UChicago PULSE Issue 9.2: Spring 2023

FROM THE EDITOR-IN-CHIEF

Dear readers,

April showers bring May owers! As we begin to wrap up this 2022-2023 academic year, we are excited to share with you this Spring’s issue. is issue is comprised of 8 articles from students’ perspectives ranging from historical narratives to opinion pieces.

Not only does this issue explore the history of medicine ranging from Napoleon’s favorite physician, Dominique-Jean Larrey, to the historical origins of healthcare systems, this Spring issue also examines important modern dicussions in healthcare, such as in the maternity ward and clinical research cohorts.

To our graduating seniors, thank you for your long-standing commitment to PULSE, and we wish you the best of luck in all your future endeavors!

Have a great summer and happy reading!

With regards,

Riley Hurr

Writers

Alexander von Kumberg

Emnet Djibtila

Hunter Bershtein

Michelle Mejia

Milla Dobrovolska-Ivanova

Rachel Zhang

Rahul Burra

Shiv Sawhney

Cover Design

Kim

Editors

Ally Wang

Aman Majmudar

Ashley Chen

Charlotte Clulow

Emily Shi

Michelle Lu

Rina Iwata

Sanaa Imami

Riley Hurr

Senior Editors

Ayman Lone

Fareen Dhuka

Managing Editor

Sophia Falk

SALUTING THE COURAGE AND DEVOTION OF NAPOLEON’S FAVOURITE PHYSICIAN

By Alexander von Kumberg

Edited By Ally Wang

It is o en the case that scienti c advancements unravel at their highest rates in times of war. For example, the Second World War forged many of the technologies that most visibly de ne the modern world: computers, jets, radars, satellites, and synthetic rubber. e medical sphere is no stranger to such an uncomfortable truth. Rather, throughout history, the greatest medical innovations are o en coupled to the most brutal wars. Such a spectacle is most apparent in the realm of surgery. Administrative tablets from the Assyrian and Babylonian civilizations dating back to 2000 BC note the practices of physician-priests titled asu who were incorporated into armies and acted as proto-military surgeons.

ese gures would utilise the skills learned on the battle eld to treat kings and priests in times of peace. Possibly, the most renowned army physicians of antiquity were found in the Roman Empire. e legions’ physicians had the unique opportunity to access the anatomical fervour of a Galenic medical education as well as the ability to dissect human

cadavers – an act seen as sacrilege in civil Roman society but one that naturally followed the practice of saving lives on a battle eld. e rise of the nation-state in Early Modern Europe enabled political entities to arm and mobilise unheard swaths of their populations. e pinnacle of such a practice is Revolutionary France’s levée en masse (mass uprising), which compelled all able-bodied and unmarried men between 19 and 25 to enlist in the Armée Révolutionnaire Française. As the Ancien Regime gave way to the republic and the ethea of Bourbon autocracy were purged by the principles of Liberty, Equality and Fraternity, the tumultuous political metamorphosis of France birthed the decades of total war that bloodied the elds of Europe during the Revolutionary and subsequent Napoleonic Wars in an unparalleled manner. As one can imagine, this era gave rise to monolithic medical advancements. However, no 18th or 19th century medical mind could rival the genius and heroism of Napoleon’s favourite physician and the father of modern

military surgery, Baron Dominique-Jean Larrey.

Dominique-Jean Larrey was born not as a baron but as a son of a shoemaker in Beaudéan, a small village in the Pyrenees. An orphan at 13, Larrey’s youth was spent with his uncle, the chief surgeon of Toulouse. A er an eight-year apprenticeship, Larrey studied medicine in Hôtel-Dieu de Paris, the clinical school of France’s leading surgeon, Pierre-Joseph Desault. Larrey’s youth was evidently spent surrounded by ingenious surgeons. Desault was renowned for his ability to construct his own surgical tools – a useful skill for any future military surgeon. Following such a superb and evidently inspiring education, Larrey was appointed as a surgeon in the Royal French Navy, and was sent to defend Newfoundland in 1787. As the youngest medical o cer in the French navy, Larrey would come to grow in renown and become a true military man. As a true polymath, Larrey would also become a budding biologist, being

spurred on by the unique ora and fauna of North America, writing his observations and later publishing them. On his return to France, Larrey continued his education at the Parisian College de Chirurgie, but was swayed by the radical enlightenment philosophy he heard on the streets of Paris. Subsequently, Larrey led a group of medical students in the storming of the Bastille in 1789. He utilised his medical skills on the very streets of the city he was studying in, and it was there that he made his rst of many novel medical advancements. Amputations were commonplace prior to the development of e ective antibiotics (3/4 of Civil War operations were amputations), as it was better for limbs with wounds favouring infection to be amputated and le to heal via way of granulation – the process by which new capillaries and thick tissue form like a scab – and/or more e ectively seal the wound by performing a sh-mouth incision. Surgeons tended to delay

amputations for 12-24 hours to allow a degree of resuscitation of the patient. However, Larrey’s experience as a surgeon on the bloody streets of Paris convinced him to immediately amputate if necessary. Such a technique unequivocally improved the results of amputations, decreasing mortality and increasing survivability. Although Larrey’s youth was certainly exemplary, his greatest and most numerous achievements developed following his enlistment in the Army of the Rhine in 1792.

e Army of the Rhine was one of the major armies of the Armée Révolutionnaire Française. Larrey’s service as a regimental surgeon-major in the army brought him to Strasburg. It was in the campaigns against the forces of Coalition that Larrey bore witness to the speed at which horse-drawn artillery traversed the battle eld. Minister Louis de Narbonne titled this artillery transportation ‘ ying artillery.’ In uenced by this military technology, Larrey formulated the ambulance volante or ‘ ying ambulance.’ General Custine, for political rather than practical reasons, allowed the young

physician to follow through with his plans to construct and proliferate these ying ambulances. e rst modern battle eld ambulance that Larrey produced was a simple horse-drawn cart, driven and manned by a physician and some nurses. Such a development was critical, as, prior to this development, surgeons were compelled to remain at least three miles behind the frontline to ensure that France’s greatest medical minds were not cut down in the midst of battle. is meant that wounded soldiers were required to make their own way to the eld hospital – or be assisted by comrades – draining men from the battle eld. Larrey’s ambulance system was a great success. It drastically improved survival rates for soldiers as well as morale. Larrey would further re ne his model with strong padding and suspension for patient comfort. Fold-down ramps were also used as makeshi operating tables, so the most direly wounded were given a ghting chance

to make it to the eld hospital. Later, a contingent of soldiers as well as a drummer were added to the ambulance to protect the removal of the wounded during the course of battle. e ying ambulance system spread to the other French armies, and it is said that all critically wounded soldiers were operated on within 24 hours – o en prior to the end of battle. By 1797, General Napoleon Bonaparte had heard of Larrey’s heroism and ingenious novelties. He personally requested that Larrey join his very own Army of Italy. During France’s Revolutionary Wars, Larrey would come to develop the earliest formulations of the contemporary triage system. Triage is used to determine which patients need to receive treatment rst by taking into account their health status, prognosis of disease, and resource availability. Larrey’s triage initiative disregarded class, name, rank, and even nationality. Soldiers of enemy armies as well as allies would be treated as if French, with the most critically injured being treated rst. is mentality grew out of Larrey’s early postulation that it is necessary to operate as quickly as possible, and he aimed to operate one hour a er the patient had received the wound.

is ensured that the patient was still in shock and the muscle tissues were more relaxed with a lower blood pressure. Hence, amputation would take less time, and less bleeding would occur. By 1798, Larrey was appointed Surgeon-in Chief and was attached to Napoleon’s expedition to Egypt. In Cairo, Larrey

established a medical school for army physicians. ere, he and his students studied Egyptian ophthalmia, a disease characterised by in ammation in the eye, and Larrey linked the condition to the red eye that was commonplace among European crusad-

ers in the Middle Ages. During the Siege of Acre Larrey was wounded thereby compelling him to return to France in 1801. Nonetheless, Larrey’s military physicianship was long from over, and his life continued to be marked by exemplary moments of surgical mastery. Such events included a successful two minute amputation of Marshal Jean Lannes’ leg, pre-anesthetic mastectomy of Madame d’Arblay, the rst successful amputation at the hip-joint, and the rst description and diagnosis of trench foot. Furthermore, Larrey pioneered the use of maggot therapy to prevent wound infection – as the green-bottle y maggots digest necrotic tissue. Yet, besides Larrey’s surgical prowess, the young surgeon was an exemplar of heroic physicianship and zealous care for patients.

e rst documentation of Larrey’s illustrious courage occurred in 1793, when Larrey drew his sword and charged at retreating French troops, ordering them to return to combat.

e troops swi ly listened to him due to the immense respect they had for him. Indeed, the French army’s respect for Larrey was insurmountable, a result of the many lives he had saved, and the care he possessed for

his comrades. In one instance, Larrey bore witness to Prussian soldiers stealing from wounded French troops. He swi ly ordered his escort to charge at the Prussians and rescue the wounded men, loaded them on his ying ambulance, and saved all of their lives. It was commonplace to see Larrey operate and perform rst aid on the battle eld itself. Indeed, while in Acre, Napoleon’s cousin Arrighi de Casanova was shot in the neck. Larrey was called for and began to apply bandages. His concern for his patient was so much that he did not take his eyes o the wound despite his hat being shot o . Another instance of Larrrey’s compassion occurred when General Maximillien du Falga tangled his wooden leg in the rigging of a ship and fell overboard. Larrey immediately dove into the sea and dragged the general to shore. Yet, critically, Larrey’s nobility is best seen in his blindness for nationality. While accompanying the Army of the Orient, Larrey complained to Napoleon himself when he saw General Dupas treating British prisoners deplorably. It is also said that Larrey saved the life of the famed Prussian General Blücher’s son. During the Battle of Borodino, Larrey performed about 200 surgeries in one day – a possible world record. Larrey’s renown was so great that it in uenced the perception of opposing generals. Indeed, despite Larrey’s support of the Revolutionary cause, he was treated well in the brief period of Bourbon restoration. Moreover, during the battle of

Waterloo, the Duke of Wellington noticed Larrey caring for the wounded under re, and ordered his men not to shoot in his direction, stating, “I salute the courage and devotion of an age that is no longer ours.” Ultimately, Larrey’s reputation saved his life. Following the defeat at Waterloo, Larrey was captured by Prussian soldiers and ordered to be shot. However, the Prussian surgeon that was meant to bandage Larrey prior to his execution recognized him. Larrey was sent to Blücher, who dined with him and gave him new clothes and enough money to travel back to Paris.

Larrey’s post war career was devoted to writing and educating. His fame was noted throughout the world, and he would visit England and present before a symposium of British surgeons. He was also o ered positions to take charge of Imperial Russia and Brazil’s armed forces, but he declined. In 1830, Larrey was elected a member of the American philosophical society. In 1842, he went to Algiers, where he contracted pneumonia on the return journey, perishing in the same year.

It is said that Fritz Haber, when referring to his own actions in the Great War, stated, “During peacetime a scientist

belongs to the world, but during war time he belongs to his country.” Such a sentiment cannot be attributed to the virtuous Dominique-Jean Larrey. Larrey’s o cial title was Surgeon-in Chief of France’s Revolutionary and subsequent Imperial armies; however, he was a caring and tremendous surgeon for all patients, regardless of allegiance. His courage and zeal to save lives de ned his practice and fueled his formulation of novel medical techniques and technologies. Larrey’s ambulances, triage system, and proto-MASH (Mobile Army Surgical Hospital) have and continue to form the bulwarks of military medicine, and thus Larrey deserves the title of the father of modern military surgery. In 2011, the Committee of Chiefs of Military Medical Services in NATO (COMEDS) bestowed the rst Dominique-Jean Larrey Award as the North Atlantic Alliance’s highest medical honour awarded for outstanding medical achievements. Moreover, Larrey has two major monuments, one outside the military hospital of Val-deGrâce and the other in the hall

of the Academy of Medicine. His name is also etched in the Southern pillar of the Arc de Triomphe in Paris. Yet, the most just and appropriate laurels Larrey could ever possess are the words of his beloved emperor, Napoleon; “If ever the soldiers erect a statue, it should be to Baron Larrey, the most virtuous man I have ever known.” Absolute fervour in pursuit of patient welfare – regardless of identity – is a necessary attribute for all physicians, and we must pay homage to those behemoths of old, like Larrey, who propelled and altogether embodied the mindset.

Sources:

Dominique Jean Larrey (1766-1842) and his contributions to military ... (n.d.). Retrieved March 20, 2023, from https://daneshyari.com/ article/preview/10215698.pdf

Dominique-Jean Larrey Biography: International Paramedics Day. Paramedics Day. (n.d.). Retrieved March 20, 2023, from https:// www.internationalparamedicsday.com/dominique-jean-larrey-biography

Dominique-Jean Larrey. CATHOLIC ENCYCLOPEDIA: Dominique-Jean Larrey. (n.d.). Retrieved March 20, 2023, from https://www. newadvent.org/cathen/09007a.htm

Dunea, G. (2017, January 22). Dominique-Jean Larrey, Napoleon’s army surgeon (1766-1842) - hektoen international. Hektoen International - An online medical humanities journal. Retrieved March 20, 2023, from https:// hekint.org/2017/01/22/dominique-jean-larrey-napoleon-army-surgeon/

Ellis H. (2016). Dominique Jean Larrey: Napoleon’s surgeon. British journal of hospital medicine (London, England : 2005), 77(6), 366. https://doi. org/10.12968/hmed.2016.77.6.366

Jensen, N. D. (n.d.). Doctor Dominique-Jean Larrey. Dominique-Jean Larrey (1766-1842). Retrieved March 20, 2023, from https://www. frenchempire.net/biographies/larrey/ Karamanou, M., Rosenberg, T., Liakakos, T., & Androutsos, G. (2011). Baron Dominique-Jean Larrey (17661842): founder of military surgery and trauma care. Chirurgia (Bucharest, Romania : 1990), 106(1), 7–10.

LA;, B. (n.d.). Baron Dominique Jean Larrey (1766-1842). father of modern military surgery, Innovater, Humanist. e Journal of thoracic and cardiovascular surgery. Retrieved March 20, 2023, from https://pubmed. ncbi.nlm.nih.gov/3537533/

Remba, S. J., Varon, J., Rivera, A., & Sternbach, G. L. (2010). Dominique-Jean Larrey: the e ects of therapeutic hypothermia and the rst ambulance. Resuscitation, 81(3), 268–271. https://doi.org/10.1016/j. resuscitation.2009.11.010

Sams, S. (2019, May 13). Dominique Jean Larrey – surgeon in chief of Napoleon’s Armies. Royal College of Surgeons. Retrieved March 20, 2023, from https://www.rcseng.ac.uk/ library-and-publications/library/blog/ dominique-jean-larrey-surgeon-inchief-of-napoleons-armies/

Outside Anatomy Class: The Lack of Health Literacy in Contemporary Society

By Michelle Mejia

Edited By Rina Iwata

Anatomy pop quiz! Point to your epiglottis.

If you pointed to an area near your throat, then you are semi-correct. If you pointed towards the back of your throat above your tonsils, then you are completely correct. e epiglottis is a ap that covers the trachea, or the windpipe, when swallowing so that food does not enter the lungs. Whenever you choke on your food, it happens because some food or object has accidentally made its way to the trachea. e epiglottis prevents this, allowing you to eat your food freely without the constant worry of possibly choking on it.

If you had trouble answering this question, you fall into the 88% of Americans who are considered health illiterate (8). Now imagine how a patient with a serious health condition feels like when they have no idea what their doctor is talking about.

e term that is used to dene what this patient is lacking is health literacy—which is gener-

ally referred to as “possession of knowledge about health among individuals.”

(5) A person that possesses health literacy is able to understand the health-related information they are given, typically by a doctor or by an online source. Additionally, they are able to use the information to make a well-informed decision about their health or the health of others. A person is considered health illiterate if they do not have the capacity to do this. However, it should be mentioned that it is not their fault. ere are many factors that have contributed to the lack of health literacy in contemporary society, and we will touch on these a er we discuss some examples of health illiteracy seen in our normal day-to-day lives.

How do we encounter anatomical illiteracy in our day-to-day lives?

If you were given an anatomy quiz today, would you ace it?

In 2016, a study was conducted in the City of Lancaster to test the health literacy of the public. e attendees of the event were given the opportunity to complete an anatomical knowledge survey (1). e rst part of the survey

included an anatomical quiz, and the second part asked for the general demographic information of the participant. In the rst part of the survey, the participants were given a body diagram, and they placed the letter that corresponded to a body part in the place where they thought the organ was located (1). e study revealed that the only organ that was answered 100% correctly was the brain, and the adrenal glands were answered correctly by less than 15% of the participants. It was found that out of the 63 participants with a mean age of 36.5 years, the participants who were employed in a health-related area scored higher than those who did not. Additionally, men were found to score higher when identifying muscles compared to women, but not when identifying organs. e results of this study revealed that there is variation in the ability of the public to identify anatomical structures, and better health education correlated to higher

scores. ese results suggest that the majority of the public is not health literate and that the only way this issue can be addressed is through the implementation of health education.

Health illiteracy in women

Health illiteracy can have di erent consequences depending on the gender of the patient, and these perspectives should be taken into account to improve the health literacy of the public.

In 2021, a study was published that tested the knowledge of the public regarding female genital anatomy and pelvic organ prolapse (POP). POP is a condition where one or more of a woman’s organs in the pelvis drop down from their normal position and start to protrude into the vagina (9). e 191 participants from a general outpatient (OPD) and urogynaecology (UG) departments at a UK teaching hospital were given a questionnaire that asked them to label a diagram with the female external genitalia and included free response questions about the symptoms and treatment for POP (3). e study revealed that out of the 191 participants, women had labeled more organs correctly compared to men. Furthermore, only 53% of the participants knew what pelvic organ prolapse (POP)—the condition wherein one or more of the organs in the pelvis slip down from their normal position and

bulge into the vagina—was. e results of the study concluded that participants had little understanding of the external female general anatomy and POP.

ese results show that there is a lack of health literacy in the public and could have a connection to the decision-making of patients regarding health-related problems. Furthermore, the study also demonstrates that there is a knowledge gap in women regarding their own anatomy.

It makes you wonder how an individual can be so uninformed about something regarding their own body that they utilize every day. In a survey conducted with participants from Great Britain through YouGov, it was revealed that over “half of women didn’t realize their vagina was self-cleaning.” (12) A poll taken by 2,000 women through Intima also revealed that “ y-seven percent of the women surveyed admitted they don’t know as much about women’s anatomy as they should.” (11) Additionally, “forty-two percent wished they had a better understanding of what the di erent organs in the reproductive system do.” (11) e fault lies in the society that stigmatizes vagina talk. It is such a taboo topic that it can also be seen in the opposite gender. BuzzFeed wrote about the responses to a Reddit thread that asked, “What’s the worst mansplanation/ misunderstanding of your reproductive anatomy that you’ve heard?” (13) One of the responses was “that we can control period ow as we do for pee.” (13) It is evident that this implication has had an e ect on both men and women.

Furthermore, this lack of knowledge has stopped women from visiting the doctor for symptoms that were pre-

sumed to not be critical. Sarah Digby had su ered from severe menstrual pain ever since she was a child, and she would put o the pain by simply thinking that she had “a weird body.” (15) Ms. Digby thought that her pain was normal and did not nd out that she had endometriosis until about 15 years a er she started menstruating. Endometriosis is a condition that causes severe pain in the pelvis because tissue that is similar to the lining of the uterus grows outside of the uterus. Many women ignore the pain because society teaches young girls that period pain is normal. Additionally, there is not much education surrounding the reproductive health and anatomy of women to begin with.

Health illiteracy in men

Health illiteracy can also be seen in the male population. In 2002 a study was conducted to measure the knowledge of mostly African-American men from two low-income clinics on common prostate terms (4). e 105 participants were chosen based on their age ( ≥ age 40 years) and on the presumption that they did not have a healthcare-related job. Face-to-face interviews were conducted where the participants were asked questions based on 28 medical terms that described “sexual, urinary, and bowel function.” (4) e questions were taken from a review of patient education

materials for prostate cancer and treatment and seven prostate health status questionnaires. e study disclosed how “fewer than 50% of patients understood the terms “erection” or “impotent”” and that the “Median literacy level was fourth to sixth grade”. Moreover, the results exposed that the prostate cancer knowledge of the participants was poor. ese results give insight to the health literacy of men overall and demonstrated that, like women, men know little about their own anatomy.

Health illiteracy has also been found to impact the willingness of men to seek medical health. A study that was published in 2021 surveyed 68 patients aged 50-75 years who had erectile dysfunc-

tion (ED) symptoms of benign prostate hyperplasia (BPH) (16). e study aimed to nd a correlation between patients with ED who do not seek medical health and health literacy. e research concluded that as the education levels and income increased, ED became more important to individuals, and they were driven to seek medical help. erefore, as an individual becomes more health literate, they are more likely to go see a doctor.

Further education surrounding human anatomy in the classroom can have signi cant impacts on the public. Not only will there be an increase of individuals seeking medical attention, but there will also be a higher quality of life.

Why is there a lack of anatomical literacy?

In 1970, a study was conducted that

tested the knowledge of 234 participants in the streets of Hamburg, Germany regarding the human anatomy and commonly used medical terms. In 2019, the same questionnaire that was used in the 1970 study was used in 2019 to measure the knowledge of 537 participants in Hamburg, Germany. e study revealed that there was more understanding in the general public concerning the human anatomy and commonly used medical terms in 2019 than in 1970. ese results were not very surprising, especially with the rise of modern technology that exposes individuals more to human anatomy. However, the results were not perfect, and it was revealed that there is more room

to grow. Although there has been an increase of the general public’s health knowledge throughout the years, there is still a great extent of health illiteracy. is is due to a systemic lack of focus on this eld in the educational environment. Knowledge of human anatomy and of medical terms is not normally taught in the classroom and is commonly learned through other means. e individuals who possess great health knowledge are usually medical professionals and those who have pursued a health education. It would be bene cial to improve the future health literacy of the public through an increased implementation of coursework on human anatomy and medical terminology in the classroom.

e mortality rate might also drastically change, since low health literacy has been found to be associated with an increased risk of death (10).

Why should we care about the lack of anatomical literacy?

Health literacy plays a huge role in the future of humanity as a whole. Our health is dependent on health literacy, and it is shameful to not treat it with the importance it deserves. When a patient goes to see the doctor, it is frequently thought that the

doctor will x everything and that a er the visit everything will be ne; however, this is not always the case. It is important for patients to be their own advocates and know what is best for them in respect to their own health.

ere have been cases of malpractice in medicine, mostly due to the pressure and time constraints that healthcare professionals constantly endure. Furthermore, women have been given the short end of the stick for most of history. Ever since the beginning of medicine, there has been a gender bias against women.

e biggest example is the illness called “female hysteria”, which was used to describe a woman that did not demonstrate acceptable behavior. Medical diagnoses like this were normalized because of the creation of the healthcare eld in a “male-dominant world”. Unfortunately, we can still see the e ects of these practices today through medical gaslighting and ignorance. Olivia Goldhill, who had struggled from menstrual pain ever since she was a child, described her pain to be “as severe as a slipped disc” (14). Her doctors told her that she probably had ovarian cysts or an STI. She described that she felt “medically gaslit,” and decided to see a specialist on endometriosis a er she read an article about the disease that identi ed the symptoms she was experiencing. If Goldhill had not self advocated for her health, then she would not know that she had endometriosis. Sadly, there are cases where patients do not nd the underlying cause of their symptoms, and they are le with

confusion. It is important to be health literate and seek di erent health professional opinions if the rst diagnosis does not seem to match with the symptoms.

How can we address this issue?

As mentioned earlier, health literacy is something that cannot be overlooked and can be improved upon in a number of ways. Some of these ways include increasing education on human anatomy and common medical terms. Furthermore, taking a di erent approach in the medical eld when explaining health-related information to patients in the medical room can also improve the health literacy of the public. It is essential to help “engage, encourage, and empower the patients in participating in their own health care and treatment decisions.” (6) is allows the patient to leave satis ed with their care and have better results in regard to their health. Medical professionals can better educate their patients by having education materials at hand and online references to help the patient better understand their medical condition and further enhance health literacy.

ere is no excuse when it comes to bettering the lives of humanity as a whole. By educat-

ing one classroom and patient at a time, we can improve health literacy dramatically.

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Ogolini, M. (2022, December 29). 26 times people had absolutely no idea how women’s bodies work, but opened their mouths anyway. BuzzFeed. Retrieved April 2023, from https://www. buzzfeed.com/mayaogolini/bad-female-anatomy

Goldhill, O. (2016, February 15). Period pain can be “almost as bad as a heart attack.” why aren’t we researching how to treat it? Quartz. Retrieved April 2023, from https://qz.com/611774/ period-pain-can-be-as-bad-as-a-heartattack-so-why-arent-we-researchinghow-to-treat-it

Blum, D. (2022, July 18). A debilitating illness, o en ignored. e New York Times. Retrieved April 2023, from https://www.nytimes.com/2022/07/18/ well/live/endometriosis-symptoms-treatment.html

Demirbas A, Gürel A, Gercek O, Topal K, Baylan B. e E ect of Health Literacy on Men Seeking Medical Attention for Erectile Dysfunction. Cureus. 2021 Dec 15;13(12):e20424. doi: 10.7759/cureus.20424. PMID: 35047263; PMCID: PMC8758978. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC8758978/

Considerations for Physician-Assisted Suicide

By Rachel Zhang

Edited By Ashley Chen

A er being diagnosed with a stage 4 malignant brain tumor, 29-year-old Brittany Maynard moved from California to Oregon to end her life via physician-assisted suicide.1 As a strong advocate for the practice, Brittany explained that any treatment would only prolong her su ering. Brittany valued her physical and mental capacities and did not want to in ict additional pain upon family and friends as they watched her slow decline. She was a strong advocate for Death with Dignity (DWD), a rming that all terminally ill patients across the U.S. should have access to assisted suicide and know it as an informed potential option.

e concerns that Brittany had towards the end of her life and her reasons for pursuing medically-assisted suicide are shared by many terminally ill patients. Patients should be ac-

tively involved in making health-related decisions pertaining to their own lives. If medically-assisted suicide is available as a su ering-reducing option, there must be transparency in access to this option; all patients deserve the autonomy to decide when and how they will die. As it currently stands, physician-assisted suicide is mandated by state law in Colorado, the District of Columbia, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont and Washington. In Montana and California, it is an option only available via court decision.2 Patients must be diagnosed with a terminal illness and have a prognosis of six months or less.

However, in a capitalist society with a large pharmaceutical industry, nationwide implementation of physician-assisted suicide would inevitably increase the frequency and pro tability of suicide-inducing prescriptions. When considering the opioid crisis and the role of pharmaceuticals in advertising and promoting highly addictive prescriptions, these companies o en prioritize nancial pro ts over the interests of individual patients.3 Similarly, in a system of for-pro t hospice care, hospices

hire salespeople to hit numerical quotas of hospice enrollees, and vague restrictions like death within 6-months allow collusion and over-enrolling to occur.4 e legalization of physician-assisted suicide on the nationwide scale runs the risk of opening opportunities for medical malpractice and pharmaceutical corruption, pushing patients towards the option of assisted suicide with a premature bias.

At rst glance, regulations for physican-assisted suicide appear to be quite stringent; nevertheless, these restrictions are designed to ensure that a patient requesting physician-assisted suicide is mentally sound and completely certain regarding their decision. In Oregon, the Death With Dignity Act requires that the patient make two oral requests to a physician, separated by at least 15 days. e patient must also provide a written request signed in the presence of two witnesses, where at least one witness is unrelated to the

patient. e physician must then con rm the patient’s diagnosis and prognosis. Further, the physician must inform the patient of all other available alternatives.5 Nevertheless, as formerly discussed, the prognosis for a patient is a subjective measure, varying from one doctor to the next. For a psychiatric patient whose ailments do not always appear physically, it can be particularly di cult to determine whether assisted-suicide is in the patient’s best interest. Coupled with concerns over the pharmaceutical industry, restrictions to physician-assisted suicide must be stringent and less subjective.

Moreover, during physician-assisted suicide, a physician supplies a patient with a prescription for an oral drug with the capacity to end one’s life. While the legalization of physician-assisted suicide nationwide would not require all physicians to participate, its normalization could create further medical mistrust amongst uninsured,

low-income, and racially disadvantaged groups.6 Although the role of a physician is primarily understood to be that of a trusted healer who cares for patients, patients who experience racism and discrimination in the medical setting are already apprehensive to and distrusting of medical intervention. Nationwide legalization of physician-assisted suicide would lead to misconceptions and draw a further line between physicians and patients who really need care.

Although physician-assisted suicide is an important option for individuals with terminal illnesses to receive, the legalization of physician-assisted suicide across the nation would have detrimental impacts. Prior to this legalization, e orts must be made to regulate the pharmaceutical industry and decrease pro tability incentives in the healthcare system. Stringent policies should also be implemented to allow for well-regulated physician-assisted suicide, and more work must be done to build physician trust with disadvantaged individuals, removing implicit bias in patient care. e resolution of these concerns is di cult, but failing to address these concerns could result in monopolization and

exploitation of patients and their lives. us, it is of the utmost importance that steps are taken to improve healthcare access and regulation, particularly in the realm of end-of-life care.

Sources: Peralta, Eyder. “As Planned, Right-to-Die Advocate Brittany Maynard Ends Her Life.” NPR. National Public Radio (NPR), November 3, 2014. https://www.npr.org/sections/thetwo-way/2014/11/03/361094919/as-planned-rightto-die-advocate-brittany-maynard-ends-her-life.

“Physician-Assisted Suicide Fast Facts.” CNN. Cable News Network (CNN), May 26, 2022. https://www.cnn.com/2014/11/26/us/physician-assisted-suicide-fast-facts/index.html.

Feldscher, Karen. “What Led to the Opioid Crisis-and How to Fix It.” Harvard T.H. Chan School of Public Health. Harvard T.H. Chan School of Public Health, February 24, 2022. https://www.hsph.harvard.edu/news/features/ what-led-to-the-opioid-crisis-and-how-to- x-it/. Kofman, Ava. “How Hospice Became a for-Pro t Hustle.” e New Yorker. e New Yorker, November 28, 2022. https://www.newyorker.com/magazine/2022/12/05/how-hospice-became-a-for-pro t-hustle.

“Frequently Asked Questions: Oregon’s Death with Dignity Act (DWDA).” Oregon Health Authority. Oregon Health Authority, 2023. https://www.oregon.gov/oha/ph/providerpartnerresources/evaluationresearch/deathwithdignityact/pages/faqs.aspx.

Bazargan, Mohsen, Sharon Cobb, and Shervin Assari. “Discrimination and Medical Mistrust in a Racially and Ethnically Diverse Sample of California Adults.” Annals of Family Medicine. e Annals of Family Medicine, January 1, 2021. https://www.annfammed.org/content/19/1/4.

“Two Healthcare Systems Walk into a Bar…”:

The Comparative Historical Account on the Bad Punchline Healthcare Systems Seemingly Exist as Today

By Rahul Burra

Edited By Michelle Lu

Mention the term “healthcare policy” to a person on the street and you are likely to immediately encounter frustration or be met with someone rolling their eyes. Indeed, people are increasingly fed up with seemingly complicated, ine cient, and expensive systems of accessing healthcare – in America perhaps more so than anywhere else. A question that follows then is, how did we get here?

In the tortuous complexity and perpetual imperfection that each remains mired in today, the United Kingdom’s National Health Service and America’s largely privatized healthcare system o er an excellent case-study in radically disparate systems whose paradoxes beg inquiry

into their historical origins. us, at a moment of burgeoning re-interest in the ideas of public health and ensuring that as many people as possible have access to adequate medical care, understanding the events and key players mediating the evolution of these two sharply distinct healthcare models is perhaps a crucial step in e orts to untangle and hopefully address their modern-day shortcomings. Indeed, while forces of social upheaval were swirling with seemingly equal ferocity on either side of the Atlantic, by the latter half of the twentieth century, the United States’ primarily employer-based private insurance model would retain only limited public options via Medicare/Medicaid while the British NHS would largely uphold its promise that all healthcare would be free at the point of delivery for those who paid, albeit higher, taxes.

In its modern form, the British NHS encompasses the NHS England, NHS Scotland, NHS Wales, and Health and Social Services Northern Ireland – each of which have variations in precise coverage, funding, and policy but share in the common fundamental organization of government-funded systems in which general practitioners providing primary healthcare and referrals, hospitals providing emergency and specialist (including psychiatric) care, and ambulatory services are all free to British citizen patients at the point of use, and the NHS retains pre-eminent market power in pricing of drugs. While niche private sectors of hospital and primary care where patients/insurers pay outright for

medical services do exist in small proportion within the British system, the NHS by and large remains the preferred route of care for the vast majority of patients in both planned and unplanned procedures. Criticisms and shortcomings of the UK healthcare system today largely revolve around issues of chronic sta shortages and overwork, backlogs in accessing secondary services in a timely manner, excessive bureaucracy, and chie y, insufcient funding – all issues particularly highlighted throughout the recent COVID-19 pandemic - rather than criticisms on the fundamental ethos of the system. On the ipside, the modern-day American healthcare system remains a bit more nebulous to describe as neatly. Most prominently, the system includes a burden primarily on the part of the individual patient rather than the government to pay for medical and ambulance services through private insurance or out-of-pocket, a historical expectation of employer-provided insurance plans, private ownership and competition among hospital systems and independent providers for (theoretically) free market patient choice, and tax-funded limited health coverage provided by state

and federal governments for certain eligible groups via things like Medicaid, Medicare, and VA care. e myriad of issues with this system are multitudinous, sobering, and need not be entirely re-tread here. ese criticisms, however, generally fall in line with such frequently cited points as the system’s facilitation of exorbitant pricing for essential medications and procedures, the large proportion of uninsured citizens and resulting cost-aversive responses to seeking care, and the poor national health statistic outcomes returned from a system with the greatest per-capita healthcare spending in the world.

Looking at the historical origins of the British healthcare system, the NHS of England was o cially created with the passage of the National Health Service Act of 1946 under the Clement Atlee Labour government and the guidance of the rst Minister of Heatlth, Aneurin Bevan MP. A key precedent to this moment was the passage of the National Insurance Act of 1911 under the David Lloyd George Liberal government. By establishing a government-provided system of health insurance for industrial workers, this act marked the rst significant departure from a prior system in which only segments of the middle and the upper class could seek out private health care and members of the working class had to rely on the services of scant charity hospitals funded by donations of the wealthy. e act severely revised

aspects of the stigmatizing Poor Law Legislation of 1832-1834, but stopped short of providing universal health coverage for all citizens largely due to harsh initial opposition from the British Medical Association (BMA), trade unions running their own insurance companies, and so-called ‘friendly societies’ (mutually-run associations of managing insurance, pensions, and savings for members). On the heels of an interwar period of signi cant economic distress and social upheaval, by the time Britain had re-entered massive global con ict in WWII and the toll of physical and mental wounds had le virtually no British citizen unscathed, the mood of the general public and leaders had signi cantly shi ed in favor of taking a more active role in addressing public health and welfare. is was the context in which economist William Beveridge authored his famous 1942 Beveridge Report describing the need for signi cant reforms in social welfare to prevent widespread disease and poverty a er the war, and in which the Ministry of Health’s 1944 White Paper proposing central taxation-funded universal healthcare was written – both of which are

considered some of the most crucial documents leading to the eventual formation of the NHS and British Welfare State. Following the Labour Party’s landslide victory in 1945, a erce battle over the creation of such a universal healthcare system ensued between new Minister of Health Aneurin Bevan and private hospitals and insurance companies, friendly societies, and particularly the BMA, who would hold out and nearly foil e orts entirely in the last hour. As the BMA argued that its steadfast resistance to negotiation re ected a widespread aversion among doctors to becoming employees of the state, Bevan would organize an immense mass publicity campaign to rally the support of the people and personally engage in intense parliamentary debates railing against the supposed political toxicity of the BMA and other interest groups ghting the Health Act. Eventually, a robust and centralized NHS would be established via passage of the National Health Service Act in 1946 with only minimal concessions by the government to give consultants and GPs the freedom to maintain private practices.

Much debate and analysis on the conditions in which this rst-of-its kind system of public

healthcare assurance came into being, has been put forth among scholars of health policy and history in the years since the NHS’s creation. According to historian Sharon Schildein Grimes in her book “ e British National Health Service: State Intervention in the Medical Marketplace, 1911-1948,” the degree of opposition to nationalized health care is o en understated and warrants greater appreciation for the e ectiveness of Labour leaders in ultimately passing the act. Grimes and other contemporary historians would seek to push back against the alternative narrative that the public’s witnessing of the drawnout collapse of the Nazi regime as a foil gure is what allowed for the passage of a socialist NHS policy and creation of British welfare state with relative ease on the part of the government. Medical historian Frank Honigsbaum, similarly looks at the creation of the NHS through the lens of the British civil service in his book “Health, Happiness, and Security: e creation of the National Health Service,” and suggests that it was a small group of important lawmakers and civil servants in between the short time range of 1936 and 1948 that were most responsible for overcoming staunch opposition from groups like the BMA and insurance groups that had stumped previous governments in similar e orts, in order to ultimately pass the NHS act.

Where the creation of the British NHS o ers a case study in clear, linear progression between well-de ned milestones in the creation of a trans-

formed healthcare system, the historical origins of the American healthcare system in the early to mid-twentieth century are less straightforward. Among key events is the creation of the rst employer-based healthcare plan for employees at Baylor Hospital in 1929 – a model initially pushed forward by labor unions for its potential to provide workers with health coverage – in what would become a precursor to future Blue Cross plans. Moreover, as the Great Depression brought social policy reform to the forefront of the public’s consciousness and Roosevelt’s presidential agenda, healthcare appeared to be among the frontiers poised for rapid government overhaul and control. However, despite strong support from Roosevelt and his Technical Committee on Medical Care throughout the 1930s, the creation of nationalized health coverage would ultimately be dropped in order to prevent the blockage of other social security measures included in the New Deal from a more reluctant Congress. At the same time, private insurance and hospital systems would see rapid growth during World War II and into the post-war period, while the American Medical Association (AMA) would emerge as a powerful bargaining wing

claiming to represent the interests of doctors (whose opposition to national healthcare stemmed from the argument that it would cause physicians to lose their autonomy, similar to the BMA’s stance). In this context, President Harry Truman would get the US as close to a nationalized health insurance system as it would ever come with the Wagner-Murray-Dingell bill introduced within his Fair Deal agenda. However, an intense campaign from the AMA against national health insurance would kill this e ort as well, in its last stage. As the private hospital system and insurance industrial complex

continued to explode and conglomerate, e orts in nationalized health insurance would fall by the wayside through the 1950s and the decades that followed in favor of more employer-based health coverage plans with increasingly pricy pre-set ‘premiums’. e most notable exception to this would of course come with Lyndon Johnson’s passage of Medicare and Medicaid under the Social Security Act, which provided some home and hospital care coverage to the elderly, poor, and disabled – albeit with many notable constraints and compromises a er lobbying by insurance and hospital groups. is passage would come despite continued intense opposition by the AMA, largely due to the e orts of union groups now in favor of more national-

ized health insurance, relentlessly campaigning social activists, and a shi ing public attitude.

Historian Rosemary A. Stevens o en speaks to the oscillating and confusing nature of U.S. healthcare policy in her essays, and suggests that an overarching theme of the history of American healthcare is that the use of ideological terms like ‘socialism’ and ‘free-markets’ have o en served more as a vehicle for various interest groups to pass isolated legislation rather than to establish a wholesale direction for U.S. health policy identity like in the UK. Some scholars, like Beatrix Ho man,

would further argue that this aspect of US healthcare is why in contrast to some healthcare systems around the world, the history of American healthcare is one having existed in a perpetual context of “rationing,” and that American medical care has never been viewed predominantly as a right, but as a commodity.

ese historians of US healthcare policy would contend that this can explain why health insurance has always been signi cantly strati ed by race, socioeconomic status, and age in the U.S. and why no American movement in healthcare thus far has successfully delivered on the idea that health is a fundamental right to be guaranteed by the government.

So, what then might a comparative analysis of the historical context in which both systems of healthcare emerged tell us? If the demographic, economic, and political forces present in mid20th century British and American society and medicine so resembled each other, why then did one country rapidly move in the direction of immense public control over the healthcare system, and the other in immense privatization of nearly every facet of the medical care process? Could it really have been largely

a result of individual gures, of a di erence in political savvy, and even partially of a con uence of right-time/right-place on one side as compared to the other? In some ways, the handful of historians on the subject presented here may indeed suggest this to be partially true and a signi cant part of the US-UK healthcare model divergence. While the post-war le -wing governments of both countries faced opposition in their e orts to nationalize healthcare from similar groups (e.g. the BMA/AMA, private hospitals, and insurance), perhaps it was simply a question of Aneurin Bevan and the Atlee Labour coalition pushing back harder against these interests than their counterparts in Roosevelt and Truman in the U.S., that le one country with the NHS and the other with its uniquely hybridized model. However, it is also clear that other macro-factors likely played a role in this divergence: for instance, a greater precedent for state intervention in health on the British side and greater logistical challenges to centralized control in the more federalized United States. Ultimately, though, if we are to ever be able to address crises of unequal, insu cient, or substandard health care access in either country (and in the United States in particular) with new policy reform, it is paramount that we not only critically understand how and why di erent systems emerged in the rst place, but that we leverage this comparative historical lens to inform future action. On the

part of policy-makers and the public, the plague of perpetual pessimism and hopelessness that has seemingly befallen the healthcare question must necessarily be replaced with a willingness to open-mindedly look to the successes and failures in the development of other healthcare systems around the world and recognize dynamism and divergence – a reminder that healthcare need never be a static notion, and that a country’s ability to better ensure adequate health access to its people can change rapidly and signi cantly with concerted action by parties involved.

Sources:

Grimes, Sharon S. e British National Health Service: State Intervention in the Medical Marketplace, 1911-1948. London: Routledge, 1991.

Honigsbaum, Frank. Health, Happiness, and Security: e Creation of the National Health Service. London: Routledge, 1989.

Ho man, Beatrix. Health Care for Some: Rights and Rationing in the United States Since 1930. IL: University of Chicago Press, 2012. Accessed February 20, 2023. ProQuest Ebook Central.

Starr Paul. 1982. e Social Transformation of American Medicine. New York: Basic Books.

Stevens, Rosemary A. Public-Private Health Care State: Essays on the History of American Health Care Policy. NJ: Transaction Publishers, 2007.

THE HEALTH EFFECTS OF AIR POLLUTION

By Milla Dobrovolska-Ivanova

Edited By Charlotte Clulow

Global warming is o en attributed to the e ects of greenhouse gasses, which trap heat in the atmosphere and prevent it from being re ected back into space. e accumulation of heat within the atmosphere leads to the overall temperature of the planet increasing. Global warming has severe, negative impacts on the planet and its inhabitants, causing extreme weather events and increased air pollution. It’s a vicious, destructive cycle; while air pollution is increased by global warming, it is also one of its causes.

Air pollution encompasses both particulate matter and toxic gasses. Particulate matter, commonly referred to as PM, is composed of small, inhalable particles which range in size from 2.5 micrometers to 10 micrometers. When coupled with toxic gasses such as carbon monoxide, sulfur dioxide, nitrogen dioxide,

and ozone, they have severe detrimental e ects on air quality.(2) PM and toxic gasses are fundamentally connected and may be emitted simultaneously. Carbon dioxide, a greenhouse gas, is the byproduct of processes which release particulate matter into the atmosphere.(3) Both PM and toxic gasses are emitted from the “incomplete combustion of fuels or chemical reactions between gases.”(2) Human actions, such as burning fossil fuels, release a signi cant amount of carbon dioxide into the atmosphere; such processes, including vehicle exhaust emissions, factory smoke emissions, and other industry-based emissions, simultaneously emit particulate matter.

While air pollution contributes to global warming, it also has a signi cant impact on human health. Serious health conditions may arise from human exposure to particulate matter.

PM and toxic gasses are released into the atmosphere from everyday activities practiced by the vast majority of people, such as driving cars, lling a gas tank, or lighting a stove. A distinction must be

made between the two main categories of air pollution: ambient and household. Ambient air pollution is present in the outside environment, while household air pollution is limited to specific homes; a daily activity which contributes to household air pollution is lighting kerosene, while the fuel combustion associated with driving cars would contribute to ambient air pollution. e dangers of particulate matter in air pollution arise from their small size. A er entering the body through the respiratory tract, PM of a small enough diameter can pass through blood vessels and enter into the bloodstream. It can thus reach every organ within the body, which leads to “systemic in ammation and carcinogenicity.”(4). Some common diseases caused by air pollution include strokes, ischaemic heart disease, chronic obstructive pulmonary disease,

lung cancer, pneumonia, and cataracts. Cataracts are only caused by household air pollution. According to the WHO, “around 2.4 billion people cook and heat their homes with polluting fuels and every year 3.2 million people die prematurely from household air pollution.”(2)

Household air pollution does not a ect everyone equally. Populations in low and middle income countries are more likely to face adverse health e ects due to household air pollution than those living in high income countries. is is typically due to a concept known as “energy poverty.” Because individuals living in energy poverty “lack the resources to obtain cleaner fuels and devices, people in lower-income households rely mostly on elds that they can freely gather, such as wood and dung and more traditional ine cient cooking stoves.” (WHO Equity Impacts) When these fuel sources are burned in slower-cooking stoves, they release more air pollutants into the household at a faster rate.

Even within households using less e cient stoves and fuel sources that emit more pol-

lutants, the consequences of pollution do not fall equally on every individual within the household. Women, the elderly, and children tend to su er from air pollutant-related side e ects more frequently. In many low and middle income countries, the tasks related to household energy, such as cooking and gathering fuel, are delegated to women and children. (5) Being exposed to these materials for greater amounts of time increases the likelihood of developing health conditions caused by particulate matter or toxic gasses.

Energy poverty contributes to a cycle of poor health. When a household relies on fuel for cooking and warmth, and there are no alternatives fuel or stove types, energy sources that emit gasses and PM are unavoidable.

e e ect of air pollution on maternal and fetal health is a topic of concern to many researchers and health professionals around the world, especially as air pollution levels continue to rise. Lead has been proven to pose maternal and fetal risks. Some investigated health conditions caused by exposure to lead include premature birth and reduced fetal growth.(2) Many other forms of pollutants have negative health e ects as well. A 2013 study by Dr. Elena Proietti, Air Pollution During Pregnancy and Neonatal Outcome: A Review, documented that maternal exposure to air

pollution during fetal development can lead to “higher infant mortality, lower birth weight, impaired lung development, increased later respiratory morbidity, and early alterations in immune development.” Some of the strongest evidence exists for increased infant mortality and respiratory issues, but adverse health e ects as a whole are notable when mothers are exposed to air pollution.(6)

Ambient air pollution, or environmental air pollution, is unavoidable, making the issue even more of a priority for health o cials. For example, smoking is known to be harmful to fetuses in utero, but this is a risk which can be avoided; in contrast, “exposure to ambient air pollution cannot be avoided and a ects large numbers of individuals.”(6)

E orts are being made to decrease the prevalence of air pollution, or at least lessen the health impacts. e World Health Organization led the Urban Health Initiative in Accra, Ghana to model ways to lessen the impacts of air pollution in the greater Accra region. Using modeling technologies, the initiative found that e cient

charcoal stoves, combined with a moderately progressive approach which involved the use of cleaner fuel sources, would signi cantly reduce the premature death rate due to household pollution in the Greater Accra Metropolitan Area.

Ambient air pollution can also be tackled through changes in transportation sources. e project’s modeled “scenarios suggested that increasing safe, active transport (walking and cycling), and shi s from car to bus use, are likely to have large health bene ts by addressing air pollution, increasing physical activity and reducing road injuries.” e report also discussed the management of solid waste, and it was concluded that the greatest reduction in emissions would be seen if the practice of waste burning was stopped.(7)

As shown in the Accra project, multiple steps can be taken to reduce the health impacts of air pollution, most of which involve reducing the emission of toxic gasses and particulate matter into the atmosphere. e report also mentioned the potential bene ts of an epidemiological and public health approach to

decreasing the impact of air pollution. Communication is of the utmost importance to public health, and it is also discussed in the Accra Initiative. ere is an emphasis on the importance of health communications campaigns that would function to spread awareness about ambient air pollution and its climate and health impacts. e initiative communicated with health workers, the media, community leaders, and informal sector workers to spread awareness about the results obtained from the models in hopes of in uencing the adoption of more e ective pollution-reducing practices.

Air pollution will certainly continue to be an issue in the coming years due to its impacts on climate change and human health. Developing, communicating, and supporting strategies for more e cient, less polluting resource use is the rst step towards being able to reduce the negative e ects of air pollution and maintain a healthier global population in the future.

Sources:

“Air Quality and Climate Change.” University Corporation for Atmospheric Research, https://scied.ucar.edu/learning-zone/air-quality/air-quality-and-climate-change#:~:text=Some%20Air%20Pollutants%20Cause%20 the%20Climate%20to%20Warm&text= e%20 recent%20increase%20in%20greenhouse,causing%20the%20climate%20to%20warm.&text=Air%20pollution%20includes%20greenhouse%20gases,Sun%20in%20the%20Earth’s%20

atmosphere

“Type of Pollutants.” Air Quality and Health, World Health Organization, https://www.who.int/teams/environment-climate-change-and-health/ air-quality-and-health/health-impacts/ types-of-pollutants

“Climate Impacts of Air Pollution.” Air Quality and Health, World Health Organization, https://www. who.int/teams/environment-climate-change-and-health/air-qualityand-health/health-impacts/climate-impacts-of-air-pollution

“Health Impact.” Air Quality and Health, World Health Organization, https://www.who.int/teams/environment-climate-change-and-health/airquality-and-health/health-impacts

“Equity Impacts of Air Pollution.” Air Quality and Health, World Health Organization, https://www. who.int/teams/environment-climate-change-and-health/air-qualityand-health/health-impacts/equity-impacts

Proietti, Elena et al. “Air Pollution During Pregnancy and Neonatal Outcome: a Review.” Journal of Aerosol Medicine and Pulmonary Drug Delivery, vol. 26,1 (2013): 9-23. doi:10.1089/ jamp.2011.0932

“WHO Urban Health Initiative in Accra, Ghana: summary of project results.” World Health Organization, 2022, https://www.who.int/publications/i/item/9789240060784

THE MISTREATMENT OF MINORITY BIRTHGIVERS IN THE MATERNITY WARD

By Emnet Djibtila

Edited By Emily Shi

ere has been a long history of mistreatment of minorities in healthcare in the United States. is can be seen time and time again in Black populations, from Henrietta Lacks to the Tuskegee syphilis experiments. is mistreatment continues into the present day with Black birth givers.

Background on Maternal Mortality in the United States

Compared to other countries around the globe, the United States has a shockingly high maternal mortality rate, especially considering its status as a developed nation. e World Health Organization describes a maternal death as the death of a birth giver while pregnant or within 42 days of termination of the preg-

nancy from a cause aggravated by the pregnancy. According to data from the Center for Disease Control (CDC), in the United States there are roughly 32.9 deaths per 100,000 live births. is issue continues to worsen with time. ese statistics become even more horri c when looking at trends through di erent racial groups. e same case study from the CDC stated that there were 69.9 maternal deaths per 100,000 live births among Black mothers. is means that maternal death is 260% more likely to happen to a Black birth giver.

Changes in Policy being Made

Although these statistics are disconcerting, there are a number of actions being taken to help x this issue. Organizations like the CDC have proposed ensuring access to quality care to birth givers in all communities and funding more research to gather data on these trends in maternal death as a starting

place to begin creating change. High quality maternal care is dened by the Maternal Health Task Force as care that is safe, e ective, timely, e cient, equitable, and people-centered. Healthcare providers would have to make an effort to provide care that minimizes risk to its users, doesn’t vary in quality based on the individual receiving it, and is customized to the preference of the person receiving the care to optimize the experience of everyone. A number of changes would have to be put into place to improve Black maternal health overall. Access to safe and a ordable housing and improving the reliability of public transport for various medical appointments as well as increasing knowledge and education on health are some of the rst steps to accomplishing this.

Advancing equity in the eld of healthcare is also crucial to improving parental health for birth givers. Many associate the diversi cation of the eld closely with the improvement of maternal health. e Commonwealth Fund suggests “diversifying the perinatal workforce”, which would allow for more space for advocacy; i.e. Black doctors knowing what Black patients need and Black patients feeling more comfortable speaking up for themselves when in the presence of a Black doctor. is sentiment has been expressed by many Black patients across

di erent elds of medicine. Adrienne Hibbert, a Black Mother from South Florida, developed a searchable directory of Black doctors in her area to help other patients feel heard. is searchable directory, called the Black Doctors of South Florida website, connects Black patients to Black doctors who would listen, understand their experiences, and ultimately preserve Black lives. She created the website a er feeling unheard by her obstetrician a er giving birth to her son 15 years ago. She told NPR that the number one request that she receives is for a Black OB-GYN. Organizations like the World Health Organization and National Institutes of Health suggest simply ensuring

ized between hospitals to ensure people of all racial groups and socioeconomic statuses receive equal care. ey also suggest introducing policy to ensure that the same quality of care is provided to all birth givers. ere are also organizations like the Black Mamas Matter Alliance that are taking the lead in a movement to change policy and advance care to protect Black birth givers. BMMA is involved in a variety of projects including impacting communities directly with access to education about how to advocate for oneself within a hospital setting through

that all healthcare is standard-

*Figure retrieved from the CDC; is gure depicts the number of deaths per 100,000 live births across di erent racial groups. Data can be found from 2018-2021.

webinars and literature on their website. ey are also involved in implementing policy with the goal of upli ing leaders who are Black birth givers and redirecting the conversation towards issues a ecting Black birth givers directly.

Even though these trends are worsening for the time being, there are many individuals in healthcare and healthcare policy who are devoting themselves to creating change in the maternity ward. If some of these proposed changes are made, there is a lot of room for turning these statistics around and reducing the number of maternal deaths in minority communities in the United States.

Sources:

Background on Maternal Mortality: Centers for Disease Control and Prevention. (2023, March 16). Maternal mortality rates in the United States, 2021. Centers for Disease Control and Prevention. Retrieved April 23, 2023, from https://www.cdc.gov/nchs/data/

hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm

Policy Changes and Solutions:

Centers for Disease Control and Prevention. (2022, June 15). State strategies for preventing pregnancy-related deaths: A guide for Moving Maternal Mortality Review Committee data to action. Centers for Disease Control and Prevention. Retrieved April 23, 2023, from https://www.cdc.gov/reproductivehealth/maternal-mortality/preventing-pregnancy-related-deaths/state-strategies.html

Policies for reducing maternal morbidity and mortality and enhancing equity in maternal health. Policies Reducing Maternal Morbidity Mortality Enhancing Equity | Commonwealth Fund. (2021, November 16). Retrieved April 23, 2023, from https://www.commonwealthfund.org/publications/fund-reports/2021/nov/ policies-reducing-maternal-morbidity-mortality-enhancing-equity

World Health Organization. (n.d.). Maternal mortality. World Health Organization. Retrieved April 23, 2023, from https://www.who.int/newsroom/fact-sheets/detail/maternal-mortality

Collier, A.-R. Y., & Molina, R. L. (2019, October). Maternal mortality in the United States: Updates on trends, causes, and solutions. NeoReviews. Retrieved April 23, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7377107/

Advancing Black Maternal Health, Rights & Justice. Black Mamas Matter Alliance. (2023,

April 7). Retrieved April 23, 2023, from https://blackmamasmatter.org/ Methodology, B. M. C. M. R., Action, G. H., International Journal for Quality in Health Care, Matters, R. H., Childbirth, B. M. C. P. and, Alliance, W. R., Beat, N. S., Healthline, & Hindu, T. (2018, April 3). Quality of Maternal Health Care. Maternal Health Task Force. Retrieved April 23, 2023, from https://www.mhtf.org/topics/ quality-of-maternal-health-care/#:~:text=High%20quality%20care%20 should%20be,knowledge%20and%20 evidence%2Dbased%20guidelines

Black women’s maternal health. Black Women’s Maternal Health: (n.d.). Retrieved April 23, 2023, from https://www.nationalpartnership.org/ our-work/health/reports/black-womens-maternal-health.html#:~:text=To%20improve%20Black%20maternal%20health,transport%20for%20 medical%20appointments%3B%20and Patient Narrative:

Zaragovia, V. (2021, May 28). Trying to avoid racist health care, black women seek out black obstetricians. NPR. Retrieved April 23, 2023, from https://www.npr.org/sections/healthshots/2021/05/28/996603360/trying-toavoid-racist-health-care-black-womenseek-out-black-obstetricians

Lack of Diversity in Clinical Research Cohorts: A Growing Problem of Inequity with Grave Health Care and Financial Consequences

By Hunter Bershtein

Edited By Aman Majmudar

Can we fully trust the supposed bene ts of FDA-approved drugs? FDA approval is a multistep process meant to ensure the safety and e cacy of drugs for human use. However, there is a growing problem in the last step of this process: the need for more diversity in human clinical trials. e US currently faces a crisis in clinical medicine where most physicians and scientists make treatment decisions based on a largely homogenous sample—one that is primarily White and male because clinical studies historically haven’t included minorities. Considering that people respond di erently to medical treatments based on race and gender, this is a serious problem with dangerous consequences that must be overcome before medical research can be considered equitable.

Indeed, the statistics highlight that minorities such as people

of color and women are continually underrepresented in clinical trials. A 2019 study in JAMA Oncology found that out of the 230 trials that led to drug approvals over the past decade, only 63% percent reported race. Out of the studies that did report racial statistics, the proportion of White people in the trials was 98% of the actual proportion of White cancer patients. On the other hand, blacks and Hispanics only accounted for 22% and 44% of their expected proportions. Regarding gender, out of all the new FDA-approved chemical entities produced by drug manufacturers from January 1988 to June 1991, women were underrepresented in 60% of Phase 2 and 3 clinical trials.

But why does the US fail to include marginalized communities in clinical trials? First, minority populations o en lack access to specialty care centers that can refer them to clinical studies since these communities are o en underfunded. Second, due to historical racism surrounding clinical trials, minorities

o en fear exploitation in medical re-

search. An infamous example of racist medical malpractice is the United States Public Health Service’s 1932-1972 “Tuskegee Study of Untreated Syphilis in the Negro Male,” which intentionally withheld the best available syphilis treatment options from over 100 African American men to observe the e ects of long-term syphilis on the human body. Some other barriers to minority participation in clinical research include nancial constraints, competing demands of time, cultural and linguistic di erences, fears of unintended outcomes, stigmatization, and healthcare discrimination.

One might think that the lack of diversity in clinical trials isn’t a big problem. A er all, we’re all human, so shouldn’t our bodies work similarly? While this is generally true, newer research reveals that disease risk, pathology, and response to treatment

di er based on race and gender. As such, if FDA-approved medicines are tested using a majority White male cohort, there is no guarantee that the drug will be as e ective in minority populations.

In the most dramatic cases, medicines that work in one demographic can be utterly dysfunctional in another. For example, up to 75% of Paci c Islanders cannot convert clopidogrel, an FDA-approved antiplatelet drug used to treat blood clots, into its active form. As such, this demographic is at a higher risk for

adverse outcomes following angioplasty, a procedure to open clogged arteries caused by coronary artery disease.

Disease pathology also di ers based on gender. Older studies assumed that heart disease functioned similarly in men and women and therefore thought it was su cient to only include male cohorts. However, more recent ndings indicate that women are more complex physiologically; giving birth can increase the risk of heart disease, and this consideration cannot be studied in a male cohort. Furthermore, heart disease is more prevalent in transgender populations, although

the reasons for this nding are largely unknown.

How do we x a problem that has plagued clinical research since the beginning? Achieving adequate clinical diversity requires participation from many parties: funders, academic institutions, investigators, and potential research participants. Funders, academic institutions, and investigators should aim to create cohorts that accurately re ect the diversity of the communities being studied. e NIH can assist in this process by in-

cluding race, ethnicity, and gender criteria to help ensure that clinical cohorts answer questions relevant to the increasing diversity of the US population with enough statistical power.

With the deep-rooted mistrust many minority communities feel towards participating in medical research, it is paramount to implement a system that e ectively communicates the current safety regulations and bene ts of minority participation in clinical trials. e 1976 Belmont report established that patients participating in clinical trials always have the right to choose the treatment they receive, must be o ered the treatment with the most bene t and least risk, and that every study should strive to share the bene ts and burdens arising from the research equally. Although safeguards exist now to protect minority communities from being exploited by medical research, this reality was not always true. e US must work to improve communication with minority communities so that they can become aware that the standards in medical research are fairer now than in the past.

Improving diversity in clinical research communities bene ts not only minority communities but also the economy. By including a fair proportion

of minorities in clinical studies, new biomedical innovations can improve outcomes for a larger proportion of the US population. is expansion in treatment e cacy would decrease the money spent treating minorities with diseases lacking race-speci c clinical evidence. For example, eliminating racial and ethnic health disparities during 2003–2006 would have reduced total medical costs by more than $1.2 trillion, and conducting clinical studies with adequate cohort diversity attacks this problem of inequity at its root.

To tackle the lack of diversity in clinical trials, both those at the forefront of clinical research and potential participants must be aware of the problem and work together to increase minority participation in medical research and rebuild trust. As the US continues to become more diverse, our leaders must take steps to ensure that medical research expands its horizons to include historically underrepresented communities. Only then can clinical research reach its most e ective, equitable form.

Sources:

“Angioplasty and Stent Placement for the Heart.” Johns Hopkins Medicine, 2023. https://www.hopkinsmedicine.org/health/ treatment-tests-and-therapies/angioplasty-and-stent-placement-for-the-heart#:~:text=What%20is%20angioplasty%3F,such%20 as%20a%20heart%20attack.

“Disparity of Race Reporting and Representation in Clinical Trials Leading to Cancer Drug Approvals From 2008 to 2018.” Jama Oncology, 2019.doi:10.1001/jamaoncol.2019.1870.

“Diversity in Clinical and Biomedical Research: A Promise Yet to Be Ful lled.” PLOS

Medicine, 2015. 10.1371/journal. pmed.1001918.

“Development & Approval Process | Drugs.” US Food and Drug Administration, 2022. https://www.fda.gov/drugs/ development-approval-process-drugs.

“Improving Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups.” e National Academic Press, 2022.

“Increasing the Number of Women and Underrepresented Groups in Clinical Trials.” American College of Cardiology, 2022. https:// www.acc.org/Latest-in-Cardiology/ Articles/2022/12/09/13/06/Increasing-the-Number-of-Women-and-Underrepresented-Groups-in-Clinical-Trials.

“Lack of Diversity in Clinical Trials: A Patient’s Guide.” Lung Cancer Foundation of America, 2023. https://lcfamerica.org/lung-cancer-info/lack-of-diversity-in-clinical-trials/.

“What was the Tuskegee Study? Planned Parenthood. 2021. https:// www.plannedparenthood.org/blog/ what-is-the-tuskegee-study

“Women’s involvement in clinical trials: historical perspective and future implications.” Phrarm Pract (Granada), 2016.10.18549/PharmPract.2016.01.708.