UChicago PULSE Issue 5.1: Autumn 2018

PULSE from the editor-in-chief Dear reader,

VOLUME 4, ISSUE 1. AUTUMN 2018

[letter]

With regards, Irena Feng

editors

writers

production

Bushra Akbar Swathi Balaji Anya Dunaif Maria Hatzisavas Rita Khouri Jui Malwankar Linus Park Abhijit Ramaprasad Fatima Sattar

Annagh Devitt Yassmin Elbanna Allison Gentry Nikki Kasal Helen Kessler Sarah Nakasone Lindsay Romano Corinne Stonebraker Scott Wu Allan Zhang Charles Zhang

Purujit Chatterjee (cover design) Irena Feng Rachel (Jingru) Wang

GENERAL EDITORS Purujit Chatterjee

other contributors Gold Standard Kaplan Test Prep The Princeton Review

BRAIN DAMAGE AND THE NFL PULSE Magazine

editors

writers

production

Bushra Akbar Swathi Balaji Anya Dunaif Maria Hatzisavas Rita Khouri Jui Malwankar Linus Park Abhijit Ramaprasad Fatima Sattar

Annagh Devitt Yassmin Elbanna Allison Gentry Nikki Kasal Helen Kessler Sarah Nakasone Lindsay Romano Corinne Stonebraker Scott Wu Allan Zhang Charles Zhang

Purujit Chatterjee (cover design) Irena Feng Rachel (Jingru) Wang

GENERAL EDITORS Purujit Chatterjee

PULSE Magazine

other contributors Gold Standard Kaplan Test Prep The Princeton Review

from the editor-in-chief Dear reader,

Just as another quarter comes to a close, so ends another year as well. As final grades start coming in for autumn quarter, hopefully you can take a break from all that and enjoy your winter break, and that this issue of PULSE can provide some interesting reads!

The autumn issue this year explores health from a more policy-centric angle than issues past, and across a diverse range of areas as well, from a large-scale view of healthcare to individual policies from sports, end-of-life treatment, and clinical practice. This focus on different policies, however, doesn't mean we miss out on other areas of biomedicine! Research continues onwards, and this issue highlights some tidbits of recent developments. Finally, in addition to looking to the future with new technologies, we also look to the past and present to learn the lessons we need to shape the future of medicine for the better.

In three weeks, we'll all be back on campus and a new year - and a new quarter! - will begin. Here at PULSE, we wish you happy holidays! We hope you enjoy the winter break, and enjoy this issue!

With regards, Irena Feng

autumn 2018

PULSE Magazine

CONTENTS EDUCATION YOUR MEDICAL SCHOOL ADMISSIONS TIMELINE MCAT CARS: INFERENCE QUESTIONS KAPLAN MCAT PRACTICE PROBLEMS THE MILITARY, SARS, AND 30 SCREAMING CHILDREN

2 6 8 10

POLICY A GRIM DIAGNOSIS: CURRENT STATE OF HEALTHCARE THE QUESTION OF DYING THE GROWING DIVIDE: RURAL PHYSICIANS CONTINUITY IN THE AIDS EPIDEMIC CHRONIC TRAUMATIC ENCEPHALOPATHY AND THE NFL

14 18 21 24 28

RESEARCH 3D PRINTING: THE FUTURE OF MEDICINE AT THE FOREFRONT: ROBOTIC CARDIAC SURGERY

32 34

EVENTS: PAST AND PRESENT ACUTE FLACCID MYELITIS ALTERNATIVE MEDICINE GLOWING GIRLS

38 41 44

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YOUR MEDICAL SCHOOL ADMISSIONS TIMELINE As a traditional medical school applicant, you will prepare for and apply to medical school during college and enter a program directly upon graduation. In addition to your science-heavy course load, graduation requirements, and extracurriculars, you now must juggle (1) preparing for and taking the MCAT and (2) applying to medical schools.

We know it feels like you have a lot on your plate. Follow this schedule to stay on track with your pre-med requirements, MCAT prep, and completing your med school applications. (We’ve got tips for non-traditional applicants, too!).

FIRST YEAR academics

• • • • •

One year of general chemistry One year of calculus One year of biology One semester of English Introductory major requirements (optional)

extracurriculars

• •

Explore all the various specialties of medical practice Begin a healthcare-related volunteer program, job, or internship Research academic societies, pre-med clubs, and other student organizations and consider joining one

•

applications

• • •

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Visit your school's premed advisor, review course requirements, and create a pre-medical game plan Continue investigating medicine. Is it right for you? What are your personal and academic goals?

Build relationships with professors who can later serve as mentors, offer you the opportunity to participate in research, or write recommendations on your behalf

EDUCATION

Want to get an edge over the crowd?

Our admissions experts know what it takes it get into med school. Get the customized strategy and guidance you need to help achieve your goals. Visit PrincetonReview.com to learn more!

Keep in mind that the courses below represent only the minimum requirements for admission to most medical school programs. You can use this timeline as a general guide, but always double-check admission requirements for the schools you are considering.

SECOND YEAR academics

• • •

One year of organic chemistry One semester of psychology or sociology Other introductory major requirements

extracurriculars

•

Did you have a positive first year experience? If so, continue with the same extracurricular activity.

If you didn't enjoy it or were not sufficiently challenged, begin a new one immediately.

•

applications

• •

Toward the end of the year, begin researching medical schoolprograms.

Continue seeking relationships with professors and begin a list of those who might write your recommendations

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THIRD YEAR, 1st HALF • • •

One year of physics One year of biochemistry Begin upper division major coursework

applications

• •

Continue doing research to find schools that are a good fit Identify and contact potential recommenders. It's a great idea to write a brief profile or bio about yourself to help your recommenders write the best letter possible

mcat

•

Start thinking MCAT. This high-stakes exam requires knowledge of biology, inorganic chemistry, organic chemistry, and physics. You must really prepare to do well. To gauge your performance, take a free MCAT practice test.

Register for the MCAT at aamc.org. (The basic fee is $300, with additional charges for re-scheduling and other services.)

Make arrangements for your MCAT prep.

academics

• •

NOTE: Timing is an important factor with the MCAT. The field of applicants grows more crowded as the admissions season advances. Therefore, the earlier you sit for the MCAT, the better off you'll be. Even if you complete the remainder of your application early, the vast majority of medical schools will not closely consider your candidacy until they have a copy of your MCAT scores.

THIRD YEAR, 2nd HALF academics

•

Continue upper division major coursework

application prep

• •

Begin drafting your personal statement in early spring Request applications from non-AMCAS medical schools in April Collects letters of recommendation to send in September of your senior year

•

mcat

• •

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Take the MCAT no later than mid-May to receive your scores in June If you are dissatisfied with your score, register for the next exam (while there is still time) and create a plan to get the score you need.

EDUCATION

SUMMER BEFORE FOURTH YEAR applications

• •

•

Finalize the list of schools you will apply to and complete the AMCAS application.

You may start the primary application process as early as April and, ideally, you should complete it by June/July. Regular deadlines stretch between now and December. (If you apply through the Early Decision Program (EDP), the deadline is August 1). If you want to be considered seriously, you’ll want to submit all materials no later than September.

Research financial aid options.

•

Pre-meds who did not take the MCAT earlier or want to retake the exam should take the MCAT as early in the summer as possible

academics

• • •

Finish remaining premed requirements.

Finish remaining major/university requirements.

Take upper-division or graduate-level courses in medically related subjects such as physiology, histology, pharmacology, and anatomy, if you have time. This will allow you some breathing room during the first two years of medical school.

applications

•

Do more comprehensive research about the medical schools to which you applied.

If a med school likes your candidacy, they will send you their own secondary application. You'll have some essays to write.

Give yourself enough time to revise and to allow someone else (a good writer) to read them.

Send thank you notes to your recommenders—it's the perfect way to gently remind them to get on this if they haven't yet.

Submit the FAFSA. Prepare for interviews, which typically take place in the fall, winter, and, at some schools, early spring.

Interview and wait for decision letters!

mcat

FOURTH YEAR

•

• • • •

Acceptances (and rejections) start arriving during the winter and spring of your senior year.

If you don't get in, reconsider your career options or prepare to apply again next year.

SUMMER: Relax (for now). Classes begin in August. Congratulations, future doctor!

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MCAT CARS:

TIPS FOR ANSWERING INFERENCE QUESTIONS Inference questions make up to 16% of the CARS section, which is about one question every eight or nine questions. Some key words to identify an inference question are imply, guess, assume, or infer.

Some inference questions are passage-wide (related to the central thesis of the whole passage), and some are idea-focused (only referring to one idea in the passage).

Some passage-wide examples include: • How can we assume the author feels about ____?

• Which of the following underlying assumptions is implied by the passage?

Idea-focused inference questions can look like this: • What can we infer about ______ given the information in the passage?

• What does the author imply about ___?

• The author implies what by saying _____?

• The author says ______. We can infer that he/she chose this fact in order to: Inference questions can be tricky because you are being asked to use the text to make an assumption, but you have to be careful not to assume outside of the passage information. To successfully answer an inference question, you’ll need to avoid bringing in outside knowledge or drawing conclusions that are not found in the text. Inference questions can also be very time-consuming relative to other questions if you don’t know what you’re looking for or don’t rule out answers quickly.

With these three tips, you’ll be able to find the author’s argument and easily rule out answers that don’t fit with the central thesis. And, as with all other question types: If inference questions are your weakness, remember to mark them to review later, and to read the answer explanations after the test.

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EDUCATION

1.

First, determine the author’s central thesis.

Break down the passage paragraph by paragraph, looking for the main theme of each. Generally, the introductory paragraph will be used to define terms and introduce ideas, while the author’s main argument can usually (but not always) be found in the last paragraph. Once you’ve determined the central thesis of the passage, any answers that don’t agree with the central thesis can be easily ruled out.

2.

Next, look at how the author connects other quotes and viewpoints with the main theme of the passage.

The author will almost always provide other sources, experts, or schools of thought. The author used these for a reason, and it’s up to you to determine whether it is to: 1) refute the point, 2) use the point to support his/her argument, or 3) consider the point (partly agree, partly disagree). Look at the vocabulary used and note the tone. Mocking, disdainful, praising, admiring, or otherwise non-neutral language are giveaways as to how to author feels about the information.

3.

Now, rule out answers that don’t work. Generally, a wrong answer for an inference question falls into one of two categories: •

•

Faulty wording. Incorrect CARS questions can often be wrong because of a single word. If an answer or an element of an answer mentions a specific word, phrase, or idea, go back to its paragraph in the passage and check to make sure the answer is consistent with what was being expressed in the passage. When you choose your answer, make sure there isn’t even one errant word that doesn’t agree with the author’s central thesis.

Unevidenced assumptions. Remember, don’t stray far from the text. Often, wrong answers will make assumptions about themes tangentially related to ideas in the text, but with no support.

Unevidenced broad generalizations or “extreme” answers can also usually be ruled out in favor of a more specific answer that has evidence in the passage. Rule out answers based on hypothetical scenarios that the passage does not address.

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Kaplan MCAT PRACTICE PROBLEMS QUESTION 1 The vestibular system of the inner ear is responsible for maintaining a sense of balance. Rapid acceleration can be disruptive. Two children sit on a rotating merry-goround of radius r. If the first child is twice as far from the center of the merry-go-round as the second child, which of the following is necessarily true if the merry-go-round rotates at a constant frequency?

A. The first child has a linear velocity that is twice that of the second child.

B. The second child has a linear velocity that is twice that of the first child.

C. Both children move at the same linear velocity.

D. Both children move at the same angular velocity of 2π.

QUESTION 2 Aerobic respiration ends at the electron transport chain, where protein complexes are reduced and oxidized in turn as electrons make their way to join O2 to form H2O. Consider the following equation: 6 Na (s) + 2 NH3 (aq) ——> 2 Na3N (s) + 3 H2 (g) Which species acts as an oxidizing agent?

A. Na B. N in NH3 C. H in NH3 D. H2

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To get started go to: https://www.kaptest.com/mcat/mcat-practice/free-mcat-practice-question-a-day • A new MCAT-style question each day to test your knowledge and skills • Complete explanations and expert strategies with every question • Compete against your friends to see who’s really ready for test day Find out with this fun and FREE way to tackle practice MCAT questions from Kaplan Test Prep. Register to receive one sample question a day for the next three months. You’ll get:

THINK YOU’RE READY FOR TEST DAY? ANSWER 1 A. As they rotate, the children's frequency is equal to the number of rotations per second. Therefore, if two children are on a merry-go-round, they have the same frequency, and they both complete 1 rotation (a full circle) in the same amount of time.

However, linear velocity is measured in meters per second. As the merry-go-round rotates, the first child sweeps out a circle that has twice the radius of the circle that the second child sweeps out. Therefore, the circumference (and hence the distance) that the first child travels is twice as large as that for the second child: since the time to travel one circle is the same for both children, the linear velocity of the first child is twice that of the second. In other words, v = 2πrf. The correct answer is (A). Both children do move at the same angular velocity, but we can't calculate that angular velocity without information about time, as angular velocity is measured in radians per second.

ANSWER 2 C. The oxidizing agent is the species that is reduced in any given equation. In this problem, six hydrogen atoms with +1 oxidation states in NH3 are reduced to three neutral H2 molecules.

EDUCATION

THE MILITARY,SARS, AND 30 SCREAMING CHILDREN WHY AND HOW WE NEED TO INVEST IN PUBLIC HEALTH EDUCATION By

SARAH NAKASONE SWATHI BALAJI (Editor)

“Anna says you were lying this morning.”

Grace’s accusation gets merely a blink from me. At barely five foot and clad in the XL paper lab coat that I pulled out of the storage room this morning, she hardly cuts an imposing figure. I’ve reached the point in my teaching career that accusations about my character rank so far down on the list of things that keep me awake at night that I can dignify her anger with a humming noise.

No one is mishandling 6 molar HCL, and no one is about to flood the lab. We’re fine.

Grace, of course, does not have the same perspective and my non-answer barely registers as she barrels right into the rant she has apparently been building ever since Anna told her whatever

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Anna told her this morning.

“Anna-says-that-you-were-lying-and-that-actually-everythingis-fine-and-that-couldn’t-be-truebecause-you-TOLD-me-that-allthat-stuff-was-happening-butAnna-seems-SO-sure-and-I-justdon’t-” We used up all the Advil last week when we had the 5th graders in the lab, so I interrupt before she can get any shriller. Of all the things I don’t expect to have to explain to high school science students, the fact I have to clarify this makes me a little disheartened for the state of STEM in our nation.

“Grace. The activity this morning? That was make believe. I’m not actually from the CDC and you certainly aren’t dying this week from SARS.”

EDUCATION

The Gains in the Education of Math and Science (GEMS) program represents one of these experiences you stumble across in your life that you simultaneously can’t believe was real and couldn’t have been more impactful. Organized by the Army Educational Outreach Program and funded by the US Department of Defense, GEMS has two related goals: 1) Ensure that students from low-income neighborhoods and schools with underfunded science programs have access to a summer experience that can spark an excitement for a future in STEM careers, and 2) Offer them college-aged mentors (called near-peer mentors) who exemplify how

minorities and first-generation college students can succeed after high school.

What this means in practice is each week during the summer, certain Army laboratories open their doors to a new group of 30 to 40 middle or high school students and 10 frazzled undergraduate students who have been tasked with the care, keeping, and edification of the next generation of brilliance. For three summers, I watched the Walter Reed Army Institute of Research (WRAIR), the seat of the world’s developments on malaria, Ebola (and at one point, HIV) vaccines, switch from military readiness operations to experiments on glowing slime, worm dissections, and something that vaguely passed for engineering but really seemed more of

a chance to clear out the extra supplies in the storage closet.

Despite my exasperation from the constantly rotating cast of gremlins with sticky fingers and lost lab coats, undergraduates like myself who worked at GEMS were more than glorified babysitters – we drove the curriculum, wrote the lesson plans, cobbled together supplies from the mosquito hatchery and Wal-Mart, and operated under a semi-autonomy that seemed like benign neglect but really represented an understanding of how to leverage a sense of ownership and pride. It was our lab for the summer, and we earned or lost the smiles and approval of the kids. These rewards, our sense of deservedness of them because everything in this lab was under our control, were strong enough

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to keep us motivated no matter what we encountered. So every June, before the DC schools let out for the summer, the other interns and I scrambled to come up with lessons we thought would be engaging and could be described in the shortest write-up imaginable.

That final year at GEMS led to my greatest work to date: a SARS outbreak.

– ·•· – A quick aside that I have learned to include, post-Grace’s comments, post-meetings with military supervisors: I do not possess and have never possessed any pathogens or strains of bacteria, viruses, or fungi that could pose a risk to national interests, student health, or my personal safety. I do not have SARS samples, inside knowledge about the SARS outbreak in 2004, or promotions about the next one that may occur.

I certainly do not have the power to orchestrate outbreaks.

I do have, however, a healthy concern about the state of public health education in the United States. In an age where local Ebola outbreaks become global catastrophes, Zika becomes front-page news, and a host of anti-vaxxers

spark childhood diseases we had imagined extinct, the case for a strong public health workforce writes itself into the media and public panic. But in reality, the field of public health is vastly under-staffed with few education-to-career pipelines to boost employment. The latest data on public health staffing vs. need estimated that the field currently lacks at least a quarter of a million people, though the analysis acknowledged that the numbers in the next decade were likely to become even more dire as the workforce generally was highly biased toward individuals nearing or past the age of retirement (1). Other research shows little focus on public health education before the university level with the existing curriculum lengthy and “hands-off,” lacking the lab work and interactiveness to engage children (2)(3).

Our way of solving these problems in GEMS? A 90-minute, immersive simulation in which we told our students that five deaths in DC-area hospitals had created concern at the CDC that the city could be ground zero for a new outbreak. Students then had 90 minutes to gather clues to “solve” the problem by identifying the specific pathogen which had killed the patients. Throughout the lab, stations staffed by other interns

in the program provided not just hints about the infection spreading throughout DC but potential careers in public health.

Students sorted through patient records and personal effects (receipts, emails, notes) to figure out who could possibly be “patient 0” (the first case of a disease) and how it had spread through the area. Students also centrifuged fake blood to conduct a mock complete blood count to determine if the disease could be attributed to a virus or bacterium, and modeled antibody-antigen tests to confirm that all patients had died of the same pathogen.

The end of the simulation featured a mad, 60-second dash to sort through disease information to identify the most likely culprit.

– ·•· – There’s a certain attraction to being the person that gets to run in the room declaring an outbreak scenario, sprinting down the hall to drag the head of the infectious disease residency program into the lab to talk to *your* kiddos, dashing around in a general level of excitement to make sure that none of the fake blood will end up painted by one child onto another’s lab coat.

But as weird and wonderful as the general pandemonium

I do not have the power to orchestrate SARS outbreaks; I do have, however, a healthy concern about the state of public health education in the United States.

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EDUCATION

was, something about the lesson got through to the kids. As part of my residence at GEMS, I was researching non-traditional forms of education to see what could be adapted effectively into the academic year (which sounds much more impressive than saying I was the survey monkey).

The comments we received from students on their post-simulation surveys were an unparalleled thrill to anything else that summer.

“I learned about different careers in public health and what they do. I felt like I'm the person who actually works at the field (professional)” “I enjoyed that we got to look at a real case and really get to know the patients and how they contracted the disease, made me feel like a real doctor… but one who didn't let the patients die because that part was sad.”

“I really liked the lesson because I thought it was real, especially the blood and the patient files. It was like being a detective or spy to solve a mystery or puzzle” The student at GEMS are the ones we write off when it comes to science careers. They are more likely to come back to our program than they are to graduate from high school, and their

ingrained belief that they are “not good enough” because of parents, teachers, peer trajectories, and other influences that weave their way through the program are a constant hum of melancholy against the science experiments.

But the logic the students were able to deploy throughout the simulation and the curiosity they exhibited throughout their week in the program is evidence that the gaps we have in the science pipeline – whether in computer science or public health – are gaps of our own making, not a dearth of students who hunger to excel in these areas. The US is no closer to resolving that gap than we were when I left GEMS three years ago, primarily because we refuse to invest in programs that do not see children as burdens.

There’s little room for optimism in public health – we couch successes in failures and deaths, and embrace the idea that if we are too happy about our achievements, we will see them unravel.

And I understand that pragmatism. But I also know that once upon a time there was a lab where I got to be a part of students embracing the excitement and possibility of public health with extended arms, and to me, that seems like more of the way we will solve problems than anything else I have seen.

Rosenstock, L. & Helsing, K. & Rimer, B.K. (2011).

Public Health Education in the United States: Then and Now. Public Health Reviews, 33.

Kaelin, M. A., Huebner, W. W., Nicolich, M. J., & Kimbrough, M. L. (2007). Field Test of an Epidemiology Curriculum for Middle School Students. American Journal of Health Education/American Alliance for Health, Physical Education, Recreation, and Dance, 38(1), 16–31.

McClamroch, K. J., & Montgomery, J. P. (2009).

Epidemiology for High School Students: Improving the Public Health Pipeline. Public Health Reports, 124(6), 898–904.

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A GRIM DIAGNOSIS

The current state of healthcare in the United States

By

SCOTT WU ABHIJIT RAMAPRASAD (Editor)

The United States health care system is at a tipping point – it’s that simple. What is not so simple are the problems threatening to push our system – and both patients and providers along with it – over the edge.

Despite numerous groundbreaking innovations in medical technology and research in recent years, health care in America has evolved into a fragmented industry plagued by intimidating problems of access and quality. Millions of Americans – rural and urban, minorities and non-minorities, and Democrats and Republicans, etc. – still lack health insurance.

Even for those fortunate enough to get care through either the private insurance system (paid for by their employer or the individual they are legally dependent upon) or the newly founded public health care

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system funded by taxes (yes, this is Obamacare, also known as the Affordable Care Act), the quality of care remains insufficient. None of the issues facing the American health care system are any one person’s fault; they are, however, everyone’s problem.

Since FDR

In the history of the United States, there have been myriad attempts to create national health care coverage, whether through whispers in the Oval Office or through national campaigns. For over one hundred years, presidential administrations have struggled to balance the demands of public interest and private influence; a system that included health care, which is available to all but not necessarily run by the government, was thus produced out of such struggle.

Meeting the needs of both the general public – not just working adults but also the young, old, and unemployed – and conflicting private interests has not been successful. Medicare and Medicaid, which, generally support the elderly and impoverished, respectively, are hailed as some of the only successful government-sponsored health care programs to ever be enacted with bipartisan support. However, they still only meet the needs of a small subset of the population. While the Patient Protection and Affordable Care Act – also mentioned under the names Affordable Care Act and Obamacare – passed in 2010

POLICY

to cover the entire nation, Americans’ accessibility to quality health care remains a struggle. But why, with these seemingly grand developments, is American health care not booming?

aspect of the health care process, the ability of everyone, from employees of large hospitals to the patients themselves, to access and understand that data is lacking. According to Nazier, hospital executives and their patients alike have a hard time accessing and using data to make decisions. Meanwhile, smaller hospitals and health systems lack the sophistication, personnel, and support necessary to perform data analytics at the level of larger hospitals (comparative analytics for various therapeutic approaches, patient health outcomes, etc.) and therefore need access to data simply to increase efficiencies, cut costs, and improve the inpatient experience. Speaking of costs – well, you might want to take a seat for this next part.

Provider burnout, data inaccessibility, and the ever-present issues of legislative stagnation and cost continue to threaten the health care system. Provider emotional burnout is quietly becoming a national epidemic; studies done by Health Care Strategic Alignment Director Tina Nazier, MBA, show that 54% of physicians exhibit one or more symptoms of considerable burnout in their careers – depersonalization and low personal satisfaction seem to be significant factors. While data is captured on every

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Despite its developed status and relatively solid emphasis on health care spending, the United States remains an incredibly low-performing country in terms of return on such investment. Simply put, given the backdrop of other developed countries, the US spends more with an insufficient return on investment. According to a report from The Commonwealth Fund, eleven high-income countries share a challenge of rising health care costs as a measure of the percentage of GDP. Shockingly – or not so shockingly if you have kept up with health care reports over the past decade – the US stands alone as the leader in spending. To make matters worse for future legislators, costs have only been somewhat managed in recent years due to low inflation because of the recession. That effect of contained costs, however, in combination with fluctuations in administrative Medicaid payments over the years, is likely to wear off soon (Canada seems alone in any curbing of inflation on a sustainable scale) and the US could thereafter see soaring costs, extending its negative lead in the health care investment return game.

The Present is a Gift, and So Are Tax Cuts

In 2018, the health care issue will continue to plague the US and its current presidential administration.

By means of the tax reform act – the Tax Cuts and Jobs Act passed by Congress and signed into law by President Trump shortly before Christmas 2017 – the individual mandate penalty required by Obamacare will expire in 2019. The mandate requires Americans to buy their own health insurance or face a penalty if

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they are not already covered by their employer or by a government program such as Medicaid or Medicare.

The new tax law eliminates the penalty beginning in 2019, allowing Americans to remain uninsured without check. President Trump – without Congressional input of any kind – can also cut the subsidies which have partially been keeping Obamacare in play.

Specifically, he can also cut the marketing and Public Announcement campaigns for signing up citizens for the program, causing a decrease in enrollments and further threatening Obamacare repeal. Beyond the individual mandate and financial cuts to Obamacare, several other items are also being considered; with the recent success of the Tax Cuts and Jobs Act under their belt, Republicans in Congress are also looking to take aim at “reforming” Medicare and Medicaid.

Given the recent outcome of the 2018 midterm elections, however, such attempts will likely be met with strong rebuke.

It’s Not All Bad

Despite the problems stated above, population health remains a top priority for the health care industry.

Large hospitals and health systems believe it is their responsibility to pioneer advancements in patient outcomes, and they are delivering with the integration of new medical technology and innovative therapies into their health care models. Small to mid-size health systems are focusing on this as well, despite the added pressure of remaining viable in the current market. Of the many post-Obama administration forces currently transforming the American health care system, none is more significant than the turn from payment based on volume, to payment based on value. Value is driving a fundamental reorientation of the health care system around the quality and cost-effectiveness of care. As in any industry, value in health care is defined through the relationship of two factors: care quality and patient costs. In addition to the new value-based payment system, lab and clinical research – which continues to be the bedrock on which the health care industry as we know it is built – is thriving. Cutting-edge work not only promises to treat notoriously prevalent diseases including cancer, diabetes, and heart disease (three of the deadliest diseases afflicting American patients in the modern

POLICY

era), but also lesser-known diseases including Hepatitis B, various STDs, and various genetic disorders.

Predominantly led by researchers throughout American universities, the work being done to innovate the health care industry at its clinical research foundation is extremely promising.

Looking Ahead

While it is true that the current state of the United States’ health care system is unsettling, our current status must not tarnish our perspective of the future.

Looking toward 2019 and beyond, Wharton’s Mark Pauly and Drexel’s Robert Field call on Americans to watch for seven key trends in American health care. They include the topics of life after the individual mandate, changes in Medicare and Medicaid, addressing the opioid crisis, prescription drug prices, CHIP (Children’s Health Insurance Program) funding, the dynamic of health and human services, and health care as a jobs-creator. Hopefully, with the information provided in this article, you – and those who legislate as well – can help to better address these issues and, with a bit of luck, keep the American health care system from falling over the edge.

Business Radio, and Health Economics. “Seven Key Issues Facing U.S. Health Care in 2018.” Knowledge@Wharton. Accessed November 17, 2018. http:// knowledge.wharton.upenn.edu/article/the-future-of-the-aca/ “Current State of the US Healthcare System | What Lies Ahead 2018 & Beyond?” Dr. Hempel Digital Health Network. February 07, 2018.

Accessed November 17, 2018. https://www.dr-hempel-network.com/ health-policies-in-india/current-state-of-us-healthcare-system/ “New Survey: Doctors Share State of Healthcare in 2018.” Physician's Weekly.

Accessed November 17, 2018. https://www.physiciansweekly.com/ new-survey-doctors-share-state-of-healthcare-in-2018 “The U.S. Health Care System: An International Perspective.” DPEAFLCIO. Accessed November 17, 2018. https://dpeaflcio.org/programs-publications/ issue-fact-sheets/the-u-s-health-care-system-an-international-perspective/

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THE QUESTION OF DYING By

CHARLES ZHANG BUSHRA AKBAR (Editor)

Introduction

Christine Fong was a mother of three, a diligent and a hardworking individual who immigrated from China as an adult to raise a family of her own. But she was also a woman with late stage bone cancer a fact that became more and more apparent as her fragile years drew on. Pain became not an occasional discomfort, but a persistent reminder of her mortality as her vertebrae vaporized beyond recognition. Although Christine’s cancer entered remission, she reflected on how the treatment drained her physically and destroyed her mental state. Never again, she would say vehemently after each chemotherapy session. So when her blight inevitably rose again, she chose to embrace that which she had run away from for so long.

On a warm afternoon in fall of 2017, Christine’s legally-planned departure succeeded as she drank the concoction that snuffed life out of her frail body – with a content smile on her lips, as her daughter Elaine had remarked.

Christine’s story is one of the many that illuminate a historical taboo in medical science. Avoided, rightfully, because it blurs the

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lines of morality and undermines hundreds of years of Hippocratic advance. And yet in a society where medicine is evolving at an all-time high, the option to abandon treatment and end it all has gained significant traction.

Assisted death, termed “medical aid in dying” by proponents and “assisted suicide” by denouncers, is perhaps one of the most controversial practices in the medical field.

It is outlawed in the majority of the states, neutrally authorized in five, and at least by virtue of polls, supported by most practicing physicians. Pro-choice organization such as Death with Dignity and Compassion and Dying have surfaced to challenge America’s perception of how, when, and why someone should die, with equal opposition to boot. So how did the conversation turn from one of preserving life to bestowing death?

The Sin of Medicine

Doctors have always believed that they can save their patients.

As an aspiring medical student, even I live with the hope that with the right treatment and research, my mother, friends, and future patients can live without ailment.

The mistake is believing we can overcome death. Since the foundation of Hippocratic ideals in ancient Greek times, medicine has been thought of as an objective science. Objectivity lends to certainty after all, and when dealing with precarious life-and-death situations, we want to be sure that treatments will cure disease.

But where scientific medicine has ushered in reliability and rapid evolution in health care, it has also brought hubris and pride. If vaccines kill measles and antiviruses defeat Ebola, then perhaps we can cure anything at any given time. The belief that preserving life is a practitioner’s chief priority has sentenced many incurable patients to prolonged agony as they instill treatment after treatment to no avail.

It’s ironic to think that the public health crisis of excessive suffering before death is a result of our attempts to save our patients, but this contrast may serve to better understand why medical aid in dying has risen in prevalence. In two recent studies at the University of California at Los Angeles (UCLA), researchers amassed statistics that suggested terminal

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patients were not receiving appropriate care for their conditions.

The first study found that only 23% of patients deemed incurably sick were admitted to hospice care, a form of medical treatment that focuses on providing comfort and mental wellness to those with life-limiting prognoses. The second study found that excessive radiation treatments were systematically prescribed to patients with bone tumors. More specifically, of 54 patients prescribed a single treatment under the center’s clinical guidelines, only one received the recommended dose. Of the other overdosages, 42 patients received 10 or more treatments.

Another similar study examined Medicare beneficiaries with and without hospice care, and found that those receiving hospice care had significantly lower rates of hospitalization, invasive operations, and medical costs in the last years of their life. And yet the Medicare requirement for hospice benefits is a prognosis of six months or less, which severely limits access for many patients.

The case of UCLA, one of the forerunning university medical centers in the country, is an exam-

ple of the overtreatment culture of American hospitals. Doctors and patients, particularly those in palliative relationships, inevitably engage in an unbalanced relationship of doctors prescribing treatments as the patients sit quiet and accept their expertise. It is unsurprising to see, then, that many doctors routinely overtreat patients as their symptoms worsen without any better results.

However, due to the difficulty in securing hospice care, many patients have no option but to continue ineffectual treatment, creating a toxic cycle of pain and agony that lasts until death.

The advent of assisted death, while controversial, has served as an answer to this crisis. In the states of California, Montana, Oregon, Vermont, and Washington, patients with less than six months to live are allowed, pending physician referral, to receive a lethal prescription. Since the implementation of Oregon’s Death with Dignity Act in 1997, the first statute to legalize assisted death, nearly 2000 Oregonians have received prescriptions to end their suffering. As of 2016, the annual Medscape Ethics Report

poll has shown that 57% of physicians believe medical aid in dying should be an option for terminal patients. The legal push has been so great that while explicitly legal in five states, nine state divisions of the American Medical Association (including the District of Columbia) have shifted their stance from opposition to neutral.

With the Massachusetts Medical Society recently adopting a policy of neutral engagement, there is little reason to believe the political effort will slow anytime soon. But is this the right trajectory?

Doctor’s Duty

The patient-biased perspective is a commonly-held view. At its roots, the doctor exists for the people, serving as a public guardian angel of sorts when the evil of illness plagues our bodies. With the landscape of medicine evolving towards a greater focus on public health and patient benefits, our perception of the doctor has accordingly shifted from that of a miracle worker to a compliant servant. Perhaps this is the reason why the larger public is so comfortable supporting euthanasia – when the focus is what we as

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The belief that preserving life is a practitioner’s chief priority has sentenced many incurable patients to prolonged agony as they instill treatment after treatment to no avail.

patients want, it’s not hard to see why we enjoy the power of choice.

Supporters of assisted suicide will inescapably relate anecdotes of loved ones’ suffering, cases told from an agonized patient’s view that would be solved with swift toxin. It’s understandable that we are angered by the mistreatment of our patients and are seeking a solution to unnecessary anguish.

However, in offering death to the terminally ill, assisted suicide could also destroy an essential aspect of what it means to be a doctor.

We trust doctors with the duty of preserving our livelihood, but where duty lies, there also exists identity and autonomy. Many individuals within the medical field believe that to be a physician is not only to serve the people, but also to be an innovator, problem solver, and comforter. When historically resilient diseases were thought to be incurable, doctors would not recount resignation, but rather vehement research in a forward push against adversity.

And when patients lie hopeless and dejected in hospitalization, it was the doctor’s responsibility to reassure them that hope is not lost, that there is always

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another way. However, legalizing assisted suicide undermines this fundamental savior spirit of the physician. Instead of owning up to our shortcomings and standing up stronger, we allow assisted death as an acceptance of defeat, a letter of resignation that we are no longer able nor willing to pursue further options for treating a patient.

Indeed, the mandate of the Hippocratic oath that a doctor must never harm a patient is an ode to the doctor’s conviction in preserving life whenever possible. In this way, by establishing medical aid in dying as a norm in society, the doctor’s identity could very well be nullified.

The implications of assisted suicide are often as blurry as its ethicality. There inevitably arise moral dilemmas that are difficult to address. What if a terminal patient is in the wrong state of mind or mentally insane, yet requests a lethal injection? What if an incommunicable patient’s decisions are determined by a caretaker? The social implications of assisted suicide can be equally difficult to assess. In a culture where suicide is becoming more prevalent, what impact can the legalization of assisted death have

on how we view suicide and selfharm? Though we may speculate on how we might address these concerns, the answers to these types of questions are often empirical, in that we have to witness them in real situations to make a judgement. As of now, we have yet to see any negative social or economic effects from assisted suicide in states where it is legal, and this trend of legalizing assisted suicide has shown no signs of stopping. Perhaps only time will tell if we have made the right decision.

Byock, Ira. “Physician-assisted Suicide won’t atone for medicine’s ‘original sin’.” STAT. January 30, 2018. Accessed November 17, 2018. https:// www.statnews.com/2018/01/31/physicianassisted-suicide-medicine/ “Historical Timeline – Euthanasia – ProCon. org.” Should Euthanasia or Physician-assisted Suicide Be Legal? Accessed November 17, 2018. https://euthanasia.procon.org/view. timeline.php?timelineID=000022 Kligler, Roger. “I’m a doctor with end-stage cancer. I support medical aid in dying.” STAT. February 06, 2018. Accessed November 17, 2018. https://www.statnews.com/2018/01/31/ medical-aid-in-dying-doctor/ Obermeyer, Ziad, Maggie Makar, Samer Abujaber, Francesca Dominici, Susan Block, and David M. Cutler. “Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor-Prognosis Cancer.” JAMA 312, no. 18 (2014): 1888. doi:10.1001/jama.2014.14950.

Physician-Assisted Suicide Fast Facts.” CNN. August 13, 2018. Accessed November 17, 2018. https://www.cnn.com/2014/11/26/us/ physician-assisted-suicide-fast-facts/index. html

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THE GROWING DIVIDE

THE CONSEQUENCES OF FEWER RURAL PHYSICIANS

By

HELEN KESSLER ABHIJIT RAMAPRASAD (Editor)

As the population in the United States continues to increase and grow older, more physicians are needed to keep the population healthy. Currently, there are almost 7,000 areas around the country with an inadequate number of primary-care providers, and with the current pace of population growth, the country could be short 95,000 doctors within the next decade. However, the lack of physicians is unevenly distributed across the country, impacting rural America the most. America is becoming more industrialized, but 97% of its land is still considered rural, and although 19.3% of the population live in rural areas, only 9% of physicians do. Nearly

half of rural populations do not have adequate access to medical services.

There are several trends driving these statistics, one of which is the flow of physicians from rural to urban areas. The physicians leaving rural practice are usually relatively young (aged 45 or younger) and predominantly female. Other populations contributing to the exodus of rural physicians include international medical graduates, those not born in rural settings, and those working in a community far from metropolitan areas. There are numerous additional challenges encountered by physicians working in rural areas, including lower reimbursements for services,

clinician lifestyle considerations, spousal career needs, and school quality. It was once believed that the lower socioeconomic status of rural areas was a direct cause for the drain of physicians, as rural populations tend to be poorer, older, and sicker than their metropolitan or suburban counterparts.

This, however, was not supported by a study completed by the American Academy of Family Physicians, which has shown that economic demographics of served populations does not affect physicians’ decisions to leave rural areas. Two major reasons for leaving, as quoted by physicians, included lack of a nearby hospital and low population. Interestingly, the decision by one physician to leave also caused nearby healthcare workers to also consider leaving, causing an exponential drain in access to health care. The ability to retain rural physicians in remote communities that lack hospitals remains one of the biggest obstacles to expanding access to care.

There is a promising statistic for rural communities: 68% of physicians stay in the place they complete their residency. Despite the draining of doctors from rural areas, it is advantageous to entice

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young physicians and residents to spend their early years away from metropolitan and suburban areas. Unfortunately, specialties ultimately affect location, and only family practitioners are as likely to settle in rural areas as urban areas; all other specialties are more likely to settle in urban areas. There are additionally fewer and fewer general practitioners in the US as the medical field continues to grow more specialized, further driving doctors towards urban areas.

In order to attract the dwindling supply of general and family practitioners, rural communities must find innovative ways to appear more enticing. This is something that both federal and state governments have recognized, and numerous programs have been established to accomplish this goal.

The most popular of these include loan forgiveness or repayment programs, which are especially appealing for recent graduates; in exchange for working in a rural community for a set number of

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years, physicians will either receive direct payment for medical school loans or have those loans forgiven.

Some states, such as Arkansas, Minnesota, Montana, and Utah, have already implemented such programs. The federal government has several similar programs, some of which target specific groups, like the Indian Health Service Loan Repayment Program, which brings physicians to Native American communities.

Loan forgiveness programs are not the only options available for rural communities. Other initiatives such as J-1 visa waivers for international medical graduates have also been implemented to attract new physicians. In 2014, Missouri passed a law that allowed assistant physicians – medical school graduates who have not yet been placed in residency programs – to practice medicine in underserved areas under the supervision of a fully-licensed doctor. Although this does not count as a residency position,

assistant physicians can work there indefinitely if they choose.

However, as this program is still relatively new, other states are holding off on implementing a similar plan until long-term effects can be determined.

Due to the shortage of rural doctors, many communities have turned towards telemedicine, which does not require a physician to physically be with the patient. By offering access to physicians via video calls and emails, access to medical information, and remote diagnosis, telemedicine increases use of medical care in rural communities. Due to the delocalized nature of telemedicine, current issues for physicians include difficulties navigating multiple databases and staying informed of technological advances; both of these lead towards confusion and a lack of clear criteria when treating the patient. However helpful, telemedicine focuses on treating the symptoms caused by lack of

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physicians but fails to solve the underlying problems.

Despite the effort that rural communities have put into attracting physicians, it may not be enough to solve the lack of rural physicians. The central issues of dwindling rural hospitals and lack of funding hinder the efforts of communities to retain the doctors they desperately need. In order to combat structural barriers like fewer hospitals and poorer populations, rural areas will continue to need special programs to assist in the support of physicians; however, local, state, and federal governments will also need to support policies that increase access to service in these areas and reverse the flow of physicians leaving. One such example is the Affordable Care Act, which drove many uninsured individuals to receive health insurance. Before this policy took effect, hospitals would treat uninsured patients, but they would not be paid, which was incredibly detrimental to rural hospitals servicing largely uninsured populations. By increasing the percentage of insured patients, the ACA was able to decrease the rate of rural hospital closures.

Failure to support these policies has immediate and lasting consequences. In states that did not accept the expansion of Medicaid under the Affordable Care Act, 47% of rural hospitals lost money in 2015, compared to 35% of rural hospitals in states that did accept the expansion. To prevent the outflow of rural physicians, governments must first ensure that rural hospitals are able to operate and provide for patients, which includes increasing coverage of uninsured individuals and funding for rural hospitals. Although rural health does not concern most Americans, approximately a fifth of the population is at risk for limited healthcare access. In a nation divided along rural and urban lines, the problem of rural health cannot be ignored any longer. To combat the impending crisis and restore health access to these disadvantaged Americans, there must be more support for rural physicians and more funding for programs seeking to increase rural access to healthcare.

Kirkham, Elyssa. "Medical School Debt: Repayment Guide for New Doctors." Student Loan Hero. October 31, 2018. Accessed November 16, 2018. https://studentloanhero. com/featured/ultimate-student-loanrepayment-guide-for-doctors/ Mareck, Daniel G. "Federal and State Initiatives to Recruit Physicians to Rural Areas."

AMA Journal of Ethics. May 01, 2011.

Accessed November 16, 2018. https:// journalofethics.ama-assn.org/article/ federal-and-state-initiatives-recruit-physiciansrural-areas/2011-05 Quinn, Mattie. "Rural America Gets Creative to Attract Much-Needed Doctors." Governing Magazine. August 21, 2017. Accessed November 16, 2018. http://www.governing. com/topics/health-human-services/ gov-doctor-shortage-residency-faith-rural.html Rosenblatt, Roger A., and L. Gary Hart. "Physicians and Rural America." National Center for Biotechnology Information. 173, no. 5 (November 2000): 348-51. Accessed November 11, 2018. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC1071163/ "Study Examines Why Primary Care Physicians Leave Rural Areas." AAFP Home. July 12, 2017. Accessed November 16, 2018. https:// www.aafp.org/news/practice-professionalissues/20170712ruralturnover.html US Census Bureau. "New Census Data Show Differences Between Urban and Rural Populations." Census Bureau QuickFacts.

December 30, 2016. Accessed November 16, 2018. https://www.census.gov/newsroom/ press-releases/2016/cb16-210.html Zhang, Xiao-Ying, and Peiying Zhang.

"Telemedicine in Clinical Setting." National Center for Biotechnology Information. 12, no. 4 (October 2016): 2405-407. Accessed November 11, 2018. doi:10.3892/etm.2016.3656.

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CONTINUITY IN THE AIDS EPIDEMIC AN EXPLORATION OF HOW AIDS REMAINS PREVALENT IN TODAY’S SOCIETIES The early days of the AIDS epidemic seem incredibly distant and foreign to our generation today, for both college students and young adults alike. The first report published on AIDS came after the publication of a Morbidity and Mortality Weekly Report (MMWR) description of five cases of Pneumocystis carinii pneumonia (PCP) among homosexual men in Los Angeles. The confusion drawn from what the nature of the illness and what caused it was attributed to how PCP was generally exclusively limited to those with cancer or other forms of severe immunosuppression. As the Center for Disease Control continued to receive reports of PCP among other opportunistic infections and cases of Kaposi’s sarcoma, a Task Force was created to conducted epidemiological investigations.

Meanwhile, the public refused to acknowledge the severity of this pandemic, believing it to only live amongst homosexual men. Those that acknowledged it referred to it as the “gay plague” or “gay cancer,” considering that AIDS is characterized by the appearance

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of blue-grey skin tumors. When news sources discussed AIDS, they would call it Gay-Related Immunodeficiency Disease (GRID). The public would only grow to realize later that cancer could not be “gay” or “straight,” and that these characterizations would limit our ability to properly address this global epidemic.

Since the 1980s, a series of changes have taken place in several topics ranging from attitudes, stigma, treatments, and policies.

Our progress in epidemic response and preemptive treatment has been so astronomical that those born after HIV flooded the nation, or those too young to remember it, can hardly picture a time when these policies and practices were not routine. The progress since then has not only been limited to our fight against HIV, but it has also served as a compass for future pandemics. Although our discussion is limited to the continental US, we still acknowledge the role HIV plays in various countries as it is a global pandemic. The advancements made since have also been adopted into other places, but there is still a long way to go. By

analyzing the changes that have occurred since the beginning of the AIDS pandemic, we seek to convey our perspective about the early days and spin some of those themes forward. The history of the response to HIV poses one overarching question: how did an infectious disease transform into a chronic disease?

Stigma encompasses one of the most complex and greatest barriers to proper healthcare for individuals living with AIDS. The attitudes that were presented in the 1980s, some of which persist today, stalled the procession in understanding the significance of this epidemic. The disproportionate impact of AIDS on homosexual and bisexual men propagated an anti-gay bias in society, which thereby led to counterproductive responses from healthcare agencies, the public, and the government. Such negative responses included the HIV travel and immigration entry ban in 1987 and the discouragement of homosexual activity in many public schools nationwide. A significant component of the fear surrounding this epidemic was

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By

YASSMIN ELBANNA RITA KHOURI (Editor)

largely due to a lack of knowledge and therefore a concern over contagion. Many people believed that HIV and AIDS were always associated with death and caused by behaviors, such as homosexuality and drug use, that were considered to be taboo in several cultures. At the time, it was considered a personal irresponsibility causing many to believe it was not their concern. Although several policy makers question the prevalence of HIV stigma presented today, many polls argue that its presence remains strong.

Approximately 22% of Americans believe that AIDS is not a concern for them or their families, while 70% of teens do not have personal concerns about getting AIDS. While the theory of transmission through casual contact has been debunked, the interference presented by earlier attitudes have delayed a better understanding of HIV and AIDS. Early stigma prevented people from being tested due to a fear of marginalization and a loss of hope. As there was no treatment plan during the 1970s, individuals did not feel compelled to subject

themselves to the societal consequences of their condition. This resulted in a significantly quicker spread of the epidemic as it was not lawfully required for individuals to disclose their status prior to intercourse, and a great number of people did not even know their status.

Continuity in the HIV and AIDS epidemic can be viewed by understanding the history of the epidemic’s treatment. Since the original discovery of the virus, more knowledge has been gained.

What was previously linked to uncommon infections, such as pneumocystis pneumonia and Kaposi’s sarcoma, is now a disease in its own right. As more targeted treatments are developed, doctors and researchers have been able to better treat their patients. Those currently living with the disease take medicine that slow the development of the virus. These drugs, generally referred to as antiretrovirals (ARTs), were first developed in the mid-1990s. This form of treatment presents a stark contrast to the earlier technique that focused on stalling death by simply treating other infections. There are

currently two main types of HIV vaccines being tested: preventative and therapeutic. These vaccines seek to accelerate the immune system in finding the infected cells and killing them, and would also work to limit or entirely stop the virus from making copies of itself when exposed. However, the sustained component in treating HIV is entirely preventing it in the first place. Preventative measures such as pre-exposure prophylaxis (PrEP) is heavily publicized and encouraged for people at high risk for HIV. PrEP reduces the risk of contracting the virus through sex by 90% and through needles by more than 70%. Testing has also been made more accessible to underprivileged communities considering that local clinics have started providing free testing days. Despite challenges presented throughout the epidemic, significant progress has been made and applied to other prevention methods.

Through treatments such as these, disease management has greatly been improved. This progress has been seen in other epidemic crises as well. While a

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treatment plan in areas such as the United States may be effective, they may not produce the same results in locations with less access to resources. Factors such as schooling, access to local clinics, and poverty levels (among other factors) highly influence the response to conditions of HIV and AIDS. They also play a role in determining how to prevent and educate local communities on their HIV status. Questions such as who should be tested are tied to age and risk factors; however, the general recommendation is that all individuals between the ages of 13 and 64 should get tested at least once. All of these components tie together to create a comprehensive treatment plan that has since evolved alongside the policies that support it.

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There are many different policies in action that tint the lens through which HIV and AIDS are currently viewed in society. The Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 both classify HIV and AIDS as disabilities, as opposed to explicitly stating that they are transmittable diseases. This has the effect of allowing the public to be aware of the chronic nature of these diseases. This is the polar opposite of the panic that had arisen due to the unknown origin of the abnormally aggressive, life-threatening, opportunistic infections that characterized he first known cases in the HIV and AIDS outbreak.

Additionally, there are 33 US states that criminalize the intentional or known exposure of HIV

to another individual. Twenty-four of these states require disclosure of HIV positive status to all sexual partners, fourteen of these stages oblige disclosure to needle-sharing partners, and eleven of these states prohibit other behaviors, such as biting, spitting, or throwing bodily fluids by individuals who have HIV. In 28 of these states, all HIV-specific criminal laws are categorized as felonies; in three states, the exposure is not a crime (although it can be an additional factor in another related crime); and in two states, it is simply counted as a misdemeanor, not distinguishing between high or low threat of transmission. In a closer examination of which states are enacting these laws, there is no specific order to which states have HIV criminalizing policies

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based on population density of high-risk individuals. For example, New York does not have any HIV criminalization laws, despite being a hotspot for the original outbreak; Alabama also lacks any HIV-specific policies regardless of the fact that there is a notably high rate of HIV-positive individuals in the southern United States.

After a courageous young man named Ryan White was diagnosed with AIDS following a blood transfusion, he was forced to fight for this right to return to school.

He eventually became the face of public education about his disease.

Ryan White implemented changes in the movement, revealing to the public that this disease was not marginalized to a single race, age, or sexuality. It was through gaining more knowledge that individuals finally began to realize the generality of this issue, which resulted in treatment plans becoming more adept.

It is significant to note that in 1990, the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act required all states to have criminal laws that were adequate to incriminate any HIV-positive individual who knowingly exposed another to HIV. These laws have the potential to alleviate some of the stigma that high-risk populations are all affected by requiring individuals to report their status. However, there are other policies in place that could reinforce these negative assumptions that HIV is particular to a group of people, that group being homosexual males in this case. Previously, the 1992 memorandum, “Revised Recommendations for the Prevention of Human Immunodeficiency Virus

(HIV) Transmission by Blood and Blood Products” recommended an infinite deferral for malesseeking-males (MSM). This has since been repealed and the policy now requires a 12-month deferral from most recent sexual contact for MSM. Additionally, there is a 12-month deferral for the most recent contact for a female who has had sexual contact with a man who has sexual contact in the last 12 months.

Furthermore, in the context of the donor history questionnaire that is required in order to donate blood, male or female gender is self-identified and self-reported. This offers the possibility of transgender and non-binary individuals, who could fall into the high-risk population that blood donation services attempt to monitor more closely, to slip under the radar. Because of this, policies have the power to perpetuate the stigma that has persisted since the first known cases of the outbreak: that HIV is a “gay man’s disease.”

While the rationale of these policies is clear, that MSM are still the highest risk populations, it is easy to extrapolate that those who are less informed could take away an incriminating message. While policies seek to aid and protect at-risk populations and those in need of blood infusions, the manner in which HIV and AIDS were viewed from the beginning is still palpable, despite the many positive steps that have been made.

CDC. (2018, November 01). Who Should Get Tested? Retrieved from https://www.hiv.gov/ hiv-basics/hiv-testing/learn-about-hiv-testing/ who-should-get-tested Centers for Disease Control and Prevention, & National Center. (2018, October 22). Where to Get Tested? Retrieved from https://www. hiv.gov/hiv-basics/hiv-testinglearn-about-hivtesting/where-to-get-tested Gay Men’s Health Crisis, City Policy Agenda 2008, New York: GMHC, 2008.

HIV Stigma and Discrimination. (2018, April 09). Retrieved from https://www.avert.org/ professionals/hiv-social-issues/stigmadiscrimination HIV/AIDS. (2018, November 01). Retrieved from https://www.cdc.gov/hiv/basics/prep.html Who Was Ryan White? (2016, October 01).

Retrieved from https://hab.hrsa.gov/ about-ryan-white-hivaids-program/who-wasryan-white

Acknowledgements. I’d like to acknowledge Isabel Suner for aiding with this paper and providing her extensive knowledge in public policy.

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CHRONIC TRAUMATIC ENCEPHALOPATHY AND THE NFL By

NIKKI KASAL JUI MALWANKAR (Editor)

Daniel Te’o-Nesheim, a former University of Washington football player who played for both the Philadelphia Eagles and Tampa Bay Buccaneers, was only thirty years old when he was found dead at a friend’s house in in October 2017 of an apparent overdose. He was later posthumously diagnosed with chronic traumatic encephalopathy, or CTE, a degenerative brain disease linked to repetitive cranial trauma. Prior to his death, Te’o-Nesheim was suffering extensive pain from the injuries caused by half a lifetime of tackle football, including bone spurs, ankle and shoulder surgery, and chronic headaches.

As his doctors prescribed ever-increasing amounts of painkillers, he became paranoid and withdrawn – a complete transformation from his friendly, family-oriented personality. He forgot purchases he had made on his credit cards, insisted he was being followed, and made worrisome phone calls to his family from unknown numbers. His sister, Marie, remembers him as distracted, overwhelmed, and dismissive. “It was scary and we tried to reach out, but could not get him to open up,” she confided in a New York Times article in May of this year. Eric Kaufman, Te’o-Nesheim’s former agent, was also among those close to the football player and privy to the direct effect of his downward mental spiral on his career.

“Without a doubt in my mind, all of these were early signs of CTE,” says Kaufman.

Te’o-Nesheim did apply for “line of duty” benefits given to football players suffering extensive physical injuries early in 2017; however, his request was turned down because his injuries were not considered severe

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enough. Less than a month later, he spent the evening at a friend’s house drinking vodka and talking. After going to sleep in one of the bedrooms for the night, he was found the next morning unresponsive and declared dead of overdose. Te’o-Nesheim had made arrangements to donate his brain to science right before his death; therefore, a subsequent microscopic examination of his frontal lobe revealed a “surprising and disturbing” amount of lesions for “a guy who was just 30,” according to Ann McKee, neuropathologist and expert in degenerative neurological disease at Boston University.

Though Te’o-Nesheim’s tragic case was not the most severe manifestation of CTE, it nonetheless was an all-too-common hallmark of one of the most acute yet widely disregarded problems in professional football. CTE is defined by the Concussion Legacy Foundation as “a degenerative brain disease found in athletes, military veterans, and others with a history of repetitive brain trauma.” Football players are particularly affected: in fact, according to a 2018 study from the VA-BU-CLF Brain Bank at Boston University, 94% of college and/or professional football players have been diagnosed with CTE. Its molecular basis is characterized by a protein called tau, which helps to support microtubule networks in neurons in a healthy brain. However, when microtubules break down due to repeated trauma, these tau proteins break free and form clumps in the brain. Eventually, these clumps begin to grow independently in a process called prion spread, at which point they can damage and interfere with regular brain func-

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tion. Since CTE requires a sample of brain tissue to be conclusively diagnosed, it can only be identified postmortem, making it difficult to recognize and seek treatment. However, those suffering mood changes, severe headaches, and memory problems can target these symptoms through treatments such as behavioral therapy and medication. Nevertheless, CTE currently has no permanent cure.

A large part of CTE’s notoriety is its connection to the world of professional football. Research by Dr. Ann McKee in 2017 found that 110 out of 111 former NFL players’ brains tested positive for the disease,

including such Pro Football Hall of Fame names as Oakland Raiders quarterback Ken Stabler and Pittsburgh Steelers center Mike Webster. This study places the rate of CTE in professional football players at a shocking 99%. Despite such overwhelming evidence, the NFL itself has historically been reluctant to acknowledge a link between CTE and professional football, citing a lack of evidence as a chief reason.

However, Jeff Miller, the NFL’s senior vice president of health and safety police, publicly acknowledged for the first time the connection between football and CTE in March of 2016. This groundbreaking

During advanced phases of CTE, prion spread causes severe brain atrophy.

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announcement raised hope both within and outside the football industry for an increased focus on player safety and potential financial compensation for affected players.

For a while, it appeared the NFL finally began treating CTE and concussions in football with the gravity they deserved. In fact, in 2016, it launched its $100 million “Play Smart Play Safe” initiative with the goal of funding “independent medical research and engineering advancements,” with an emphasis on concussion research. However, the first study funded by the grant in 2017 involved the research of CTE in

NFL Concussion Settlement website states that as of November 5, 2018, 675 monetary awards have been issued to former players for a total amount of just under $600 million. However, the settlement provides mainly for the families of deceased CTE sufferers, and since the disease can only be diagnosed posthumously, any living players with possible CTE symptoms would find it difficult to take advantage of the claims. Moreover, the settlement only covers players who retired in or before June 2014, meaning any current players who are beginning to experience symptoms are also disadvantaged.

horse jockeys, not football players. Given the remarkably different physical natures of these professions, one concussion expert noted that comparing the two would be like “comparing apples and pears.” Similarly, Joel Sitzel of the Wake Forest Baptist Medical Center, a biomedical engineering expert consulting for the NFL, was told when he suggested looking into the long-term effects of subconcussive impacts that this was not the scope the NFL was trying to evaluate.

Additionally, in June 2015, a judge approved a class-action lawsuit settlement filed against the NFL by thousands of retired players and their families. This settlement allocated up to $5 million per player for complications resulting from repeated head trauma during the player’s career, including ALS, Parkinson’s, and Alzheimer’s disease. The

Despite the contentious legal atmosphere surrounding the relationship between CTE and football that pits players against the NFL, not all voices in both the football and medical communities are united on a single front. Former NFL running back and ESPN sports analyst Merril Hoge has published a book in the last couple months with the incisive title “Brainwashed: The Bad Science Behind CTE and the Plot to Destroy Football”. Coauthored by Peter Cummings, assistant professor of neurobiology at the Boston University School of Medicine, this work aims to debunk the connections made between CTE and professional football through the work of Dr. Ann McKee. Hoge points to the aforementioned 2016 study that found CTE in 110 or 111 NFL brains as flawed due to its lack of control group; however, he

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POLICY

neglects to mention an associated 2015 study with the Mayo Clinic that was akin to a control group in testing 198 brains of non-players and finding all free of CTE. Though the blurb of Hoge’s book asserts he writes with the intention of supporting the “survival of our nation’s most beloved game,” Chris Nowinski, CEO of the Concussion Legacy Foundation, has his apprehensions. “Every time a football industry person belittles the issue of CTE within their sport, they are not just hurting football families, they also are hurting military families who need the science community to continue working together to find a cure for CTE,” asserts Nowinski.

So what does the future hold regarding CTE in the world of professional football? Though the debate about its impact rages on, the NFL’s statement affirming the connection between CTE and football was a step forward in the fight for the safety of its players, both past and present. The NFL’s efforts are also not intangible – its settlement and research funding may need to be revisited, but they nevertheless represent steps toward change. Indeed, research done at Boston University into the underlying genetic factors behind the disease has this past month has identified two categories of TMEM106B genetic variations that were present in almost 100% of CTE brains tested.

"Understanding the genetic risk factors might allow us to predict who will be most at risk for disease and therefore who to follow more closely clinically and get treatment when possible," says the study’s author Thor Stein. "Genetic risk factors can also provide clues for possible mechanisms that lead to disease and help guide how we might eventually target treatments for CTE.” In the meantime, many in the football community are calling for the NFL to reform the game itself to make it safer for all players. Some progress has been made on this front – this past March, the NFL moved to ban a dangerous technique that allowed players to lower their heads and use their helmets as weapons during a tackle. Several states are also considering a ban on youth tackle football. Since CTE is noticeably more present in players who began tackle football before the age of 12, such a decision may ultimately prove effective in the prevention of the disease in future generations.

Many apprehensions about such measures ultimately come down to concern for the preservation of this all-American game. “There are risks in contact

sports. There's risk in football to injury,” says NFL commissioner and high school player Roger Goodell.

“You have to do what you can to manage that. That's a personal decision ultimately. But I believe the game of football has taught me values and lessons. I would not give back a single moment of playing football because it taught me about teamwork, it taught me about perseverance, it taught me about myself.”

This rosy image is a sharp contrast to NFL player Daniel Te’o-Nesheim’s slow surrender to his disease.

“He would talk and would make you feel sore just listening to him,” says Kaluka Maiava, Te’o-Nesheim’s close friend. “Just seeing him, he looked like he never slept, exhausted all the time. He’d be up all night in the dark staring at the walls dealing with the stuff in his head.”

In order for the NFL and society as a whole to truly offer past CTE victims the care and respect they deserve, as well as to advocate for its prevention in current and future players, even the most hardpressed football fanatic among us must realize that tradition is not worth the ultimate price of human lives. Football viewership in America is higher than ever – with the whole country watching, now is the time for the football industry to champion lasting reform.

Belson, Ken. “A Football Player's Descent Into Pain and Paranoia.” The New York Times, The New York Times, 27 Sept. 2018, www.nytimes.com/ interactive/2018/09/27/sports/football/nfl-cte-daniel-teo-nesheim.html.

Bien, Louis. “The NFL Is Going to Insulting Lengths to Prove That CTE Isn't a Problem.” SBNation.com, SBNation.com, 31 Aug. 2017, www.sbnation. com/2017/8/31/16233630/nfl-concussion-study-funding-cte-horsejockeys.

Brennan, Christine. “Merril Hoge, Co-Author of New Book Are Way off Target in Discussing Football, CTE.” USA Today, USA Today, 24 Oct. 2018, www. usatoday.com/story/sports/christinebrennan/2018/10/24/cte-footballmerril-hoge-ignores-evidence-facts/1750125002/.

Martin, Jill. “NFL Acknowledges CTE Link with Football. Now What?” CNN, Cable News Network, 16 Mar. 2016, www.cnn.com/2016/03/15/health/ nfl-cte-link/index.html.

Ward, Joe, et al. “111 N.F.L. Brains. All But One Had C.T.E.” The New York Times, The New York Times, 25 July 2017, www.nytimes.com/ interactive/2017/07/25/sports/football/nfl-cte.html.

“What Is CTE?” Concussion Legacy Foundation, Concussion Legacy Foundation, 6 Nov. 2018, www.concussionfoundation.org/CTE-resources/ what-is-CTE. Image – “Brain in Helmet.” University Family Medicine Center, www. ufmcpueblo.com/football-brain-injury/.

Image – “Football Players During Tackle.” The 300s, https://the300s. com/2017/07/26/out-of-202-studied-177-football-players-had-cte/.

Image – “Image of CTE.” Boston University Center for the Study of Traumatic Encephalopathy, Boston University, https://www-cache.pbs.org/wgbh/ pages/frontline/art/progs/concussions-cte/h.png.

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3D PRINTING: THE FUTURE OF MEDICINE By

ALLAN ZHANG LINUS PARK (Editor)

With the creation of 3D printing, a whole new field of science has been created. When one thinks about 3D printing, they probably think of 3D printed guns, tools, and other machinery. 3D printing excels at creating intricately detailed 3D structures, typically from inert materials like plastic or metal. However, in recent years, scientists have been able to manipulate 3D printing to “print” cells and other organic substances.

Through this advancement, the creation of human organs is now becoming a reality via technology.

No longer will donors have to give up their lives or organs in order to save another person. However, problems are arising with the creation of such technology. The organs in our body are incredibly complex, with millions of vessels and capillaries running through them and distributing nutrients to every cell of our body.

This biological “machinery” is incredibly intricate and even harder to recreate. To solve this problem, researchers at Harvard University have developed several ”bio-inks” – an ink with an unusual property of melting as it

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cools, rather than as it warms up, which allows scientists to create and mimic blood vessels. This discovery allowed the scientists to first print an “interconnected network of filaments, then melt them by chilling the material and suction the liquid out to create a network of hollow tubes, or vessels.”1 Consequently, they created the structure of blood vessels for the tissue, allowing for the distribution of nutrients required to sustain development.

However, researchers at Wake Forest University have approached this problem in a different manner.

Rather than having a main focus on the creation of blood vessels, they “[created] the [Integrated] Tissue and Organ Printing System (ITOP) over the past decade. The system involves a custom-designed 3D printer that utilizes a water-based ink optimized to promote the health and growth of encapsulated cells.”2 It also prints impermanent channels along which nutrients can be distributed to the cells, helping the tissues survive long enough to produce their own blood vessels.

The creation of blood vessels

hasn’t been the only problem that scientists have faced with 3D printing. With organs that have different cells and several dissimilar layers of tissues, researchers have had to find a way to create a “heterogeneity of cells in 3 dimensions.”3 Different types of cells in the human body have different functions, and the environment in which they thrive is dependent on their location. In many cases, the lack of heterogeneity between cells in tissues has been closely linked to different diseases, as well as cancer. Ultimately, by capitalizing on the different sensitivities of certain tissues and hydrogels to light, “photo-liable reactions have been widely exploited to spatially soften or stiffen hydrogel structures in 2D structures.”1 However, in 3D structures, a new challenge arises, mainly due to the light scattering as a result of the homogeneity of the structures. Oxygen inhibition layers do show promise in preventing the problems that arise with light scattering, but it causes incomplete growth of tissues and uneven surfaces.

Using “continuous liquid interface production, an oxygen-perme-

RESEARCH

able layer can be created on the oxygen inhibited layer, allows for the printing of 3D structures with heterogeneity.”3 Having discovered a solution to cell differentiation and the creation of blood vessels throughout an organ, researchers are now attempting to grow organs using actual tissue from humans.

Researchers at Organovo, a San Diego-based company, has created the ability to print bio-inks of tissues recreated from the cells of humans. However, the implications for this research extend far beyond that of organ replacement. This new 3D printed tissue could serve as a way to test new drugs, rather than using animals or clinical trials which often carry risk to the recipients. Believing in the potential for this technology to combine with other areas of study, researchers are attempting to interface 3D printing with the

liver’s regenerative ability to heal chronic liver conditions. A team at the MRC Centre for Regenerative Medicine at the University of Edinburgh is attempting to use macrophages (white blood cells) that are “very effective at stimulating regeneration in the liver by breaking down scar tissue that accumulates during liver disease.”4 By attempting to grow healthy macrophages in a laboratory setting, Professor Stuart Forbes, Director of the MRC Centre, hopes to insert these cells into the liver to induce self-regeneration. However, in cases where the liver is too damaged, researchers hope to replace parts of the liver with healthy tissue that can then provide an impetus for healing and regrowth.

Despite the many challenges that accompany 3D printing of organs, the technology displays a potential to exceed all expectations

and prove useful in many facets of medicine through the application of organ replication, drug testing, as well as, interfacing with new areas of medicine.

1. “Essential Step toward Printing Living Human Tissues.” ScienceDaily. February 19, 2014. Accessed November 03, 2018. https://www.sciencedaily.com/ releases/2014/02/140219095501.htm 2. Scott, Clare. “Wake Forest Researchers Successfully Implant Living, Functional 3D Printed Human Tissue Into Animals.” 3DPrint. com. December 15, 2016. Accessed November 03, 2018. https://3dprint.com/119885/wakeforest-3d-printed-tissue/ 3. Yin, Hang, Yonghui Ding, Yao Zhai, Wei Tan, and Xiaobo Yin. “Orthogonal Programming of Heterogeneous Micro-mechano-environments and Geometries in Three-dimensional Bio-stereolithography.” Nature News. October 05, 2018. Accessed November 03, 2018. https:// www.nature.com/articles/s41467-018-06685-1 4. Franco, Michael. “One Big Question: Why Can't We 3D Print Functioning Organs Today?”

August 26, 2016. Accessed November 03, 2018. https://newatlas.com/1q-3d-printedorgans/44126/ Image – 3D Printing of an ear. Wake Forest Institute for Regenerative Medicine. February 16, 2016. Winston-Salem.

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AT THE FOREFRONT:

ROBOTIC CARDIAC SURGERY

THE NEWEST INNOVATION IN HEART SURGERY, AND THE SURGEON BEHIND IT

By

CORINNE STONEBRAKER SWATHI BALAJI (Editor)

In the United States, heart disease is the leading cause of death, causing approximately 1 in 4 deaths each year. While heart disease describes a range of conditions that can affect the heart, including coronary artery disease, arrhythmias, congenital heart defects, and many others, coronary artery disease (CAD) is responsible for about 60% of heart disease-related deaths. CAD can be treated with medication, or if necessary, angioplasty and stent placement, where a small mesh tube called a stent is used to open narrowed or blocked blood vessels.

However, CAD often progressively worsens over time, and frequently requires coronary artery bypass graft (CABG) surgery. In fact, nearly 500,000 CABG surgeries are performed each year, making it one of the most common major operations in the nation.

The conventional CABG surgery uses a mechanical saw to split and open the breastbone in order to access the heart; this approach, called a “median sternotomy,� requires an eight-inch incision down the length of the

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chest and complete fracture of the sternum. After the surgery, the fracture is wired together and a long and painful process of recovery begins. Healing of the breastbone takes at least six weeks and is fairly painful; it is the primary limitation in recovering from CABG surgery. At most hospitals across the nation, CABG surgery is performed in this conventional manner with long and painful recovery ahead.

However, at UChicago Medicine, patients leave the hospital less than 48 hours after CABG surgery, with minimal pain and no more than three to four eight-millimeter incisions. This incredible feat is made by possible by a handful of skilled surgeons and a powerful robotic surgical system.

Originally, the Da Vinci Robotic Surgical System was created for the United States military in the 1990s as a way for surgeons to treat fallen soldiers in the field without being exposed to the frontline. Although it did not come to fruition in military use, the da Vinci robot was soon appropriated for clinical use. The first specialists to

adapt the technology widely were urologists, for use in minimally invasive robotic prostate surgery.

Only in the past ten years has minimally invasive robotic surgery pervaded other specialties, including thoracic surgery, gynecological surgery, and cardiac surgery.

In August, UChicago Medicine completed its 10,000th robotic surgery across all specialties. At other centers, robotic cardiac surgery is used is used mainly for a few specific procedures, like valve repair, but very few have embraced robotics in the majority of procedures the same way UChicago Medicine has.

I had the opportunity to sit down with Dr. Husam Balkhy, the Director of Minimally Invasive and Robotic Cardiac Surgery at UChicago Medicine, a pioneer in the field of minimally invasive and robotic cardiac surgery, and the only surgeon in the world with extensive experience performing multiple vessel CABG surgery with a robotic surgical system and innovative anastomotic devices.

This surgery, known as robotic totally endoscopic beating heart

RESEARCH

AT UCHICAGO MEDICINE

coronary bypass grafting (TECAB) surgery, is what Dr. Balkhy refers to as “the highest form of coronary bypass.” Rather than using a median sternotomy, the surgical team makes four to five slits on the chest, each about eight millimeters. These allow the surgical instruments and video camera attached to the “arms” of the da Vinci robot to access the heart through the ribcage. While the surgical team stays at the operating table with the patient, the surgeon performing the procedure sits at a console about ten feet away.

By manipulating the arms of the robot, the surgeon can precisely control surgical instruments with a degree of movement and precision equal to, if not superior to, the human wrist and hands. With this degree of precision, the heart does not need to be stopped, as in traditional CABG surgery. “When we operate with the robot in between the ribs, there's really no breaking of bone or waiting for any bone to heal. My patients – they can go out and do whatever they need to do within a week or two,” explains Dr. Balkhy. “The

(Top) The arms of the da Vinci robot operate on a patient through small holes in the chest. [Photo

by Ramakanta Panda.]

(Bottom) A surgeon sits at the console (left), controlling the robot (right), which operates on the patient.

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only limitation is pain, and most patients are not having any pain past the first two weeks. Even if they are, they usually don't ever have to take their pain meds.”

Dr. Balkhy first became interested in minimally invasive surgery in 1997, not long after finishing his training. “I spent two years doing heart surgery the way I was trained to do it – it was the open technique, it was stopping the heart – and that was just how it was done,” he recounts. “And then I kind of had a one-on-one with myself and I said ‘this is crazy.’ I mean, we're having great outcomes but we're making really big cuts.” Inspired by a professor from his training who emphasized what is known in surgery as “respect of tissues,” Dr. Balkhy began his exploration into minimally invasive heart surgery. “The first thing that I taught myself how to do was operate while the heart was beating – I had never trained to do that. It was a little bit of a leap of faith, but around 1999 or 2000 I started teaching myself how to operate on a beating heart, without the use of a heartlung machine.” In the present day, every ten minutes someone has Dr. Husam Balkhy operates at the Da Vinci Surgical System console while his team works with the patient about 10 feet away.

[Photo By Robert Kozloff.]

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this “off-pump” bypass surgery.

But 20 years ago, Dr. Balkhy taught himself how to do it, never having been trained in the procedure.

And that was just the beginning.

Simply operating on a beating heart is not what Dr. Balkhy calls the “Holy Grail of Coronary Bypass.” As he sees it, “it’s using all arterial grafts, it’s operating without stopping the heart, it’s doing it without opening the chest, it’s the use of anastomotic devices.”

As he says this to me, Dr. Balkhy opens one of the cabinets above his desk and takes out what looks like a long, very thin stapler. He was the first to use this tool, called an anastomotic device, in robotic TECAB surgery after it was first approved in 2006. Unlike the typical suture-based connection, an anastomotic device essentially allows the surgeon to immediately “staple” two arteries together to form a connection. Aided by extensive experience using anastomotic devices, Dr. Balkhy is the only surgeon in the world who performs beating heart multi-vessel TECAB surgery using this approach. His penchant for new technologies and techniques has cemented his position as a lead-

ing authority in cardiac surgery innovation.

While other centers like the Mayo Clinic and the Cleveland Clinic use a robotic surgical system in mitral valve surgery, few have ventured beyond valve repair.

Why does UChicago Medicine remain relatively alone in its use of the da Vinci system for more advanced surgeries like coronary artery bypass? “Because they’re not us,” Dr. Balkhy says, chuckling. “I think one of the things that some of these hospitals put at the at the front of their considerations is how they are going to look on U.S. News and World Report rankings,” he explains. “So as you might imagine, anytime you venture out and you do something different, there's always the possibility of failure, but the only way to advance is to kind of go through the learning curve. It seems to me that there are a lot of big-named institutions that are averse to having complications, and therefore don’t offer this technology to higher risk patients – even though they are the ones who benefit most from the less invasive approach.

In our case, we went through the learning curve long ago, and

RESEARCH

now it's just a matter of bringing this expertise to more and more cardiac conditions.” This is true – with UChicago Medicine having established itself as the leader in robotic cardiac surgery, patients come from all over the country to undergo procedures that they could not get anywhere else.

Dr. Balkhy tells me the remarkable story of one such patient who came to UChicago Medicine in search of care he couldn’t receive anywhere else. “I got a call from an emergency room doctor who lives in Oregon – a young guy in his late 30s – who found that he had a tight blockage in his artery on the back of the heart. He went to the cardiologist, and they put a stent in it. Unfortunately, the stent didn't work.” This is a common problem, when the degree of blockage is severe enough that a stent is not sufficient. “He was told that he needed to have open heart surgery. He advocated for a less invasive option, and was told that there's a guy who does robotic surgery at the University Hospital in Portland.” The patient was planning on leaving in four weeks for a year-long backpacking trip with his family, and he knew that a traditional CABG procedure would make this impossible.

“The surgeon in Portland said to him, ‘You should go and check out University of Chicago, because that's the only place that you can get this done using the TECAB approach.’ So he came, and we did the surgery. He was out the hospital in two days, flew back to Portland, and made his trip.

If he had gotten the traditional surgery, none of that would have been possible.” Every few weeks, the patient would send Dr. Balkhy

pictures of his family climbing mountains in China, Iran, and South America.

While the advances in cardiac surgery afforded by the da Vinci system and anastomotic devices are remarkable, Dr. Balkhy is always looking towards the next innovation. “I think the new robotic devices that are coming out on the horizon are going to be impactful. There's a lot of companies that are working on artificial intelligence like Google and Microsoft.” Indeed, Google and Johnson and Johnson are currently working on an AI surgical robot, expected to be released in 2020.

“Robotics right now is a $25 billion industry. It's a big deal.” Is there a time when robots could act without manipulation by the surgeon?

“There might be a time when you could task a robot with doing some small steps of the procedure, and then the surgeon would take over. But I think we're still far away from that.”

Dr. Balkhy is also working on reducing the cost of the da Vinci robot, which can cost up to $2 million, and making it more accessible. “I work with a company in China that is trying to make a robot for a quarter of the price.

While the robot is expensive, a lot of times that's not even the highest cost – the highest prices are in the disposables. When you take an instrument in and out, you can't use it forever. The cost is a huge challenge, and it is the main reason that robotics is not reaching a majority of people yet.”

Globally, robotics is only available to about 7% of the human population, mostly in the United States, Western Europe, and Japan.

Further exploration into AI and

cost-effective materials is needed to make this extraordinary technology into a global phenomenon.

As Dr. Balkhy and UChicago Medicine continue to innovate at the forefront of medicine, we can only await a greater future, where technology is more widely incorporated into medical procedures on a global scale.

“Coronary-Artery Bypass Grafting versus Stent Implantation.” New England Journal of Medicine 353, no. 7 (2005): 735-37. doi:10.1056/nejm200508183530718.

“Heart Disease Facts & Statistics.” Centers for Disease Control and Prevention. Accessed November 6. https://www.cdc.gov/ heartdisease/facts.htm “Husam H. Balkhy, MD.” UChicago Medicine - At The Forefront. Accessed November 6, 2018. https://www.uchicagomedicine.org/find-aphysician/physician/husam-h-balkhy “Major Innovations in Cardiac Treatment | Chicago Health Magazine Online.” Chicago Health.

December 04, 2017. Accessed November 6, 2018. https://chicagohealthonline.com/hopefor-hearts/ Medtronic. “What Is Beating Heart Bypass Surgery? Coronary Artery Disease (CAD).”

Mission | Medtronic. Accessed November 6, 2018. http://www.medtronic.com/us-en/ patients/treatments-therapies/heart-surgerycad/beating-heart-bypass-surgery-what-is-it. html “National Center for Health Statistics.” Centers for Disease Control and Prevention. March 17, 2017. Accessed November 6, 2018. https:// www.cdc.gov/nchs/fastats/leading-causes-ofdeath.htm Porter-Woodruff, Jordan. “UChicago Medicine Completes 10,000th Robotic Procedure.”

UChicago Medicine - At The Forefront. August 05, 2018. Accessed November 6, 2018. https:// www.uchicagomedicine.org/surgery-articles/ surgery-team-completes-10000th-roboticprocedure Rupp, Scott. “The Da Vinci Medical Robot and AI.” Electronic Health Reporter.

Accessed November 6, 2018. https:// electronichealthreporter.com/the-da-vincimedical-robot-and-ai/ Themes, UFO. “Beating Heart: Totally Endoscopic Coronary Artery Bypass Surgery; Robotic Endoscopic Multi-vessel Anastomotic Connectors.” Thoracic Key. February 26, 2017. Accessed November 6, 2018. https://thoracickey.com/ beating-heart-totally-endoscopic-coronaryartery-bypass-surgery-robotic-endoscopicmulti-vessel-anastomotic-connectors/ “Totally Endoscopic Coronary Artery Bypass (TECAB) Surgery.” UChicago Medicine At The Forefront. Accessed November 6, 2018. https://www.uchicagomedicine.org/ conditions-services/heart-vascular/coronaryartery-disease/coronary-artery-surgery/tecab

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ACUTE FLACCID MYELITIS REMEMBERING THE POLIO EPIDEMIC AND LOOKING BEYOND By

ALLISON GENTRY FATIMA SATTAR (Editor)

One of the most notable medical achievements of the past century in the United States has been the eradication of polio, a highly infectious viral disease that causes paralysis in young children. There have been several significant polio epidemics throughout the history of the United States, with the peak occurring in 1952, when there were 57,879 cases and 3,145 deaths reported. Jonas Salk’s vaccine, which was developed in 1954 through a trial of nearly two million children, was eventually used to vaccinate children across the United States. Through the widespread implementation of this vaccine beginning in 1955, the number of polio cases decreased rapidly until the disease was officially eliminated in 1979.

Over the course of the past four years, however, there have been a rising number of cases of a poliolike disease of unknown causes in the United States.

This viral disease is known as acute flaccid myelitis, a rare but serious infection that affects the gray matter of the spinal cord and can cause severe weakening of muscles within the body. The symptoms for acute flaccid myelitis may develop after a viral infection such as adenovirus or West Nile virus; however, in some cases, there are no clear causes. From 2014 to the present, there have been 386 confirmed cases of acute flaccid myelitis in the United States. To this day, possible causes and treatments for all of these cases remain unknown.

This graph illustrates the number of cases of AFM recorded in the United States from August 2014 to August 2018.

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EVENTS

What we know about AFM

Acute flaccid myelitis (AFM) is an extremely rare disease, and the sudden increase in the number of cases in the United States has caused public concern.

While there are records of AFM cases in the past, they have yet to be compiled. The CDC is currently collaborating with various medical institutions to determine the number of cases that occurred in the United States before 2014, which was when the increase in cases was first noticed. In 2018 alone, there have been cases officially reported in 22 states, the majority of which have been seen in children, with the average age of patients being four years old. It can be difficult to diagnose a patient with AFM, as the symptoms share some similarity to neurological diseases such as transverse myelitis and Guillain-Barre syndrome, both of which also affect the nervous system. The

symptoms of AFM include losing control over some reflexes and losing muscle tone in the arms and legs, facial drooping, and slurring of speech. In more severe cases, the muscles controlling the respiratory system may be affected, which can cause difficulty with breathing and ultimately be life-threatening.

These symptoms share some resemblance to the more serious symptoms of poliomyelitis, or polio, which include weakness or paralysis in the arms or legs. An emergency room visit is necessary for diagnosing AFM to enable doctors to take a sample of a patient’s spinal fluid, which elucidates any signs of injury or viral infections within the spinal cord. There is still much to be discovered about AFM, and until the necessary research has been conducted, the exact mechanism of the disease will remain unknown.

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What we have yet to learn

specified treatments other than physical and occupational therapy in order to assist patients dealing with loss of muscle control. Some researchers are also attempting to find ways to diminish the amount of inflammation in the spinal cord in order to prevent further attacks on the nervous system by the patient’s immune system. To prevent the contraction of viruses that could potentially cause AFM, certain precautions have been advised by health organizations such as the CDC, including minimizing exposure to mosquitos and staying up-to-date on available vaccinations.

New age, similar fears

however, it may also lead to the greater dedication of time and commitment to research, allowing for us to discover more about the disease and possible treatments. AFM may not be directly related to the polio virus, but by examining the precedent of the studies and solutions developed during the polio epidemic, the medical and public health communities may be able to discover new approaches to treating AFM and be better prepared for the future.

While there are no confirmed causes for AFM, it may possibly be related to a virus, environmental toxin, or genetic disorder. It is still unclear why some cases are related to previous viral infections and others are not, and it is unknown how those viral infections initiate AFM. Due to the fact that the symptoms are similar to that of polio, some have assumed that a virus may be a possible cause as well; however, no traces of it have been found in any of the confirmed AFM patients. As of now, AFM has no

The polio epidemic in the United States left a significant mark on the memories of many. Throughout the early 20th century, late summers were spent wary of swimming pools and public theaters in order to avoid catching the disease, since much about the virus remained unclear. It was later found that the disease was transmitted through contact with nasal, oral, or fecal secretions, which could all be present in public areas. However, without this concrete knowledge, the fears that children may contract this potentially deadly disease were amplified and any assumptions, however outrageous they may have been, about the causes of polio were believed as they were the only preventative measures available. Due to the prevalence and visibility of the disease in everyday life, people were spurred to action, and the necessary time and funds were dedicated to research and development of a vaccine. Once the effectiveness of the vaccine was proven, the US Public Health Service began a national immunization program, leading to a sharp decline in cases across the country. The impact that the polio epidemic has had on the history of the United States provides clarity into why the sudden increase in the number of cases of AFM has caused such alarm. The shadow of polio still looms over our society, and many fear that this may be history repeating itself. The shared fears of an unknown, rare disease affecting young children may incite anxieties;

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"Acute Flaccid Myelitis." Centers for Disease Control and Prevention. October 15, 2018. Accessed October 21, 2018. https://www.cdc.gov/acute-flaccidmyelitis/about-afm.html "Acute Flaccid Myelitis (AFM) - Symptoms, Diagnosis, Acute Treatments, Information Sheets." The Transverse Myelitis Association. Accessed October 21, 2018. https://myelitis.org/living-with-myelitis/diseaseinformation/afm/ "Acute Flaccid Myelitis." Genetic and Rare Diseases Information Center.

Accessed October 22, 2018. https://rarediseases.info.nih.gov/ diseases/13142/acute-flaccid-myelitis "Acute Flaccid Myelitis Infographic." Centers for Disease Control and Prevention. July 12, 2017. Accessed October 21, 2018. https://www.cdc. gov/acute-flaccid-myelitis/infographic.html Beaubien, Jason. "Wiping Out Polio: How The U.S. Snuffed Out A Killer."

NPR. October 15, 2012. Accessed October 21, 2018. https://www.npr.org/ sections/health-shots/2012/10/16/162670836/wiping-out-polio-how-theu-s-snuffed-out-a-killer "Polio." Our World in Data. Accessed November 03, 2018. https:// ourworldindata.org/polio "Polio." Mayo Clinic. December 09, 2017. Accessed October 21, 2018. https:// www.mayoclinic.org/diseases-conditions/polio/symptoms-causes/ syc-20376512.

"Polio Elimination in the United States." Centers for Disease Control and Prevention. November 28, 2017. Accessed October 21, 2018. https://www. cdc.gov/polio/us/

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ALTERNATIVE MEDICINE

THE DECEPTIVE DAMAGE OF HARMLESS TREATMENTS

By

ANNAGH DEVITT MARIA HATZISAVAS (Editor)

In a standard tumor board – think cancer conference – an atypical case was brought forth that left the health-care practitioners divided. The case was standard to begin with: a woman in her thirties found a small bump in her breast, which was classified as indeterminable (somewhere between benign and cancerous).

The doctors agreed on what to do next: remove the tumor with a simple biopsy, followed by radiation therapy and chemotherapy.

Her odds of survival were high, nearly 97%, yet this woman chose not to pursue her doctor’s recommended path and instead sought out alternative medicine (AM). For three years, the woman drank teas, ate organic foods, rubbed herbs all over her body, and visited numerous “healers.” By the time the woman went back to conventional medicine, it was far too late. Her tumor had grown from 1 centimeter to 6 centimeters, and attached to her chest wall. In addition, she showed symptoms of palpable axillary lymph nodes and metastases.

Her case went from Stage I treatable breast cancer to Stage IIIC invasive breast cancer with very low chance of survival.1 Her choice to forego conventional medicine

had cost her many things, including a divorce and custody of her three children, and above all, it cost her life.

This woman's case is an extreme in terms of dependence, but it is not necessarily odd in terms of practice. Between 40% to 70% of cancer patients use a form of complementary alternative medicine (CAM) alongside their conventional cancer treatments (CCT).2 Additionally, about one out of three adults utilize AM, making it a $34 billion industry.3 Seeking out nonconventional pain relief is not abnormal, regardless of causes or levels of pain. But we should be asking why that is the case. Why do cancer patients, those with chronic illness, and regular adults opt for alternative medicine in lieu of or in addition to modern methods?

Most people who turn to AM partake in holistic medicine, like acupuncture and yoga, to deal with pain.4 Cancer patients use these practices to counterbalance the side effects from chemotherapy; those with chronic illness or otherwise healthy individuals also use them for similar pain-relieving benefits. Numerous studies have shown that these practices have

greatly improved the quality of life for cancer patients but have virtually no effect on their cancer progression.

Other forms of alternative medicine, such as spiritual healing and natural remedies, also do not typically have a negative effect on the patient (unless products in the natural supplements interfere with a patient’s medication).

While alternative medicine and its various branches are essentially placebos – they have neither positive nor negative effects, but the user perceives a difference – the real harm lies in the attitudes surrounding these methods. For some people, alternative medicine can consume their life.

“Cult medicine.”1 This is what a doctor present at the tumor board for the case of the cancerstricken woman later described the practice of AM. In all major ways, AM treatments resemble that of a spiritual cult: a leader who proclaims to know more, a believer who is isolated from their friends and family, and a scheme that provides hope at exorbitant fees. The most infamous quack doctor to this effect was Harry M. Hoxsey. This cult leader of sorts was estimated to make nearly $1.5

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million during the height of his scheme in the 20th century. His panacea was an herbal paste that he claimed was passed down from his great grandfather and used on thousands of patients. Unfortunately, one of the main ingredients to his cancer remedy was arsenic, a flesh-eating and otherwise toxic chemical. If his patients survived cancer, they would die due to his “cure.” However, that did not stop most people. Hoxsey often held rallies and speeches akin to religious gatherings. Even today, despite the numerous legal battles brought against Hoxsey with the government and scientific-evidence to refute his claims, the Hoxsey method still exists as an alternative to CCT (though the treatment no longer contains arsenic). In fact, the woman discussed by the tumor board who refused traditional treatment used the Hoxsey method among other AM to “treat” her cancer.5 Despite these factors, the woman’s decision was, after all, her decision. It is not uncommon for someone to deny cancer treatment, especially considering its severe side effects. However, there is something fundamentally different between someone who refuses medical treatment and someone who refuses it in lieu of alternative medicine. For example, a widow in her 80’s – the most common demographic for patients who refuse care – was diagnosed with

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lung cancer. Similar to that of the 30-year-old woman, her case was very treatable and offered a high chance of survival, and this woman also refused treatment. However, instead of seeking alternative treatments, the widow simply resigned to her fate: “I’m alone. I’ve lived a good life, but I miss my husband.

I’m happy with what my life has been. I don’t want treatment.”6 The expectations of these two similar cases are what define them. The young mother refused treatment expecting to live, while the widow refused treatment expecting to die of her cancer.

The tragedy of the false expectations brought on through AM is best illustrated in the famous case of Kathy Acker, a feminist writer diagnosed with breast cancer at 48.

After finding a cancerous tumor in her breast, she requested a double mastectomy against her doctor’s advice and refused radiotherapy and chemotherapy claiming, “I was terrified of cancer. I feared chemotherapy more.”7 She later recounted the surgery in a Guardian article called “The Gift of Disease,” where she explained how the experience marked the tipping point for her total denial of conventional medicine: “I realized that if I remained in the hands of conventional medicine, I would soon be dead, rather than diseased, meat…When I walked out of that surgeon’s office, I thought that I might be about to die, to die without any idea why.

My death, and so my life, would be meaningless.”

Determined to give her life meaning, Acker consulted a number of “healers” who instructed her to will the cancer away with her mind. Greg Schelkun, chief among them, instructed her that if she could resolve a regression in her past or past life, she would be able to find out what caused her cancer and would be able to heal herself.

Nearly four months later, she claimed to be cancer-free.8 In the last two years of her life, her health deteriorated greatly.

She was not able to digest food, could not walk for more than a few blocks, and whittled away to just under 100 pounds. She attempted to seek more care at an alternative cancer clinic in Tijuana, but they could not admit her because her cancer was too advanced. Eventually, she died in a similar clinic surrounded by a handful of friends (many became estranged due to her refusal to seek conventional care) in a room she dubbed “Room 101” after a torture scene from George Orwell’s 1984.9 At age 50, barely a year after claiming to be cancer-free, Kathy Acker lost her fight.

Acker’s attitudes towards AM, especially her “cure,” are destructive not only to herself but to others facing chronic or life-threatening illness. Hank Green, an author and vlogger with ulcerative

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colitis, remarked on how harmful even simple comments like “you should try X treatment” are to his mental health, since “what I’m hearing is not ‘take it easy, we support you.’ Instead, I’m hearing ‘I have the secret to your wellness and if only you had the courage and fortitude to implement it, you would no longer be sick.”10 New York Times columnist and ovarian cancer fighter, Susan Gubar, has dubbed the movement the “heal-yourself-with-a-positive-attitude movement.”11 This type of thinking, Gubar claims, is simply victim blaming – it implies that those who have cancer got it in order to resolve some issue in their life, and those who recover are somehow better than those who die from their cancer. In response to Acker’s “Gift of Disease,” Gubar replies that “cancer is not a gift I would want to give or receive.”

If anyone could see the truth in this, it would be the doctors who treat cancer patients on a daily basis. Whether it’s a patient like the 80-year old widow or someone like Kathy Acker, doctors must accept the decisions of their patients, and that takes a toll.

Doctors, especially cancer specialists, work with patients everyday who fight tirelessly for their lives, so seeing a patient who could be easily cured refuse treatment or seek unsubstantiated cures in AM can be disheartening. As Dr. Vic Velanovich from the University of South Florida puts it, “Unlike any

other disease, the federal government declared a war on cancer, so with all this effort, how could you possibly refuse treatment?”6 A question of this nature was posed to the tumor group that was discussing the 30-year-old mother’s case: was her decision to refuse treatment ultimately a failing of the healthcare system? The room was split. On one side, physicians argued that the woman was fully informed of her condition and options and, despite the advice of her doctors and the wishes of her family, refused conventional treatment. The other half of physicians said that they would take such a case to be a failing on themselves as doctors for not being able to convince the patient to pursue conventional medical treatment. A similar sentiment was aired by Sean Ransom, the psychologist who dealt with the case of the 80-year-old widow.

To him, “at the time, it felt like a failure, but I would treat her much differently today than I did then… [what] I needed to do [was] to be of greatest service to her – regardless of what that service needed to be.”6 That is the reality today.

Alternative medicine cannot be barred against, just as much as conventional treatments cannot be forced upon patients. Doctors find themselves in this grey area: willing to help the patient by all means possible but forced to allow for the harm they might put themselves through.

1. Gorski, David. “Death by ‘Alternative’ Medicine: Who’s to Blame?” Science-Based Medicine, July 7, 2008. https://sciencebasedmedicine.org/ death-by-alternative-medicine-whos-to-blame/ 2. Kabat, Geoffrey. “Why Resorting To Alternative Medicine To Treat Cancer Is A Bad Idea.” Forbes. Accessed November 14, 2018. https://www.forbes. com/sites/geoffreykabat/2018/02/10/ why-resorting-to-alternative-medicine-totreat-cancer-is-a-bad-idea/ 3. “The Quack-up - Pretend Medicine.” Accessed November 16, 2018. https://www.economist. com/united-states/2016/05/21/the-quack-up 4. Singh, Priyanka, and Aditi Chaturvedi.

“Complementary and Alternative Medicine in Cancer Pain Management: A Systematic Review.” Indian Journal of Palliative Care 21, no. 1 (2015): 105-15. https://doi. org/10.4103/0973-1075.150202.

5. Young, James Harvey. “The Medical Messiahs: Chapter 17.” Quackwatch. Accessed November 17, 2018. http://www.quackwatch.org/13Hx/ MM/17.html 6. Ruth Davis Konigsberg. “Why Some Cancer Patients Reject Their Doctor’s Advice - Health Special: Cancer - TIME.” Time, June 2, 2011. http://content.time.com/time/specials/ packages/article/0,28804,2075133_2075127_ 2075099-3,00.html 7. Acker, Kathy. “The Gift of Disease.”

Editions Ismael, January 18, 1997. https:// editions-ismael.com/en/names-dates/kathyacker-1968-1979-2/ 8. Kraus, Chris. “‘Cancer Became My Whole Brain’: Kathy Acker’s Final Year,” August 11, 2017. https://www.newyorker.com/books/ page-turner/cancer-became-my-whole-brainkathy-acker-final-year 9. McBride, Jason. “The Last Days of Kathy Acker.”

Hazlitt, July 28, 2015. https://hazlitt.net/ feature/last-days-kathy-acker 10. Green, Hank. Your Illness Is Not Your Fault, 2016. https://www.youtube.com/ watch?v=3krVl6UMIeo 11. Gubar, Susan. “Living with Cancer: The Lure of Alternative Remedies,” November 5, 2015.

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GLOWING GIRLS THE RADIUM TRAGEDY THAT CHANGED HISTORY By

LINDSAY ROMANO ANYA DUNAIF (Editor)

If someone asked you about radium, you would probably tell them that it’s very dangerous or that it glows. These days, it is well known that this element is a health hazard, but how was this discovered? The first examples of radium poisoning recorded are dial painters who worked during the early 1900s in radium factories. They were named “The Radium Girls” by the media, and the name stuck.

Their story sparked a revolution for workers’ rights and inspired safety improvements for the scientific field.

Radium was discovered by Nobel Laureates Marie and Pierre Curie in 1898. However, it was not until 1902 that radium was isolated with electrolysis, the process of running an electric current through a solution. Curie expressed in her notes that radium was a highly dangerous element.

She and her husband had experienced burns while working with the element and noted that it was harmful in ways akin to x-rays.

Even today, more than a century later, the notebooks used by the Curies are too radioactive to be handled. The radium isotope that is commonly discussed is radium226. It has a half-life of 1600 years and emits ionizing radiation as it decays, mainly in the form of alpha particles and radon gas. Alpha

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particles kill cells by destroying their DNA. Additionally, radium is hazardous because it behaves much like calcium; it is easily absorbed by the body through the digestive system and deposits into the body’s tissues.

In the first decade of the 20th century, doctors began experimental radiation treatments with radium because of its similarity to x-rays. Radiation therapy was very successful with cancer patients and helped shrink tumors.

It wasn’t long before radium was coined a cure-all. Radium became a part of everyday items such as

toothpaste, beauty products, and butter in addition to treatments for any common ailments. Radium water was especially popular, and consisted of putting water in a radium-lined bucket and leaving it overnight. The radium craze took off and the public disregarded the Curies and other scientists’ warnings. There were no studies that showed the effects of radium poisoning, so people were not willing to heed their caution. Radium also became popular for another distinct property: its glow.

Radium watches were all the rage because of their eye-catch-

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ing luminescent numbers. The original need for them came from the first World War because it was helpful for soldiers to be able to see the time in the trenches.

One radium watch factory was located in Orange, New Jersey and began production in 1917. It was owned by the U.S. Radium Corporation (USRC) and had its maximum number of dial painters from 1917 to 1918 at 300 women.

Dial painting was considered to be a woman’s position because it required manual dexterity and a light touch. In the factory, conditions were considered very

good for the time. Many women were happy to have a job during and after the war. The wage was more than the median income for women. Many dial painters encouraged other women in their families to apply to the factory.

Women were compensated per watch, which motivated them to work quickly. The factory managers encouraged dial painters to lick the paintbrush to create a finer point. There were no protective measures given to women in the factories because they were using a small amount of paint each day.

Lead aprons were supplied to the

men, and few women employed in other areas of the factory with large amounts of radium. The fact that there were no safety measures did not concern the dial painters because they had been assured that they were safe on several occasions. These claims didn’t change the high-risk of working with radium substance, and its effects soon became prevalent.

The initial effects of radium seemed harmless, and the substance was popular amongst the younger girls in the factory.

They would go home from a day of painting with their clothes

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glowing from the radium exposure. Some would even paint the buttons on their dresses or their nails, but the joy of the radium glow was short lived. Long-term radiation sickness symptoms soon became present among many of the women who worked with radium paint. Common issues included bone cancer, anemia, lesions, and sores. These problems were exhibited in Amelia Maggia, the first dial painter to die from radiation sickness. Amelia worked in the factory for almost a decade and was known to be a diligent employee. Amelia had initially gone to the doctor complaining of a toothache and got an extraction.

However, the ache in her jaw continued. When the doctor performed surgery, he found deterioration of her lower jaw bone and tissue damage from the radiation. Most of her jaw was removed and she developed severe anemia.

Amelia passed away in September of 1922 at the age of 25, and her

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death was wrongly attributed to syphilis.

Amelia was not the only dial painter to face such serious health problems. Soon five women who had been employed in the U.S Radium Corporation factory filed a lawsuit against the USRC. However, the company had prepared for the coming battles by funding studies that corroborated their story as soon as concerns among the women had arisen. The legal process was long drawn out, and by the second hearing, most of the Radium Girls were too sick to attend. When the battle finally ended in 1928, the women were financially compensated, but most of the money went towards their own funerals. Additionally, more protective measures were put in place for the women at the USRC factory. Radiation poisoning went on to cause health problems such as bone fractures, necrosis of the jaw, and anemia for many of the women. However, these women

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began a revolution that affects all of us today.

The Radium Girls’ lawsuit paved the way for improved working conditions in America. This case began the conversation about occupational disease labor law, which mandates that if workers are ill because of conditions in the workplace, they must be compensated. In addition, the severity of radium sickness gave insight about how to improve experimentation with radioactive substances in the future. This includes work on the Manhattan Project, which had many safety precautions to prevent a tragedy like this from occurring again. The study of human radiobiology was also born

from this event; survivors of the factory participated in testing in later years. These women are key to making predictions about the effects of radiation fallout and nuclear warfare. The Radium Girls are not to be forgotten – their sacrifices have and continue to save many lives.

Clark, Claudia. Radium Girls: Women and Industrial Health Reform, 1910-1935. 1st ed.

Chapel Hill, NC: University of North Carolina Press, 1997.

Kenneth A. DeVille and Mark E. Steiner, New Jersey Radium Dial Workers and the Dynamics of Occupational Disease Litigation in the Early Twentieth Century, The, 62 Mo. L. Rev. (1997).

Reitman, Matthew. “How ‘The Radium Girls’ Left a Legacy of Scientific and Civil Rights Contributions.” RealClearLife. May 11, 2017.

Accessed November 9, 2018. http://www. realclearlife.com/history/radium-girls-leftlegacy-scientific-civil-rights-contributions/

Stockton, Richard. “The Sad Deaths And Disfigurements Of The ‘Radium Girls’.” All That’s Interesting. October 22, 2018. Accessed November 10, 2018. https://allthatsinteresting. com/radium-girls/3 Image – “Radium Is Restoring Health to Thousands”; Radium Appliance Co. 1916. http://lemuriablog.com/wp-content/ uploads/2017/05/radium-ad.jpg Image – U.S Radium Corporation. http://www. realclearlife.com/wp-content/uploads/2017/05/ radiumgirls_050517_0002.jpg Image – Amelia Maggia. “They said she died of syphilis. But, when they opened the coffin …” YouTube video, 9:19, posted May 15, 2018, https://www.youtube.com/ watch?v=e5mpiBSjrfk Image – Reitman, Matthew. "How 'The Radium Girls' Left a Legacy of Scientific and Civil Rights Contributions." RealClearLife. May 11, 2017. Accessed November 9, 2018. http://www. realclearlife.com/history/radium-girls-leftlegacy-scientific-civil-rights-contributions/

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