UChicago PULSE Issue 3.3: Spring 2017

PULSE PULSE VOLUME 3.3, SPRING 2017

VOLUME 3.3, SPRING 2017

THE EFFECTS OF VIRTUAL REALITY ON

THE BRAIN

from the editor-in-chief

Dear reader, As summer springs upon us and the longest break of the year arrives, we bring you another issue of PULSE for the spring quarter! In this issue, our cover story takes a look at the newest tech - and what effects its regular use could have on our neural systems.

We also broadly highlight some features with drug use, both medicinal in recreational; with articles on marijuana, opioids, and even placebos, some of the rapid changes in the pharmaceutical industry are brought to light. Additionally, this issue covers the role of volunteerism in medicine, whether as a feature of public health policies in Kenya or as extracurriculars at the local hospitals and clinics in Chicago.

The end of a school year (and the beginning of the next, for those taking summer courses) brings to an end the three issues of the 201617 school year. Regardless of whether each of us is involved in medicine or health over the summer, I hope PULSE can bring some intriguing topics to mind, and to your interest as well. Happy reading!

With regards, Irena Feng

editors Purujit Chatterjee Kalina Kalyan Madeline Kim Nikita Mehta Abhijit Ramaprasad Scott Wu

writers Swathi Balaji Meera Dhodapkar Kalina Kalyan Natalie Kessler Jui Malwankar Medha Reddy Fatima Sattar Michelle Siros

production Purujit Chatterjee (cover design) Jihana Mendu Yolanda Yu

other contributors Gold Standard MCAT-Prep.com Kaplan Test Prep The Princeton Review

pulse - spring 2017

CONTENTS SEVEN TIPS FOR YOUR MED SCHOOL 2

PERSONAL STATEMENT

A feature from The Princeton Review WHEN TO TAKE THE MCAT 4

A feature from Gold Standard MCAT-Prep KAPLAN MCAT QUESTIONS 6 ORAL CANCER IN SOUTH ASIA 7 420: WHEN SCIENCE CANNOT CATCH UP 8 PRESCRIPTION PLACEBOS 11 ON THE FRONT LINES: THE DRUG EPIDEMIC 14

IN RURAL AMERICA THE EFFECT OF VIRTUAL REALITY

ON THE BRAIN (cover story)

18

POLICY ANALYSIS OF VOLUNTARY MALE 20

CIRCUMCISION IN THE LUO COMMUNITY THE MARIA SHELTER CLINIC 24 KAPLAN MCAT ANSWERS 27 THE BENEFITS OF BABY CUDDLING 28

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THE PRINCETON REVIEW’S 7 TIPS FOR YOUR MEDICAL SCHOOL PERSONAL STATEMENT Medical schools want to enroll bright, empathetic, communicative people. This means admissions committees care about more than just your MCAT score. They want to know who you are and why you're passionate about becoming a doctor.

Your personal statement is the first opportunity you have to tell a medical school about yourself in your own words.

Choosing Personal Statement Topics

How to Write a Personal Statement

Your medical school personal statement is a component of your application submitted to AMCAS or AACOMAS (NB: If you are applying to medical school in Canada, confirm the application process with your school, as not all application components may be submitted through AMCAS).

They don't provide a prompt, but they do offer topics to consider.

Many approaches are acceptable.

You'll write an additional essay (or two) when you submit secondary applications to individual schools. These essays require you to respond to a specific question. Admissions committees will review your entire application, so choose subject matter that complements your original essay.

If you believe that you are more than your grades and test scores, don't pass up this opportunity to share some genuine insight into who you are.

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1. Stay focused.

Choose a theme. Stick to it, and support it with specific examples.

2. Good writing is simple writing.

Good medical students—and good doctors—use clear, direct language. Make clear points and remove extraneous words. Your essays should not be a struggle to comprehend.

When choosing a topic, you could write about • an experience that challenged or changed your perspective about medicine • a relationship w/ a mentor or another inspiring individual • a challenging personal experience • an overview of your academic or life story • an insight into the nature of medical practice

3. Stay on topic.

5. Find your

4. Stick to the rules.

6. Don't overdo it.

Keep your personal statement relevant to why you're choosing a life in medicine. If you choose to write about an experience that is not directly related, explain how it contributed to your desire to go to medical school or how it will inform your experience as a medical student.

Give what is asked of you— your essays aren't the place to work out your authority issues.

No small fonts, funny margins, or doodles.

unique angle.

What can you say about yourself that no one else can?

Remember, everyone has trials, successes and failures. What's important and unique is how you reacted to those incidents. Be personal and be specific

7. Get feedback.

The more time you have spent writing your statement, the less likely you are to spot any errors.

A professor or friend whose judgment and writing skills you trust is invaluable. Give yourself (and your proofreaders) the time this task truly requires.

Beware of being too self–congratulatory or too self– deprecating.

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HOW TO DETERMINE WHEN TO TAKE THE MCAT When should I take the MCAT? This is the perfect example of one question with more than one correct answer! The reason for this is because each individual’s situation is different. In order to choose when to take the MCAT, you must first ask yourself a series of questions such as: • When will I apply for admission to medical school?

• How long do I need to study for the MCAT? • What materials will I use to study for the MCAT? • Where will I register to take the MCAT? • Will I take the MCAT just once or will I want to retake it?

Depending on where you are in your education (i.e. high school student, college student, etc.) or career (i.e. nontraditional student, career changer, etc.), answering these questions may feel a little overwhelming or even premature. Nevertheless, they each have a major impact on the timing of your MCAT test date. So, let’s walk through these questions together and move you closer to determining when to take the MCAT.

When will I apply for admission to medical school?

If you have not discovered this already, then you should know that medical school demands as much of a time investment as it does a financial investment. And that investment of time begins with the application process. Whether you are applying to allopathic or osteopathic medical schools, you must apply for admission one year prior to the year in which you intend to start medical school. Your MCAT score is not only a required part of your application, but also an important component to medical school admissions personnel in considering you for acceptance. Consequently, the later you receive and submit your MCAT score the further you will delay the review of your application.

OUR TIP: Take the MCAT exam before your application year begins.

How long do I need to study for the MCAT?

Again, everyone’s study needs are different; so, take some time to evaluate your strengths and weaknesses within the content you will be tested on. Are you strong in the sciences or not so much? How prepared do you feel for the CARS section or taking a timed exam in general? You should think about these ideas and start drafting an effective MCAT study schedule. In your schedule, tackle your more difficult subjects first then move onto the subjects in which you feel more comfortable.

OUR TIP: Allow a minimum of 3 to 6 months to study for the MCAT prior to your test date and check out our MCAT study schedule at www.mcat-prep.com.

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What materials will I use to study for the MCAT?

This question may not seem applicable to your MCAT test date, but it is! For example, if you are studying on your own with an online prep course then you have a reasonable amount of autonomy over when or how often you study. On the other hand, if you take an in-person prep course then you must attend classes and review material according to a predetermined length of time (i.e. 6 months, 9 months, etc.). Therefore, you must consider (a) how much you trust your study materials and (b) how prepared for the MCAT you believe you will be at the end of your program.

OUR TIP: Consult your peers and reliable online reviews to select the MCAT prep courses or programs that will meet your needs and conclude shortly before your test date.

Where will I register to take the MCAT?

Location is everything – and that cannot be more true when choosing the testing site for your MCAT exam. Although test dates are available January through September (excluding February), your preferred testing site may be full for your desired test date. So, consider how far you are willing (and can afford) to travel. Will you need to stay in a hotel the night before to reach your testing site on time? Similarly, timing is everything. Will you encounter traffic or a railroad crossing on your way to the testing site?

OUR TIP: Select a MCAT test date at a testing site that offers you the smoothest, most stress-free commute, and register as early as possible.

Will I take the MCAT just once or will I want to retake it?

Taking the MCAT once and getting a competitive score unfortunately does not happen for all pre-med students. If this happens to you, there are a few steps you can take to decide if retaking the MCAT is a good option for you. However, it is often best to plan ahead; so, choose an earlier test date that will allow you enough time to retake the exam (if necessary) before submitting your medical school applications.

OUR TIP: Take your MCAT exam either in the year prior to your application year or early in the year you wish to apply.

As you have most likely concluded, determining when to take the MCAT is strictly up to you. Yet, keeping these questions and topics in mind will guide you to delivering your best performance on test day. Best of luck to you!

For more than 25 years, Gold Standard MCAT-Prep.com applies the problem-based learning approach using multimedia to innovate, simplify and provide extensive preparation and practice for the MCAT. Come learn from our experience.

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Kaplan MCAT QUESTIONS QUESTION 1 Matt and Cati discuss the reasons why they avoid driving above the speed limit. Matt says that he wants to avoid a traffic fine, while Cati says that speeding is dangerous and, if everyone did it, there would be more accidents and people would get hurt.

According to Kohlberg, which of the following describes the phases of moral reasoning demonstrated by Matt and Cati, respectively?

A. B. C. D.

Preconventional; conventional Preconventional; postconventional Conventional; preconventional Post-conventional; conventional

QUESTION 2 Which of the following is true regarding bipolar disorders?

I. They have little, if any, genetic heritability.

II. They are associated with increased levels of serotonin in the brain.

III. They all require at least one depressive episode for diagnosis.

A. B. C. D.

I only II only I and III only II and III only

QUESTION 3 Biologically important carboxylic acids include pyruvic acid, citric acid, and the C-terminus of amino acid chains. Which of the following carboxylic acids will be the most acidic?

A. B. C. D.

CH3CHClCH2COOH CH3CH2CCl2COOH CH3CH2CHClCOOH CH3CH2CH2COOH

See page 27 for answers!

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ORAL CANCER IN SOUTH ASIA A Background and Barriers to Disease Prevention Author: Meera Dhodapkar Editor: Abhijit Ramaprasad It is well known that cancer is the leading cause of death worldwide, but what is less understood is how the landscape of the disease varies in different parts of the world. While in the US, breast cancer and skin cancer are the most prevalent and have gained the most public awareness, other forms of cancer dominate in other parts of the world. In Denmark and the UK, for example, and in other countries where anti-smoking campaigns haven’t been so avidly launched, lung cancer is the most common form of cancer. It is important to study these differences as understanding the types of cancer that are prevalent in particular parts of the world is critical in understanding the social and cultural determinants behind cancer.

Oral cancers (OC) are particularly prevalent in Asian countries, especially India, Pakistan, Taiwan, Thailand, Bangladesh, and Sri Lanka.

The pathology of OC is particularly brutal: most cases originate from normal-appearing endothelium (organ lining), but some cases arise from pre-existing malignant lesions that are untreated. These lesions can be gruesome in appearance and make speaking and eating extremely painful. OC spreads locally from these regions, metastasizing to nearby lymph nodes and permanently disfiguring its victims. The resulting tumors can range in size and shape, but tend to be located in the jaw and face area. In addition to making dental hygiene and maintenance of nutrition difficult, these tumors are large and gruesome-look-

ing. Thus, afflicted patients can experience lowered self-esteem as well as overall decreased quality of life. The burden of OC is high due to the cost of treatment, permanent physical impairment, and high mortality rate.

Asians have cultural practices that particularly enhance their risk for OC, the most notable being betelquid chewing, chewing tobacco use, and alcohol use. Southeast Asia is home to about 250 million smokers and an equal number of smokeless tobacco users, and many users of these substances have no idea of the substances’ health consequences. For example, paan, also known as betel leaf or betel nut quid, is a preparation combining betel leaf with areca nut and sometimes also tobacco.

It is chewed (and then spat out or swallowed) for its stimulant and psychoactive effects. In North India, it is traditional to chew paan after Diwali pujas (prayers) for blessings. While many do criticize these behaviors, they unfortunately tend to focus not on the related health issues but instead on the public cleanliness issues, drawing public attention away from these health issues.

WHO South Asia, however, has recognized the severity of this epidemic; the WHO Oral Health Program has established oral cancer and risk factors surveillance at a global level. First, the establishment of the World No Tobacco Day on 31 May 2005 was dedicated to the role of health professionals in tobacco control. Another WHO initiative, the Crete Declaration on Oral Cancer

Prevention analyzes the evidence on oral cancer and the implications for prevention and public health programs. Participants from 57 countries emphasized their commitment to oral health as a human right and agreed to key areas in education, risk screening, and cancer control.

The prevalence of oral cancer in South Asia, which is a relatively uncommon disease in North America, is still important in treatment practices here. Especially when clinicians are treating immigrants, or advising them on healthy habits, it is important that a patient’s cultural background is recognized and incorporated into their treatment. In this way, oral cancer in South Asia is not isolated to that part of the world; it is an epidemic we must all work to overcome.

Coelho, K. R. (2012). Challenges of the Oral Cancer Burden in India. Journal of Cancer Epidemiology, 2012, 701932. doi:10.1155/2012/701932 Zohaib Khan, Justus Tönnies, and Steffen Müller, “Smokeless Tobacco and Oral Cancer in South Asia: A Systematic Review with MetaAnalysis,” Journal of Cancer Epidemiology, vol. 2014, Article ID 394696, 11 pages, 2014. doi:10.1155/2014/394696 Khan, Z., Khan, S., Christianson, L., Rehman, S., Ekwunife, O., & Samkange-Zeeb, F. (2016).

Smokeless tobacco and oral potentially malignant disorders in South Asia: a protocol for a systematic review. Systematic Reviews, 5(1), 142. doi:10.1186/s13643-016-0320-7 Sinha, D. N., Abdulkader, R. S. and Gupta, P. C. (2016), Smokeless tobacco-associated cancers: A systematic review and metaanalysis of Indian studies. Int. J. Cancer, 138: 1368–1379. doi:10.1002/ijc.29884 Sankaranarayanan R, Ramadas K, Qiao Y-l.

Managing the changing burden of cancer in Asia. BMC Medicine. 2014;12(1):3.

Cheong SC, Vatanasapt P, Yi-Hsin Y, Zain RB, Kerr AR, Johnson NW. Oral cancer in South East Asia. Translational Research in Oral Oncology. 2017; 2. doi:10.1177/2057178X17702921.

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420: WHEN SCIENCE SIMPLY CANNOT CATCH UP Author: Swathi Balaji Editor: Scott Wu

On april 20th,

many across the nation celebrated the existence of 420, the codeword for cannabis, which is otherwise known as marijuana. April 20th also marked the passing of three months since President Donald Trump’s inauguration, and his administration’s stance on the legalization – or illegalization – of marijuana

currently more worried about more dangerous drugs, such as heroin, methamphetamine, and cocaine, and asserted that the administration has not yet pursued any postulated war against the recreational use of marijuana. However, Sessions and the rest of the Trump administration still maintain a strong stance against marijuana, and Hickenlooper qualified his reassurances, stating that Session’s current lack of action “doesn’t mean that he feels in any way that

Will the legalization of marijuana be left to the states? Will marijuana remain a Schedule I drug, regardless of its potential medical benefits?

As of now,

twenty-eight states have legalized the medical use of marijuana, and eight of those states have also approved its recreational use.

However, many states still stand opposed to the medical or recreational use of marijuana, namely in the Midwest and the South. To understand the controversy over the legalization of marijuana, it is crucial to understand its impact on human health. The opposition arising in many states seems to be rooted in the detrimental effects of the drug – that it is a gateway drug, that it causes addiction, and that it negatively impacts the health of its users. Is it actually a gateway drug? How accurate are these conceptions of marijuana?

On our own campus, still remains unclear. Attorney General Jeff Sessions recently reassured Colorado Governor John Hickenlooper that he is

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he should be cutting any slack to marijuana.” Thus, the question remains: what federal stance will the Trump administration take?

Dr. Ashley Vena and Dr. Dave Arndt were invited to address these questions and discuss the health effects of cannabis and behavioral responses to the compounds in the renowned

plant. According to Dr. Ashley Vena, a postdoctoral fellow from the de Wit Lab at the University of Chicago, there is sufficient evidence that cannabis is beneficial for the treatment of chronic pain, multiple sclerosis-related spasticity, and other conditions.

However, cannabis use also poses risks, including bronchitis, cognitive impairments, potentially development of testicular cancer, driving impairments, and lower birth rates. Dr. Vena emphasizes that marijuana lies, as of now, on the same plane as alcohol and nicotine, and thus is not a gateway drug. Gateway drugs are defined as substances that encourage users to consume more dangerous and addictive drugs; however, the majority of marijuana users do not go on to use “harder� substances.

The cannabis plant

has over 400 compounds, many of which are psychoactive and affect brain functionality, but the primary and most abundant compound that has significant health impacts is tetrahydrocannabinol (THC). We have endogenous cannabinoid receptors, known as CB1 and CB2, distributed across our brain, our peripheral nervous system,

and even our T cells, which are crucial to the immune system.

These receptors are a part of the endocannabinoid system, which seeks to maintain homeostasis or balance; while the receptors are usually activated by substances produced in our bodies, THC can directly activate them as well.

The presence of these receptors in our brain implies that THC, as a

According to dr. arndt,

direct activator of CB1 and CB2, can have profound effects on our decision-making skills, cognition, self-regulation, memory, and other functional aspects. Since CB1 receptors are present in the hippocampus and prefrontal cortex sections of the brain, THC can inhibit memory formation, impair response inhibition, reduce facial threat perception, and impair one’s attention span and ability to reverse learning, which includes making discriminations and learning to choose the opposite. According to Dr. Vena, THC also has significant subjective neurological effects, such as an altered perception of time, anxiety, tension, racing thoughts, tachycardia (fast heart rate), hypothermia (sudden loss of body heat), reduced motor activity, and heightened sociability. It is thus evident that THC, which is the primary psychoactive drug in recreational marijuana, has detrimental effects on our functionality, which explains why there is a negative stigma around the legalization of marijuana in many states.

not approved for CBD to be a compound present in medical marijuana, since its health benefits, either alone or with THC, remain unclear. As a whole, the Cannabis plant remains a Schedule I drug, which means that efficient research is needed for it to be approved for medical usage. With support from the Attorney General Jeff Sessions and the Department of Health and Human Services, who work closely with the Drug Enforcement Administration (DEA) and Food and Drug Administration (FDA), it may be possible to reschedule marijuana so that it is classified as a Schedule II drug, in line with opioid painkillers, such as Codine, Norco, and Vicodin. However, this rescheduling is unlikely to occur, given the current political climate.

In order to pursue research with Schedule I drugs, there are numerous security requirements, excessive paperwork, and a limited supply of the drug; moreover, if the state agency does not approve of the research, all prior efforts to proceed with the research become meaning-

a postdoctoral fellow also from the de Wit lab, other compounds such as cannabidiol (CBD) do not have such significant health impacts, do not alter responses to emotional stimuli, and only have mild sedative and anxiety-relieving effects. The Food and Drug Administration has

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less. As a result, science remains inconclusive as to the full effects of cannabis and its benefits, which could outweigh its risks in various scenarios, such as the ability of marijuana to stop a child’s seizures or its ability to treat chronic pain. Without state endorsement of further research, it will be impossible for science to determine the full therapeutic effect of cannabis, especially when the plant is not approved for consumption by the FDA. While states are gradually becoming more receptive to the legalization of both medicinal and recreational marijuana, the science surrounding its impact on health is still inconclusive.

Only time will tell whether marijuana will be legalized in more states, or whether the Trump administration will enact federal restraints on its use. When

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“

As a result, science remains inconclusive as to the full effects of cannabis and its benefits.”

science simply cannot catch up, a game of politics is enacted, hopefully a game that will bring about change and allow for scientific progress by the next 4/20.

Vena, Ashley. “Cannabis.” Behavioral Responses to Cannabidiol (Brain Awareness Week 2017). Chicago, IL. 20 Apr. 2017. Lecture.

Arndt, Dave. “THE BLAZED BRAIN: Behavioral Responses to Cannabidiol (CBD).”

Behavioral Responses to Cannabidiol (Brain Awareness Week 2017). Chicago, IL. 20 Apr. 2017. Lecture.

Brain Regions and Their Functions. Digital image.

Brain Basics. National Institute of Mental Health, n.d. Web. 12 May 2017.

Blake, Andrew. “Jeff Sessions Not Poised to Intervene in States with Legal Marijuana: Colorado Governor.” The Washington Times.

The Washington Times, 28 Apr. 2017. Web. 12 May 2017. <http://www.washingtontimes. com/news/2017/apr/28/jeff-sessionsmarijuana-crackdown-cole-memo-colora/>.

“Is Marijuana a Gateway Drug?” NIDA. National Institute on Drug Abuse, n.d. Web. 12 May 2017. <https://www.drugabuse.gov/ publications/research-reports/marijuana/ marijuana-gateway-drug>.

Sulak, Dustin. “Introduction to the Endocannabinoid System.” The National Organization for the Reform of Marijuana Laws. NORML, n.d. Web. 12 May 2017. <http://norml.org/library/item/introductionto-the-endocannabinoid-system>.

Young, Saundra. “Marijuana Stops Child’s Severe Seizures.” CNN. Cable News Network, 07 Aug. 2013. Web. 12 May 2017. <http://www. cnn.com/2013/08/07/health/charlotte-childmedical-marijuana/>.

Brain Regions and Their Functions. Digital image.

Drugabuse.gov. National Institute on Drug Abuse, Feb. 2016. Web. 12 May 2017.

Monsivais, Pablo Martinez. Attorney General Jeff Sessions. Digital image. Washingtontimes.com.

The Washington Times, 27 Mar. 2017. Web. 12 May 2017.

State Marijuana Laws in 2017 Map. Digital image. Governing.com. Governing, n.d. Web. 12 May 2017.

Location of CB1 and CB2 Receptors. Digital image. About CBD & The Endocannabinoid System. Blue Ridge Hemp Co., n.d. Web. 12 May 2017.

PRESCRIPTION

PLACEBOS Author: Medha Reddy Editor: Kalina Kalyan

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PRESCRIPTION PLACEBOS

Medicine is largely concentric upon supplementing the human body’s ability to heal itself. However, recent developments have suggested that this supplementation may merely need to take the form of suggestion. The placebo effect describes a perceived beneficial outcome from treatment that is solely attributable to a recipient’s faith in the intervention. While the effect has been largely applied in research and analytic measures, endeavors may be underway in the near future to bring placebos to home medicine cabinets.

The placebo effect has been documented as early as 1572, as Michel de Montaigne noted “there are men on whom the mere sight of medicine is operative”[1]. However, the phenomena was more recently popularized by Henry Beecher, a World War II medic who began supplying patients with saline solution under the guise of morphine due to a depleted supply, and noted that 40% of patients reported eased pain due to the substituted drug [2].

Contemporary studies report that the effect has become more prevalent with time; in a study of the effects of opiate drugs versus placebos, patients taking the drug reported a 27% greater symptom relief than those taking the placebo in 1990, but by 2013, the treatment group only had 9% greater symptom relief [3].

Some individuals even report that openly marketed placebo or sugar pills have been effective in treatments of “IBS, depression and migraine” according to

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Ted Kaptchuk, Director of the Harvard Program in Placebo Studies and the Therapeutic Encounter.

Kaptchuk describes that “the placebo effect is more than positive thinking – believing a treatment or procedure will work. It’s about creating a stronger connection between the brain and body and how they work together” [4]. “[Many of the] same biological changes that are happening when you take a drug are also happening when you take a placebo,” explains Jo Marchant, a journalist who explored the effect in her best-selling novel Cure: A Journey into the Science of Mind over Body [5]. The earliest evidence of the biological basis of the placebo effect was when a dentist noted that most patients who received saline injections after oral surgery still reported symptom relief until they were administered a drug that blocks endorphins [5], indicating that the feelings of symptom relief were associated with the presence of endorphins. The mere presentation of a “treatment,” placebo or otherwise, inspires the brain to release neurotransmitters such as endorphins and dopamine. Your brain is essentially expecting the treatment to work, and naturally attempting to supplement these assumed effects.

Kaptchuk advises that patients “recognize that it might be ‘in [their] head’ – but there’s nothing wrong with that” [6]. Placebos do not directly address physiological disorders as other drugs do, and their effects cannot be used to, for

example, to fight cancer using a placebo in lieu of chemotherapy (as the tumor will more likely than not persist without direct interventions). However, placebos have been effective in treating a range of disorders, including depression, Parkinson’s disease, chronic pain, IBS (irritable bowel syndrome), and other gastrointestinal disorders [7]. The effects of neurotransmitters associated with placebos directly explain why they are most useful in treating conscious symptoms, such as “pain, nausea, and fatigue” [8].

Yet, the high response rate of IBS patients seems somewhat difficult to grasp. Studies of this observance have actually concluded in an international study that the effectiveness of the placebo is actually quite variable; however, “more stringent entry criteria [of those included in the study] and an increased number of office visits appear to independently decrease the placebo response” [9].

These findings may partially be attributable to the global scale of the study, as the placebo effect has been found to significantly vary across nations. In a placebo, “the sugar, the cellulose in that pill does nothing,” Kaptchuk reminds us. “It’s because of the context that surrounds the pill.

That’s cultural, psycho-social” [8].

Recent studies have documented an increase in the placebo effect since 1990 in America, but not in European or Asian nations, findings that may be partially attributable to more comprehensive studies over the years [5]. Pills are the most effective

placebo in Europe, whereas sham surgeries show higher success rates in most other countries; the US is a hybrid, where placebo pills are more effective for sleep disorders, but pain relief was better alleviated by sham acupuncture [3].

Despite the varying effectiveness of each of these procedures, the study of the inflated effectiveness of placebos in treating IBS reveals the effectiveness of placebos can also be explained by the clinical care provided. While it’s entirely possible that openly marketed placebos will become available in the near future, the medical community of today must question what lessons the effects of placebos may provide.

Marchant emphasizes how a patient’s response is dependent upon the amount of time doctors devote to patients, the doctor’s body language, and the doctor’s faithin the drug [5]. Professionals from Stanford University argue

that medicine must devote more emphasis to the “psychological and social forces in healing,” beginning with endeavors such as training “[medical] students and residents …to connect with patients and learn the best ways to harness social context and patient mindset” [10].

The potential rise of prescription placebos illuminates the “mind over body” aspects of medicine that should be more readily discussed to improve a patient’s course of care. While the potential of placebos has not yet been comprehensively or conclusively evaluated, the importance of recognizing the psychological and “mindful” side of medicine in treating patients is starkly apparent.

Vance, Erik. “Power of the Placebo.” Discover Magazine. N.p., n.d. Web. 13 May 2017.

Madden, Chris. “Placebo Effect Drug Companies.” Drug Information & Side Effects Database. N.p., n.d. Web. 13 May 2017.

[1] “Great expectations: The placebo effect. (The ethics of placebos).” The Economist (US).

Economist Newspaper Ltd. 2008. HighBeam Research. 30 Apr. 2017 [2] Society for Neuroscience. “The Power of the Placebo.” BrainFacts.org. Society for Neuroscience, 31 May 2012. Web. [3] Cahalan, Susannah. “Medical Mystery: Why Are Placebos Becoming More Effective?”

New York Post. N.p., 24 Jan. 2016. Web. 1 May 2017.

[4] Publications, Harvard Health. “The Power of the Placebo Effect.” Harvard Health. N.p., n.d.

Web. 1 May 2017.

[5] Marchant, Jo. Cure: A Journey into the Science of Mind over Body. Melbourne, Vic.: Text, 2017. Print.

[6] Publications, Harvard Health. “Putting the Placebo Effect to Work.” Harvard Health.

N.p., n.d. Web. 1 May 2017.

[7] “When a Placebo Might Be the Best ‘Drug’.”

The Placebo Effect | Placebo Treatment – Consumer Reports. N.p., n.d. Web. 1 May 2017.

[8] Cahalan, Susannah. “Medical Mystery: Why Are Placebos Becoming More Effective?”

New York Post. N.p., 24 Jan. 2016. Web. 1 May 2017.

[9] Patel, S. M., W. B. Stason, A. Legedza, S. M. Ock, T. J. Kaptchuk, L. Conboy, K. Canenguez, J. K. Park, E. Kelly, E. Jacobson, C. E. Kerr, and A. J. Lembo. “The Placebo Effect in Irritable Bowel Syndrome Trials: A Meta-analysis.” Neurogastroenterology and Motility: The Official Journal of the European Gastrointestinal Motility Society.

U.S. National Library of Medicine, June 2005.

Web. 1 May 2017.

[10] “Stanford Experts Urge Healthcare Professionals to Harness Power of People’s Mindsets.” Stanford News Service. N.p., 27 Feb. 2017. Web. 1 May 2017.

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ON THE FRONT LINES: THE DRUG EPIDEMIC IN RURAL AMERICA Author: Fatima Sattar Editor: Madeline Kim

Of all the

ailments that doctors treat, pain is one of the most unique.

Because there are no physical manifestations of it and treatment is mostly based on the patient’s word, it lies on the harder end of symptoms to care for. A doctor may not be able to tell if a patient is exaggerating their pain, or if a patient’s pain tolerance is lower than usual and the patient perceives it as worse than it actually is. On the patient’s end, they find it difficult to describe their pain, which only makes the doctor’s job harder. As a result, patients feel misunderstood as they are passed from specialist to specialist – all of whom are looking to identify the root causes of the pain, while not always addressing the most immediate and pressing issue of living with the pain.

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As a temporary solution to hold over patients, doctors turn to the best form of immediate relief: prescription painkillers, which are usually some type of opioid-based medication. For most patients, doctors do not see prescription medications as a permanent solution. Instead, they urge the patient to consider more long-term options, like surgery or physical therapy, which are more effective at addressing root causes. The long-term use of opioids subjects individuals to a wide array of side effects detrimental to the brain, body, and overall health. These side effects, such as drowsiness, lethargy, nausea, and respiratory problems just to name a few, are harmful not only to one’s health but also social interactions because they interfere with a person’s ability to engage with their families and communities. For these reasons, most doctors only put a patient on painkiller prescriptions for a limited amount of time.

When a part of our body is injured, nerve endings send electrical messages back to the brain, signaling a harmful stimulus. The worse the injury, the greater the signal. Our brain then translates this message into the sensation of pain. The sensation of pain is necessary for survival because it draws attention to a problem in our body. However, sometimes the signal can be too strong and unproductive, which causes it to be bothersome. This is where opioids can be useful.

Opioids mimic

the shape of chemical signals called neurotransmitters and can block receptors on cells that interact with pain signals sent from the injured parts of the body. They also work in the brain’s reward center: opioids signal the release of elevated levels of dopamine into the synaptic cleft, resulting in the “high” that people experience.

Repeated exposure to relief and

high feelings can ultimately lead to addiction because the patient becomes dependent on the drugs to provide these feelings. In addition, over time, the body gets used to the drug by establishing a new normal baseline, whereby the same dose of the drug is no longer as effective, and the dosage must be increased. The body is so accustomed to the opioids that stopping drug usage would lead to intense withdrawal – a tough process to overcome. It is difficult for a doctor to abruptly end a prescription due to a patient’s dependence on the drug. If the physician does halt prescrip-

“

doctors to prescribe more drugs with higher bonuses, inundated doctors with promotional material, and spent millions ($166 million in 1993), on advertising to convince Americans that these drugs were the solution.

However, it was not long before people came to the realization that these drugs were not the end-all solution to Americans’ pain: cases of addiction, drug abuse, and dependence escalated as doctors increased prescriptions of drugs like Oxycontin and Vicodin, just to name a few.

Since then, things only worsened on the drug front. With an

Because the issue of opioid runs so deep, the solutions have to run even deeper.”

tions, addicted patients often resort to “doctor-shopping,” a common term for seeking a new prescription from a new doctor, or even multiple doctors, and, ultimately, the black market. It is at this point that consumption and acquisition of these drugs consume patients’ lives, an increasing problem among prescription painkiller users in the United States.

THE SPREAD OF RURAL DRUGS IN AMERICA

The War on Drugs is by no means a recent problem in America. In the mid ‘90s, painkillers became cheaper and more accessible to Americans. During this decade, the pharmaceutical industry went on a frenzy convincing doctors that these new drugs could essentially solve all their patients’ pain problems. Companies incentivized their employees to encourage

estimated 38% of the population currently on prescription drugs, Americans have become the biggest consumers and producers of narcotics in the world, and since the 1990s, the number of drug-related deaths in the country has increased every year.

In 2014 alone, an average of 52 people died per day due drug use. While the opioid epidemic is prevalent throughout the United States, a subset of the population has been particularly affected: the lower-income communities in rural America.Rural America is truly on the front lines of the War on Drugs. The root causes of opioid use in this region run deep, tracing their way back to the growing scarcity of jobs.

Once the American centers of heavy industry, many rural areas are desolate, now that most production has moved abroad.

With high rates of unemployment came financial difficulties, and families still struggle to make

ends meet. Food, clothes and shelter are their immediate needs, while healthcare is almost forced to become secondary to necessities.

Rural America is truly on the front lines of the War on Drugs.

The root causes of opioid use in this region run deep, tracing their way back to the growing scarcity of jobs. Once the American centers of heavy industry, many rural areas are desolate, now that most production has moved abroad. With high rates of unemployment come financial difficulties, and families still struggle to make ends meet.

Food, clothes and shelter are their immediate needs, while healthcare is almost forced to become secondary to other necessities.

When an individual gets injured or is involved in an incident, opioids are an easy, relatively low-cost solution. In parts of rural America where resources are low, painkillers are a doctor’s easiest answer to a patient with chronic pain.

With a lack of resources and facilities for alternative options like surgeries, injections, and physical therapy, which are far more costly, doctors often turn to drugs to help their patients deal with pain and injury. The factors that led to increasing opioid use in rural America are far from simple. Among them are doctors who abuse the healthcare system, tight-knit communities in which opioid usage and drug trafficking are rampant, and lack of incentives like employment to get treatment and support for addictions.

When individuals in low-income areas reach the point of addiction, there are few options of escape. For members of poor communities, enrolling in programs at their local hospitals

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can be expensive, if the hospital even has such a program.

Addiction clinics are far and few between. Patients sometimes travel a few hours to get to the nearest clinic, and it is unlikely a one-time visit will sober up a patient. It requires multiple sessions over a long period of time to make true progress. It is even harder when others around an individual â&#x20AC;&#x201C; friends, family, and everyone in between â&#x20AC;&#x201C; are abusing the substance that the individual is trying so hard to quit. Additionally, addiction treatment centers are overwhelmed with the number of patients that would like a spot in their program. With low resources and too few personnel, addiction centers can help only

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what they can handle at a given time, leading to the long waiting lists found at a lot of centers. In the meantime, patients can find themselves entering deeper in the downward spiral of addiction as they wait for spots to open up.

The addiction epidemic is not confined to one generation, in reality spanning across many.

Even babies are born into the system, promoting a vicious cycle. A recent study conducted at the University of Michigan found that an increasing number of babies born in rural America experience drug withdrawal symptoms after birth. When a pregnant woman suffers from an opioid addiction, her fetus is also exposed to the drugs, resulting in babies emerging from the womb

already dependent on opioids.

Rural infants account for 20% of all babies born in the U.S. with an opioid dependence, a number that has only increased over the years. Symptoms of opioid dependence at such a young age include increased likelihood of seizures and being underweight.

While it is possible to help babies with withdrawal symptoms using the proper resources and support, experts say that the best solution is to target the mother with her addiction during her pregnancy to prevent an infantâ&#x20AC;&#x2122;s dependence in the first place.

WHAT'S NEXT?

America has declared a war on drugs for decades now, with only minor improvements. Studies show that Americans are only growing more reliant on opioids with death rates and prescription painkiller abuse increasing each year. While education for adolescents is important, it does not do as much to help the current opioid users and addicts.

In an attempt to thwart resources for addicts, authorities tried to crack down on doctors to stop them from over-prescribing. While it seemed like a viable solution, rural communities found users only turning to more dangerous means of obtaining drugs: the street. Patients also learned ways to circumvent the system by trying to get multiple prescriptions from multiple doctors.

Because the issue of opioid use runs so deep, the solutions have to run even deeper. The first step is removing the stigma surroun-

ding addiction. It is only through this that individuals will realize the depths of their problems and be willing to seek help. However, in order for patients to seek out help, there must be more options for treatment. One overwhelmed clinic two hours away is not an effective solution.

If America wants to finally see a victory on the War on Drugs, it needs to channel resources to its rural areas, which have the highest rate of deaths related to opioids according to the CDC. Improving access to addiction clinics, therapists, drug addiction doctors, and support groups available for affected individuals is key for success. If America continues with its current status quo and doesnâ&#x20AC;&#x2122;t turn to longterm, effective solutions to target such a deep-rooted issue, drugs will continue to plague rural America and become an even more difficult problem to solve in the future.

Boddy, Jessica. "POLL: More People Are Taking Opioids, Even As Their Concerns Rise." NPR. NPR, 03 Mar. 2017. Web. 15 May 2017.

Drug Overdose Deaths. Digital Image. Coalition Against Drug Abuse. DrugAbuse.com. Web. 15 My 2017.

Ingraham, Christopher. "Prescription Painkillers Are More Widely Used than Tobacco, New Federal Study Finds." The Washington Post.

WP Company, 20 Sept. 2016. Web. 15 May 2017.

Khazan, Olga. "The New Heroin Epidemic." The Atlantic. 30 Oct. 2014. Web. 15 May 2017.

Martin, Laura. "Pain Medications - Narcotics."

MedlinePlus Medical Encyclopedia. U.S. National Library of Medicine, 3 May 2015.

Web. 15 May 2017.

"Most Doctors 'Overprescribe' Narcotic Painkillers." WebMD. WebMD, 25 Mar. 2016.

Web. 15 May 2017.

Mostafavi, Beata. "Study: Rural Communities See Steep Increase in Babies Born with Opioid Withdrawal." Neonatal Abstinence Syndrome: Opiate Withdrawals in Rural Babies.

University of Michigan, 12 Dec. 2016. Web. 15 May 2017.

Nicholas Gerbis "How do painkillers know where you hurt?" 29 June 2014. HowStuffWorks. com. <http://health.howstuffworks.com/ medicine/medication/how-do-painkillersknow-where-you-hurt.htm> 15 May 2017 "The Opioid Epidemic: By the Numbers."

Department of Health and Human Services 2016. Web. 15 May 2017.

Patterson, Eric. "The Effects of Opiate Use." DrugAbuse.com. Sober Media Group, 11 May 2017. Web. 15 May 2017.

Runyon, Luke. "Why Is The Opioid Epidemic Hitting Rural America Especially Hard?"

NPR Illinois. Web. 15 May 2017.

Staff, NPR. "We Found Joy: An Addict Struggles To Get Treatment." NPR. NPR, 05 May 2016.

Web. 15 May 2017.

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THE EFFECTS OF VIRTUAL REALITY ON THE BRAIN Author: Kalina Kalyan Editor: Nikita Mehta Virtual reality quite literally has all eyes on it. Virtual reality rose to popularity following its public release in 2016. Doing exactly what its name states, virtual reality allows for those who partake in it to experience “a realistic and immersive simulation of a three-dimensional 360º environment.” While virtual reality has rapidly become an entertaining and exciting pastime, there are potential health risks associated with this fad. Virtual reality is still relatively new and thus, no long-term studies have been conducted in order to test its true effects on the human brain. However, virtual reality can have both psychological benefits and consequences.

While virtual reality is a new hobby for technology enthusiasts, it has also been considered as a therapeutic tool. Certain studies have found that virtual reality has aided patients who suffer from

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“phantom limb syndrome” – a medical condition where one continues to feel pain from an amputated limb. Virtual reality permits those with the condition to mentally correct their “body map,” allowing for patients to become more in touch with themselves. Those with PTSD may also benefit from virtual reality as it allows for what is essentially an “escape” from the real world. Virtual reality has the primary goal of creating a sense of immersion in the person who is experiencing it. It is critical that the viewer does not just see what is presented in front of them, but rather is convinced of the fact that they are in the situation. This feeling of presence is derived from the senses of sight and sound. Virtual reality is able to essentially confound these two senses, both of which are critical to creating a sense of what is happening in the world. Virtual

reality can’t possibly provide the full array of senses that would allow for one to feel actually present in a particular situation.

However, some people can feel vertigo from looking over the edge in a virtual reality simulation. This is why prediction in the human brain is incredibly critical.

Virtual reality feels so real largely because of its control over what the brain will predict. The brain predicts things in order to help humans avoid danger to survive. Virtual reality enhances this sense of prediction because the brain is constantly forced to predict what is to happen next, possibly feeding into increased feelings of anxiety or stress.

However, due to the fact that virtual reality is a recent innovation, there are few studies regarding it. Despite this, there have been studies demonstrate that we engage with virtual reality in ways which are relayed

through physical behaviors.

For example, if a character in the virtual reality environment were to smile at you, you would likely smile back even if you were unaware of doing so. Participants have also been shown to be perceptive to threats and physically recoil when threatened.

These effects show us that the psychological effects of virtual reality must be further explored.

However, there has already been some research conducted on how virtual reality affects the neurons responsible for creating visual maps in the brain (“GPS cells”).

GPS brain cells have been found to act as a positioning system through creating a mental map of the environment. Virtual reality creates an artificial environment, so the question of whether or not it activates a mental map in the same way as reality does is critical in determining key effects of virtual reality on the brain. Scientists have tested this through a study that involved placing rats on treadmills in a 2D virtual reality situation. As the rats explored the virtual room, the researchers measured the response of neurons in the brains of the rats.

Signals from the hippocampus, a section of the brain involved in learning and memory, were recorded in this study and researchers then compared the brain activity in the virtual room to that measured while the animals explored a real, identical room. It was discovered that when the rats explored the virtual

room, the GPS neurons seemed to fire at random. However, in the real room, their GPS neurons fire in a pattern that produced a mental map. While this study was only tested in rats, it is likely that human brains respond similarly to virtual reality. The lack of brain mapping during simulations in virtual reality can be seen as something that is neither positive nor negative. However, virtual reality has the potential to have both positive and negative effects on the brain, and these effects can only be seen through further research and investigation in the field.

Virtual reality is both promising and exciting as there is a plethora of opportunity for advancement in diagnosis of neurodegenerative disorders. A novel solution involving virtual reality has been created in order to diagnose diseases such as multiple sclerosis and Parkinson’s early on. This solution could revolutionize testing in countries where there is limited access to advanced diagnostic technology. Virtual reality headsets and Microsoft Kinect would be used in these diagnostic tests; these technologies are relatively inexpensive and allow for the monitoring of people’s movements in virtual environments. How one responds to the virtual reality environment could provide revealing information to the physician making the diagnosis. Given what is known about it, virtual reality has the ability to

be both beneficial and negative.

The continued advancement of research in the area of virtual reality will allow for the determination of the true effects of virtual reality on the brain.

López, Leticia Lafuente. "Virtual Reality And Augmented Reality In Education." ELearning Industry. April 18, 2016. Accessed May 12, 2017. https://elearningindustry.com/virtualreality-augmented-reality-education.

"Psychological Implications of Virtual Reality."

HealthGuidance.org. Accessed May 12, 2017. http://www.healthguidance.org/ entry/17150/1/Psychological-Implicationsof-Virtual-Reality.html.

Branstetter, Gillian. "Your brain isn't ready for virtual reality." The Daily Dot. March 29, 2016. Accessed May 12, 2017. https://www. dailydot.com/via/your-brain-isnt-ready-forvirtual-reality/.

Seetharaman, Deepa. "What Does Virtual Reality Do to Your Body and Mind?" The Wall Street Journal.January 03, 2016. Accessed May 12, 2017. https://www.wsj.com/articles/ what-does-virtual-reality-do-to-your-bodyand-mind-1451858778.

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POLICY ANALYSIS OF VOLUNTARY MEDICAL MALE CIRCUMCISION

IN THE LUO COMMUNITY Author: Natalie Kessler Editor: Purujit Chatterjee

Background

The AIDS epidemic devastated the world in the 1980s, killing hundreds of thousands of people.

In order to slow the infection rate, international health institutions created campaigns, trying to convince people to practice safe sex, use condoms, and know their HIV status. In 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) held an international conference to review the evidence of three trials researching the effects of male circumcision on HIV acquisition. Due to circumcised malesâ&#x20AC;&#x2122; reduced risk of acquiring HIV infection by approximately 60%, WHO and UNAIDS concluded that circumcision is an effective intervention

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in preventing HIV infection and endorsed the implementation of male circumcision programs that target regions that have high rates of HIV and low rates of male circumcision (1).

WHO and UNAIDS focused male circumcision programs on sub-Saharan Africa, an area of the world most affected by HIV/AIDS. One region that was selected was the Nyanza province of Kenya. Nyanza is in the southwest corner of Kenya and has a large proportion of the Luo ethnic group, a traditionally non-circumcising community.

This lack of circumcision and other cultural practices have led to high rates of HIV in Luo communities. In 2003, 46.4% of men in the Nyanza province were circumcised with only 16.9% of

the Luo men circumcised. For comparison, the other six Kenyan provinces on average had 91% of their men circumcised (2). This low prevalence of circumcision among the Luo coupled with the highest percentage of HIV infection in Kenya (21.8% among the Luo) made Nyanza an ideal place to begin male circumcision programs. The high percentage of HIV infection can be partially attributed to the Luo practice of cleansing, or extramarital sex.

For this custom, a widow must be cleansed by someone in her in-lawsâ&#x20AC;&#x2122; family before she can re-enter society, and young men cleanse a new home with someone who they will not marry. The practice of cleansing encourages the Luo to have more than one sexual partner at a given time,

possibly contributing to the spread of HIV. Even in the wake of the HIV epidemic, this custom still persists due to strong societal pressures and the current imbalance between honoring tradition and protecting oneself from HIV (3).

Implementation

Subsequent to the WHO’s policy recommendation, the Kenyan government began to implement male circumcision programs in the province of Nyanza in 2008. Kenya’s success with the programs has been attributed to the Kenyan government’s strong and sustained presence throughout the entire process (4,5). The government’s oversight came in several forms, from early engagement with traditional leaders in non-circumcising communities to the creation of flexible male circumcision programs, which allowed a variety of on-site models for a given community and non-physicians to perform the procedure (5). With these steps supplementing the government’s outspoken support for circumcision, the “National Guidance for Voluntary Male Circumcision in Kenya” was drafted, translating policies into effective programs that focused on education and other HIV prevention strategies. The government also met with the Luo Council of Elders, leading to Kenya’s official adoption of the term “voluntary medical male circumcision” (VMMC) (5). By changing the name, the government emphasizes that male circumcision for HIV prevention would be a voluntary program implemented due to medical, not cultural reasons.

Despite these steps towards making male circumcision common, the Luo community had some concerns regarding

the procedure. Throughout the implementation of VMMC, the barriers to and facilitators of male circumcision were examined extensively. One of the significant barriers to undergoing VMMC is the concern that those who would undergo the procedure would take too much time off of work for recovery. This issue is especially prevalent if the man is the sole provider for his family, making time off financially unfeasible (6). Men also indicated

ences and can be quite volatile.

In one instance, members from a traditionally circumcising ethnic group forcibly circumcised Luo men for the purpose of making them “man” enough to contribute in society (8). For some, especially young men, the opportunity to become accepted by other cultures romantically, socially, and professionally is alluring and well-worth the in-culture stigma of circumcision.

NYANZA

that by becoming circumcised, they would be going against their custom of being a traditionally non-circumcising ethnic group (6,7). To some, breaking these cultural and societal norms was unthinkable. The main facilitators of male circumcision uptake are the hygienic benefits, protection from HIV and STIs, and improved societal relations, the last of which is especially salient due to the Luo’s position as a traditionally non-circumcising community (6). The relationships between different ethnic groups are tense due to cultural differ-

Plans for the Future

The ability of circumcision to reduce HIV infection has encouraged the WHO and the Kenyan government to implement plans to scale up VMMC programs.

The plan implemented by the WHO set a goal to have 90% of all eligible men circumcised by 2021 (10). To meet this goal, the WHO has programs that target health sector development and education; generally, WHO calls for VMMC to be added to already existing and future healthcare programs and plans in

spring 2017 || 21

order to reach the largest audience possible (10). However, it must be noted that this framework for VMMC programs aims at all Southern and Eastern African countries, not just Kenya.

Due to the cultural factors influencing male circumcision uptake, a slightly different approach should be taken, which Kenya’s government addresses within their own plan.

In order to expand the VMMC program and increase the number of circumcised men in Kenya, the Kenyan government includes pre-adolescent boys (ages 10-14) and infants (0-60 days) in their scale-up efforts (11). The inclusion of boys in the program speaks to younger generations’ higher acceptance of VMMC despite cultural pressures and the “natural demand” of VMMC in adolescents, where upon reaching puberty, boys desire to undergo VMMC in order to benefit from the advantages of circumcision (10, 11).

The introduction of early infant male circumcision (EIMC) is also

intended to have high levels of success, due to a higher acceptability in the community of infants undergoing circumcision.

Parents were accommodating of having their sons undergo EIMC due to circumcision’s role in reducing the risk of acquiring HIV (12).

Nevertheless, the programs, goals, and policies set forth by the WHO and the Kenyan government still do not address the main barriers to VMMC that the Luo face. While both programs mention incentives for working men, neither program mentions what form these incentives will take. One possible program would offer financial incentives, either in the form of food vouchers or cash, which would diminish the economic barriers of VMMC uptake. When these incentives were offered in a study, there was a higher uptake of the procedure among married and older men – two groups that have been harder to reach through other avenues (13). With financial incentives, however, comes

the dilemma of amount, for the compensation needs to be high enough to offset the lost earnings, but not high enough to pressure men into undergoing the procedure.

Furthermore, neither program addresses the issue of cultural norms within traditionally non-circumcising communities.

Education and societal pressures can only go so far in convincing men to go against their culture.

The traditional factors that influence older men to not undergo VMMC need to be addressed if the WHO and Kenyan government wish to reach their goals.

Although strong governmental and international support can produce change, the barriers blocking the last percentages need to be taken into consideration in order to reach the largest number of people affected. Only after these cultural differences are effectively addressed can male circumcision be completely accepted in society and become a cultural practice across all communities.

*Average of the data from all Kenyan provinces except for Nyanza.

(9) Data taken from: The Demographic and Health Surveys, Kenya, 2003, 2008-2009, 2014

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Conclusion

The progress made from the VMMC programs in Kenya is discernible, with large percentages of the men in Nyanza and the Luo group now circumcised.

As of 2014, 59% of Luo men and 72% of men in the Nyanza region were circumcised, an increase from the years prior to the VMMC program implementation (9). With these visible successes, other countries following the policy recommendation of WHO/UNAIDS should look to Kenya’s VMMC program as they create, implement, and sustain their own policies. The barriers that face Kenya’s goal of having 90% of all men circumcised may also apply to other sub-Saharan countries that have their own traditionally non-circumcising communities within their borders. With other countries sharing in Kenya’s successes and failures, Kenya should address the cultural differences of its communities in order to present a program that fully grasps these variations.

1- World Health Organization (2007) New data on male circumcision and HIV prevention: policy and programme implications. Geneva, Switzerland: WHO Document Production Services 2- Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro.

3- Ayikukwei, R., Ngare, D., Sidle, J., Ayuku, D., Baliddawa, J., & Greene, J. (2008). HIV/ AIDS and cultural practices in western Kenya: the impact of sexual cleansing rituals on sexual behaviours. Culture, Health & Sexuality, 10(6), 587-599. doi:10.1080/13691050802012601 4- Dickson, K. E., Tran, N. T., Samuelson, J. L., Njeuhmeli, E., Cherutich, P., Dick, B., . . .

Hankins, C. A. (2011). Voluntary Medical Male Circumcision: A Framework Analysis of Policy and Program Implementation in Eastern and Southern Africa. PLoS Medicine, 8(11). doi:10.1371/journal.pmed.1001133 5- Mwandi, Z., Murphy, A., Reed, J., Chesang, K., Njeuhmeli, E., Agot, K., . . . Bock, N. (2011).

Voluntary Medical Male Circumcision: Translating Research into the Rapid Expansion of Services in Kenya, 2008–2011.

PLoS Medicine, 8(11). doi:10.1371/journal. pmed.1001130 6- Herman-Roloff, A., Otieno, N., Agot, K., Ndinya-Achola, J., & Bailey, R. C. (2011).

Acceptability of Medical Male Circumcision Among Uncircumcised Men in Kenya One Year After the Launch of the National Male Circumcision Program. PLoS ONE, 6(5). doi:10.1371/journal.pone.0019814 7- Westercamp, M., Agot, K. E., Ndinya-Achola, J., & Bailey, R. C. (2011). Circumcision preference among women and uncircumcised men prior to scale-up of male circumcision for HIV prevention in Kisumu, Kenya. AIDS Care, 1-10. doi:10.1080/09540121.2011.59 7944

8- Izugbara, C., Ochako, R., Egesa, C., & Tikkanen, R. (2013). Ethnicity, livelihoods, masculinity, and health among Luo men in the slums of Nairobi, Kenya. Ethnicity & Health, 18(5), 483-498. doi:10.1080/1355785 8.2013.771853 9- Kenya, Kenya National Bureau of Statistics. (n.d.). The Demographic and Health Surveys Program. Retrieved January 26, 2017, from http://www.dhsprogram.com/pubs/pdf/ FR151/FR151.pdf, https://dhsprogram.com/ pubs/pdf/fr229/fr229.pdf, http://dhsprogram. com/what-we-do/survey/survey-display-451. cfm, 10- World Health Organization. (2016). A framework for voluntary medical male circumcision: effective HIV prevention and a gateway to improved adolescent boys’ & men’s health in Eastern and Southern Africa by 2021. Geneva, Switzerland: WHO Document Production Services.

11- Government of Kenya, Ministry of Health, National AIDS and STI Control Program (2015). National Voluntary Medical Male Circumcision Strategy, 2014/15 - 2018/19.

Nairobi, Kenya: 12- Young, M. R., Adera, F., Mehta, S. D., Jaoko, W., Adipo, T., Badia, J., . . . Bailey, R. C. (2016). Factors Associated with Preference for Early Infant Male Circumcision Among a Representative Sample of Parents in Homa Bay County, Western Kenya. AIDS and Behavior, 20(11), 2545-2554. doi:10.1007/ s10461-016-1288-y 13- Thirumurthy, H., Masters, S. H., Rao, S., Bronson, M. A., Lanham, M., Omanga, E., . . . Agot, K. (2014). Effect of Providing Conditional Economic Compensation on Uptake of Voluntary Medical Male Circumcision in Kenya. Journal of American Medical Association, 312(7), ]. doi:10.1001/ jama.2014.9087

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THE MARIA SHELTER CLINIC Interview with Ms. Nzuekoh Nchinda and Mr. Tyrone Johnson, Co-Directors of Maria Shelter Clinic in Engelwood, Chicago, IL Author: Jui Malwankar Editor: Abhijit Ramaprasad Note: The Maria Shelter Clinic is one of five student-run free community clinics throughout Chicago’s West, North, and South Sides that are operated by the Pritzker School of Medicine at the University of Chicago. The Maria Shelter Clinic in particular is a homeless shelter for women and children located in the Engelwood neighborhood; their mission is to “provide superior health care in a compassionate manner, ever mindful of each patient’s dignity and individuality.” The co-directors of the clinic are MD candidates Nzuekoh Nchinda and Tyrone Johnson, and the board for the shelter is advised by faculty member Andrew Davis, MD, MPH, Department of Medicine. For more information about the clinic (or about the four other clinics run by Pritzker students), visit https://pritzker.uchicago.edu/page/student-run-free-clinics-and-service-groups.

Thank you so much in advance for taking the time to answer questions about Maria Shelter! First off, can you give a brief introduction of yourself (undergrad institution, home state/country, year of medical school, current activities at Pritzker, etc)?

Ms. Nchinda (N): Hi, I’m Nzuekoh Nchinda. I was born in Cameroon and grew up in Wisconsin.

I attended college at Harvard University. I am a first-year medical student at the Pritzker School of Medicine. I am most interested in pursuing a surgical sub-specialty. I am one of the co-directors, along with Ty Johnson, for Maria Shelter Clinic, so I am most involved with the operations and volunteering at the clinic. Additionally, during my first year at Pritzker, I have been involved with Docs and Debates, Say Ahh, Pritzker Dance Crew, JOURNEES, South Side Science Scholars, and Pritzker Christian Fellowship.

Mr. Johnson (J): I was born and raised in California, and graduated from UCLA in 2015 with a B.S. in Microbiology, Immunology, and Molecular Genetics. I am a first-year at Pritzker. Currently, my interests lie in Internal Medicine with an academic focus on the doctor-patient relationship and mentorship for underrepresented minority (URM)

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students in the educational pipeline. In addition to Maria Shelter, I am a board member of SNMA (Student National Medical Association), and serve on the Identity & Inclusion Committee. I also do research on community violence and am a 20172018 Albert Schweitzer Fellow.

What made you decide to volunteer for the clinic?

How long have you been volunteering?

N: I came into Pritzker with a strong interest in volunteering at Maria Shelter Clinic. I was first drawn to the clinic for the opportunity to primarily work with and empower women and their children.

I enjoy the small, intimate nature of the clinic in that we are able to take time to listen to each patient and address their particular concerns thoroughly.

Given that the patients live in the same site as the clinic, we are able to care for them in a setting that is their home for the time being. It encourages the volunteers to consider the full health of patients and to see them as people first. I have been volunteering for the Maria Shelter Clinic since November 2016.

J: At UCLA, I spent three years as a volunteer and eventual Undergraduate Coordinator of the UCLA

Mobile Clinic Project, a multi-disciplinary studentrun free clinic providing medical and social service homeless populations in Los Angeles. During these years I began to grasp, firsthand, the true impact of the social determinants of health, and especially the importance of relationships to one’s health.

Our patients dealt with a dearth of positive social support and connection every single day, and our goal as undergraduate caseworkers at Mobile Clinic was to erode the stigma they endured by being, first and foremost, an active audience to their incredible tales.

As a medical student, I was excited to be able to combine my skills in social support with actual training in medical care. I knew I wanted to keep working with homeless populations when I came to Chicago, so dedicating my time to Maria Shelter was always a high priority for me. Our current board members and volunteers have been serving since the fall.

What is a typical volunteering session like for you?

How many people at the shelter do you interact with each time? What are the main activities for each session?

N: On a clinic evening, at least two board members (medical students) will be on staff. They arrive along with 2-3 additional medical student volunteers. Board members take care of logistics, such as acquiring the list of patients that will be seen and organizing pertinent records. An attending and either a resident or senior medical student arrive to guide the medical student volunteers. Student volunteers will see each patient one-on-one, present to the attending, and help develop a plan to address the patient’s chief concern. Typically, between 3-12 adult and pediatric patients will be seen. During general clinic, the Maria Shelter Board regularly runs additional health programs for residents.

These programs include educational activities such as yoga, knitting, and CPR training or community outreach programs such as an HIV clinic.

What has been your favorite memory or experience at the clinic so far?

N: My favorite memory was watching the yoga class led by Kate Arnold (MS2) and organized by education co-coordinators Maura Clement and Julia Naman (MS1s). The women who participated looked very much at peace and were so engaged.

My favorite experiences so far have been conversations with patients.

J: I always love seeing the children. The mothers and their children are in an incredibly vulnerable place in their lives, but the highest impact will be on the kids – when you see them, you realize how important our mission is. Every single effort we can make to support them is critical.

What do you think has been your most rewarding (or unexpected) lesson from volunteering at this type of organization? Would you recommend it to other interested students?

N: The most rewarding lesson has come from witnessing the resilience our patients. Patients at the Maria Shelter have lived a wealth of experiences that provides them with insight on how to care for their health. Thus patients are an integral part of the team caring for their health. I would highly recommend volunteering at the Maria Shelter.

J: Similar to my time at MCP, the greatest reward is building community with our patient population and experiencing the incredible strength that they possess. Whether in the meeting room, where we discuss the difficulties our fellow human beings face, or on site, where we see those difficulties manifest themselves and practice what it means to be human to those who are fundamentally the same as us, I have found the opportunity to support underserved communities to be a beautiful endeavor yielding unparalleled returns. I would overwhelmingly recommend volunteering to other students.

Thank you so much for sharing your experiences at the Maria Shelter! One last question – do you have any advice for incoming medical school students or pre-med UChicago students now that you have completed that process? What has been the most unexpected thing so far about medical school?

N: I have felt privileged to be in medical school every day that I have been here. I think what makes medicine remarkable is the intimacy of the doctor-patient relationship. You have the unique opportunity to meet patients in their vulnerable moments and are made privy to the most personal aspects of that person – their body, their psyche, and their life experiences. It is humbling to have a

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patient put their trust in you. And I enjoy seeing physicians transform patientsâ&#x20AC;&#x2122; lives with a healing hand and a listening ear. The most unexpected thing so far about medical school is how much fun it has been. Pritzker is a warm and vibrant place to be as a medical student. I encourage incoming medical students and pre-med UChicago students to seek opportunities to be involved with the care of patients. Memories of experiences with patients will serve as a reservoir of motivation as you study during medical school.

J: Firstly, enjoy your time off! Secondly, be prepared to transition from an undergraduate environment where success is often second nature to a curriculum where it is impossible, and unexpected, that you will know 100% of everything. The most unexpected thing about medical school compared to undergrad is the adjustment that being comfortable with â&#x20AC;&#x153;just passingâ&#x20AC;? will take. Thirdly, try to reach out and establish your mentors early. This will provide you with a lot of valuable support during your pre-clinical years.

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Thank you so much for your time! I truly appreciate it.

Students interested in learning more about or getting involved with the Maria Shelter Clinic can contact Mr. Johnson or Ms. Nchinda via the link provided at the beginning of the article.

Kaplan MCAT

ANSWERS & EXPLANATIONS QUESTION 1 A, Matt's reasoning reflects a desire to avoid punishment, which reflects stage one in Kohlberg's preconventional phase (obedience). Cati's reasoning takes into account social order, reflecting stage four in teh conventional phase (law and order).

QUESTION 2 B, Bipolar disorders have been shown to be highly heritable and are associated with increased levels of norepinephrine and serotonin in the brain. Bipolar I disorder can be diagnosed with a single manic episode and does not require a major depressive episode. Bipolar II disorder requires at least one hypomanic episode and one major depressive episode. Cyclothymic disorder contains at least one hypomanic episode and dysthymia.

QUESTION 3 B, The acidity of carboxylic acids is significantly increased by the presence of highly electronegative functional groups. Their electron-withdrawing effect increases the stability of the carboxylate anion, favoring proton dissociation. This effect increases as the number of electronegative groups on the chain increases, and it also increases as the distance between the acid functionality and electronegative group decreases. This answer has two halogens bound to it, at a smaller distance from the carboxyl group compared to the other answers.

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THE BENEFITS OF BABY CUDDLING Author: Michelle Siros Editor: Madeline Kim I’m sitting in a rocking chair with a tiny, sleeping infant holding my thumb to their heart as we rock back and forth holding one another. The baby begins to stir, but when they open their eyes they are reassured by my presence and the knowledge that they hold my hand in theirs and they are with someone who cares. I am a baby cuddler at Comer Children’s Hospital. My experience working in the Neonatal Intensive Care Unit (NICU) has led me to value the role I can play in making others’ lives better, and it has inspired me to encourage others to join me in this rewarding volunteer experience.

My journey to baby cuddling began with an online application. A few questions asked me to detail my dedication to volunteerism, my goals for the experience, and eventually my answers led me to an interview. I got a badge and began my childlife volunteerism experience with 40 hours in the Comer playroom. In the playroom, I played with all sorts of hilarious, witty, intelligent, curious patients.

The children were happy to be out of their beds, playing and just being kids!

As a playroom volunteer, I took toys to patients who were too ill to come to the playroom, and I also transported patients to and from their rooms and the playroom. In the playroom we played video games, did arts and crafts, and had fun despite the hospital setting. The playroom was a stepping-stone to baby cuddling, but it was an experience not to be missed. Some of the patients were older and had grown out of games and art, like the one taught me about rap music. I listened to 2Chainz for the first time and laughed when I couldn’t hear the patient over the sounds of the booming speakers. Other patients were shy and didn’t want to talk, but were happy to paint little cardboard jewelry boxes and contest color choices. One patient spent an hour painting a heart-shaped box in all different colors, only to ask me if I wanted it as a thank-you for help-

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ing them paint it. The patients in the playroom were some of the kindest kids I had ever met, and the smiles and laughter that often filled the playroom added a happiness generally lacking in hospitals.

After 40 hours in the playroom, I became eligible to attend a bi-annual orientation to be a baby cuddler. I attended the cuddler orientation overjoyed to start a new task with the hospital’s youngest patients.

My first patient was particularly fussy. The nurse told me that the baby had been throwing up whatever they ate and crying, restless all day and night.

The baby hadn’t slept for more than an hour or two straight for over two weeks. I remember the nurse being scared that I would end up the target of projectile vomiting; I was not deterred. I sat in a recliner, and got handed a bundle of joy. I sat there and sang and read to this precious infant, all the while noticing the drooping eyelids and the slowing respiratory rate melting into a deep sleep. As cuddlers, we hold babies for at least an hour each so as not to disturb any for just a short stay. However, this first baby I ever held, sleeping so peacefully, with a tiny smile of contentedness stretched over their face, held me in the hospital for much longer than an hour. In fact, they slept on me peacefully for four hours. When I finally separated myself from the baby, the nurse asked me when I could come back. And just like that, after cuddling one baby, voilà! I was hooked, made into a cuddler for life from just one minute with a little angel.

The next time I went back, I gave myself a strict two-hour time limit, only because homework doesn’t complete itself and cuddling can be hard to stop. I held my new patient in my arms for a couple hours, every minute further passing the two hours I thought “one more minute,” and yet a couple more hours went by. This patient was fussier and a little harder to calm down. They wanted to see out their window, a view inaccessible from the crib, but also

to sleep. The moment their view was covered by the blanket or taken away from the angle at which I held them, they wailed and wailed. Eventually, they rested peacefully lying vertically on my torso.

They slept as if resting in a lawn chair with their head on my chest. Their eyes were closed, but their face showed the satisfaction they felt at knowing that once they opened their eyes, the view out the window would be right there.

A few things take some getting used to, but they are well worth it. When I walk into the NICU for a shift, the first thing I do is clean under my nails with a nail pick. Then I use Avagard, a more intense version of your average Purell. It soaks into your hands, arms, and under your nails. I then walk around, asking nurses if they know of any babies who need a little attention. Usually, there is no shortage of babies seeking arms to hold them, and I get directed to infants of all different ages, illnesses, and personalities. Some babies need to be bounced, others need encouragement, and some can only sleep when they are being held. No matter what, I always fall entirely under the spell of the tiny humans holding my heart.

The hours spent as a cuddler are always fulfilling.

As a cuddler, you hold babies in the NICU, each for at least an hour. You can go anytime day or night, and have no set schedule, as long as you work 100 hours as a volunteer for the hospital in your first year. It is the most fabulous volunteer post for a university student. When you are awake at 3 AM and cannot go to sleep, the babies are there, waiting to be cuddled.

University of Chicago Medicine is not the only hospital with a program for baby cuddlers. Many hospitals, including Stanford Childrenâ&#x20AC;&#x2122;s Health, have found that cuddling allows the infants a sense of security and comfort when their parents canâ&#x20AC;&#x2122;t be there. In addition, babies with uncomfortable illnesses or treatments are often hard to console, especially for nurses with more than one patient.

In these cases especially, having a cuddler come in and pay the baby some undivided attention aids the baby in sleeping and remaining calm. Some hospitals have observed that the effects of baby cuddling are seen even in their medical charts! Winchester Medical Center in Virginia reported that baby cuddling helps to cut the time a baby stays in the hospital, and reduces the amount of medication they need when they are there.

For me, the most compelling reason to go cuddle is the happiness of the patients. I cuddle so that I can enter a patient room and watch the patient change from a fussy, uncomfortable, wailing ball of tears into a happy, smiling, or finally restful infant.

As the baby sleeps in my arms, they usually keep one of my fingers wrapped tightly in their little hands. I can feel the small pressure of their tiny grasp on my finger, and I feel comforted in their serenity. The peace of the patient room surrounds us as we rock back and forth, back and forth, happy to be cuddling each other.

"Hospitals Recruiting Volunteers to Cuddle Babies Addicted to Opioids."

Fox News. FOX News Network, 3 June 2016. Web. 05 May 2017.

"Volunteer Cuddlers Offer Comfort to Infants and Parents." Stanford Medicine. Stanford Medicine Newsletter, 2014. Web. 05 May 2017.

Where to find the volunteer application: http://www.uchospitals.edu/contact/volunteer/

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ulse p THE PRE-MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION the university of chicago FACEBOOK /uchicagopmsa WEBSITE pmsa.uchicago.edu