxic shock syndrome, and infertility. In rural areas in some countries, females do not have access to menstrual products.

Quality Problems 1. Most sanitary feminine products end up landfills and it takes long time to break down 2. Many pads and some tampons contain plastic chemicals and BPA (Bisphenol A). A lots of small blood vessels run to vaginal area, where the skin is thin, so that those chemicals can easily enter the body 3. Most sanitary products contain a synthetic fiber called rayon. It is the only synthetic fiber allowed in tampons mixed with cotton. It is more absorbent than cotton. However, synthetic fibers can cause production of toxins absorbed by vaginal mucosa and further cause TSS (Toxic Shock Syndrome) which is a systemic illness leading to high fever, low blood pressure and vomiting.

High Cost In developing nations, 60% of women and girls don’t have access to sanitary goods. Some girls in low income families choose to skip classes during period. In East Africa, menstruation is one of the biggest reasons why adolescent girls miss school. In Kenya, girls will miss an average of 4 days of school each month – adding up to about 20% of the school year. When girls don’t have access to sanitary pads, they will often choose to leave school early, or stay home altogether. In the U.S.: Tampons: $6.79/box * 9 boxes/year: $61.11 Pads: $7.99/package * 7 packages/year: $59.43 Menstrual Cup: $30, up to 5 years: ~$6/year Cloth Pads: $3 * 10 pads, about 5 years: ~$6/year Assuming 40 years of menstruation: ~$2500/female

Sallyakinscom. 2018. Available at: https://www.sallyakins.com/wp-

content/uploads/2016/03/TamponTax.jpg. Accessed March 31, 2018.

It is a controversial topic whether tampons need to be taxed. In some European countries, tampon tax charges as much as 20% (Slovakia) and even 27% (Hungary). But there are several countries which do not impose a Tampon Tax. Sanpro in Ireland is zero-rated, several states in the US also have 0% tax on sanpro and Canada abolished its own tampon tax in 2015.

Access to Birth Control Lack or Misunderstanding of Reproductive Knowledge Lack of sex education can lead to tremendous public health threat. In the U.S., a huge number of adolescents do not receive adequate sex education, such as how to prevent unwanted pregnancy, HIV, sexually transmitted diseases (STD) and even how to get some condoms. Less than 40% of schools nationwide required sex education. Report from the CDC suggests that less than half of all high schools and only a fifth of middle schools in the country teach the basics of sex education. Many schools in the U.S. provided information to high school students on hormone-based birth control, including pills, patches, intrauterine devices, rings, implants and next-day emergency contraception.

Jalili C. These Are The Most Popular Contraceptive Methods Around The World. Elite Daily. 2018. Available at: https://www.elitedaily.com/dating/contraceptive-method-world/1528728. Accessed March 31, 2018.

The picture above shows most popular birth control methods used by every country. More short-term methods (i.e condoms) are more popular in European and African countries. Contrastingly, more long-term methods (i.e IUD, female sterilization) are popular in American and Asian countries. And while female sterilization is the most popular form of birth control in the U.S. and the northern part of South America, male sterilization is more popular in Canada. The pill is popular across the globe, from several countries in Africa to Australia to Western Europe and even parts of South America.

Cost A 2010 survey found that more than a third of female voters in the U.S. have struggled at some point in their lives to afford prescription birth and as a result used birth control inconsistently. This isn’t surprising considering co-pays for birth control pills typically range between $15 and $50 per month.

Where on Earth? – Free the Pill. Free the Pill. 2018. Available at: http://freethepill.org/where-on-earth/. Accessed March 31, 2018.

As shown in the graphic above, many developed countries require a prescription for hormonal birth control pills. This can be a barrier for some women, particularly those without insurance or access to doctors. However, there are a few options now. There is a service called NURX, as well as a few similar services, in which females can simply answer questions via video-chat, enter insurance and shipping information. The doctor there would review and write a prescription without requiring insurance, and the birth control ships to their door. However, it is currently only available in 18 states.

Access to Birth Control | Power to Decide. Powertodecideorg. 2018. Available at: https://powertodecide.org/what-we-do/access/access-birth-control. Accessed March 31, 2018.

“Reasonable access” is defined as at least one clinic or provider for every 1,000 women in need of publicly funded contraception. However, more than 19 million women in need live in contraceptive deserts which means that seeing a provider, accessing trusted information, and finding the right birth control becomes nearly impossible. 30

Nutritional & Environmental Effects on Female Reproductive Health

premature births (41% more likely), and low-birth weight babies. The damage done to the victims can also impact their mental health and lifestyle. Victims commonly suffer from: PTSD and other mental health problems in the victims; eating disorders in the victims; higher rates of depression and drinking (both twice as likely).

Nutrition: Nutrition is a major factor in the regulation of the menstrual cycle. Low iron in diet combined with menstruation can lead to anemia.

Reproductive Rights for Females: How They are Being Restricted and Violated

Undernutrition can stop menstrual cycles when 1015% of body weight is lost. It is more common in developing countries, typically due to food shortages, but can also occur in developed countries, typically the result of eating disorders or excessive exercise.

Choosing to Reproduce

Overnutrition (obesity) is more common in developed countries. It can: decrease fertility; deregulate or stop periods; cause failure of tubal rings; cause failure of hormonal contraceptives. It is also linked with higher rates of both miscarriage and stillbirth.

Many cultures pressure females to reproduce early, and will go so far as to question the womanhood of any female that elects to not have children. The belief that women’s fertility decreases rapidly with age. Forced marriages occur in some parts of the world in part because of this. Counter to that, forced or coerced sterilization is still a common practice worldwide, effectively taking the choice out of a female’s hands and directly placing it into the governments’. Prior to World War II, the Eugenics movement favored sterilization of any parties they considered to be less than perfect; eugenics fell out of favor with the human experimentation performed by the Nazi War Doctors. In India, citizens are offered monetary incentives to be sterilized. China, when they still had the “One Child Law,” required females to be sterilized after having a child. Worldwide, it can be part of a legal penalty, which is the form it appears in in the U.S. The figure below shows four different ways of performing a tubal ligation.

Environment Many things can affect menstrual cycle, including: o Workplace/Occupation o Exposure to organic solvents o Lifestyle factors: smoking, excessive exercise o Medical conditions o Air pollution Social environment plays just as large a role as physical environment. According to the WHO, violence against women happens in toxic social environments in which violence against women is a social norm and there is gender inequality. Violence against women is far more likely when the environment: has low education for males or females; exposure to domestic violence against their mothers or other females in their life; abuse during childhood (females); unequal gender norms that emphasize the idea of male privilege and female subordinate status; acceptance of violence and/or a sense of entitlement over women (males); access to paid employment inadequate for females; beliefs in sexual purity and/or family honor; weak/absent legal sanctions for perpetrators of sexual violence. This toxic, violent environment can have the following effects on female reproductive health (Worldwide statistics, 2013): higher rates of gynecological problems, STDs (1.5x more likely), unintended pregnancies, and induced abortions (twice as likely) ; increased likelihood of miscarriages (16% more likely), stillbirths,

Tubal Ligation: What to Expect at Home. MyHealth.Alberta.ca Government of Alberta Personal Health Portal. https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=zy1248. Accessed April 3, 2018.

Choosing to use Contraceptives

dangerous complications, and can account for 4.713.2% of all maternal deaths annually. Every single one of these deaths and complications could be prevented with access to legal, safe abortions, contraceptives, and proper sex education.

Access to contraceptives is limited in some countries (see Access to Birth Control above), and many cultures actively discourage the use of contraceptives (ex. some sects of Abrahamic religions). This cultural pressure is only compounded by the lack of proper reproductive education. Comprehensive reproductive education is not universally offered; some areas don’t offer sex-education for women, or offer abstinence only education which has been proven to be ineffective. Access to female-controlled contraceptives is also a huge issue, as increasingly control over family planning is taken out of the female’s hands and put into the male’s. For a comparison, let’s look at Male (external) condoms vs Female (internal) condoms. • Average cost of internal (female) condoms: $20/12, or ~$1.67 each • Average cost of external (male) condoms: >$12 /12, or >$1 each • Internal condoms: only 1 brand FDA approved, now prescription only at drugstores and sometimes free at clinics • External Condoms: many brands, wide variety of sizes, available OTC at drugstores and free at clinics, community centers, doctors office, etc. Contraceptive choices that are solely under the female’s control are typically more difficult to get and/or more expensive than male-controlled contraceptives. In the U.S., hormonal birth control pills are by prescription only. Internal condoms, which the female can put in hours before sex if they so choose, are also prescription only. Long-term hormonal birth control (ex. IUD) have to be surgically implanted, and female sterilization procedures are in-patient procedures that can take months to heal from.

Professional Opinion 51% of the female population are in the reproductive age range, therefore approximately 1.8 billion females worldwide need information, products, facilities, support, etc. to manage their reproductive health. There are untold numbers of females in both developed and developing countries that lack the proper resources to effectively manage their reproductive health. The fact that many cultures refuse to view feminine products as a medical necessity as opposed to a luxury to be taxed is frankly appalling, and global recognition of the necessity of sanitary products for both the health of women and the population as a whole is needed. The lack of access to and respect of women’s choice to use various contraceptives, as well as the toxic environments that make their reproductive choices dangerous, are a worldwide problem that needs to be addressed before any real strides can be made for women.

References

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Choosing to Abort Abortion is outright illegal in some areas of the world, and actively discouraged by many communities. The WHO reports that between 2010-2014: 25% of all pregnancies ended via induced abortion, with more abortions being performed in developing areas than developed; an average of 56 million safe and unsafe abortions occurred worldwide each year. The WHO also reports that about 25 million unsafe abortions take place worldwide each year, with nearly all of them happening in developing countries. Over half were in Asia, the highest risk of maternal death was in Africa, and 75% of all abortions in Africa and Latin America were unsafe. Unsafe abortions lead to

13. 14. 15. 16. 17.

18.

19. 20. 21. 22. 23. 24. 25. 26. 27.

Feminine Hygiene Icon Set. Vecteezy. 2018. Available at: https://www.vecteezy.com/vector-art/100199feminine- hygiene-icon- set. Accessed March 31, 2018. Mama K. Natural Alternatives to Pads &amp; Tampons | Wellness Mama. Wellness Mama®. 2018. Available at: https://wellnessmama.com/25415/problem-with- pads-tampons/. Accessed March 31, 2018. 3. Women Beware: Most Feminine Hygiene Products Contain Toxic Ingredients. HuffPost. 2018. Available at: https://www.huffingtonpost.com/dr-mercola/feminine- hygiene-products_b_3359581.html. Accessed March 31, 2018. PATH: Sanitary pads. Pathorg. 2018. Available at: http://www.path.org/projects/sanitary-pads.php. Accessed March 31, 2018. Jannese S. Why Lower-Income Girls Are Forced to Skip School During Their Periods. Babble.2018. Available at: https://www.babble.com/parenting/girls-missing- school-periods- sanitary-products/. Accessed March 31, 2018. Rutgersinternational. 2018. Available at: https://www.rutgers.international/sites/rutgersorg/files/PDF/Facts%26Figures%201weekextra%20Engels. pdf. Accessed March 31, 2018. Akins S. Superdrug pays back your Tampon Tax - Sally Akins. Sally Akins. 2018. Available at: https://www.sallyakins.com/superdrug-tampontax/. Accessed March 31, 2018. U.S. Educators Still Won’t Talk About Sex. Newsweek. 2018. Available at: http://www.newsweek.com/usschools- still-lack- sufficient-sex- education-programs- 404328. Accessed March 31, 2018. 7 Facts You Need to Know About Birth Control Coverage. Plannedparenthoodactionorg. 2018. Available at: https://www.plannedparenthoodaction.org/issues/birth-control/facts- birth-control-coverage. Accessed March 31, 2018. Access to Contraception - ACOG. Acogorg. 2018. Available at: https://www.acog.org/Clinical-Guidance-andPublications/Committee-Opinions/Committee- on-Health- Care-for-Underserved-Women/Access- toContraception. Accessed March 31, 2018. Jalili C. These Are The Most Popular Contraceptive Methods Around The World. Elite Daily. 2018. Available at: https://www.elitedaily.com/dating/contraceptive-method- world/1528728. Accessed March 31, 2018. Access to Birth Control | Power to Decide. Powertodecideorg. 2018. Available at: https://powertodecide.org/what-we- do/access/access-birth- control. Accessed March 31, 2018. Menstrual Hygiene Management: A Review of the Evidence : PSI. Psiorg. 2018. Available at: http://www.psi.org/publication/menstrual-hygiene- management-a- review-of- the-evidence/. Accessed March 31, 2018. Contraception allows women to thrive. newsobserver. 2018. Available at: http://www.newsobserver.com/opinion/op-ed/article178735791.html. Accessed March 31, 2018. Access to Contraception - ACOG. Acogorg. 2018. Available at: https://www.acog.org/Clinical-Guidance-andPublications/Committee-Opinions/Committee- on-Health- Care-for-Underserved-Women/Access- toContraception. Accessed March 31, 2018. The ESHRE Capri Workshop Group. "Nutrition and Reproduction in Women." Human Reproduction Update 12, no. 3 (June 1, 2006): 193-207. doi:10.1093/humupd/dmk003. Jahanfar, Shayesteh. "Figure 2f From: Irimia R, Gottschling M (2016) Taxonomic Revision of Rochefortia Sw. (Ehretiaceae, Boraginales). Biodiversity Data Journal 4: E7720. Https://doi.org/10.3897/BDJ.4.e7720." Indian Journal of Human Genetics 18, no. 2 (May/June 2012): 187-92. Accessed April 3, 2018. doi:10.3897/bdj.4.e7720.figure2f. Belief in Family Planning Myths at the Individual And Community Levels and Modern Contraceptive Use in Urban Africa. (2018). Guttmacher Institute. Retrieved 3 April 2018, from https://www.guttmacher.org/journals/ipsrh/2015/12/belief-family-planning-myths-individual-andcommunity-levels-and-modern Compulsory sterilization. (2018). En.wikipedia.org. Retrieved 3 April 2018, from https://en.wikipedia.org/wiki/Compulsory_sterilization Mahalingaiah, S., Missmer, S., Cheng, J., Chavarro, J., Laden, F., & Hart, J. (2018). Perimenarchal air pollution exposure and menstrual disorders. Retrieved 3 April 2018, from Preventing unsafe abortion. (2018). World Health Organization. Retrieved 3 April 2018, from http://www.who.int/mediacentre/factsheets/fs388/en/ Preventing unsafe abortion. (2018). World Health Organization. Retrieved 3 April 2018, from http://www.who.int/mediacentre/factsheets/fs388/en/ Reproductive rights. (2018). En.wikipedia.org. Retrieved 3 April 2018, from https://en.wikipedia.org/wiki/Reproductive_rights Violence against women. (2018). World Health Organization. Retrieved 3 April 2018, from http://www.who.int/mediacentre/factsheets/fs239/en/ Violence against women. (2018). World Health Organization. Retrieved 3 April 2018, from http://www.who.int/mediacentre/factsheets/fs239/en/ Where Can I Buy Condoms & How Much Will They Cost?. (2018). Plannedparenthood.org. Retrieved 3 April 2018, from https://www.plannedparenthood.org/learn/birth-control/condom/how-do-i-get-condoms Where Can I Buy Female Condoms & How Much Will They Cost?. (2018). Plannedparenthood.org. Retrieved 3 April 2018, from https://www.plannedparenthood.org/learn/birth-control/female-condom/how-do-i-buyfemale-condoms

Christopher Blackwell & Logan Cathro BSPS Students Spring 2018

Food Safety Background Although the safety of our food has increased dramatically in recent decades, food contamination is still a serious health risk. According to the World Health Organization nearly 600 million people each year fall sick as a result of eating contaminated food, and more than 400,000 of those die. Food recalls are still common; more than 20 million pounds of food were wasted last year because of recalls. We will be looking at four ways that consumers are exposed to contaminated food, and discussing specific examples of how they have impacted specific populations. Restaurant Outbreaks - Chipotle A major problem that came up and hit closer to home for people around here is the Chipotle recall in 2015. From November 2015 to January 2016 there was an E. coli outbreak at multiple Chipotle outbreaks, affecting 60 people. 55 people were infected by one strain and 5 were infected by another. They were all reported eating at Chipotle. The major problem wasnâ&#x20AC;&#x2122;t at just one or two restaurants, it spread across 14 states, primarily in Washington and Oregon. Due to this disaster, Chipotle closed 41 stores in the Pacific Northwest region. The problem with this outbreak was that the FDA investigation never determined which ingredient was the cause. It shows how difficult food safety can be since even under investigation, no cause was determined and no regulations were broken.

Factory Contamination - Blue Bell A common reason for many food recalls is factory sanitation conditions not being met. Poor sanitations in one factory can cause widespread disease outbreak due to large distribution. A specific example of this is the Blue Bell Creameries recall in 2015. The cause for this outbreak was not E. coli this time but Listeria. Listeria monocytogenes is a bacteria that is commonly found in contaminated food. It has similar symptoms as other food borne diseases. The problem with listeriosis is that symptoms usually take between one to four weeks to appear but some people have reported it taking up to 70 days. It can life threatening to pregnant women, elderly and people with a weakened immune system. In April 2015 Blue Bell had to recall all of its products. 10 people were hospitalized in Texas, Kansas, Oklahoma, and Arizona and there were three deaths. There were several products in multiple Blue Bell factories found to have Listeria. Previous employees have reported that Blue Bell would cut corners in sanitation conditions. It was found that products were stored in damp areas and water dripping in others. The example shows that sanitation is important and problems can arise when shortcuts are made. Safe Food in Developing Economies Access to safe food is also a critical issue. In many developing nations, the poorest citizens often cannot afford to purchase much of their food from regulated channels such as grocery stores. Instead, they must rely on cheaper but unregulated sellers, normally street venders, which are called â&#x20AC;&#x153;informal marketsâ&#x20AC;?. Because of this lack of oversight, there is a higher risk of food being sold that is spoiled or otherwise contaminated. It is important to note that most food sold through informal markets is as safe as food sold through formal markets, and that

even contaminated food can often be consumed safely if properly prepared, but the risk of unsafe contamination is still higher. Oftentimes the street vendors have no running water or electricity, although this varies by region. One survey in a town in South Africa found that over half of the street vendors struggled to find a supply of water, and only one seller had access to a refrigerator. This can be a serious issue with perishable foods. The figure to the right shows increasing rates of contamination in milk before pasteurization. Milk is often sold unpasteurized in informal markets, and therefore has this higher contamination risk, and even boiling the milk cannot remove all toxins. In fact, as much as 25% of cooked meat, and nearly all of the raw meat that was sold at those vendors was found to have been unacceptably contaminated. All the meat sold in the village was originally purchased from a butcher or other formal retailer, which means that it would have passed an inspection as some point. Therefore, it is likely the unsafe storage and preparation conditions caused the contamination. These are just a few examples, but the risk caused by the lack of safety standards is a common feature of informal markets. Access After Natural Disasters A more specific situation where access to safe food is problematic is immediately following natural disasters such as a hurricane or tsunami. Many familiesâ&#x20AC;&#x2122; food supplies are destroyed in the disaster, especially if there is heavy flooding. Most businesses, including grocery stores and restaurants, are closed in the days after the disaster, and those that are open may have limited stock. Because of this, access to food, and access to safe food, is a major issue. In addition, power and water services may be shut off for multiple days or even longer, especially in poorer areas or less developed nations. Because of these problems, many people rely on either aid workers to bring supplies or for restaurants to reopen in order to

access safe food. In fact, the Federal Emergency Management Agency has used the Waffle House Index, the number of Waffle Houses reopening after a storm, as an unofficial measurement of that storm’s severity. All restaurants, not just Waffle Houses, that are damaged in a storm must repair equipment, wash and sanitize all equipment following FDA standards, and and seek approval from local regulatory body to reopen. Professional Opinion These examples demonstrate that food safety is still a prevalent issue, and that consistent action must be taken to maintain access to safe food. We believe that the Chipotle and Blue Bell examples show that more care can be taken to prevent the contamination of food during processing and preparation. The current regulations for prepared food should be sufficient to maintain safety, but these outbreaks show a problem with adherence to those regulations and standards. The root cause of a lack of access to safe food, especially in developing nations, is poverty. Food safety policies exist, but are not enforced in these markets for economic reasons, and therefore improved infrastructure or economic growth will likely have a more significant impact on access to safe food than individual legislation or regulations. Bibliography Emergencies - Restaurants and Grocers Reopening After Hurricanes and Flooding. U S Food and Drug Administration Home Page. https://www.fda.gov/Food/RecallsOutbreaksEmergencies/Emergencies/ucm112713.htm. Accessed March 20, 2018. Food safety. World Health Organization. http://www.who.int/mediacentre/factsheets/fs399/en/. Published October 2017. Accessed March 20, 2018. Listeria (Listeriosis). Centers for Disease Control and Prevention. https://www.cdc.gov/listeria/outbreaks/ice-cream-03-15/index.html. Published July 13, 2015. Accessed March 20, 2018. Outbreaks - FDA Investigates Multistate Outbreak of E. coli O26 Infections Linked to Chipotle Mexican Grill Restaurants. U S Food and Drug Administration Home Page. https://www.fda.gov/Food/RecallsOutbreaksEmergencies/Outbreaks/ucm470410.htm. Published February 1, 2016. Accessed March 20, 2018. Roesel K, Grace D. Food Safety and Informal Markets: Animal Products in Sub-Saharan Africa. London: Routledge, Taylor & Francis Group; 2015. Summary of Recall Cases in Calendar Year 2017. Recall Summaries 2017. https://www.fsis.usda.gov/wps/portal/fsis/topics/recalls-and-public-health-alerts/recall-summaries. Accessed March 20, 2018.

PHRM 485

Spring 2018

Geriatric Health By: Amanda Graboski, BSPS student and Siena Cooper, BSPS student

Geriatric health is a branch of medicine that deals with issues regarding aging and the elderly. A patient is considered geriatric at the age of 70. This field of medicine is extremely important because as a person ages their organs and immune system begin to work less efficiently leaving them susceptible to more diseases than others. Not only can the poor function of their organs lead to arthritis, heart failure, and blood pressure issues, but can easily lead to infections such as UTIâ&#x20AC;&#x2122;s and tuberculosis.

Another reason why geriatric health is of importance is due to youth negligence. The elderly community needs supervision and enrichment but the younger generations view them as a burden. Old people are subject to abuse from their families as their health and wellbeing arenâ&#x20AC;&#x2122;t a priority compared to work schedules and kids of their own. When the elderly are left unattended, most deal with overwhelming feelings of dejection and purposelessness. It is important for younger generations to better understand geriatric health and the effects their negligence has on the heath of others.

How socialism makes old people want to kill themselves: A true story. (n.d.). Retrieved March 30, 2018, from https:// www.lifesitenews.com/blogs/how-socialism-makes-old-people-want-to-kill-themselves-a-totally-true-story

1. Sexual Health Professional Opinion:

STD’s:

Geriatric patients are vulnerable to illnesses involving sexual health for the obvious reasons of aging. Since unplanned pregnancy is not possible, unprotected sex seems inconsequential without infection education. Elderly patients are also less likely to feel comfortable discussing their sexual activity or sexual symptoms with their doctors. These factors combined with impaired immune health leave geriatric patients susceptible to these sensitive infections. Geriatric patients need better education on the possible risks of unprotected sexual activities, and healthcare providers are responsible for regularly initiating conversations that will improve geriatric sexual health.

According to the CDC, the geriatric population is dating again and elders are less likely to be educated about the risks of STD’s and safe sex. The likelihood of no education on the subject matter along with the absense of fear of unplanned pregnancy leaves many elders at risk for STD transmission.

“Older people in the United States are more likely than younger people to have late stage HIV infection at the time of diagnosis”

2. Depression According to the CDC, depression is characterized by many weeks of feeling sadness or anxiety that may be accompanied by other symptoms such as feelings of worthlessness, loss of interest, loss of appetite, irritability, and insomnia. These symptoms overlap with many normal ailments that plague aging people. Therefore, elderly depression can often be overlooked or even mistaken for other illnesses such as dementia. Due to general loss of mobility and loved ones, loss of independence, and even losing their homes, the elderly themselves often do not understand that their symptoms are not a normal result of the difficulties of aging. And, to make matters worse, the CDC estimates that about 80% of older adults have a chronic health condition and 50% have more than one.

It is proven that the geriatric population is less likely to discuss their sexual habits with their primary caregiver. They may miss being diagnosed or tested for an STD even though they see doctors more regularly compared to the rest of the population. They are also more likely to mistake HIV symptoms for natural aging and may not seek medical treatment.

UTIs: Urinary tract infections are common in the geriatric populations mainly due to unprotected sex and catheters. An issue with UTIs is that in older adults, particularly those in long-term care facilities, dont show with the same symptoms as a typical infection. This leaves no proper way to diagnose the elderly with these infections. This leads to higher chances of long term antibiotics use which can cause a variety of consequences including the development of multidrug-resistant organisms. 38

Sad and depressed elderly woman. (n.d.). Retrieved March 30, 2018, from https://www.shutterstock.com/video/ clip-7519549-stock-footage-sad-and-depressed-elderly-woman.html

Depression in geriatric patients proves difficult to identify, especially since older adults are less likely to seek help or even acknowledge that their symptoms are treatable. Treatments of geriatric depression include antidepressants, life enriching activities, spending time with loved ones, and psychotherapy. The life adjustments are not easy, but finding purpose in life when they are unwell or missing loved ones is achievable. Professional Opinion: Depression in geriatric patients proves difficult to identify, so the professional evaluating the psychological wellbeing of patients must be able to properly diagnose depression as opposed to other forms of psychological or physical illness. Caregivers and family members must support the affected patient throughout treatment and recovery. The life adjustments are not easy, but finding purpose in life when unwell or missing loved ones is achievable.

Help End Alzheimer’s. (n.d.). Retrieved March 30, 2018, from https://www.alz.org/

Other degenerative disorders: Other degenerative diseases that plague elderly Americans include glaucoma, osteoporosis, arthritis, parkinson’s, etc. These diseases can cause the elderly to become more fragile and spend more time in the hospital or intensive care as they progress. As degenerative diseases progress, elderly patients lose their independence, their health, and even their minds.

3. Degenerative Disorders Alzheimers: According to the Alzheimer’s Association, Alzheimer’s is the 6th leading cause of death in the United States. 1 in 10 people over the age of 65 have been diagnosed with Alzheimer’s which is about 5.3 million Americans. This number is projected to reach 16 million by 2050.

Awareness, Adherence Key to Improved Osteoporosis Care. (n.d.). Retrieved March 30, 2018, from https://www. odtmag.com/contents/view_breaking-news/2017-06-23/awareness-adherence-key-to-improved-osteoporosis-care

Caring for Someone Who Suffers from Dementia. (2017, June 03). Retrieved March 30, 2018, from https://healthery.com/caring-for-someone-who-suffers-from-dementia/

The total medical care costs of those with Alzheimer’s and dementia is projected to reach $1.1 trillion by 2050. Elderly people with Alzheimer’s and dementia are more likely to need intensive care and have higher risks of causing harm to themselves or others due to confusion or fear.

Professional Opinion: Degenerative diseases in geriatric patients prove difficult to identify, especially since older adults are less likely to seek help or acknowledge that their symptoms aren’t normal signs of aging. It is the responsibility of health care providers to determine possible causes of psychological or physical symptoms. Providers must especially work to differentiate psychological changes from other age-related conditions to avoid misdiagnosis and promote treatment. It is also very important to educate the caregivers and family of the elderly person so that they may understand the physical or psychological condition and be prepared and vigilant to changing symptoms or signs of decline in the patient’s health.

4. Difficulties in Treating In an interview from the chief medical director of Cardiology Today, Dr. Carl J Peptine, MD, MACC, treating aging patients can be difficult because aging is a heterogeneous process. By this, he means that some peopleâ&#x20AC;&#x2122;s bodies and minds age much differently than others. This may mean that an 85 year old patient could be much healthier than a 65 year old patient. While this poses a challenge for physicians, geriatric patients are also often less likely to ask for help until they are severely troubled which makes it even harder for their primary caregivers.

Miller MS. Communication is key when dealing with aging parents. Penn State University. http://news.psu.edu/ story/342263/2015/01/27/research/communication-key-when-dealing-aging-parents. Accessed March 31, 2018.

Geriatric patients may also be confused and unable to acknowledge that they are in need of help. They may suffer from paranoia and refuse medication they need to take. Lastly, geriatric patients come from a time of less readily available knowledge. At a time in the past, patients were less empowered to complain, question their doctors, or request second opinions. For this reason, elders without caregivers may be more susceptible to neglect or malpractice. This can put them in dangerous situations ranging from unnoticed bed sores to unnecessary surgeries. Professional Opinion: Elderly patients need extra attention from healthcare providers due to their age-related diseases, weakened immune systems, and the possibility of cognitive loss. Geriatric patients may lose the capability to care for themselves or take their medications. They are more likely to develop psychological disorders that could make them wary of medications and resistant to medical treatment. Geriatric patients are challenging to treat; and without loving caregivers, dedicated doctors, vigilant pharmacists, and tailored medical treatments, many elderly individuals would be victims of complications of aging and even death.

Miller B, Jones A. What Is a Medical Practice? wiseGEEK. http://www.wisegeek.com/what-is-a-medical-practice.htm#didyouknowout. Published March 28, 2018. Accessed March 31, 2018.

It is also possible that elderly adults may have other conditions that weaken their immune system, such as diabetes or HIV. This makes treatment significantly more difficult for the physician and the patient.

References Introduction to Geriatrics - Geriatrics. Merck Manuals Professional Edition. http://www.merckmanuals.com/professional/geriatrics/approach-to-the-geriatric-patient/introduction-to-geriatrics. Accessed March 30, 2018. Inc. Importance of Elderly Care Services | CARE Blog. CARE, Inc. http://www.careinc.com/care-blog/importance-of-elderly-care-services. Published April 8, 2015. Accessed March 30, 2018. HIV/AIDS. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/group/age/olderamericans/index.html. Published February 12, 2018. Accessed March 30, 2018. Rowe TA, Juthani-Mehta M. Urinary tract infection in older adults. Aging health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3878051/. Published October 2013. Accessed March 30, 2018. Healthy Aging. Centers for Disease Control and Prevention. https://www.cdc.gov/aging/mentalhealth/depression.htm. Published January 31, 2017. Accessed March 30, 2018. An Uphill Battle. BrightFocus Foundation. https://www.brightfocus.org/alzheimers-macular-degeneration-glaucoma/infographic/uphill-battle. Published June 22, 2017. Accessed March 30, 2018. 40

Genetically Modified Organisms (GMOs)

https://www.tes.com/lessons/eojLzBSGoJFy3A/genetically-modified-organisms

Mark Choi, BSPS Student Ethan Chau, BSPS Student Spring 2018

President Obama. Under this new law, labeling of GMOs would become mandatory instead of voluntary. The implementation of this law has begun, though noticeably slow. This is due to the fact that the classification of products considered “bioengineered” or “genetically modified” is often subjective. Therefore, the United States Department of Agriculture (USDA) holds the power to shape and enforce these regulations. Deadlines for establishing these regulations according to the new law were set for as early as July 2018. To complicate matters, it is very likely that agricultural and biotechnology companies will want to challenge provisions of the new law, and could file lawsuits in the future. Though the original GMO labeling law passed by Congress was aimed primarily at ensuring safety and quality of food as well as establishing a national set of guidelines, the law most likely will be amended in the future to accommodate the concerns of corporations.

Introduction Genetically modified organisms, or GMOs for short, are utilized throughout the developing world in a wide range of ways. Most notably, they have been used to revolutionize the agriculture industry by changing the way that farms plant and grow their crops. GMOs are synthesized primarily through transgenic technology or genetic engineering. Transgenic technology such as the transgenesis process, is simply a process that introduces new genetic material into a living organism. This living organism will then transfer this revised genetic sequence to offspring. In the year 2011, about 160 million hectares of biotechnology crops were grown. To put this into perspective, 160 million hectares is equivalent to about 10% of the Earth’s arable land. However, a significant portion of these crops are used for animal feed or biofuel, rather than for human consumption.

Product Labeling One of the most hotly debated issues regarding GMOs is the issue of product labeling and what role the government should play in regulating GMOs. Currently, the the Food and Drug Administration (FDA) does not require food manufacturers to disclose on their product labels whether or not they contain GMOs. However, manufacturers can state that their products contain “No GMOs” which is a common marketing strategy used to increase sales and boost brand recognition. In July 2016, Congress passed a new GMO labeling legislation which was signed by then

https://www.naturalnews.com/054578_GMOs_labeling_Roberts-Stabenow_legislatio n.html

Feeding the World A major argument put forth in favor of the widespread use of GMOs is that with the increasing severity of worldwide hunger, GMOs provide a way to alleviate the shortage of food supply in many underdeveloped countries. Over the past few decades, environmentalists have noted that climate change has had a significant impact on crop growing. Many fruits and vegetables are only able to grow in certain climates and climate change has threatened the supply of these crops. GMOs give farmers a way to combat the loss of production due to changing climates. Not only do GMOs help increase produce output, they have also shown extended shelf life. This helps with the transportation of produce around the world and makes delivery of produce more cost effective for vendors and consumers.

https://www.farmaid.org/issues/gmos/gmostop-5-concerns-for-family-farmers/ Those costs far outpaced the market price farmers received for corn and soy, leaving them tighter margins on which to run their farms.

Pesticide Resistance A trait that has been engineered into the majority of GMO crops is the resistance to pesticides and herbicides, specifically resistance against those containing glyphosate. Farmers can then use these herbicides to kill a broad spectrum of weeds surrounding the crops without affecting the integrity of the crops.

Agriculture Industry There are farmers who object to the strict regulation of these products because they can increase the cost of goods production and could drive away customers who have a negative perception of GMOs. Since the commercial introduction of GMOs, the seed industry has rapidly consolidated. Today, just four companies control almost 60% of the seed market. For certain crops, the market is even more concentrated. The “big four” seed companies – Monsanto, DuPont, Syngenta and Dow – own 80% of the corn and 70% of the soybean market.

https://en.wikipedia.org/wiki/Glyphosate Glyphosate

Since glyphosate resistant corn, soybean, canola, and cotton were introduced in the 90s, there have been a widespread increase in the use of glyphosate around the world. This has led to the emergence of resistant weeds that have adapted to these herbicides. Today, there are 18 different species of herbicide resistant weeds that have evolved through selection against glyphosate. Resistance causes increased herbicide and weed management costs for farmers. There are potentially negative effects of increased herbicide use to human health and the environment. One of those most common herbicides being used, glyphosate, has been listed by the World Health Organization since 2015 as being a probable carcinogenic.

https://www.ecowatch.com/monsanto-glyph osate-resistance-2449686645.html

Professional Opinion GMOs have created an abundant source of food that has greater yield and potential than others. Although the industry has varying opinions on this topic, the fact is GMOs are useful in providing food for the masses. We believe that the potential negative effects of GMOs are outweighed by the positive benefits that it provides to the world. The agriculture industry has been able to maintain production of various fruits and vegetables during climates that usually may not have been able to grow them. From a developed countryâ&#x20AC;&#x2122;s standpoint, the introduction of GMOs into the food source may be uncomfortable and controversial. But the introduction of GMOs on the continent of Africa has been critical to the efforts to alleviate hunger on the continent during the past decade. This goes to show that perhaps developed countries view GMOs as a luxury while others view it as a necessity.

References 1. 2. 3.

Diehel, P. (2018, March 1). How GMOs Can Feed the World. Retrieved March 30, 2018, from https://www.thebalance.com/can-genetically-modified-food-feed-the-world-375634 GMOs - Top five concerns for family farmers â&#x20AC;&#x201C; Farm Aid. (2018, January 04). Retrieved March 30, 2018, from https://www.farmaid.org/issues/gmos/gmos-top-5-concerns-for-family-farmers/ GMO Facts. (n.d.). Retrieved March 30, 2018, from https://www.nongmoproject.org/gmo-facts/

HUMAN TRAFFICKING AVNI BHALGAT MADDISON MCATEER BSPS STUDENTS SPRING 2018 PHRM 485

PROFESSIONAL OPINION In our professional opinion, we noticed in our research that many groups of people in the United States fail to recognize the severity of this issue. The definition of human trafficking constantly changes. To help rectify the situation, we think it is necessary to attack this problem on two fronts: at home and abroad. Here in the United States, it is important to educate people on what products to boycott that are connected to human trafficking, to join and donate to organizations that work with governments to end human trafficking, and to ask people to petition to their elected officials to get more involved in this cause. Abroad, the problem is more complex because it is not in front of you. However, we hope that the information we have provided here would encourage people to elect government officials that will put anti-human trafficking laws at the forefront of their campaign. To end this criminal enterprise, a joint effort is required from several afflicted nations who,

have many cultural differences. However, in order to get these victims the help and care they need to rehabilitate, nationsâ&#x20AC;&#x2122; leaders must work together to look out for these men, women, and children that often times are overlooked or forgotten because of their economic status or race. 49

INTRODUCTION

Source: https://humantrafficwatch.wordpress.com/2013/03/31/human-trafficking-visualized/

BACKGROUND

Human trafficking is reported to by the International Labor Organization to be a $150 billion industry worldwide. Nonprofit organizations such as the Ark of Hope for Children and Polaris report that the illegal sale of persons has already surpassed the illegal sale of arms and will surpass illegal sale of drugs by 2021.

Currently, worldwide, there are approximately 20.9 million victims of human trafficking globally according to the International Labor Organization. This modern form of slavery, as of present day, has not had many real talks about how to provide a solution on a global scale given the cultural complexities that surround it. Issues such as the age of the victims who are 26% of the time children provide complications for government agencies (State department report on HT). The struggle to get countries to work together and communicate effectively is highly political and often too slow to stop trafficking rings that can form overnight. Several victims are not even considered to be accounted for as these people are often runaways, immigrants, or missing. And finally there is an issue of making criminals and the public aware who benefit financially from trafficking (ie. forced labor of textiles) that they are doing so at the cost of the psychology of victims.

DESCRIPTION Human trafficking is a growing criminal enterprise that began as early as the 1400s and continues today. This complex form of slavery is hard to define for health professionals even today. However, the working definition from the United Nations Office On Drugs and Crime is:

“Recruitment, transportation, transfer, harboring, or receipt of persons for the purpose of exploitation, which includes exploiting the prostitution of others, sexual exploitation, forced labor, slavery or similar practices, and the removal of organs.”

AID: GOVERNMENTAL AND OTHERWISE Nationally- Nationally the United States is credited with several different efforts to combat this growing global problem. Inside the government, different sectors are responsible for coordinating different objectives. For example, the State Department works with other countries to communicate intel on current cases of traffickers and help to stop rings from forming. The Defense Department on the other hand acts more directly, like the police, and will work with the FBI and CIA to plan operations to arrest traffickers or rescue victims. Then the Justice Department is obviously responsible for ruling over these complex cases and working with other countries because this problem often crosses borders of several different countries. Besides the government, the US also has over 100 nonprofit organizations dedicated to this cause that actively work alongside international and national government agencies.

B16 L22 Corner Avenue, OH, 1234

This heat map shows where in the US that human trafficking has been observed/disrupted as of 2016. Source: Polaris Project

632 123 2718 / 625 281 2938

Internationally- This is where this issue takes on a different view than it has in the United States, Canada, and parts of Europe. A large amount of victims of human trafficking come from forced labor. According to the Walk Free Foundation and International Labor Organization as of 2017, “The Asia-pacific region accounts for the largest number of forced laborers— 15.4 million (62% of the global total). Africa has 5.7 million (23%) followed by Europe and Central Asia with 2.2 million (9%). The Americas’ account for 1.2 million (5%) and the Arab States account for 1% of all victims.” However, in many of these nations the amount of poverty and lack of access to education means that several people are quite literally “forced” into forced labor and these conditions. Victims in debt bondage or who were already impoverished often see exploiting themselves to traffickers as their only way to survive. Construction, mining, and manufacturing are the most common forms of work followed by domestic and agricultural work.

Since 1990, the FBI has reported that the majority of countries around the world have outlawed slavery. Yet, by 1995 the bureau witnessed a steady rise in the number of victims moving out of Asia. Since then, trafficking has continued to increase.The FBI also states that 38 countries currently have laws against extradition, so traffickers can still be held accountable for crimes in their native country if they flee. However, the 38 countries would not be named and that still leaves several countries as places these criminals can inhabit and prosper in. The question now is what solutions can people provide to stop slavery and begin to give these people back real freedom back, despite cultural and political barriers.

1 in 8

endangered youths is a victim of child trafficking

CHILDREN'S ISSUES Child Sex Trafficking

When a child (under 18 years of age) is induced to perform a commercial sex act, proving force, fraud, or coercion against their pimp is not necessary for the offense to be characterized as human trafficking. There are no exceptions to this rule: no cultural or socioeconomic rationalizations should prevent the rescue of children from sexual servitude. The use of children in the commercial sex trade is prohibited both under U.S. law and by statute in most countries around the world. Sex trafficking has devastating consequences for minors, including long-lasting physical and psychological trauma, disease (including HIV/AIDS), drug addiction, unwanted pregnancy, malnutrition, social ostracism, and even death. At least 7 countries use trafficked children for child pornography with Russia only taking in children for the purpose of porn

Forced Child Labor

Source: https://www.haikudeck.com/child-labor-uncategorized-presentationXXA0H3C5Bh

VICTIM PSYCHOLOGY

The psychological impact of victimization may be more severe than the physical violence (WHO, 2012). Victims who have been rescued from sexual slavery, typically present with various psychological symptoms and mental illnesses, including the following: Post-Traumatic Stress Disorder (PTSD), Depression, Anxiety, Panic disorder, Suicidal ideation, Stockholm Syndrome, Substance abuse. Since most victims that are rescued assume different identities and are protected it is B 1perform 6 L 2 2 extensive C o r n e r research A v e n u eon , O H, 1234 hard to the exact6psychological 3 2 1 2 3 2 7 state 1 8 / of 6 2victims. 5 281 2938

Although children may legally engage in certain forms of work, forms of slavery or slavery-like practices continue to exist as manifestations of human trafficking, despite legal prohibitions and widespread condemnation. A child can be a victim of human trafficking regardless of the location of that nonconsensual exploitation. Some indicators of possible forced labor of a child include situations in which the child appears to be in the custody of a non-family member who requires the child to perform work that financially benefits someone outside the childâ&#x20AC;&#x2122;s family and does not offer the child the option of leaving. Anti-trafficking responses should supplement, not replace, traditional actions against child labor, such as remediation and education. When children are enslaved, however, their abusers should not escape criminal punishment by taking weaker administrative responses to child labor practices. Peddling is a prevalent yet lesser known form of child labor, where children sell cheap goods, such as candy, magazines, or other trinkets, often going door to door or standing on street corners or in parks, regardless of weather conditions and without access to food, water, or facilities. Like victims of sex trafficking, labor trafficking victims are kept in bondage through a combination of fear, intimidation, abuse, and psychological controls. It is important to remember that child victims of labor trafficking also may be sexually abused or simultaneously victims of sex trafficking.Â 52 52

MISSING NUMBERS

71%

There are a lot of gaps in the reports and a lot of incidents of human trafficking that go unreported. This section is dedicated to all the victims we will never know of.

labor trafficking victims entered USA on lawful visas in 2014

In 2014, the National Urban Institute did a study, “Hidden in Plain Sight” that showed 71% of labor trafficking victims in the study entered the US on lawful visas. This meant that this percentage of people were given fake promises of better lives and freedom; they instead worked for several hours in horrible conditions and were not always paid enough to live. San Diego State University recently did a similar study where they reported 31% of undocumented spanishspeaking migrant workers had experiences some form of labor trafficking.

86%

endangered, runaway, child sex trafficking victims were under foster care or social services before being trafficked

Even more devastating, the Polaris Foundation has worked with the National Center for Missing and Exploited Children to uncover that 1 out of 6 endangered runaway has likely been affected by sex trafficking and 86% of those children were under foster care or social services when it happened. In other words, these traffickers take total advantage and control over people in our society that are already vulnerable to hardship. Although anyone can fall victim to modern day enslavement, it is scary to think that if 31% of a study done at a university showed that these “missing” or unaccounted for people were impacted, then who really knows how many current people living in our communities today really have the freedom we always brag about.

REFERENCES Definitions and Methodology. U.S. Department of State. https://www.state.gov/j/tip/rls/tiprpt/2012/1 92352.htm. Accessed February 26, 2018. Polaris. Polaris. https://polarisproject.org/. Accessed February 26, 2018. We'll Listen. We'll Help. National Human Trafficking Hotline. https://humantraffickinghotline.org/. Accessed February 26, 2018.

Hidden in plain sight. Hidden in Plain Sight. http://apps.urban.org/features/us-labortrafficking/. Accessed March 12, 2018.

Influenza: In 1918, there was an Influenza pandemic that killed 50-100 million people. Then an influenza epidemic recurred as the swine Flu which killed thousands more. There is a threat each year of influenza epidemics, which usually infect ~15% of a population HIV/AIDS: In the 1980s, the human immunodeficiency virus (HIV) emerged rapidly and has since infected around 60 million people and killing around 30 million people. This virus slowly kills of specific immune cells, leaving the host defenseless to more infectious. The weakening of the immune system can take years and has no apparent symptoms; therefore, an estimated 18% of people are unaware that they are infected (CDC).

Stephen Purdy (BSPS) and Arbaaz Mukadam (BSPS) Spring 2018

Infectious Diseases Devastating Effects of Infectious Diseases According to the World Health Organization, multiple infectious diseases are listed on the top 10 causes of death in the world, especially in low-income countries. Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites, or fungi. The devastating effects of Infectious diseases have been documented for thousands of years. The most recent â&#x20AC;&#x153;scariestâ&#x20AC;? outbreaks, characterized by infection rate and mortality rate, are summarized below.

SARS: Severe acute respiratory syndrome first emerged in China, but spread to 37 countries within weeks via airborne transmission. Malaria: Malaria is highly prevalent in tropical regions due to its high transmission rate via mosquitos. In 2010, Malaria infected 219 million people and killed hundreds of thousands. Tuberculosis: Tuberculosis has been around for thousands of years and has been the second greatest killer among infectious disease. Recently, tuberculosis has become resistant to many treatments, increasing its infection rates and death counts.

Figure 17.1 Environmental Science 2012 W.H. Freeman and Company

References

CDC Newsroom. (2016, January 1). Retrieved February 27, 2018, from https://www.cdc.gov/media/ releases/2016/p0503-unnecessary-prescriptions.html Antimicrobial resistance. (2018, January). Retrieved February 27, 2018, from http://www.who.int/me diacentre/factsheets/fs194/en/ The top 10 causes of death. (2018). Retrieved February 27, 2018, from http://www.who.int/mediacen tre/factsheets/fs310/en/index1.html Gholipour, B. (2013, November 25). 5 Scariest Disease Outbreaks of the Past Century. Retrieved February 27, 2018, from https://www.livescience.com/41478-scariest-disease-outbreaks.html

Written by Joe Myers, Formative Content. (2016, September 23). This is how many people antibiotic resistance could kill every year by 2050 if nothing is done. Retrieved February 27, 2018, from https://www.weforum.org/agen da/2016/09/this-is-how-many-people-will-die-from-antimicrobial-resistance-every-year-by-2050-if-nothing-is- done/ Friedland, A. J., Relyea, R., & Courard-Hauri, D. (2012). Environmental science for AP*. New York: W.H. Freeman. 54

Infectious Disease Difficulties Treating Infectious Disease

Merck in Canada

There are many approved antimicrobials approved to treat and often cure infectious diseases; however, there has been many cases of pathogens developing resistance to these antimicrobials. These resistant strains of microorganisms can be called “superbugs” in reference to their difficulty to kill. Due to ineffective treatment of these superbugs, these tend to have higher mortality rate. In some cases, pathogens may develop resistance to a specific antimicrobial but there may be a different therapy that works. Unfortunately, these other therapies tend to me much more expensive, increasing the cost of healthcare significantly, to the point that some patients may be unable to afford such treatments. Antimicrobial resistance is becoming more significant for multiple reasons. A large contributor to the problem is that doctors are over-prescribing antibiotics often. When patients present symptoms of certain infections, they often prescribe antibiotics. How-

ever, if those symptoms are due to a viral infection, rather than a bacterial infection, the antibiotics are useless and are being taken unnecessarily. The over-use of antibiotics allow bacteria to slowly develop resistance to these antibiotics. According to the CDC, around 30% of antibiotics prescribed in the United States are prescribed unnecessarily. Another contributing factor to antimicrobial resistance is the patients’ actions. Patients are often prescribed a regimen of antibiotics to take over the course of 5-10 days. However, symptoms often alleviate before the entire course of antibiotics. At this point, some patients will stop taking the antibiotics because they think they are infection-free. However, there is a small amount of bacteria left that will be relatively tolerant to those antibiotics, which can rapidly divide and restore the symptoms of the original infection. In addition to this, some countries allow patients to obtain antibiotics without the supervision of healthcare

by Joe Myers, Formative Content

professionals. This contributes to the problem, because these patients do not know the correct use of these medicines. Personally, I do not think that the antibiotic misuse by patients is all of the patients’ faults. I do not think all healthcare professionals explain the need to complete the full regimen of antibiotics or the repercussions if they do not follow the full regimen. I believe this is a weak point in the healthcare field based on my experiences. Often the doctors have told me to take the antibiot

ics for a certain amount of days but that is it. Without prior knowledge, it would seem like a good idea to stop using the antibiotics when the patient does not feel sick anymore. To someone in the healthcare field, taking the full regimen is a no-brainer; however, for someone that is not educated on the matter, it is a different story. People need to be educated further, whether that be from their prescribing physicians, pharmacists, or another source.

CDC Newsroom

Influence of Environment on Infectious Diseases • Environmental factors can have an impact on propagation of disease. The CDC classifies these environmental factors as: o Climate Example: how influenza (virus) transmission can increase in colder temperatures o Food Example: appearance of avian flu (virus) in individuals that consumed infected poultry

Cholera. Environmental Health Group RSS

o Water supply

•

Differences in technology between first and third world countries, used to try to limit these factors, can result in such diseases being more common in poorer countries and harder to control

•

Unfortunately, hard to prevent since most factors are out of the control of individuals. However preventative measures can be taken like vaccines and being aware. Education is the best tool to raise awareness, to try and get people to combat those factors that can be controlled

o Sanitation facilities • An example of such disease would be cholera – a waterborne disease found only in locations with an inadequate quality of water

Case Study: Malaria in Greece

he European Environment and Epidemiology (E3) Network was able to successfully intervene an endemic of malaria that occured in Greece during 2009-2012. By using climatic and geo-referenced environmental information, E3 was able to generate a disease risk map for areas predicted to have high rates of malaria transmission. E3 found that the transmission of malaria was more favorable in areas that had: • • • •

Warmer temperatures Low elevation Agriculture which is irrigated all year round Complex agriculture cultivation patterns

The data was made public and distributed to health practicioners who helped with integrated preparedness and response activities. By using targeted entomological and epidemiological surveillance, vector control activities and increasing the awareness of the public, tranmission of malaria in Greece was finally interrupted in 2013.

J. Semenza, Prototype Early Warning Systems for Vector-Borne Diseases in Europe.

Globalization • Frequency at which people are travelling from one country to another keeps increasing day by day • This can result in the spreading of infectious disease from places where they originate to places where they wouldn’t be able to reach by themselves • With the number of people carrying the disease increasing, the chances of mutations for the disease increase as well • This can make it a lot harder to try to expect and control infectious diseases

REFERENCES

• Affected the US in 1999 with worst epidemic in 2012 • With an increase in global incidence of an infectious diseases, chances of resistant strains developing, for the same disease, also increase • Also something that can’t be prevented. People can become more aware and educated so that they make smarter decisions with precaution. Try to contain diseases until necessary resources are expended to combat it

• Example would be the west nile virus

• Transmission of Influenza Viruses from Animals to People. www. cdc.gov. Published May 12, 2016,. Accessed April 2, 2018. • Longman M. The Impact of Climate Change on Flu. Concentra. https://www. concentra.com/resource-center/ articles/the-impact-of-climatechange-on-flu/. Published November 13, 2017. Accessed February 26, 2018. • Semenza J. Prototype Early Warning Systems for Vector-Borne Diseases in Europe. International Journal of Environmental Research and Public Health. 2015;12(6):6333-6351. doi:10.3390/ijerph120606333. • Cholera. World Health Organization. http://www.who. int/mediacentre/factsheets/ fs107/en/. Accessed April 3, 2018.

• First detected in Uganda in 1937, kept growing in African continent • By 1960s the virus was detectable in Australia, southwest asia and southern Europe

• Cholera. Environmental Health Group RSS. http://ehg.lshtm. ac.uk/cholera/. Accessed April 3, 2018

Z. Li, Globalization and China: The Story Doesn’t End Here

Personal Opinion of Authors

n our opinion, there is always going to be a race between nature’s ability to generate pathogens and humankind’s ability to generate treatments to combact the resulting infectious diseases. Although we cannot eliminate potential novel infectious diseases or mutations, by trying to understand more about this topic, we can help try and slow down the rate at which these epidemics occur. This allows time for us catch up with nature while also allowing us to utilize and implement our resources more carefully.

• Environmental factors influencing the spread of communicable diseases. WHO. http://www. who.int/environmental_health_ emergencies/disease_outbreaks/ communicable_diseases/en/. Accessed April 3, 2018. • Li Z. Globalization and China: The Story Doesn’t End Here. CKGSB Knowledge. http://knowledge. ckgsb.edu.cn/2016/12/14/ globalization/globalizationand-china-doesnt-stop-here/. Published December 16, 2016. Accessed April 3, 2018. • Calisher CH (2000). “West Nile virus in the New World: appearance, persistence, and adaptation to a new econiche— an opportunity taken”. Viral Immunol. 13 (4): 411–4. doi:10.1089/vim.2000.13.411. PMID 11192287

Medical Errors: first do no harm? Spring 2018

Though classifying and quantifying what counts as a medical error has been elusive, thanks to the article to Err is Human published by the institute of health (IOH) in 1999, there is at least an agreement as to what should be considered an error. More importantly, this article was the first of many reports acting as a much needed wakeup call for healthcare everywhere. For instance, here on some statistics that have been reported in recent years that have followed the issue:

By: Quinton Thompson BSPS Student Anthony St. John BSPS Student

Background Medical errors are an increasingly more researched topic that has emerged in recent years due to patient safety becoming a forefront issue in both government policy and societal trust in our healthcare system.

What is a Medical Error?

Fatal errors occur in 0.71% of hospital admissions

Statistically this means that 251,000 patients in America die from fatal errors 45% of all surgeries from 2013-2014 had drug errors or unintended drug side effects Medication errors occurred 1 in every 20 medications

Medical errors have recently become known as the third leading cause in the United States. But what exactly is a medical error? A medical error is a preventable adverse effect of care, whether it is evident or harmful to the patient. This might include inaccurate/incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment. Due to this loose definition these errors have gone unnoticed and undocumented for many years, causing it to grow to the problem seen today. A large part of this issue is the lack of a proper way to code them. The CDC system for coding records on death certificates data does not capture things such as communication breakdowns, diagnostic errors, and poor judgement that ultimately result in oneâ&#x20AC;&#x2122;s death.

This is not to say that 251,000 deaths each year are solely attributed to our healthcare system, but medical errors were involved in the deterioration of patients. Another point of interest from the IOH article is that it has brought public awareness to the issue not just in the US, but across the globe. The general public from several developed nations was asked whether they thought they were affected by a medical error, and the results from this study are shown below.

http://www.commonwealthfund.org/publications/pressreleases/2005/nov/international-survey--u-s--leads-in-medical-errors

As the results show, nearly a quarter of the population or more had thought they experienced some form of a mistake while they received medical treatment. These results only highlighted the growing need for change in healthcare delivery.

https://www.usatoday.com/story/news/politics/2016/05/03/second-study-saysmedical-errors-third-leading-cause-death-us/83874022/ical-errors-thirdleading-cause-death-us/83874022

What is the cause of so many medical errors?

reporting system for errors committed in the hospital. That means less than half of states have to be held accountable for their mistakes. This also suggests that there is not a centralized agency to address patient safety and collect all of the information possible.

Medical errors are not a new concept even though the efforts towards improving patient safety are. Even before modern hospitals it was common for surgical wounds to be infected and lead to death. So with new technology and a much more sanitary patient environment it is important to look at where the medical field is lacking now. One of the most common theories for why medical errors occur so frequently is the number of patients and overcrowding of hospitals. Though it is fortunate that we live in an era where access to healthcare is widespread and not focused on the wealthy, having busier hospitals does lead to disorganization and ultimately chaos when trying to treat a multitude of patients. For instance, researchers analyzed Australiaâ&#x20AC;&#x2122;s overcrowded hospitals and found higher rates of mortality compared to standard hospitals, due to systemic failures, patients being placed in wrong medical wings, and doctorsâ&#x20AC;&#x2122; orders being mixed up due to some patients being left on beds in hallways. Though it seems like a reasonable cause of error, mortality only increased by 30% when compared to hospitals with <90% occupancy, which would not account for the nearly 10% of all deaths in Australia alone. The next major theory is that maybe it isnâ&#x20AC;&#x2122;t directly because of patient volume, but because practitioners are overworked, leading to inaccurate decision making and burnout. Statistics have shown that nearly every outlet of healthcare, physicians to dentist to pharmacists, are getting overworked with an increase in demand for their skills, caused by an increase number of patients. As the figure to the right shows, well over half of doctors alone are feeling overworked. Though all of these theories individually make sense, none of them account for how large this issue seems to be. So the last theory to address is that our health care system is flawed. As of 2008, less than half of U.S. states have a mandatory

Percent of Physicians feeling burned out in the US, as of 2017, by specialty (above). Amount of time U.S. primary care physicians spent with each patient as of 2017 (left). https://www.statista.com/topics/1244/physicians/

In addition to a lack of centralized data tracking and error reporting, the Center for Disease Control and World Health Organization both do not recognize errors as a cause of death ultimately 59

1955

1964

1977

1995

1999

2004

2005

2012

2005- The U.S. passed the Patient Safety and Quality Improvement Act, promoting aggregation of patient safety data without violating HIPPA. 2005- The U.K. began training medical doctors through the Modernizing Medical Careers initiative. 2012- Kenya began auditing hospitals on patient safety with KEPSIE (Kenya: Patient Safety Impact Evaluation) As this timeline suggests, patient safety was not acknowledged very heavily before the early 2000’s. Whether this was a systemic negligence or not is difficult to say, but that clearly poses a few challenges for the future, due to lack of reliable data. Originally, errors were not viewed as preventable because medical professionals ultimately saw it as a minor drawback to technological advancements that significantly improved patient outcomes. Once third party insurance became a common place strategy for paying for medical services though, patient safety did become an issue. This was mainly a financial issue though because mistaken procedures were then being considered potentially compensable. Ultimately, patient safety did not become a major concern until to Err is Human was finally published.

leading to a blanketing effect on public and professional awareness of an issue. In conclusion, there are several sources for such a pandemic problem, from individual errors up to an entire global culture that sweeps patient safety under the covers. Due to lack of useful data over long term trends, it is difficult to determine an actual source, but hopeful time will tell whether this is an issue that can be fixed.

How did we get here? Before we consider changing our healthcare system, it is important to know where we started. How did we not know that one of the biggest killers in medicine was us? Ultimately, the timeline below describes how we first viewed errors and how that has been changing. Time line: 1955- Earliest stages of patient safety studies began, which most doctors reported as “Diseases of Medical Progress”. 1964- Noxious episodes became a new term to describe mishaps in the hospital that were caused by proper and legitimate medical procedures 1977- The California Medical Insurance Feasibility Study began addressing error and patient safety in regards to finance and potentially compensable events that insurance could charge to medical facilities. 1995- The Quality in Australian Health Study initiated one of the first major findings on wide scale medical error and adverse 1999- To Err is Human is published, leading to the statistic that 98,000 people potentially die in the U.S. each year due to medical errors. This study influences major change across the globe on how patient safety is addressed. 2004- The WHO organization started the “World Alliance for Patient Safety” setting guidelines for acceptable practices in surgery preparation and other more minor procedures.

What has been done since? Some changes have occurred since 1999. In 2012, I-PASS was created as a system of training to prevent transmission errors when exchanging patients, and the results showed doctors making 22% less preventable mistakes. This system has since begun to be used across the US though no mandatory policies have been made. In regards to US policy, the Patient Safety and Quality Assurance Act started a voluntary error reporting system, though there is still some speculation as to how many professionals use the reporting system. 60

Work

Professional Opinion:

On the other side of the globe, Australia and New Zealand began auditing surgical accidents and have decreased any deaths in surgery by 30%. The UK’s National Health Service on the other hand began a campaign similar to I-PASS attempting to better educate new doctors on how to pass on patient information properly to limit confusion. Data from this program is still being collected. Unfortunately, there are also some issues with recognizing medical errors because there are no major national or international organizations that consider medical errors a cause of death still, which ultimately limits our knowledge on the issue. Instead we have to trust researching algorithms to get estimates.

Ultimately, our views are fairly straight forward. Medical errors are clearly an issue that both needs to be addressed and also is not being addressed effectively. Our information is limited by lack of a coherent body for reporting, and it is even further hindered by not having any mandates for reporting mistakes made in the medical field. Ultimately, society needs to become accustomed to the idea of healthcare professionals owning up to their mistakes and not being worried of the consequences. And we all need to seek out better methods of insuring safety for every patient as best as possible. One of the most important quotes to be remembered is taken from our very own Hippocratic oath, swearing to protect all of our patients. That quote is, “First do no harm.”

Work Cited: 1. Presant, C.A. (2016, July 21). Medical Errors Are the Third Leading Cause of Death – How you can avoid them. Retrieved March 20, 2018, from https://www.hufingtonpost.com/cary-a-present-md/medical-errors-are-the-th_b_11117808.html 2. R. S., Guy, G. S., Majid, A. J., Babidge, W., & Maddern, G. J. (2015). The Australian and New Zealand Audit of Surgical Mortality—Birth, Deaths, and Carriage. Annals of Surgery, 261(2), 304–308. https://doi.org/10.1097/SLA.0000000000000581 3. Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., … Landrigan, C. P. (2014). Changes in Medical Errors after Implementation of a Handoff Program. New England Journal of Medicine, 371(19), 1803–1812. https://doi.org/10.1056/NEJMsa1405556 4. e, L. L., & Berwick, D. M. (2005). Five Years After To Err Is Human. JAMA, 293(19), 2384. https://doi.org/10.1001/jama.293.19.2384 5. Kc, D. S., & Terwiesch, C. (2009). Impact of Workload on Service Time and Patient Safety: An Econometric Analysis of Hospital Operations. Management Science, 55(9), 1486–1498. https://doi.org/10.1287/mnsc.1090.1037 6. Wafula, F., Dolinger, A., Daniels, B., Mwaura, N., Bedoya, G., Rogo, K., … Olayo, B. (2017). Examining the Quality of Medicines at Kenyan Healthcare Facilities: A Validation of an Alternative Post-Market Surveillance Model That Uses Standardized Patients. Drugs - Real World Outcomes, 4(1), 53–63. https://doi.org/10.1007/s40801-016-0100-7 7. Landrigan, C. P., Rothschild, J. M., Cronin, J. W., Kaushal, R., Burdick, E., Katz, J. T., … Czeisler, C. A. (2004). Effect of Reducing Interns’ Work Hours on Serious Medical Errors in Intensive Care Units. New England Journal of Medicine, 351(18), 1838–1848. https://doi.org/10.1056/NEJMoa041406

Julia Czarnik, BSPS student Danielle Derosas, BSPS student | Spring 2018

Fact: There are 200 classified forms of mental illness. Common disorders include depression, bipolar disorder, dementia, schizophrenia and anxiety disorders

Mental Illness

â&#x20AC;&#x153;Mental illnesses are health conditions involving changes in

thinking, emotion or behavior (or a combination of these). These are associated with distress and/or problems functioning in social, work or family activities.â&#x20AC;? â&#x20AC;&#x201C; American Psychiatric Association

Background 1 in 4 people in the world will be affected by mental or neurological disorders at some point in their lives. Around 450 million people currently suffer from such conditions, placing mental disorders among the leading causes of ill-health and disability worldwide.

62 https://www.psychiatry.org/patients-families/what-is-mental-illness

Causes/Risk Factors

Access to Healthcare Lack of Health Insurance

Causes • • •

•

Inherited traits Environmental exposures before birth Genetics

•

Risk Factors • • • • • • • •

Blood relatives with mental illness Stressful life situations (finance, death) Use of alcohol/recreational drugs Child abuse/neglect Unhealthy relationships Previous mental illness Chronic medical condition Traumatic experiences

•

Out-of-pocket expenses •

Current Treatment • • • • • •

Psychotherapy Case management Hospitalization Support group Complementary & Alternative Medicine Medication

•

The unin sure

Health care spending can be unexpected and expensive Low reimbursement rates and a high demand for help forces families and individuals to pay high out-of-pocket fees or go without care

Lack of availability of services •

http://www.who.int/mental_health/mhgap/risks_to_mental_health_EN_27_08_12.pdf

•

Older children age 7 to 18 are more likely to be uninsured The uninsured are more likely to be Hispanic and to be noncitizens. Many noncitizens are employed in low-wage jobs without health benefits and are ineligible for public coverage in most states. People without insurance coverage have worse access to care than people who are insured.

Areas that are rural and have low-income per capita are most affected. 1 in 5 say they or a family member did not get mental health services due to these conditions: o Can’t afford it o Insurance won’t cover it o Afraid or embarrassed to seek care o Didn’t know where to go get care o Lost job or changed employers o Self-employed; or employer does not offer coverage o Lost eligibility for Medicaid o Became ineligible for coverage because of age or because left school o Don’t know or refused

Socioeconomic Status Economic stress correlates with low socioeconomic status and mental illness The capacity for an individual to develop and flourish is deeply influenced by their immediate social surroundings â&#x20AC;&#x201C; including their opportunity to engage positively with family members, friends or colleagues, and earn a living for themselves and their families â&#x20AC;&#x201C; and also by the socio-economic circumstances in which they find themselves. Restricted or lost opportunities to gain an education and income are especially pertinent socio-economic factors

More complications that can cause mental illness and/or result in: o o o o o o o o o

Unhappiness Family/relationship conflicts Social isolation Work/school problems Legal and financial problems Poverty and homelessness Self-harm or harm to others Weakened immune system Heart disease and other medication Conditions

Awareness http://www.corepsychcenter.com/go-green-mental-illness-awareness-week/

Understanding Issues •

Mental health disorders are real, common and treatable. It is estimated that approximately 1 in 5 American adults (nearly 44 million people) and 13-20% of children living in the United States will experience a diagnosable mental health disorder in a given year

Diagnosis • • •

It is important to pay attention to sudden changes in thoughts and behaviors. Self-diagnosis often do more harm than good, because the internet is full of false-information Your doctor is there to help you with your mental and physical health.

Seeking Help • •

Where you go for help will depend on who has the problem (an adult or child) and the nature of the problem and/or symptoms. Often, the best place to start is your local mental health organization

Access to resources • •

Over 4,000 areas across the US are considered ‘mental health professional shortage areas’. These individuals are left to travel hours across state lines to access services Mental Health America, World Health Organization, National Institute of Mental Health, etc. are all great organizations to contact if you need help.

Professional Opinion We believe that Mental Illness is not a condition to ignore, even though there are not usually any physical symptoms involved. It is recommended that people who are suffering from mental illnesses should seek guidance from a professional. It is proven that 1 in 4 people in the world will be affected by mental or neurological disorders at some point in their lives. Whether you or a loved one is suffering, you are not alone in this because there are many organizations that want to help. References Graves, J. and Long, S. (2018). Cite a Website - Cite This For Me. [online] Urban.org. Available at: https://www.urban.org/sites/default/files/publication/50831/411317-Why-Do-People-Lack-Health-Insurance.PDF [Accessed 26 Feb. 2018]. Parekh, R. (2018). Global study finds mental illness widespread. [online] msnbc.com. Available at: http://www.nbcnews.com/id/5111202/ns/health-mental_health/t/global-study-finds-mental-illness-widespread/ [Accessed 26 Feb. 2018]. Psychiatry.org. (2015). What Is Mental Illness?. [online] Available at: https://www.psychiatry.org/patients-families/whatis-mental-illness [Accessed 26 Feb. 2018].

Mental Illness Karen Ho, Zoe Harves (BSPS students), Spring 2018

Background

Source: from https://www.news-press.com

Mental illnesses are health conditions involving changes in thinking, emotion, or behavior. It has become a huge problem in America. There are over 200 forms of mental illness which includes depression, anxiety, bipolar disorder, dementia, ADHD, and schizophrenia. 19% of U.S. adults experience some form of mental illness, 56% of adults with a mental illness do not receive treatment and 4% of adults in America live with a serious mental illness. Around 50.5% in 20.2 million adults in the U.S who experienced a substance use disorder had a co-occurring mental illness. The consequence of lack of treatment in serious mental illness patients results in a loss of $193.2 billion earnings per year in America.

Issue 1: Increasing Awareness Raising awareness can reduce misconceptions about mental illness because mental health issues are often not viewed as real medical problems. It was found that out of 176 people, 50% people were unaware of how to access mental health services. People with mental illness are often attached with negative labels due to the lack of awareness. By promoting awareness on the issue, it can educate the public on what mental illness really is and let them know what they can do to help those who suffer from mental illness. People can reduce the stigma by speaking out loud and declaring their support. The more open the public is to discuss about mental health, the easier it will be for their loved ones and friends to go to them for help. It is especially important for those who are in a depressed state to know that they are not alone and they have someone to help them through this hard time. Community awareness for mental health can reduce stigma and increase the chance for early intervention which can help patients to have a faster recovery. If more people are aware of mental illness then there will be less negative adjectives to describe mental illness patients. There is a campaign called #EndTheStigma on social media. It allows users to post the badges (picture on the right) to their accounts and talk about living with invisible illnesses to show others that they are not alone in their struggles. The goal of the campaign is to let more people to use these images as profile pictures or simply share them as a method of sharing their experience. So overall raising awareness can help reduce the stigma of mental illness and encourage more people to seek treatment for their illness. Source: https://tosavealife.com/mental-health/socialmedia-end-the-stigma/ 66

Issue 2: Drug Abuse The rate of drug abuse is unusually high among those with mental illness. About 50% of people with a mental illness also suffer from substance abuse. People who have substance abuse and mental illness at the same time or at different lengths of time are considered as having co-occurring disorders, or dual disorders. Source: http://www.newbridgerecovery.com/dualdiagnosis-treatment/

Mental illness greatly increases the risk of drug abuse and drug use is significantly higher in the population of those with a mental illness compared to the general population. There is high correlation between these two disorders because they are caused by common risk factors. The drugs that are most commonly abused range from the legal: alcohol and tobacco to the illegal: stimulants, opioids and hallucinogens. According to the result data from the Substance Abuse and Mental Health Services Administration (SAMHSA), it was found that alcohol is the only substance with consumption levels very closely matched between people with mental illness and people without Source: https://www.mentalhelp.net/ mental illness. This could be due to its legality and prevalence in the Western culture and society. Drugs produce psychotropic effects that can relieve the emotional distress caused by mental illness but these effects only last for a short time. Many people with mental illness abuse drugs to self-mediate their symptoms, but in reality, it worsens them and adds many more complications. A person must continue to consume a higher amount of the substance in order to alleviate their symptoms. This use will lead to drug abuse or dependence.

Abuse or Dependence by Drug and Mental Illness A survey conducted in 2013 by SAMHSA divides mental illness into three categories based on the severity of impairment which includes mild, moderate and serious. People with more serious mental illness are more likely to have abused or had a dependency to alcohol, illicit drugs, or both. This result is supporting the self-medication theory, which it means that the more severe the symptoms, the more drugs are needed to mitigate these symptoms. This theory can also be reversed as drug abuse can alter brainâ&#x20AC;&#x2122;s chemistry which could cause emotional distress like other mental illnesses. It is hard to determine the order of causation but drug abuse could also lead to secondary psychiatric conditions.

Issue 3: Living with Mental Illness Mental illness affects every person differently. For some, they can live their day to day lives with little to no interference from their illness. However, others may face many struggles on a daily basis due to their illness. For example, it can affect relationships with others. For disorders such as depression or bipolar disorder, people may distance themselves from others which can put strain on relationships. In addition to the illnesses impacting daily lives, many of the medications used to treat mental illnesses can have many adverse side effects which can add difficulties or even lead people to stop taking their medications which could have many negative effects or even put them or others in danger. Also, those with a mental illness may be hesitant to tell others, including their loved ones, about their mental illness which can also cause strain on relationships. Certain mental illnesses can also affect how they learn including problems with attentiveness, concentration, the ability to communicate, and the ability to organize. About 40% of adults with a mental illness, also have a learning disability. It is harder to diagnose mental health issues in people with learning disorders because it can be hard to tell the two conditions apart. This means that mental health conditions in these people are not always recognized meaning they do not get the appropriate treatment which can make their daily lives very difficult. All of these issues discussed can create many barriers and difficulties for people suffering from a mental illness. The following is a quote of one person’s testimony on what it is like to live with a mental illness: “Mental illness feels like you’re losing control of you. You don’t know who you truly are because this disease controls you and takes over your emotions.” It is totally possible for people to overcome their mental illness and not let it affect their lives. The first step to this is acknowledging that they may need assistance and then seeking the appropriate help. With help, it is possible to overcome symptoms and to live a life without interference from a mental illness. It may take some time and a lot of hard work, but it is completely possible for those with a mental illness to live a fully successful life.

O t S t y j Source: http://www.revelist.com/viral/mentalillness-awareness-comics-gemma/4618

Source: http://www.revelist.com/viral/mental-illness-awareness-comics-gemma/4618

Issue 4: How to Seek Support There are many resources available to those suffering from a mental illness. The first and often times most important step in seeking support for mental illness is finding a mental health professional. It is important to determine exactly what you are seeking, whether it is talking with a therapist or being prescribed a medication to help manage symptoms. Once this is determined it is important to build and maintain a relationship with whomever has been chosen as they will be able to play a role in helping overcome the mental illness.

Source: Supporting Someone with Mental Illness. https://dearestsomeone.com

Other resources include mental health organizations. Many people do not know about or do not utilize them. Some organizations that provide help and information about mental illness include National Alliance on Mental Illness (NAMI), National Institute of Mental Health (NIMH), and Substance Abuse and Mental Health Service Administration (SAMHSA). NAMI provides a toll-free helpline as well as hosts different awareness events around the year. They are currently the nationâ&#x20AC;&#x2122;s largest mental health organization. NIMH is the largest scientific organization in the world focused on researching mental illness. However, they also provide education to the public and ways to seek help if anyone is suffering from a mental illness. In addition to these organizations, there are organizations that can assist in covering the cost of mental health medications for those that may need it. Most health insurance plans are required to cover mental health medications, however, if someone does not have insurance or their insurance does not cover their medication, there are prescription assistance programs available. Some of these include government programs such as medicaid, NeedyMeds, RxAssist, RxHope, and GoodRx. Also, some pharmaceutical companies may even offer direct payment assistance to those who qualify.

Sources: https://www.nimh.nih.gov/index.shtml, https://www.nami.org, HTTP://WWW.SAMHSA.GOV Professional opinions: We believe that mental illness is a serious problem and needs to be addressed. It needs to universally be acknowledged as an actual medical condition, which it is. It does not get nearly enough of the attention it deserves which leads to many conditions going untreated which can create numerous problems. Anyone around us can experience mental health problems. Friends and family play a critical role to make all the difference in a personâ&#x20AC;&#x2122;s recovery process. If we find out a friend or family member is suffering from mental illness, it is important to be a good listener, show support and offer help. Reference: MentalHealth.net. Mental Illness & Substance Abuse. https://www.mentalhelp.net/aware/mental-illness-andsubstance-abuse/. Accessed March 30, 2018 End The Stigma Today. #ENDTHESTIGMA. https://www.endthestigmatoday.com/. Accessed March 30,2018 NAMI. Living With A Mental Health Condition. https://www.nami.org/Find-Support/Living-with-a-Mental-HealthCondition. Accessed March 30, 2018 Mental health - research and statistics. Mencap. https://www.mencap.org.uk/learning-disability-explained/researchand-statistics/health-research-and-statistics/mental-health. Published May 12, 2017. Accessed March 31, 2018. 69

MYCOBACTERIUM TUBERCULOSIS YIMING LI, BSPS STUDENT JOANNE LIN, BSPS STUDENT DATE: SPRING 2018

Background TB is an airborne infectious disease caused by Mycobacterium tuberculosis. It can spread from person to person through tiny droplets released into the air via coughs, sneezes or spits. It is diagnosed by TB skin test and TB blood test (to see if there is TB bacteria or not). http://www.wikiwand.com/en/Tuberculosis

It is troublesome to cure because it can evade human immune system by releasing virulence factor ESAT-6 which will break phagolysosome and cause apoptosis to macrophage. Also, it is hard to develop the antibiotics due to its specific lipid component called Mycolic acid which coats the cell envelope, similar to a waxy layer. This creates some difficulty for the drug to get into the bacteria cell and cause damage to the bacteria.

There are some drugs currently approved by the U.S. Food and Drug Administration (FDA) to treat TB, dividing into first-line agents and second-line agents. The first-line anti-TB agents that form the core of treatment regimens are: isoniazid (INH), rifampin (RIF), ethambutol (EMB), pyrazinamide (PZA). If the treatment of first-line agents fails, there are second line of antibiotics.

https://www.sciencedirect.com/science/article/pii/S1740676510000234

FOUR ISSUES

INEFFICIENT AND INEFFECTIVE TREATMENT Inefficient: the treatment period takes at least 6 months up to 2 years, it uses combination of multiple antibiotics and gives several side effects including nausea, vomiting, weight loss, decreased appetite, dry mouth, sore throat, skin rash, jaundice and blurred version. Ineffective: current treatment doesn’t control the incidence and mortality of TB. TB still causes 1.7 million total deaths annually. Globally, the total treatment success rate is not good enough - around 50% in total. Global incidence for TB tends to be increasing about 1% per year, with 8.8 million new cases of active disease annually. The treatment does not tend to cure the disease but rather tend to arise a further big problem - can easily develop to drug-resistant type TB. Usually, TB happens in developing countries in Africa and Asia. It is very possible that patients with low income cannot afford the payment of treatment (combination of multiple type of antibiotics). Also, even if patients can pay for the treatment and get the antibiotics, beside the symptom of TB such as coughing with blood, weight loss, chest pain, and fever, they have to suffer several side effects coming from antibiotics during the period of treatment (6 months to 2 years)

Two figures above are retrieved from: https://welfarejambo.blogspot.com/2016/11/tuberculosis-in-children.html

DEVELOPMENT OF DRUG-RESISTANT TB Drug resistance occurs when the drugs used to treat TB are misused or mismanaged. Multidrug resistant TB(MDR-TB) is defined as resistance to the two most potent first-line TB drugs rifampicin and isoniazid, i.e. two most effective antibiotics doesn’t work anymore. That’s why we have a second-line regimen to treat this MDR-TB, but with more costs and more side-effects. Extensively drug-resistant TB(XDR-TB) is resistant to three or more of the six classes of second-line drugs. Thus, seldom antibiotics can be used to treat XDR-TB effectively. There is very high mortality rate for XDR-TB at the end.

https://www.cdc.gov/antibiotic-use/community/images/how-AR-happens.jpg 7171

FINANCIAL HARDSHIP According to World Health Organization (WHO), it is estimated about 118 low and middle-income countries with 97% of the worldâ&#x20AC;&#x2122;s notified TB cases. Although with the increased of domestic and international funding, the amount for diagnosis and treatment of drug-susceptible TB and multi-drug resistant TB (MDR-TB) increases from US$ 2.0 billion in 2017 to US$ 3.6 billion by 2020. This indicates commitments are still needed to close the funding gap. Additionally, the total amount required for implementation of TB prevention, diagnostic and treatment intervention is approximately US$ 58 billion from 2016 to 2020 and has an increasing trend throughout each year.

Three figures above are retrieved from Global Tuberculosis Report: http://apps.who.int/iris/bitstream/handle/10665/259366/9789241565516-eng.pdf;

Financial hardship has been a major issue faced by TB patients and their households in low- and middleincome countries. Universal Health Coverage (UHC) established by WHO has been required for the provision of TB care by addressing both social and economic factors and reducing financial barriers. However, there are still many problems that needed to resolve. For example, the cost of drug-susceptible TB and multi-drug resistant TB (MDR-TB), calculated by WHO shown the median cost per patient treated in 2016 was US$ 1253 and US$ 9529 respectively. This demonstrates a catastrophic expenditure due to TB disease and colossal burden an individual or a household needs to carry throughout the treatment. The two figures above are surveys conducted in Vietnam, which is considered as lower-middle income country and is one of the 30 high TB burden countries.

VACCINATION (BACILE CALMETTE GUERIN OR BCG VACCINE) Bacile Calmette Guerin (BCG) vaccine is a live attenuated vaccine designed for prevention of TB. Most important protective benefits are in minimizing the risk of death and meningitis in neonates and young children. However, it fails to protect against pulmonary tuberculosis in adults. Correct vaccination almost always results in local reactions, small ulceration and eventually scar formation. Also, BCG may cause a false positive reaction to Tuberculin skin test which is a common diagnosis of TB infection and may further complicate decisions in regard to prescribing treatment.

https://www.cdc.gov/antibiotic-use/community/images/how-ARhappens.jpg

Additionally, substrain diversity of the BCG vaccine is another critical problem across the globe. Since the continued growth of the original BCG strain lacked standardization guidelines, it resulted in the emergence of over 20 BCG substrains. This lead to function variability and lack of uniformity of BCG vaccines across the globe. 72

PROFESSIONAL OPINION To prevent the development of drug resistance, the dose of antibiotics administrated by patients should be strictly controlled. New drug should be encouraged to develop with more effectiveness and efficiency - reduce the treatment period, side effect and overcome the current drug resistance. Cost should be concerned as well. This would involve some new mechanism. The existing drugs are targeting the synthesis of mycolic acid, ribosome and protein synthesis - that’s why we need to use a combination of antibiotics to increase the strength of treatment because blocking just one of them cannot kill the bacteria. New treatment that are still in process (lead optimization) including targeting the ATPase EccCa1 and PhoP. The ATPase EccCa1 is an enzyme that pumps the virulence factor ESAT-6 out of the bacteria cell. Blocking the ATPase so that no ESAT-6 can be released and break the phagolysosome would successfully arrest bacteria inside macrophage. PhoP is a positive regulator that controls secretion of ESAT-6. The regulatory of PhoP is dependent with environmental pH inside macrophage. It contributes to much of the secretion of ESAT6, gives the expression of ESAT-6, controls RD1 which encodes ESX-1(a whole system to secret ESAT-6, including one of the ATPase EccCa). If we block the PhoP, all the regulatory stuff helping release the virulence factor will be blocked. The graph below shows the genes regulated by PhoP. .

(figure: Schematic representation of the PhoPregulated genes within the extRD1 region, by Gonzalo-

Asensio, Jesús, et al.) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2566814/

REFERENCE European Bioinformatics Institute Protein Information Resource SIB Swiss Institute of Bioinformatics. “ESX-1 Secretion System Protein EccCa1.” eccCa1 - ESX-1 Secretion System Protein EccCa1 - Mycobacterium Tuberculosis (Strain ATCC 25618 / H37Rv) - eccCa1 Gene & Protein”. www.uniprot.org/uniprot/P9WNB3. Accessed April 12, 2017. Gonzalo-Asensio, Jesús, et al. “PhoP: A Missing Piece in the Intricate Puzzle of Mycobacterium Tuberculosis Virulence.” PLoS ONE, Public Library of Science. www.ncbi.nlm.nih.gov/pmc/articles/PMC2566814/. Updated 2008. Welfare Jambo. Tuberculosis in Children: Treatment of TB and Graphs. Welfarejambo.blogspot. https://welfarejambo.blogspot.com/2016/11/tuberculosis-in-children.html. Updated 2018. Tuberculosis (TB) – BCG Vaccine. Centers for Disease Control and Prevention. https://www.cdc.gov/tb/publications/factsheets/prevention/bcg.htm. Published May 4, 2016. Updated September 12, 2016. Tuberculosis (TB)) and Poverty in SEAR. World Health Organization. http://www.searo.who.int/tb/topics/tb_poverty/en/. Updated 2018. Global Tuberculosis Report. World health Organization. http://apps.who.int/iris/bitstream/handle/10665/259366/9789241565516eng.pdf. Updated 2018. Jose I Figueroa-Munoz a, Pilar Ramon-Pardo. Tuberculosis control in vulnerable groups. Bulletin of the World Health Organization. 2008; 86(9): 657-736. http://www.amamanualofstyle.com.ezproxy.lib.purdue.edu/view/10.1093/jama/9780195176339.001.0001/med9780195176339-div2-81#. Published September 2008. Moliva JI, Turner J, Torrelles JB. Why dose BCG fail to protect against tuberculosis. Atlas of Science. https://atlasofscience.org/whydoes-bcg-fail-to-protect/. Accessed September 27, 2015. Ian M. Orme. Tuberclosis Vaccine Types and Timings. Clinical and Vaccine Immunology. 2015; 22(3): 249-257. http://cvi.asm.org/content/22/3/249.full. Published December 24, 2014.

Nutrition and Health Joanna Shao and Maddie Brown, Pharmacy Students Spring 2018

Background What is nutrition? Nutrition is defined as the intake of food, considered in relation to the body’s dietary needs.1 It can be grouped into 5 food groups: 2 cups of fruits, 2.5 cups of vegetables, 6 ounces of grains, 5.5 ounces of protein, and 3 cups of dairy.2 What is classified as malnutrition? Malnutrition is defined as deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. It includes both undernutrition and overnutrition.3

Childhood Obesity Long-term consequences Childhood obesity has immediate and long-term effects on physical, social and emotional health ● Higher risk for chronic health conditions such as asthma, sleep apnea, bone and joint problems, type 2 diabetes and risk factors for heart disease4 ● More likely to suffer from depression and lower self-esteem; children with obesity are bullied and teased more4 ● Will likely to have obesity as an adult and higher risk of developing the chronic health conditions

Let’s Move! Initiative School meal programs are offering meals that

meet national nutritional standards and investing in cafeteria facilities to store and prepare healthy Foods Let’s Move! Is a comprehensive initiative, launched by Michelle Obama, dedicated to reduce childhood obesity. It strives to fund for healthy food in schools, improve access to healthy, affordable foods and increase physical activity amongst children. The goal is to reduce the childhood obesity rate to just 5 percent by 2030.5

Nutrition. World Health Organization. http://www.who.int/topics/nutrition/en/. Accessed April 3, 2018. MyPlate. Choose MyPlate. https://www.choosemyplate.gov/MyPlate. Published January 26, 2018. Accessed April 3, 2018. Double burden of malnutrition: Infographics. World Health Organization. http://www.who.int/nutrition/double-burden-malnutrition/. Accessed April 3, 2018. 4 The State of Childhood Obesity. The State of Childhood Obesity - The State of Obesity. https://stateofobesity.org/childhood-obesity-trends/. Accessed April 2, 2018. 5 School Meals, Competitive Foods, and the School Food Environment. Obesity Prevention Source. https://www.hsph.harvard.edu/obesity-prevention-source/obesity-prevention/schools/school-meals-competitive-foods-and-the-school-food-environment/. Published April 13, 2016. Accessed April 2, 2018. Graphic from: https://stateofobesity.org/childhood-obesity-trends/

Childhood Malnutrition How is Undernutrition Measured? Stunting and wasting are used to measure undernutrition. Stunting is the most prevalent form and is defined by the WHO as “minus two standard deviations from median height-for-age. It is measured in children ages 0-5.4 How Prevalent is Stunting? Across the world, about 1 in 4 children are stunted. The overall percentage of children considered stunted has decreased from 39.5% (254 million) in 1990 to 22.9% (155 million) in 2016.5 Why is Stunting Important? Stunting in children is associated with an underdeveloped brain and long-lasting, harmful consequences, including diminished mental ability and learning capacity, poor school performance in childhood, reduced earnings, and increased risks of nutrition-related chronic diseases such as diabetes, hypertension, and obesity in the future. It can also be used to measure a country’s socioeconomic status .4 Where is it Most Prevalent? Stunting is a global issue, affecting children in all countries from all backgrounds. India has the highest stunting rate in the world with 46.8 million stunted children, representing one-third of the global stunted children under the age of five. The United States has a 3% stunting rate.6

Fad Diets Atkins Diet ●

● ● ● ● ●

Low-carb diet; limits patient’s intake of sugar and carbohydrates so the body burns fat for fuel. You do not experience the sugar “highs” (where excess sugar is actually stored as fat in the body) and sugar “lows” (where you feel fatigued and ravenously hungry for more carbs and sugar) Focuses on proteins and fats like: meat, poultry, seafood, eggs, butter, oils and cheesE No starchy and sugary carbs like: bread, pasta, potatoes, chips, cookies and candy Exercise is not vital for weight loss Claims to lose 15 lbs in the first two weeks Can result in ketosis because the body is not getting enough sugar for energy7

Joint child malnutrition estimates - 2017 edition. UNICEF. https://data.unicef.org/topic/nutrition/malnutrition/. Accessed March 28, 2018. Improving Child Nutrition: The achievable imperative for global progress. UNICEF. https://www.unicef.org/gambia/Improving_Child_Nutrition_-_the_achievable_imperative_for_global_progress.pdf. Accessed March 28, 2018. 6 Global Overview Child Malnutrition. The World Bank. http://datatopics.worldbank.org/child-malnutrition/. Accessed March 28, 2018. 7 Atkins Diet: What's behind the claims? Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/atkins-diet/art-20048485?pg=2. Published August 16, 2017. Accessed April 2, 2018. 5

Does the Atkins Diet Work? ● Research shows that it works but limited research on how the higher amounts of animal protein and fat in the Atkins diet affect long-term health. ● Research shows that people who chose foods rich in plant fat and protein did better with their health than those who went with the diet rich in animal fat and protein.

Cabbage Soup Diet ● ● ● ● ● ● ● ● ● ● ●

Fat-free cabbage soup, eaten two to three times a day Low-fat, high-fiber diet Claims to lose 10 lbs in a week Claims that cabbage is such a low-calorie food that your body ends up burning more calories digesting it than the cabbage itself contains. Therefore, the more soup you eat, the more weight you lose. The diet is intended to last no longer than one week at a time!! Each day has a different rule Exercise is not recommended on such a low-calorie diet Mostly lose water weight Hungry, weak and boring Not suitable for long-term weight loss Does not provide enough nutrient; decreased vitamins and minerals8

Does the Cabbage Soup Diet Work? ● Never been studied so it is not possible to truly confirm its effectiveness but because the diet is very low in calories, it will probably cause weight loss. The weight will most likely come back as soon as you stop the diet. ● Your body also responds by lowering metabolic rate, meaning you burn fewer calories per day than you used to. ● Studies show that only about 34% of the weight lost is actually from fat, the other two-thirds comes from lost water weight and muscle mass.

Inuit Paradox How do Eskimos receive proper nutrition while living in an area with no access to fruits and vegetables? Not only do they receive proper nutrition, but they are healthier than the average American.

Graphics from: https://data.unicef.org/topic/nutrition/malnutrition/, https://nutritionandfoodfacts.com/prevention-of-stunting/, https://www.mayoclinic.org/healthy-lifestyle//atkins-diet/ 8

Watson S. The Cabbage Soup Diet. WebMD. https://www.webmd.com/diet/a-z/cabbage-soup-diet. Accessed April 2, 2018. Graphics from: https://www.webmd.com/diet/a-z/cabbage-soup-diet, https://www.youtube.com/watch?v=GEHm8P-ulRA

What is the Inuit Diet? The Inuit Diet is considered to be a high-protein, high-fat diet. For the most part, they bypass carbohydrates. Approximately 50% of calories come from animal fat. The meat mostly consists of seal, whale, and walrus. Compared to the American diet, the Inuit Diet does not use chemically modified oils and saturated fats and uses more monounsaturated fats. Inuits commonly consume whale blubber, which is comprised of 70% monounsaturated fat and close to 30% omega-3s. How Do They Avoid Scurvy? The Inuits live in a place with no access to fruits and vegetables yet they avoid scurvy. Scurvy is defined as complications that can arise from a lack of vitamin C. In the American diet, vitamin C is mostly obtained through fruits such as oranges, apples, and strawberries. The United States recommended minimum daily allowance of vitamin C is 75 milligrams. However, studies have shown the minimum amount of vitamin C needed to avoid scurvy is 10 milligrams. Inuits can obtain this minimal amount of vitamin C in fish and sea mammals, as well as raw animal organs. Raw caribou liver supplies almost 24 milligrams, seal brain contains 15 milligrams, and raw kelp has more than 28 milligrams.9

Professional Opinion Nutrition is a very important aspect of human life; we need to eat a balanced diet in order for good health and wellbeing. The issues that we have focused on relates to the lack of a balanced diet and should be addressed. Childhood obesity is a serious and growing concern, both domestically and internationally. Low overall health early in life can lead to severe long-term complications. Although fad diets may seem like an option for weight loss, it should not be used long-term due to its negative consequences. It is important that people are educated on these fad diets before they begin the diets. Next, childhood malnutrition is also a serious global health concern. Malnutrition is often measured as stunting, and stunting has long-term, harmful consequences on both the individual and the community. Lastly, the Inuit Paradox is comprised of a diet much different than the typical American diet, but yet they still acquire the necessary vitamins and nutrients needed for a healthy lifestyle. A proper diet is necessary to avoid long-term complications and chronic diseases, such as diabetes, hypertension, hyperlipidemia, and arthritis. Therefore, a well-balanced diet gives an individual an edge in terms of increased mental ability, increased focus, and increased performance at school and in the workplace.

The Inuit Paradox. Discover Magazine. http://discovermagazine.com/2004/oct/inuit-paradox. Access March 26, 2018. Graphic from: http://www.ucl.ac.uk/news/news-articles/0915/170915_Inuit_diet

Pollution: A Health Crisis Kai Gao, BSPS Student Spring 2018

Abstract:

In this monograph, the impacts of pollution, both primary and secondary, on human health will be discussed. Air pollution has some very direct influences on health, especially in regard to pulmonary diseases and lung health. Prolonged exposure to pollutants in the air is known to cause lung damage and lead to chronic pulmonary diseases. It is known that climate change has been shown to impact vascular disease through extreme weather.1 Changes in weather patterns caused by climate change have influenced the spread of infectious diseases as well.2 Pollution of water sources is also a significant problem, not only for people in the US, but all around the world. Within the states, the residents of Flint, Michigan are currently suffering from lead contamination within their primary water source. Consumption of their leadened water would cause a multitude of health problems.3 Acute mercury poisoning is also a major health problem around the world. Fishing countries like Japan have passed regulations in an effort to control the level of mercury to accumulate in fish, and ultimately in humans.4 This has been done as a means to prevent mercury poisoning for their population.

https://19january2017snapshot.epa.gov/climate-impacts/climate-impacts-human-health_.html https://www.sciencedirect.com/science/article/pii/S0160412015300489 3 https://www.cnn.com/2016/03/04/us/flint-water-crisis-fast-facts/index.html 4 http://www.env.go.jp/chemi/tmms/pr-m/mat01/en_full.pdf 2

Air pollution: As for air pollution, air is one of the most essential element for human to survive, so quantity of air decides quantity of human life. Humans enter in contact with different air pollutants primarily via inhalation and ingestion, while dermal contact represents a minor route of exposure. Air pollution contributes, to the contamination of food and water, which makes ingestion in several cases the major route of pollutant intake. Via the gastrointestinal and respiratory tract, absorption of pollutants may occur, while many toxic substances can be found in the general circulation and deposit to different tissues. Elimination occurs to a certain degree by excretion. 1 Hazardous substances (For example hazardous chemicals) which are discharged as air pollutants may find their pathway to human exposure through multiple routes such as ingestion and dermal contact, and direct inhalation. The mechanisms for modeling and understanding the fate of air pollutants through atmospheric transport, deposition into water and soil, bioaccumulation, and ultimate uptake to receptor organs and systems in the human body are complex. Pollution prevention programs can be better engineered, pollution priorities can be identified, and greater environmental public health gains can be achieved by evaluating the multiple pathways to human exposure and through improved dosage calculations. 2 A single contaminant source often may represent only a fraction of a total body pollutant burden. Further research is needed on source culpability and attributable risk, long-range transport of air pollutants, human dose contributions by various pathways, better techniques for health risk assessment, and an identification of human behavior patterns that affect exposure and dose. 3

1 http://accesspharmacy.mhmedical.com/content.aspx?bookid=449&sectionid=39910771 2https://ehp.niehs.nih.gov/1307866/ 3 Mehlman, MA, ed. Health hazards and risks from exposure to complex mixtures and air toxic chemicals. Princeton, N.J.: Princeton Scientific Publishing Co., Inc., 1991

Climate Change impacts on health: Based on research nowadays, climate change should count as a including topic of air pollution because it basically caused by CO2 emit in atmosphere. It can also deal damage to human health in three parts. Impact on vascular disease: Vascular disease is the kind of disease of blood vessels. In some condition like when human body in an extreme outside environment, vascular disease is always happened. Erythromelalgia is one of good examples of vascular disease which is commonly triggered by the involvement of change in temperature. This kind of disease leads to syndromes including burning pain, increased temperature, erythema and swelling, of mainly the hands and feet that are affected. 1 Impact on infectious diseases: Infectious disease is not direct caused by climate change; However, climate change has such a big influence in infectious disease. For example, extreme weather patterns are creating extended rainy seasons in some areas, and extended periods of drought in others, as well as introducing new climates to different regions. The changing of weather in certain areas will create a better living environment for certain virus or bacteria which will direct decrease the difficulty for infectious disease to develop. This means the fast increasement of infectious disease. 2 Impact of extreme weather: This kind of situation only happened in several extreme weather areas. However, with the influence of global warming, those areas are increasing. An extreme weather pattern often responsible for increased precipitation, resulting in increased flooding, creating a more promising breeding ground for a plethora of vectors that both carry and cause infectious diseases. This means it could cause different kind of infectious disease by extreme environmental condition which caused by extreme weather. 3 1 https://rarediseases.org/rare-diseases/erythromelalgia/ 2

https://www.sciencedirect.com/science/article/pii/S0160412015300489

3 https://nca2014.globalchange.gov/highlights/report-findings/extreme-weather

Flint Water Crisis: Since 2014, the city of Flint Michigan has been without clean drinking water. The water crisis started after the city officials decided to change the source of water from Detroit’s water source to the Flint River. The decision to change water sources stemmed from an ongoing financial crisis in the city of Flint, after the GM plant downsized. 5 The shift in water source would save the city money from the cost of transporting water from another city. A failure to treat the water with corrosion inhibitors lead to breakdown of old lead pipes caused by the Flint River’s excess of disinfection byproducts.6 Flint’s unclean water had lead to residents and children with elevated levels of mercury to be found in their blood.7 8 A lot of blame for the water crisis is directed at Gov. Rick Snyder, who is considered to be responsible for the switch and the ultimate lead contamination caused by it. I personally think this blame is warranted. The Flint River was tested and shown to have higher levels of corrosives before the switch was made, yet the choice was still made. Gov. Snyder also failed to ensure the treatment of the pipes with anticorrosives. Gov. Snyder made the decision to give unchecked power to “emergency managers” who he appointed himself to address the issues. Ultimately, these folks prevent the EPA and other federal officials from being able to do their jobs without their blessing. 9 It doesn’t help that Gov. Snyder has made countless attempts to assure the residents of Flint that the city water is fine, including a “30-Day Flint Challenge” which ended prematurely as he traveled to Europe.

Roger & Me by Michael Moore

6 7

http://www.mlive.com/news/flint/index.ssf/2015/01/flint_water_has_high_disinfect.html http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2015.303003

Illustration by: Jake Thrasher

9 https://www.washingtonpost.com/opinions/the-flint-disaster-is-rick-snydersfault/2016/01/25/9c77e036- c3b1-11e5-a4aa-f25866ba0dc6_story.html? utm_term=.68f1085d2053 81

Acute Mercury Poisoning from Fish: Through a process called biomagnification, larger fish accumulate a higher concentration of harmful methylmercury in their bodies than what we would deem safe for human consumption. Elevated levels of methylmercury can lead to a variety of CNS damage-related symptoms, including peripheral vision impairment, stinging or needle-like sensations in the extremities and mouth, loss of coordination, muscle weakness, and other impairments of speech and hearing.10 Because most of the methylmercury that humans consume is found in fish, mercury poisoning disproportionately affects folks whose use fish as a primary food source. Ghana, for example, uses a lot of fish in their diet as they are a small, coastal country. Mercury is also used in small-scale gold mining by many of the folks living there and it ends up polluting the air and ground water.11 There was a test done, showing that women of the Amazonian Basin had a significantly higher level of mercury in their hair when water levels rose and their diets shifted to contain more fish.12 In Japan, the consumption of dolphin meat is a traditional practice. In the city of Taiji, dolphin hunting an annual celebration and a regularly sold food. Residents of Taiji are shown to have extremely elevated mercury levels in their blood, with higher concentrations in older folks.13

Professional opinion: In my opinion, mercury poisoning isn’t being handled as well as it could. There are national regulations on the amount of mercury that can enter the water supply, but there are none surrounding the mercury contained in food. I would like to see more education and food alternatives for the people most affected by mercury found in fish.

https://www.emedicinehealth.com/mercury_poisoning/article_em.htm#what_are_the_symptoms_of_ mercury_poisoning 11

https://www.hrw.org/news/2017/03/29/ghana-ratifies-mercury-convention

12 Dolbec, Julie; Mergler, Donna; Larribe, Fabrice; Roulet, Marc; Lebel, Jean; Lucotte, Marc (2001). "Sequential Analysis of Hair Mercury

Levels in Relation to Fish Diet of an Amazonian Population, Brazil". Science of the Total Environment. 271 (1–3): 87–97. doi:10.1016/s00489697(00)00835-4. PMID 11346043. Retrieved 8 Apr 2014. 13

https://www.japantimes.co.jp/news/2009/09/23/news/mercury-danger-in-dolphin-meat/#.WpTpLainFhE

TOPICS COVERED: Benefits of Therapy Risk of Therapy Ethics 83

Governmental Regulation

Benefits of Therapy • Stem cell therapy can help multiple diseases such as Parkinson’s disease, Alzheimer’s, certain cancers, cardiovascular disease, Autism, injury to bones and cartilage and other major health conditions • An example is the picture shown on the left of Parkinson’s Disease therapy. Once stem cells are implanted, they can generate into anything including functioning nerve cells. https://www.slideshare.net/AmyMehaboob1/stem-cell-therapy-76590209

•

Used for drug research by differentiating into the target o Able to make antibodies for the created cell Clinical trials by testing on specific cells instead of live individuals

http://cellerant.com/science_technology/cancer-stem-cell-biology.html

Risk of Therapy Understanding of risks of cell therapies is limited

• Can risk of infectious disease transmission ever be eliminated? o Cells and tissues often cannot be sterilized fully o Donor screening – difficult to obtain complete history for deceased donors o Subjective nature of exclusion decisions o Evolving knowledge (e.g. prions and degenerative neurological diseases • Many biologicals cannot be stopped because only some stem cell therapies are in formal clinical trials and adverse events can also be masked by poor progress of critically ill patients • Unforseen reactions have been reported o e.g. heart attack, severe thrombosis, encephalomyelitis, bone tissue 84

Ethics Before 2008, almost $700 million was provided in federal funding. Since then, President Bush banned funds of stem cell research. Itâ&#x20AC;&#x2122;s almost impossible for patients to receive treatment with stem cells due to high costs. Without federal funding, itâ&#x20AC;&#x2122;s almost impossible to have clear regulations on the treatment using stem cells. If stem cell research was funded more in the future, it would expedite the process of finding donor cells and get patient the treatment needed . http://excitingembryonicstemcellresearch.yolasite.com/innovators.php

Most of the debate of stem cell research revolves around the moral ethics of where stem cells come from. During most of the debate, stem cells where only achieved from embryonic stem cells, instead of adult reverse engineering. Since then there has been development. Morally, many religious and pro-life organizations opposed this research due to the embryonic state. It is based on the belief that life starts after conception. Therefore, embryonic stem cell research is unethical to some individuals. http://r.search.yahoo.com/_ylt=AwrEwSyeW7Fa6XkAnemWnIlQ;_ylu=X3o

Governmental Regulation

Our Views Without the funding of stem cell research, it is almost impossible to treat patients. Since the major debate in 2008 about the morality of stem cell research, scientists have developed a way to reverse engineer stem cells which is both helpful and morally accepted. However, these cells are not as effective as embryonic cells. But, there may be a middle ground that America can get behind.

American's Support of Stem Cell Research

References •

• • •

• • • • •

TGA Australia Follow. Stem cells now and in the future: regulation in Australia. LinkedIn SlideShare. https://www.slideshare.net/TherapeuticGoodsAdministration/stem-cells-now-and-in-the-future-regulation-in-australia. Published May 7, 2015. Accessed March 6, 2018. Cellerant Therapeutics. http://cellerant.com/science_technology/cancer-stem-cell-biology.html. Accessed March 6, 2018. Advancells. Alzheimer Treatment| Dementia Treatment by Stem Cell in India. Advancells Stem Cell Therapy. https://www.advancells.com/stem-cell-treatment-alzheimer.php. Accessed March 6, 2018. Amy Mehaboob, Student at ST JOSEPHs COLLEGE OF PHARMACY, NAIPUNYA ROAD Follow. Stem cell therapy. LinkedIn SlideShare. https://www.slideshare.net/AmyMehaboob1/stem-cell-therapy-76590209. Published June 2, 2017. Accessed March 6, 2018. Biotech Innovators of Embryonic Stem Cell Research . Innovators. http://excitingembryonicstemcellresearch.yolasite.com/innovators.php. Accessed March 6, 2018. Funding the Future: Embryonic Stem Cell Research. Almost Human. https://my.vanderbilt.edu/almosthuman/2013/04/fundingthe-future-embryonic-stem-cell-research/. Accessed March 6, 2018. MNT Editorial Team. What are Stem Cells. Medical News Today. https://www.medicalnewstoday.com/info/stem_cell. Published 19 July 2017. Accessed 20 Feb 2018. Stem Cell Basics. National Institutes of Health. https://stemcells.nih.gov/info/basics.htm. Published 2016. Accessed 20 Feb 2018. American’s Support Stem Cell Research. Research America. https://www.researchamerica.org/advocacy-action/issuesresearchamerica-advocates/stem-cell-research. Published 2016. Accessed 24 Feb 2018

Background

Validity of Alternative Treatments Nikki Kouknas and Jacob Leclaire (BSPS), Spring 2018

Alternative treatments and therapies are a big practice in the Eastern world where as the Western world tends to write them off as ineffective or worse, rumors spread that they can be harmful to the body. However, there is evidence that most alternative therapies can be just as effective as a Western medication. Medical grade honey has shown evidence on being a great antibiotic and has yet to be the subject of mutation from bacteria. White Willow bark contains the active ingredient from Aspirin as well as antioxidants that are not typically present in the medication. Cannabidiol oil has shown efficacy for prevention of epileptic seizures and help with anxiety and depression. Lastly, hypnosis, one of the popular alternative therapies, has shown efficacy in helping with smoking cessation and losing weight.

Medical Grade Honey Properties: Medihoney is gamma irradiated to inactivate spores such as those from Clostridium botulinum. This does not have a detrimental impact on the antibacterial activity of honey and is done as a precaution. Medihoney is hygroscopic meaning it draws moisture out of the environment, thus dehydrating bacteria. The honey has a high sugar content and low pH (mean 4.4) that is able to hinder the growth of microbes, and no drug resistance is seen in the use of medical grade honey. Administration: Medical honey dressings should keep the honey in contact with the wound for at least 12 h, but preferably for 24 h. The medical product can be purchased as a paste or bandage soaked in the honey.

Products: Medihoney may be produced and purchased in several ways including: Hydrogel-Non-Adhesive; Hydrogel-Adhesive; Gel; Gel-Tub; Paste; HCS Non-Adhesive; Surgical HCS; Fenestrated HCS-Non-Adhesive; Calcium Alginate; Honeycolloid Non-Adhesive; Honeycolloid Adhesive Safety: Honey should never be administered orally to an infant due to Clostridium botulinum spores contained in nontreated honey products. Medical honey does not display the problem of systemic absorption and thus can even be utilized in patients with diabetes mellitus without adverse effects on blood glucose levels.

Thoracotomy wound of a patient with acute myeloic leukemia after surgical site infection (Medihoney™ was applied on a calcium-alginate dressing and left in the wound for 24 hours) 87

Natural Anti-Inflammatory: White Willow Bark Extract Properties: The extract contains the compound Salicin, which is similar to the compound, Salicylic Acid found in Aspirin. Although willow bark extracts are generally standardized to salicin, other ingredients in the extracts including other salicylates as well as polyphenols, and flavonoids may also play prominent roles in the therapeutic actions. Upon oral ingestion, more than 80% of salicin present in willow bark extract is absorbed and metabolized by the liver to salicylic acid.

Study Example: In a study conducted by Chrubasik et al. 210 patients were randomized to placebo, 120 mg or 240 mg salicin in a 4-week trial. The number of patients that were pain free in the last week of treatment was 39% for the high dose, 21% for the low dose, and 6% for the placebo, thus showing evidence for the effect of White Willow bark extract.

Safety: Adverse effects appear to be minimal as compared to non-steroidal anti-inflammatory drugs including aspirin. The primary cause for concern may relate to allergic reactions in salicylate-sensitive individuals. It has been suggested that people with gastritis, stomach ulcers, diabetes, asthma, or hemophilia should avoid willow bark extract. Furthermore, it has been noted that willow bark may interact with anticoagulants (increase the risk of bleeding), beta blockers and diuretics (decrease the effect of the drugs), and NSAIDs (increase the risk of stomach bleeding) In addition, children under the age of 16 years should not use white willow bark extract because of the potential for causing Reye syndrome.In general, drug interactions associated with salicylates may apply to willow-containing products.

Google images Fig 1: Treatment of low back pain with willow bark extract vs placebo 88

Medical Cannabis Background: Cannabis is a plant that contains two main active ingredients. Tetrahydrocannabinol (THC) and Cannabidiol oil (CBD). THC is a psychoactive compound, and is considered a stimulant, while CBD demonstrates stimulant properties but does not have any psychoactive effects. Microdosing: giving a subtherapeutic dose to reap some benefit from a drug but not experience a full body response. Microdosing CBD Oil Benefits ● Great for preventative medicine ○ Can help prevent age related osteoporosis ● Improve mental illnesses (serotonin receptor agonist) ○ Anxiety and depression ● can reduce neurodegenerative diseases ● Can reduce epileptic seizures ● Anti-inflammatory and pain reliever.

Professional Opinion These treatments provide an alternative to mainstream medication that may not be a good match for the patient. Whether allergies, beliefs, or other circumstances, these treatments can provide the patient with relief from certain symptoms without taking tthe conventional medication. Our professional opinion, we believe it is best to consult a physician before trying any of these products to see what is best for you.

https://420evaluationsonline.com/health-and-news/th e-amazing-benefits-of-micro-dosing-cbd Google images

Hypnotizing Treatments Hypnosis: Scientifically described, hypnosis is “extreme focus and narrowing of attention along with physical relaxation”. This makes the patient more open to suggestions such as stop smoking, or lose weight. It is important to note these are suggestions not something the patient is forced to do. Scientific Basis/Procedure ● Having the patient focus on something (a watch or a conversation) ● Breaking the concentration and inserting a suggestion to remain relaxed. These two actions simultaneously can put the patient into a trance-like state (similar to when you daydream) open for suggestion. Used for: ● Losing weight ○ Hypnosis subjects lost more weight than 90% of others who did not. And were able to keep it off. ● Addiction (smoking cessation) ○ 87% of people who tried hypnosis to stop smoking said it worked and have abstained from tobacco ● Anxiety and depression

Google images

Common Myths 1. Hypnosis can make you do something you wouldn’t normally do. Myth 2.

Hypnosis can make you forget something you want to remember. Myth

Hypnosis is like mind control. Myth

Bibliography ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Cooper, R. A., PhD, & Jenkins, L., BSc. (2014, December 26). A Comparison Between Medical Grade Honey and Table Honeys in Relation to Antimicrobial Efficacy. Retrieved February 26, 2018, from http://www.woundsresearch.com/content/a-comparison-between-medical-grade-honey-and-table-honeys-relation-antimicrobial-efficacy Ehrlich, S. N., NMD. (n.d.). Willow bark. Retrieved February 26, 2018, from https://www.umm.edu/health/medical/altmed/herb/willow-bark Hoffman, A. (2017, July 05). Microdosing With Cannabis: Benefits Without the Buzz. Retrieved February 26, 2018, from https://www.leafly.com/news/cannabis-101/microdosing-weed-guide Simon, A., Traynor, K., Santos, K., Blaser, G., Bode, U., & Molan, P. (2009). Medical Honey for Wound Care—Still the “Latest Resort”? Evidence-Based Complementary and Alternative Medicine : eCAM, 6(2), 165–173. http://doi.org/10.1093/ecam/nem175 Staff, 4. M. (2017, November 22). THE AMAZING BENEFITS OF MICRO-DOSING CBD. Retrieved February 26, 2018, from https://420evaluationsonline.com/health-and-news/the-amazing-benefits-of-micro-dosing-cbd Cannabidiol. (2018, February 20). Retrieved February 26, 2018, from https://en.wikipedia.org/wiki/Cannabidiol How CBD Works. (n.d.). Retrieved February 26, 2018, from https://www.projectcbd.org/science/cannabis-pharmacology/how-cbd-works Manuka Honey. (n.d.). Retrieved February 26, 2018, from https://www.webmd.com/a-to-z-guides/manuka-honey-medicinal-uses#1 Shara, M., & Stohs, S. J. (2015, August). Efficacy and Safety of White Willow Bark (Salix alba) Extracts. Retrieved February 26, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/25997859 Tetrahydrocannabinol. (2018, February 26). Retrieved February 26, 2018, from https://en.wikipedia.org/wiki/Tetrahydrocannabinol What are the statistics on the effectiveness of hypnosis? (n.d.). Retrieved February 26, 2018, from https://www.professionalhypnotherapists.com.au/articles/what-are-statistics-effectiveness-hypnosis What is Hypnosis Therapy? Is it good for addiction treatment? (n.d.). Retrieved February 26, 2018, from https://www.treatmentsolutions.com/therapies/hypnosis/ Willow Bark Uses, Benefits & Side Effects - Drugs.com Herbal Database. (n.d.). Retrieved February 26, 2018, from https://www.drugs.com/npc/willow-bark.html WILLOW BARK: Uses, Side Effects, Interactions and Warnings. (n.d.). Retrieved February 26, 2018, frohttps://www.webmd.com/vitamins-supplements/ ingredientmono-955-willow%20bark.aspx?activeingredientid=955&activeingredientname=willow%20bark

“Day Zero”:

Delaram Hojati:

Student Pharmacist

In mid-January 2018, Cape Town Mayor Patricia de Lille announced that the city would be forced to shut off most of the municipal water supply

JIayang Huang: BSPS Student

if conditions do not change. Day Zero would be declared when the water level of the city's major dams reaches 13.5%. When this occurs, municipal

Spring 2018 PHRM 485

water supplies would be largely switched off, and residents would rely on 149 water collection points around the city to collect a daily ration of 25

Background Introduction:

litres of water per person.

Water pollution is the contamination of water bodies (e.g. lakes, rivers, oceans, aquifers and groundwater), usually as a result of human activities. Water pollution is one of many types of pollution which results from contaminants being introduced into the natural environment. Pollution causes adverse change. Water pollution is often caused by the discharge of inadequately treated wastewater into natural bodies of water. This can lead to environmental degradation of aquatic ecosystems. In turn, this can lead to public health problems. For example, people living downstream may use the same polluted river water for drinking or bathing or irrigation.(1)

Issue 1: Cape Town Water Crisis: A drought in the Western Cape province of South Africa began in 2015 and is resulting in a severe water shortage in the region, most notably

Water supply would be maintained in the city's CBD, in informal

affecting the city of Cape Town. With dam levels predicted to decline to

settlements (where water is already collected from central locations) and

critically low levels, the city announced plans for "Day Zero", when the

essential services such as hospitals. In January 2018, the date 22 April

municipal water supply will largely be shut off, potentially making Cape

2018 was initially named as Day Zero, shortly afterwards revising it

Town the first major city to run out of waterThrough water saving

forward to 12 April. The Day Zero date is projected based on the

measures and water supply augmentation, by March 2018 the City had

fortnightly change in dam storage levels, assuming that this rate will

reduced its daily water consumption by more than half to around 500

continue unchanged, with no further rainfall or change in water

million litres per day, resulting in the initial prediction of Day Zero in

demand.[32] Due to reduced agricultural and residential usage, as well as

April 2018 being pushed back to 2019. The situation however remains

water transferred from the Groenland Water User's Association, the

severe, particularly if the run of record dry winters continues through

date was moved back to 16 April,[33] then to 11 May,[34] 4 June,[35][36] 9

2018. (2)

July[32] and then to late August.[3]

Professional In-Depth Opinion: Though the municipality is ultimately responsible for sorting out the water crisis, provincial and national government are also on the hook. The Constitution gives municipalities exclusive power over “potable water supply systems and domestic waste-water and sewage disposal systems”, but higher tiers of government must monitor and support development of local government capacity. (3)

Issue 2: Pathogenic Agents in Water

Most Dangerous Water Borne Disease:

Water-borne pathogen contamination in water resources and related

Cholera is an acute diarrheal infection caused by ingestion of food or

diseases are a major water quality concern throughout the world.

water contaminated with the bacterium Vibrio cholera. Cholera remains a

Increasing interest in controlling water-borne pathogens in water

global threat to public health and an indicator of inequity and lack of

resources evidenced by a large number of recent publications clearly

social development. (5)

attests to the need for studies that synthesize knowledge from multiple fields covering comparative aspects of pathogen contamination, and unify them in a single place in order to present and address the problem as a whole.

Lymphatic filariasis, commonly known as elephantiasis, is a neglected tropical disease. Infection occurs when filarial parasites are transmitted to humans through mosquitoes. (6)

Typhoid fever is a serious disease spread by contaminated food and water. Symptoms of typhoid include lasting high fevers, weakness, stomach pains, headache, and loss of appetite. Some patients have constipation, and some have a rash. Internal bleeding and death can occur but are rare. (7)

Providing a broader perceptive of pathogen contamination in freshwater (rivers, lakes, reservoirs, groundwater) and saline water (estuaries and coastal waters) resources, this review paper attempts to develop the first comprehensive single source of existing information on pathogen contamination in multiple types of water resources. In addition, a comprehensive discussion describes the challenges associated with using indicator organisms. Potential impacts of water resources development on

Diarrhea is a condition that involves the frequent passing of loose or

pathogen contamination as well as challenges that lie ahead for

watery stools while Dysentery is an intestinal inflammation, especially in

addressing pathogen contamination are also discussed. (4)

the colon, that can lead to severe diarrhea with mucus or blood in the feces.

Professional In-depth Opinion Considering the limited ability of existing models to predict pathogen contamination, improvement and development of new models are needed so that pathogen levels can be predicted more accurately. Integrating knowledge from multiple fields (e.g., hydrology, microbiology, and ecology) would increase the understanding of pollution levels and potential causes of pollution, and can also help devise long-term strategies to improve water quality. (4)

Issue 3: Flint Water Crisis, Michigan

White House: Obama Administration

The Flint water crisis began in 2014 when the drinking water source for

After approving Governor Snyder's application for an emergency

the city of Flint, Michigan was changed to the Flint River. Due to

declaration, President Barack Obama said of the crisis, "What is

insufficient water treatment, over 100,000 residents were potentially

inexplicable and inexcusable is once people figured out that there was a

exposed to high levels of lead in the drinking water. After a pair of

problem there, and that there was lead in the water, the notion that

scientific studies proved lead contamination was present in the water

immediately families weren't notified, things weren't shut down. That

supply, a federal state of emergency was declared in January 2016 and

shouldn't happen anywhere."[295] President Obama visited Flint on May 4,

Flint residents were instructed to use only bottled or filtered water for

2016 to reiterate his thoughts and drank a glass of filtered Flint water

drinking, cooking, cleaning, and bathing. As of early 2017, the water

to show it was safe.

quality had returned to acceptable levels; however, residents were instructed to continue to use bottled or filtered water until all the lead pipes have been replaced, which is expected to be completed no sooner than 2020. (8)

Prevention:

President Barack Obama sips filtered Flint water following a roundtable

Failed infrastructure and economic decline resulted in the toxic levels of

on the crisis at Northwestern High School on May 4, 2016.

lead in the city's water supply. According to an article published in

Professional In-depth Opinion

the American Journal of Public Health, to prevent another contamination crisis, officials such as Governor Snyder should consult "professionals" and make "qualified” decisions. "Snyder and his administration introduced

We have supported their exercise of academic freedom, even as their

a corrosive water source into an aging water filtration system without

views played out painfully and publicly in the pages of the NYT

adequate corrosion control (APHA).

Magazine, Chronicle of Higher Education, and in a letter to ES&T’s Editor to which we were compelled to respond “We Helped Flint Residents Save Themselves and Are Proud of It.” But it has become increasingly difficult to ignore their underhanded tactics of trolling us on social media, accusing students of perpetrating grave injustices in Flint under our unethical leadership, and putting into practice principles of science anarchy that they teach in the classroom (illustrated below in an excerpt from Dr. Riley’s course): “By questioning the commonly held

Return to Detroit Water:

assumption, shared by engineers and non-engineers alike, that engineers

In March 2015, Flint voted to

hold, or ought to hold, particular expertise and power around

switch back to the Detroit Water and Sewerage Department. This vote

technology… disruption of engineering expertise is a central goal of the

was motivated by residential complaints and recommendations

course.” (9)

from Veolia North America to prevent the city from further violating the Safe Drinking Water Act. Jerry Ambrose, Flint’s emergency manager and financial supervisor, disagreed with the reintroduction of the Detroit water source. Ambrose argued, "Flint water today is safe by all Environmental Protection Agency and Michigan Department of Environmental Quality standards, and the city is working daily to improve its quality."

Issue 4: Regulation

Environmental protection Agency

Safe Drinking Water Act The Safe Drinking Water Act (SDWA) was established to protect the quality of drinking water in the U.S. This law focuses on all waters actually or potentially designed for drinking use, whether from above ground or underground sources the Act authorizes EPA to establish

The United States Environmental Protection Agency was born on

minimum standards to protect tap water and requires all owners or

December 2, 1970. The documents below shed some light on its birth and

operators of public water systems to comply with these primary (health-

early years. Note that these documents are now in EPA's archive. To find

related) standards.

one, click on the Search EPA Archive button and copy the name of the document into the search box on the archive home page. To ensure the best search results, be sure to put quotes around the name of the document.

Professional In-depth Opinion The 1996 amendments to SDWA require that EPA consider a detailed

The mass-mailing and petition letter campaigns made up the majority of

risk and cost assessment, and best available peer-reviewed science, when

the over one million comment letters received by the Docket. These

developing these standards. State governments, which can be approved to

letters addressed many of the major issue areas, often overlapping each

implement these rules for EPA, also encourage attainment of secondary

other both in terms of content as well as specific wording. Almost all of

standards (nuisance-related). Under the Act, EPA also establishes

the mass mailing campaign letters were brief and followed a similar

minimum standards for state programs to protect underground sources

format. The letters provided a clear statement of support or opposition

of drinking water from endangerment by underground injection of fluids.

to the proposed rule, citing one or more issues as reasons to support the position taken and to advocate for a particular direction for the final rule. Those that expressed support for the rule generally also supported a broader scope of jurisdiction, while those who expressed opposition to the rule supported a narrower scope of jurisdiction. (11)

References: (1). https://en.wikipedia.org/wiki/Water_pollution (2).https://en.wikipedia.org/wiki/Cape_Town_water_crisis#Day_Zero (3). https://www.sapeople.com/2018/01/19/facts-myths-cape-townswater-crisis/ (4).https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4077002/ (5).http://www.who.int/mediacentre/factsheets/fs107/en/ (6).http://www.who.int/mediacentre/factsheets/fs102/en/ (7).https://wwwnc.cdc.gov/travel/diseases/typhoid (8).https://en.wikipedia.org/wiki/Flint_water_crisis (9). http://flintwaterstudy.org/ EPAâ&#x20AC;&#x2122;s and statesâ&#x20AC;&#x2122; primary means of monitoring public water system

(10). https://www.epa.gov/compliance/safe-drinking-water-act-sdwa-

compliance with the SDWA and its implementing regulations is the review

compliance-monitoring

and evaluation of analytical results of water samples collected by public

(11). https://www.epa.gov/sites/production/files/2015-

water systems. When results indicate that a contaminant is present at a

06/documents/cwr_response_to_comments_mass_mailing_campaigns.pdf

level that exceeds standards, states and EPA work with public water systems to take steps to prevent or remove the contaminants, and notify consumers so that they can make informed choices. (10)

What’s In Your Water? Water Pollution and Its Effects on Human Health Jory Goff, B.S.P.S. Student

Spring 2018 caused by the Flint River’s excess of disinfection byproducts.3 Flint’s unclean water had led to residents and children with elevated levels of lead to be found in their blood. 4

In this monograph, I will be discussing the health and political implications of pollution of the Earth’s water. Pollution of water sources is a significant problem, not only for people in the US, but all around the world. Within the states, the residents of Flint, Michigan are currently suffering from lead contamination within their water supply. Consumption of their lead-contaminated water would cause a multitude of health problems.1 Acute mercury poisoning is also a major health problem around the world. Fishing countries like Japan have passed regulations in an effort to control the level of mercury to accumulate in fish, and ultimately in humans.2 This has been done as a means to prevent mercury poisoning for their population.

A multitude of test had indicated the presence of coliform bacteria in the Flint water supply, starting as early as August of 2014, which are early indicators of aging pipes. A Fling City Council vote of 7-1 was overturned by one of Gov. Snyder’s emergency managers in an effort to prevent a rise in the price of water. Flint was not switched back to a clean water source until October of 2015. As of today, Flint is still without clean water.

The Flint Water Crisis: Since 2014, the city of Flint Michigan has been without clean drinking water. The water crisis started after the city officials decided to change the source of water from Detroit’s water source to the Flint River. The decision to change water sources stemmed from an ongoing financial crisis in the city of Flint, after the GM plant downsized. The shift in water source would save the city money from the cost of transporting water from another city.

Illustration by Adam Zyglis / Buffalo News

A failure to treat the water with corrosion inhibitors lead to breakdown of old lead pipes 1

Flint Water Crisis Fast Facts. (2017, November 28). Retrieved April 03, 2018, from https://www.cnn.com/2016/03/04/us/flint-watercrisis-fast-facts/index.html 2 Ministry of Enviornment. (2013, September). Lessons from Minamata Disease and Mercury Management in Japan. Japan, Tokyo 3 Fonger, R. (2015, January 03). City warns of potential health risks after Flint water tests revealed too much disinfection byproduct. Retrieved April 03,

2018, from http://www.mlive.com/news/flint/index.ssf/2015/0 1/flint_water_has_high_disinfect.html 4 Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response. (2016, January 21). Retrieved April 03, 2018, from http://ajph.aphapublications.org/doi/full/10.2105/A JPH.2015.303003

Because most of the methylmercury that humans consume is found in fish, mercury poisoning disproportionately affects folks whose use fish as a primary food source. Ghana, for example, uses a lot of fish in their diet as they are a small, coastal country. Mercury is also used in small-scale gold mining by many of the folks living there and it ends up polluting the air and ground water.6 There was a test done, showing that women of the Amazonian Basin had a significantly higher level of mercury in their hair when water levels rose and their diets shifted to contain more fish.7 In Japan, the consumption of dolphin meat is a traditional practice. In the city of Taiji, dolphin hunting an annual celebration and a regularly sold food. Residents of Taiji are shown to have extremely elevated mercury levels in their blood, with higher concentrations in older folks.8

Thoughts from the Author: A lot of blame for the crisis is directed at Gov. Rick Snyder, who is considered to be responsible for the switch and the ultimate lead contamination caused by it. I personally think this blame is warranted. The Flint River was tested and shown to have higher levels of corrosives before the switch decided on, yet the choice was still made. Gov. Snyder also failed to ensure the treatment of the pipes with anticorrosives. Gov. Snyder made the decision to give unchecked power to “emergency managers” who he appointed himself to address the issues. Ultimately, these folks prevent the EPA and other federal officials from doing their jobs.

Thoughts from the Author:

Acute Mercury Poisoning from Fish:

In my opinion, mercury poisoning isn’t being handled as well as it could. There are national regulations on the amount of mercury that can enter the water supply, but there are none surrounding the mercury contained in food. I would like to see policy to regulate and maybe tests for the mercury contained in foods. Possibly warning labels or education to targeted communities to protect those vulnerable populations.

Through a process called biomagnification, larger fish accumulate a higher concentration of harmful methylmercury in their bodies than what we would deem safe for human consumption. Elevated levels of methylmercury can lead to a variety of CNS damage-related symptoms, including peripheral vision impairment, stinging or needle-like sensations in the extremities and mouth, loss of coordination, muscle weakness, and other impairments of speech and hearing.5 5

Davis, C. P. (2017, December 13). Mercury Poisoning: Treatment & Prevention. Retrieved April 03, 2018, from https://www.emedicinehealth.com/mercury_poison ing/article_em.htm#what_are_the_symptoms_of_ mercury_poisoning 6 . Ghana Ratifies Mercury Convention. (2017, May 23). Retrieved April 03, 2018, from https://www.hrw.org/news/2017/03/29/ghanaratifies-mercury-convention

Dolbec, Julie et al. (2001). "Sequential Analysis of Hair Mercury Levels in Relation to Fish Diet of an Amazonian Population, Brazil". Science of the Total Environment. 271 (1–3): 87–97. doi:10.1016/s00489697(00)00835-4. PMID 11346043. Retrieved 8 Apr 2014. 8 Johnston, E. (2009, September 23). Mercury danger in dolphin meat. Retrieved April 03, 2018, from https://www.japantimes.co.jp/news/2009/09/23/ne ws/mercury-danger-in-dolphinmeat/#.WpTpLainFhE

Women's Health

Mayp Clinic. Women’s Health Research Center For: Improving Health Care for Women of all ages. 1998-2018 http://www.mayo.edu/research/centers-programs/womenshealth-research-center

Veronica Welch, BSPS student Diana Zhang, BSPS student

Spring 2018

…….. Why is Women’s Health Important? All over the globe, and even in the US, Women are disadvantaged by discrimination rooted in sociocultural factors that affect their abilities to access and receive appropriate care. Issues surrounding Women’s Health Education: Giving a better understanding of health problems a woman might face in her lifetime and how she can be proactive in preventing or treating issues. Also educating both men and women globally about women’s health, especially periods, to decrease the negativity women experience about natural processes of their bodies. Access: People in the US that are below the poverty line and many women in third-world countries don’t have adequate access, or any access, to sanitary products and this can lead to unsafe practices that can cause serious infections and other health problems. Cultural Impact: Religious and other cultural practices may prevent women from getting the care they need, protecting them from avoidable diseases, or cause actual harm that can significantly impact their health. Regulations: There are some laws in place in the US and in other countries that have had a significant impact on improving women’s health, but there are still others that are making it hard for women to receive appropriate healthcare. Professional Statement: The disadvantages that women face that affect their care include: unequal power relationships; Exclusive focus on women’s reproductive roles; potential or actual experience of physical, sexual and emotional violence.

Education

Medifee. What’s a Pap Test? Diagnosis, Procedure & Price in India. N.p. https://www.medifee.com/blog/whats-a-pap-test-diagnosis-procedure-price-in-india/

Health-Monitoring: Pap smear: a screening procedure for cervical cancer tests for the presence of precancerous or cancerous cells on the cervix. Women should start getting regular Pap smears at age 21. More frequent testing may be necessary for an HIV-positive individual or those with a weakened immune system from chemotherapy or an organ transplant. Those over 30 having three normal Pap tests in a row, should ask their doctor about having one every five years if the test is combined with

Spring 2018

a human papillomavirus (HPV) screening. Women over the age of 65 with a history of normal Pap test results may be able to stop having Pap smears. Testing for osteoporosis: Bone density tests check the strength of bones by measuring a small part of one or a few of them. According to the U.S. Preventive Services Task Force, BMD tests are recommended for all women ages 65 and older and younger women with a higher-than-normal chance of fracture for their age. Menopause: The diagnosis of perimenopause can usually be made by reviewing a woman’s medical history, her menstrual history, and her signs and symptoms. The most common symptoms women in their 40s notice are changes in periods and the onset of hot flashes. Menopause is defined as 12 months without a menstrual bleed, in the absence of other conditions. Breast cancer testing: Women ages 40 to 44 should have the choice to start annual breast cancer screening. Women age 45 to 54 should get mammograms every year. Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening. Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer. Hygiene: When cleaning “down there,” the best way to do it is to use water and gently remove any possible dirt and debris. Try to avoid products with perfumes as it may irritate the area. Use hypoallergenic and pH-balanced gentle cleansers. Try not to overdo cleansing in the area because it may cause an imbalance of the normal growth of bacteria around the vagina and lead to possible infections. Try to take showers and not baths. Always wipe from front to back after using the bathroom. Doing it the opposite way increases the chances of bacteria from the butt region moving to the vaginal region, which can cause a urinary tract infection. Lastly, using condoms during sex helps to protect against sexually transmitted infections (STIs). It is important to change condoms when switching from oral or anal sex to vaginal sex, to prevent the introduction of harmful bacteria into the vagina. Young Women: Breast budding in girls starts around age ten, with some girls starting as early as eight and others not starting until thirteen. Girls should be checked by their pediatrician if they begin puberty before age eight. The peak growth period (in height, weight, muscle mass, and the like) in girls occurs about one year after puberty has begun. Menstruation usually starts about 18 months to two years after the onset of puberty. On average, the first menses occur just before girls turn thirteen. If a girl shows no signs of puberty by age 13, consult with a pediatrician. Opposite Sex: Not only women: male education about women’s health is a key piece of the puzzle to changing social stigma around menstruation, and other changes throughout a woman’s lifetime. In many traditional societies, boys and men in many societies are the main decision makers. They need to accurately understand the challenges faced by their female colleagues, friends, and family members. Many studies have shown that men’s knowledge of menstruation is either completely lacking, or ripe with misinformation. This applies in the developing world, but is also a problem in more developed nations like the US.

Access

Christie, Victoria. Ottawa Shelter Calls for Better Access to Menstrual Products. 29 Sep 17. https://capitalnews.ca/ottawa-shelter-calls-formore-menstrual-products/

Global Problems: Some countries, like those in Southeast Asia and Africa, don’t have widespread access to sanitary feminine hygiene products due to either a lack of production capability, or delivery capability. This leaves the women of these countries with few options for caring for themselves during their menstrual cycles. Many use unsanitary reusable rags resulting in infection and missed work [Bangladesh], or young girls escorting in order to afford products [Mukuru, Nairobi]. In many of these countries there is also limited access to places where a woman can privately tend to her needs in public places, such as schools and working facilities. UNICEF reported that as much as 83% of girls in Burkina Faso and 77% of girls in Niger are unable to find a private place to change sanitary menstrual materials. This leads to many them being unable to attend school. Similarly, for working women, this means missed days from work and losing income. The lack of access also affects women in the United States that live below the poverty line or that are homeless. This is because many cannot afford to purchase sanitary menstrual products. There is also a lack of programs that could aid these women in either affording or obtaining the necessary products for a safe and healthy menstrual cycle. Access Organizations: There are some organizations that help women around the world get better access to feminine hygiene products and education on vaginal health. Dignity Period is an organization that provides access to hygiene products and education about women’s health to men, women, and adolescents around the world. There is also Femme International that provides hygiene kits for people in East Africa and CORA that provides feminine hygiene products to women in India for every product package that is bought on their online site. There are also some US based organization, such as Helping Women Period, that provide feminine hygiene products for women in need.

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Cultural Impact

Wikipedia. FGM Prevalence UNICEF. 2013. https://en.wikipedia.org/wiki/File:FGM_prevalence_UNICE F_2013.svg

Female Genital Mutilation: Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. Traditional circumcisers, who often play other central roles in communities, such as attending childbirths, mostly carry out the practice. FGM is recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death. The reasons why female genital mutilations are performed vary from one region to another as well as over time, and include a mix of sociocultural factors within families and communities. The most commonly cited reasons include, the social pressure to conform to what others do and have been doing, as well as the need to be accepted socially and the fear of being rejected by the community. These are strong motivations to perpetuate the practice. In some communities, FGM is almost universally performed and unquestioned. FGM is often considered a necessary part of raising a girl, and a way to prepare her for adulthood and marriage. It aims to ensure premarital virginity and marital fidelity. FGM is in many communities believed to reduce a woman's libido and therefore believed to help her resist extramarital sexual acts. When a vaginal opening is covered or narrowed (type 3), the fear of the pain of opening it, and the fear that this will be found out, is expected to further discourage extramarital sexual intercourse among women with this type of FGM. FGM is associated with cultural ideals of femininity and modesty, which include the notion that girls are clean and beautiful after removal of body parts that are considered unclean, unfeminine or male. Though no religious scripts prescribe the practice, religious leaders take varying positions with regard to FGM. Some promote it with religious support, some consider it irrelevant to religion, and others contribute to its elimination. Local structures of power and authority, such as community leaders, religious leaders, circumcisers, and even some medical personnel can contribute to upholding the practice. Contraceptives: Leaders of some countries blast condom use as dangerous. Their anti-condom rhetoric is bringing down their people and could ultimately hurt the world at large. For example, in Nigeria, although condoms are openly available throughout the country because of health organizations’ efforts, only 52% of sexually active citizens who are engaging in high-risk sex use condoms. And while the national government is supportive of reproductive health efforts, the measures are much less embraced by certain states of Nigeria. It is illegal to encourage condom use in in southeast Nigeria’s Anambra State, because the fundamentalist leaders believe condoms encourage immorality. In The Philippines The Philippines’ condom use is one of the lowest in Asia. It is also one of only seven countries globally where HIV cases have risen by 25 percent or more since 2001, according to the UNDP. More than 80% of the population is Catholic, and the Catholic Church in the Philippines has waged a war against the president’s efforts to curb HIV/AIDS through free condoms and sex education, believing that lifestyle change, not condom usage, will stop the AIDS epidemic in the Philippines. In Indonesia, according to the United Nations, the HIV epidemic in Indonesia is one of the fastest growing in Asia. And over 81% of recent HIV/AIDS cases are the result of unprotected sex, mostly with commercial sex workers. Health Minister Nafsiah Mbo said that with increased awareness of condom usage, infection rates would decrease. However, whenever someone brings up sex education in Indonesia, he or she is scolded by Muslim leaders. Mboi was summoned to parliament following accusations by conservative Muslim groups that her condom message was dangerous because it promoted promiscuity. One government agency wanted to ban selling condoms to teenagers altogether. In Zambia, former President Frederick Chiluba once said, "I don't believe in condoms because it is a sign of weak morals on the part of the user." His comment is an example of the extreme Christian ideologies that rule this nation. This anti-condom rhetoric is one of the many reasons more than one in every seven adults has HIV/AIDS in Zambia.

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Regulations There are some places around the world that understand the necessities of providing government funding for access to important products and aid for women, and others that don’t. There are even some controversial issues that have negatively impacted women’s access to health without any provisions for addressing them. Healthcare and Products: In Scotland, they have programs that provide free feminine hygiene products for women below the poverty. They are the first country to do so, and hopefully other countries will be following their lead. In many first world countries there are provisions in their healthcare system so that women aren’t taken advantage of, or discriminated against. In the US, there are many federal, or national, laws or regulations that provide women with protection against discrimination for healthcare coverage. The area that needs improvement, is when discussing women who are below the poverty line or that are homeless. There is far less protection for these women in concerns to healthcare coverage. There is also a need to create a national program for providing women with access to feminine hygiene products for those that are unable to afford them. On average, the yearly cost for feminine hygiene products alone is between $150-$300 for a woman. Most states don’t provide a program that includes these products because they don’t consider them essential items. They also place a tax on these items even though some of these states don’t place taxes on other items such as sunscreen. There are a few states, like Maryland, that don’t have a tax on feminine hygiene products and have named them as necessary medical products. There are still many third world countries that do not have guidelines so that women won’t be discriminated against, and that don’t provide specific health services for women. Women often have to rely on women they know to guide them through a specific condition, and hope that the remedies that are passed down will help their condition. Permissions on Women’s Bodies: There are even some controversial issues, such as permissions on women’s bodies. There are a lot of laws and regulations that heavily impact women’s health, such as the mixed views on abortion. In some countries there aren’t any accepted reasons for abortions and in some cases, this leads the woman to find dangerous resources in order to get rid of an unwanted pregnancy. There are some third world countries like Kenya, Ethiopia, and Rwanda, that have placed amendments to their strict abortion laws, allowing them to occur in the instance that the mother’s life is in danger. In many Latin American countries, abortion Banned Mother’s health Socioeconomic status regulations have continued to become increasingly stricter. No reason needed In the US, laws for abortion are determined mostly by the states, and very widely based on how conservative the Joshua Keating. How Do America’s Abortion Laws Compare to the Rest of population is. For example, in Oklahoma there was a law the World’s? 6 Nov 2014. that didn’t pass that wanted to make it mandatory for a http://www.slate.com/blogs/the_world_/2014/11/06/how_do_america_s_ woman to get written permission from her sexual partner in abortion_laws_compare_to_the_rest_of_the_world.html order to terminate a pregnancy. There has also been a national struggle for one of the US’s largest network provider of women’s health, Planned Parenthood which in 2017 received a drastic cut in federal funding. In the US and other first world countries, like those in Europe, abortion isn’t restricted based on reasons.

Sources Referenced: 1.

Kuhlmann, Anne Sebert, PhD, Henry, Kaysha, BSc, and Wall, L. Lewis, MD,DPhil. Menstrual Hygiene Management in Resource-Poor Countries. NCBI.. 2017 Jun 20. doi: 10.1097/OGX.0000000000000443 2. World Health Organization. Women’s Health. WHO. 2018. http://www.who.int/topics/womens_health/en/ 3. Webster, Catriona. Scotland may be the First Country to Offer Free Sanitary Products to Poor Women. Bussiness insider. 2017. http://www.businessinsider.com/scotland-first-country-to-offer-free-sanitary-products-to-poor-women-2017-7 4. Goldberg, Eleanor. All the Inconceivable Ways Women Deal with Their Periods Worldwide… and How to Help. Huff Post. 2017. https://www.huffingtonpost.com/2015/07/14/menstruation-myths_n_7495568.html 5. Five Things to Know About Menstrual Hygiene Around the World. Dignity Period. 2018. http://dignityperiod.org/five-things-to-knowabout-menstrual-hygiene-around-the-world/ 6. National Women’s Law Center. Women and the Health Care Law in the United States. 16 May 2013. https://nwlc.org/resources/womenand-health-care-law-united-states/ Spring 7. 2018 Joshua Keating. How Do America’s Abortion Laws Compare to the Rest of the World’s? 6 Nov 2014. http://www.slate.com/blogs/the_world_/2014/11/06/how_do_america_s_abortion_laws_compare_to_the_rest_of_the_world.html

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