Vol. 13 Issue 1 (SP2020) by Frontiers: Washington University Review of Health

IN THIS ISSUE

Volume 13 Spring 2020 Issue #1

COVID-19: What Went Wrong? Physicians on FaceTime: The Future with Telehealth A Living Plague

FRONTIERS Washington University Review of Health

Washington University Review of Health

Writers Audrey Bochi-Layec Heather Chung

Annie Feng

Akshay Govinand

Alyssa Hyman

Ricky Illindala

Jihoon Kiel

Ben Lieberman

Shuyu Lin

Hei-Yong Lo

Haley Pak

Rehan Mehta

Vaibav Nandeesh

Maya Patel

Rishi Samarth

Daniel Berkovich

Julia Bulova

Ryan Chang

Hannah Chay

Casey Connelly

Annie Feng

Frank Lin

Anhthi Luong

Morgan Leff

Rehan Mehta

Shubhanjali Minhas Amaan Qazi

Soyi Sarkar

Sophia Xiao

Editors

Illustrators Elena Bosak

Jennifer Broza

Shubhanjali Minhas Helen Xiu

Angela Chen Lily Xu

Executive Board

Yu Xin Zheng

Lily Xu

Senior Executive Director

Lucy Chen

Co-Director of Design

Keshav Kailash

Executive Director

Eugenia Yoh

Co-Director of Design

Daniel Berkovich

Executive Director

Victoria Xu

Co-Director of Design

Anu Balasubramanian

Senior Editor-In-Chief

Shubhanjali Minhas

Director of Outreach

Anhthi Luong

Co-Editor-In-Chief

Ayda Oktem

Director of Outreach

Soyi Sarkar

Co-Editor-In-Chief

Yumi Sasaki

Co-Web Editor

Isaac Mordukhovich

Director of Operations

Ryan Chang

Co-Web Editor

Alyssa Hyman

Director of Finances

Amaan Qazi

Co-Web Editor

Jennifer Broza

Co-Director of Public Relations

Casey Connelly

Co-Director of Public Relations

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Contents 4

Riding the Germline: The Unforeseen Effects of Genetically Modified Humans

Writer : Ben Lieberman

Writer : Audrey Bochi-Layec

Editor : Shubhanjali Minhas

Editor : Amaan Qazi

A Call for Correctional Healthcare Reform

Writer : Heather Chung

A Living Plague

Unnatural Selection: Targeting Cancer With Evolution

Writer : Akshay Govindan

Starting Today Writer : Hei-Yong Lo

Gene Therapy: A Possible Cure for Hemophilia Editor : Annie Feng

What’s Your Healthcare Plan?: Universal Healthcare Around the World Writer : Vaibav Nandeesh

Editor : Ryan Chang

Writer : Shuyu Lin

Writer : Rehan Mehta

Writer : Annie Feng Editor : Julia Bulova

COVID-19: What Went Wrong? Editor : Morgan Leff

Editor : Julia Bulova

Can Phage Therapy be the solution to antibiotic resistance?

Editor : Sophia Xiao

Tapeworms and Tumors: How Repurposed Medicine Can Cure Cancer Writer : Haley Pak

Editor : Daniel Berkovich

Editor : Frank Lin

Why Antibiotics are Not the Answer to Everything: Urgent Cares and the Rise of Antibiotic Resistance Writer : Alyssa Hyman

Editor : Casey Connelly

A “Vegetable-less” Campus Writer : Ricky Illindala

Physicians on FaceTime: The Future with Telehealth Writer : Maya Patel Editor : Hannah Chay

40 Illustration Feature

Editor : Soyi Sarkar

Get Busy Living Or Get Busy Dying Writer : Jihoon Kiel Editor : Anhthi Luong

Pre-Existing Conditions: Another Possible Change in American Healthcare? Writer : Rishi Samarth Editor : Dany Matar

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Riding the Germline: The Unforeseen Effects of Genetically Modified Humans Writer: Audrey Bochi-Layec | Editor: Amaan Qazi | Illustrator: Shubhanjali Minhas

n 1990, Herman the Bull was born in Leiden, the Netherlands. He was the first transgenic bovine, having been micro-injected with human embryonic cells with the gene coding for lactoferrin. This allowed the bull’s female offspring to produce the human milk protein in its own milk, which could then be extracted. Since then, a large variety of genetically modified animals have been produced in laboratories all over the world—from colorful fish, to glowing rats, to translucent frogs. On a more practical level, goats have been modified to produce drugs in their milk, pigs have been given a gene that makes them more efficiently digest phosphorus, and a cow was given a gene allowing it to produce human breast milk. In many of these cases, human genes were injected into animals— but what if someone did the opposite? In October 2018, Lulu and Nana were born in secrecy at China’s Southern University of Science and Technology, the first genetically modified human beings. Using Cas9, a protein developed from CRISPR (Kolata, 2018), Dr. He Jiankui had targeted the CCR5 gene of two zygotes in an attempt to inflict the CCR5 Δ32 mutation, which is believed to confer innate immunity to HIV (Belluck, 2018). At the time, human genetic modification of this type was illegal in the United States due to risks associated with passing on modified genes to children, but its legality was unclear in China (Marchione, 2018).

Nonetheless, following the announcement of this achievement in November of that year, widespread controversy ensued, both about the experiment itself and the secrecy surrounding it. One biochemist, Jennifer Doudna, said she was “horrified and stunned” by the process (Cyranoski, 2018), and the Chinese Academy of Medical Sciences denounced the research, stating that it was “opposed to any clinical operation of human embryo genome editing for reproductive purposes” (Criss, 2019). In December of 2019, Dr. He Jiankui was sentenced to three years in prison for “illegal medical practices,” the official document stating “he had defied government bans and conducted the research in pursuit of personal fame and gain” (Normile, 2019).

Dr. He Jiankui was sentenced to three years in prison for “illegal medical practices” When discussing the ethics of He Jiankui’s actions, criticism largely surrounded three major topics: the experiment’s/plan’s secrecy and violation of norms, its danger to the children, and on the very concept of embryonic genetic engineering itself.

Jiankui’s choice to keep the experiment a secret, even failing to mention his genetic modification of human embryos to his ethics committee (Lovell-Badge, 2019), was greatly criticized. Further criticism centered around his use of a germ-line editing technique that would affect any future offspring of the children. Such germ-line editing is considered to be something that is only done to “treat a serious disease for which there are no other options— if it is to be done at all” (Kolata, 2018). To cover this up from an ethics board is a serious offence. Though the secrecy surrounding the experiment is a major ethical issue, it is also a largely procedural concern that could have theoretically been solved with greater transparency and care. Those criticisms revolving the potential danger to the children, as well as human engineering itself, deal with more fundamental ethical concerns. The Cas9/CRISPR technology used by He Jiankui is still in its relative infancy and prone to mistakes. CRISPR often “inadvertently alters genes other than the one being targeted,” and can lead to a form of “chimeric mosaicism” whereby only some cells contain the desired gene (Kolata, 2018). Many believe that the technology is too underdeveloped to be used on human embryos in such an aggressive manner. Further ethical complications were introduced when it was revealed that the children may have unintentionally had their brains altered by

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the experiment, possibly improving their memory, as well as other unintended effects (Regalado, 2019).

Many believe that the technology is too underdeveloped to be used on human embryos in such an aggressive manner. Alongside these concerns about the experiment’s design, there are additional concerns about human genetic modification as a whole. The specific form of human engineering used by He Jiankui, human germline modification is illegal in more than 40 countries including the United States (Regala). Moreover, there is a growing international movement towards a total moratorium on this type of research (Lander). Most of these concerns are based on fears surrounding unintentional side effects being inherited by the children of the original patient (Lander, 2019 ). Similar outcries have also arisen against so-called “designer babies” (Ball, 2017).

The ethical concerns around “designer babies’’ are numerous.

Many bioethicists are concerned that modification of the human germline for medical purposes will inevitably lead to similar modification for cosmetic purposes and, perhaps, even to improve human attributes such as intelligence and strength (Ball, 2017). The societal implications of a caste of genetically modified humans, mostly born to those with the means to obtain such genetic modification, can be hard to fathom, but seem largely negative.

The ethical concerns around “designer babies’’ are numerous. However, much of the concern around He Jiankui’s research was not based solely on the fact that he was modifying the human germline, but rather that his reckless approach would “have a chilling effect on support for legitimate and valuable gene-editing research” (Kolata, 2018). Indeed, prior to Jiankui’s experiment, many medical research institutions had given

qualified support of the idea of human germline modification, albeit with “stringent oversight” (“With Stringent Oversight”). One bioethicist, Mrs. Charo, notes that even “[i] f we have an absolute prohibition [on genetic engineering] in the United States with this technology advancing, it’s not like it won’t happen” anyway (Kolata, 2018). Some bioethicists, like Dr. Kincaid, have come out fully in support of germline engineering, considering it the “logical continuation of the way we’ve long approached parenting” (Kincaid, 2015). He Jiankui’s experiment was extremely irresponsible and unethical by most standards, both national and international. His secrecy is difficult to defend, as was his choice

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to ignore the great potential dangers of using such a young technology on children — especially considering it could affect their future potential offspring. At the same time, this experiment forces medical authorities to deal with the fact that the ability to genetically modify the human germline, however crudely, is here. We will increasingly have to face the question: Can we afford to keep this technology illegal?

References Kolata, Gina, and Pam Belluck. “Why Are Scientists So Upset About the First Crispr Babies?” The New York Times, The New York Times, 5 Dec. 2018, www.nytimes.com/2018/12/05/ health/crispr-gene-editing-embryos.html. Belluck, Pam. “Chinese Scientist Who Says He Edited Babies’ Genes Defends His Work.” The New York Times, The New York Times, 28 Nov. 2018, www.nytimes.com/2018/11/28/world/ asia/gene-editing-babies-he-jiankui.html. Marchione, Marilynn. “Chinese Researcher Claims First Gene-Edited Babies.” AP NEWS, Associated Press, 26 Nov. 2018, apnews. com/4997bb7aa36c45449b488e19ac83e86d. Cyranoski, David. “CRISPR-Baby Scientist Fails to Satisfy Critics.” Nature News, Nature Publishing Group, 28 Nov. 2018, www.nature.com/ articles/d41586-018-07573-w. Criss, Steven D, et al. “Cost-Effectiveness and Budgetary Consequence Analysis of Durvalumab Consolidation Therapy vs No Consolidation Therapy After Chemoradiotherapy in Stage III Non-Small Cell Lung Cancer in the Context of the US Health Care System.” JAMA Oncology, American Medical Association, 1 Mar. 2019, www.ncbi.nlm.nih.gov/pmc/articles/ PMC6439842.

Normile, Dec, Dennis, et al. “Chinese Scientist Who Produced Genetically Altered Babies Sentenced to 3 Years in Jail.” Science, 30 Dec. 2019, www.sciencemag.org/news/2019/12/ chinese-scientist-who-produced-genetically-altered-babies-sentenced-3-years-jail. Lovell-Badge, Robin. “CRISPR Babies: a View from the Centre of the Storm.” Development, Oxford University Press for The Company of Biologists Limited, 1 Feb. 2019, dev.biologists. org/content/146/3/dev175778. Regalado, Antonio. “China’s CRISPR Twins Might Have Had Their Brains Inadvertently Enhanced.” MIT Technology Review, MIT Technology Review, 22 Feb. 2019, www.technologyreview.com/s/612997/the-crispr-twins-hadtheir-brains-altered/. Regala, “About Human Germline Gene Editing: Center for Genetics and Society.” About Human Germline Gene Editing | Center for Genetics and Society, Lander, Eric S., et al. “Adopt a Moratorium on Heritable Genome Editing.” Nature News, Nature Publishing Group, 13 Mar. 2019, www. nature.com/articles/d41586-019-00726-5.

Ball, Philip. “Designer Babies: an Ethical Horror Waiting to Happen?” The Guardian, Guardian News and Media, 8 Jan. 2017, www.theguardian.com/science/2017/jan/08/designer-babies-ethical-horror-waiting-to-happen. “With Stringent Oversight, Heritable Human Genome Editing Could Be Allowed for Serious Conditions.” National Academies Web Server www8.Nationalacademies.org, www8. nationalacademies.org/onpinews/newsitem. aspx?RecordID=24623. Kincaid, Ellie. “Designer Babies Will Just Be a Logical Continuation of the Way We’ve Long Approached Parenting.” Business Insider, Business Insider, 24 June 2015, www.businessinsider.com/designer-babies-are-an-exercise-of-parents-reproductive-freedom-2015-6?r=US&IR=T.

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A Call for Correctional Healthcare Reform Writer: Heather Chung | Editor: Julia Bulova | Illustrator: Helen Xiu

ncarcerated people are the only people who are constitutionally guaranteed primary healthcare (Estelle v. Gamble, 1976). It was determined that a failure to provide proper medical care to inmates violates the eight amendment. Yet, incarcerated and non-incarcerated population have among the most stark health disparities. According to a 2017 Bureau of Justice statistics, more than half of state prisoners and two thirds of jail inmates met the criteria for drug dependence from 2007 to 2009 (Bronson et al., 2017). Mental illness prevalence in prisons is “roughly 50% compared to approximately 10% in the community, and 28% to 52% if Americans with serious mental illness have been arrested at least once” (Rich, 2014). From 2011 to 2012, 40 percent of prisoners and jail inmates reported having a chronic medical condition. Additionally, 21 percent of prisoners and 14 percent of jail inmates reported ever having tuberculosis, hepatitis, or STDs excluding HIV or AIDS (Maruschak, 2016). Compared to the general population, the incarcerated population are disproportionately affected by severe conditions and illnesses that result in poor health. The U.S. has the highest incarceration rate in the developed world at 655 per 100,000 as of 2019 (Walmsley, 2019). With the “tough on crime” rhetoric during the Reagan Administration, incarceration rates peaked during the 90s, resulting in

millions of people in jails and prisons. According to 2018 Bureau of Justice statistics, nearly 2.2 million people were incarcerated in U.S. prisons and jails by the end of 2016 (Kaeble, Cowhig, 2018). With longer sentences, the average age of the incarcerated population rose. From 1993 to 2013 the number of inmates aged over 55 increased 400 percent (Carson, 2016). The increase in mass incarceration over the last 40 years, propelled by the War on Drugs and harsher sentences for criminals, has led to overcrowded facilities and a burden on state correctional budgets.

Mental illness prevalence in prisons is “roughly 50% compared to approximately 10% in the community, and 28% to 52% if Americans with serious mental illness have been arrested at least once” (Rich, 2014). Prisons are inherently unfit to manage chronic disease cases because they require a high level of

extra care and accommodation that many correctional settings do not have the financial resources to provide. This fact becomes especially important because longer sentences increase the portion of older inmates. Correctional facilities should account for the increase in age of the population in order to deliver proper health care that supports older inmates and prisoners. However, the issue is rooted in having a lack of funding for structural changes that allow for better access to care for chronically ill inmates. One of the most concerning issues that arises with the rapid influx of inmates in the prison system is the massive consequence on the health of prisoners. Correctional facilities have seen an increase in cases involving chronic conditions, such as cancer and high blood pressure, and therefore an increase in healthcare costs (Maruschak, 2015). The crowded conditions and lack of proper resources and education make prisoners much more susceptible to communicable diseases like tuberculosis, HIV, and Hepatitis C (Restum, 2005). Furthermore, according to an assessment done by the Justice Department, the institutions with the highest percentages of aging inmates “spent five times more per inmate on medicare—14 times more per inmate on medication” than those with lower percentages (McKillop, Boucher, 2018). The growing population of older prisoners does require more money to be spent on treating their illnesses.

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tation. With this goal in mind, outcomes for prisoner health could be drastically improved. Rehabilitation programs that provide prisoners with education and resources for employment opportunities can reduce recidivism rates. For example, in Ohio, inmates who enrolled in college courses had a re-offending rate of 18 percent, while inmates who did not take any courses had a re-offending rate of 40 percent (Reich, 2017). In Minnesota, prisoners who had participated in work-release programs, which gave prisoners opportunities to work in the community as they reached their release dates, were twice as likely to find work within the first couple years of release than inmates who were not enrolled in the program (Duwe, 2014). From 2007 to 2011, the state of Minnesota was able to save $1.25 million due to the decrease in recidivism rate. Unfortunately, the state of most of our correctional systems and its healthcare system conflicts with the idea of optimal medical care and rehabilitation for correctional populations. Privatization of prison health care systems as a cost cutting measure compromises quality of medical care. By hiring private companies over individual medical practitioners, states are not required to pay benefits and pension costs to state workers (Andrews, 2017). While privatization is a cheaper option to minimize costs and maximize profits for shareholders, these companies are not subject to government standard accountability. For example, in 2012, “a court-ordered investigation of Corizon in Idaho revealed ‘inhumane’ conditions… where terminally ill inmates were left for periods of time without food or water and slept in soiled linens” (Markowitz,

2016). Ultimately, corporate executives and shareholders profit as prisoners become victims of malpractice and wrongful death or injury. Nevertheless, society has to pay the price for the shortcomings of “both private health care providers—who often fail to deliver adequate care—and of public health care for released inmates receiving treatment and for their families and friends who become infected and cannot afford private care” (Restum, 2005). The fundamental question is what is the purpose of prisons and jails? Is it public safety and reduction in recidivism? The core purpose of criminal justice should be rehabili-

How can we improve the standard of care of prisoners and promote rehabilitation among incarcerated populations? There are multiple layers to addressing the unethical issues that pervades correctional facilities, but the most long-lasting and effective change happens at the policy level. Often, the role of doctors who work in prisons is complicated by having multiple and possibly conflicting duties. According to a review of prison-specific ethical and clinical problems by Jean-Pierre Restellini and Romeo Restillini, doctors have a duty to “protect and promote the health of prisoners and to ensure they receive the best care possible,”

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while also having to follow the responsibilities of prison management (Restillini, Restillini). That means doctors may be required to disclose medical information regarding the patient to courts and officials. A physician’s primary obligation should be to the wellbeing of their patients. Medical staff working in corrections facilities should have the ability to fully practice clinical independence, which is the “assurance that individual physicians have the freedom to exercise their professional judgement in the care and treatment of their parties without undue influence by outside parties or individuals” (Pont et al., 2018). It has been historically difficult to obtain clinical independence for doctors in the prison setting because correctional health care professionals were obliged to participate in custodial measures, such as matters of discipline or “performance of body cavity searches or the retrieval of body fluids for testing for illicit drugs, even when there are no medical indications for such actions” (Pont et al., 2018). In order to amend these issues, the state should instigate structural reforms such as the separation of “health care provision from medical activities commissioned for forensic purposes by third parties” to reduce dual loyalty conflicts for doctors. Third parties that can commission medical activities include the correctional facilities administration, prosecutors, and government authorities. (Pont et al., 2018). Ensuring clinical independence for medical professionals can support the overarching goal of providing medical care that protects the welfare and autonomy of the

patients. By establishing strict guidelines for physicians’ duties, correctional facilities can prevent maltreatment of prisoners. With the creation of Medicare and Medicaid in 1965, the “inmate exception” excluded Medicare and Medicaid from paying for healthcare in jails and prisons in the nation. This has adversely affected the under-resourced correctional health system that is “isolated from mainstream medicine and shielded from critical accreditation and external quality oversight mandates” (Fiscella, 2017). Repealing the inmate exception could improve both correctional health and community health as well as reduce wasteful public spending. Alleviating problems in correctional healthcare directly relates to community health once inmates are released back into free society. If chronic problems as well as infectious diseases, such as tuberculosis, HIV, and Hepatitis C, are not adequately addressed and treated by the correctional health care system, it can put a strain on community hospitals (Fiscella, 2017). By repealing the inmate exception, the federal government would take up the responsibility of providing quality medical care for prisoners and states would be relieved of the pressure to lower costs or privatize health care services. Opioid addiction treatment tends to heavily rely on correctional health care systems that often do not consider long term treatment options and rehabilitation. Yet, evidence-based substance abuse treatment can be a cost-effective solution to the high percentage of prisoners with substance abuse and mental illness. Punishment is an ineffective method for treating

prisoners whose substance abuse is directly related to their criminal behavior. In order to promote rehabilitation for prisoners, correctional health care systems should provide evidence-based treatment to alleviate withdrawal symptoms for prisoners and aid them in reducing their usage to a safe level. According to the National Institute on Drug Abuse, “the large economic benefit of treatment is seen in avoided costs of crime” (NIDA, 2014). Furthermore, many prisons generally lack a design that can accomodate proper geriatric care. Many older prisoners face environmental challenges such as poor lightning and dimly lit hallways, high bunk beds, steep staircases and low toilets (CorrectionsOne, 2018). Structural designs of prisons are not the only issue for geriatric care in prison. Lack of access to resources and social limitations exacerbates physical and mental ailments older prisoners have. For example, “limited visitors policies, restricted opioid-prescribing practices, and mistrust between patients and clinicians” are barriers to the needed palliative care for this growing portion of the prison population (Rich, 2014). Corrections facilities should reconstruct their design to tend to the needs of elderly inmates and remove barriers that prevent them from obtaining proper medication and treatment. We must promote rehabilitation as the foundation of prison rather than isolation and punishment. Part of rehabilitation is providing the necessary health services for addiction and other conditions as well as fostering education. What we need is an evidence-based approach that puts the needs and

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We must promote rehabilitation as the foundation of prison rather than isolation and punishment.

interests of patients in quality care and policy that improves public health after release from prison. The U.S. has developed a system in which people who live in poverty and illness are punished and that punishment in turn generates more poverty and illness. In order to address the root of the problem, the solution has to come from the community. There needs to be better community health care so that people don’t have to get incarcerat-

ed in the first place. There needs to be a policy that instigates a positive-feedback system in which better healthcare for the incarcerated populations results in better community health and better community healthcare results in less incarcerations. We cannot forget that the prison population is part of the general population.

References Andrews, J. (Feb. 2017). The Current State of Public and Private Prison Healthcare. Retrieved from https://publicpolicy.wharton. upenn.edu/live/news/1736-the-current-stateof-public-and-private-prison/for-students/blog/ news.php#_edn20

Reform_of_Correctional_Health_Care

Bronson, J., Stroop, J., Zimmer, S., Berzofsky, M. (Jun. 2017). Bureau of Justice Statistics: Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009. Retrieved from https://www.bjs.gov/index. cfm?ty=pbdetail&iid=5966

Markowitz, E. (Sep. 2016). Making Profits on the Captive Prison Market. Retrieved from https://www.newyorker.com/business/currency/making-profits-on-the-captive-prison-market

Carson, A. (May. 2016). Aging of the State Prison Population, 1993-2013. Retrieved from https://www.bjs.gov/content/pub/pdf/ aspp9313.pdf CorrectionsOne. (Dec. 2018). Research Analysis: Identifying Elderly Inmates’ healthcare needs. Retrieved from https://www.correctionsone.com/issues-correctional-healthcare/articles/research-analysis-identifying-elderly-inmates-healthcare-needs-KHjhZa0GjhRG7aSO/ Duwe, G. (Mar. 2014). An Outcome Evaluation of a Prison Work Release Program: Estimating It’s Effects of Recidivsm, Employment, and Cost Avoidance. Retrieved from https://journals.sagepub.com/doi/ abs/10.1177/0887403414524590 Fiscella, K., Beletsky, L., Wakeman, S.E. (Mar. 2017). The Inmate Exception and Reform of Correctional Health Care. Retrieved from https://www.researchgate.net/publication/314144858_The_Inmate_Exception_and_

Kaeble, D., Cowhig, M. (Apr. 2018). Correctional Populations in the United States, 2016. Retrieved from https://www.bjs.gov/content/ pub/pdf/cpus16.pdf

Maruschak, L.M., Berzofsky, M., Unangst, J. (Oct. 2016). Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-2012. Retrieved from https://www.bjs.gov/content/ pub/pdf/mpsfpji1112.pdf Mckillop, M., Boucher A. (Feb. 2018). Aging Prison Populations Drive up Costs. Retrieved from https://www.pewtrusts.org/en/research-and-analysis/articles/2018/02/20/ aging-prison-populations-drive-up-costs NIDA. (Apr. 2014). Principles of Drug Abuse Treatment for Criminal Justice Populations - A Research-Based Guide. Retrieved from https://www.drugabuse.gov/publications/ principles-drug-abuse-treatment-criminal-justice-populations/providing-drug-abuse-treatment-to-offenders-worth-f Pont, J., et al. (Apr. 2018). Prison Health Care Governance: Guaranteeing Clinical Independence. Retrieved from https://www.bjs.gov/ content/pub/pdf/mpsfpji1112.pdf Reich, J. (Aug, 2017). The Economic Impact

of Prison Rehabilitation Programs. Retrieved from https://publicpolicy.wharton.upenn.edu/ live/news/2059-the-economic-impact-of-prison-rehabilitation/for-students/blog/news. php#_edn5 Restillini, J.P., Restillini, R. Prison and Health, 3 Prison-specific Ethical and Clinical Problems. Retrieved from http://www.euro.who. int/__data/assets/pdf_file/0009/249192/ Prisons-and-Health,-3-Prison-specific-ethical-and-clinical-problems.pdf Restum, G. Z. (Oct. 2005). Public Health Implications of Substandard Correctional Health Care. Retrieved from https://www.ncbi.nlm.nih. gov/pmc/articles/PMC1449420/pdf/0951689. pdf Rich, J.D., Allen, S.A., Williams, B.A. (Dec. 2014). The Need for Higher Standards in Correctional Healthcare to Improve Public Health. Retrieved from https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC4371015/ Walmsley, R. (2019). World Prison Brief. London: Institute for Criminal Policy Research. Retrieved from http://www.prisonstudies.org/ world-prison-brief (1976). Estelle v. Gamble 429 U.S. 97. Retrieved from https://www.loc.gov/item/ usrep429097/

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A Living Plague Writer: Annie Feng | Editor: Julia Bulova | Illustrator: Helen Xiu

ff the coast of Florida, a slow alien invasion is in progress. Native to the South Pacific, the lionfish now gobbling up the reef is more familiar to most as an aquarium dweller. Indeed, the most likely source of the invasion is unwanted pets released into the ocean (Boissoneault, 2016). In humans, its venomous spines can cause intense pain and in some cases, paralysis and respiratory distress. Its lack of natural predators and voracious appetite devastates both ecologically and commercially important fish populations. In the warm waters of the Bahamas, it has gobbled up between 65-95 percent of native reef fish in just 30 years (Crowl et al., 2008). The proposed solution? Eat them. Lionfish are increasingly in demand in local restaurants, encouraging fishermen to hunt them down. However, as more diners find an appetite for the prickly predator, conservationists also may have to contend with the possibility that they will become popular enough to be overfished in their native waters as well (Boissoneault, 2016). In many ways, the lionfish is emblematic of the damage invasive species can have on native environments, species, and subsequent impacts on human health Though lionfish are one of the flashiest invasive species, its impact on humans is for now mostly limited to run-ins with commercial fishermen and unwary swimmers. Other species pose a more systemic

threat by damaging crops, injuring people and livestock, and uprooting entire communities. Plants harmless in their native ranges can reshape entire ecosystems. The prickly pear cactus, introduced to Kenya as an ornamental plant by European colonizers, has been overtaking the fragile rangelands that cattle herders and their animals depend upon. Animals who attempt to feed on the plant ingest thorns that catch in their stomach lining which cause them to eventually die. Even grazing on other plants nearby can result in livestock being blinded by thorns. As a result, the herders are forced off of their lands and lose access to the medicinal native plants that have been choked out by the cactus (Discover the Impacts of Invasives, 2019). Other species like the fall armyworm (another North American species that has spread extensively across Africa) directly attack important crops like corn. The extensive insecticide use required to control it means farmers are forced to choose between a potentially tainted harvest or none at all (Discover the Impacts of Invasives, 2019). The impact of invasive species such as these is felt most by developing nations that do not yet have the extensive infrastructure and technological and economic resources to control their spread. In the U.S, control of invasive species costs the nation $120 billion annually (Invasive Species & Disease). While the prickly pear cactus and fall armyworm attack crops and

livestock directly, other invasive species worsen the effects of climate change by reshaping habitats. For example, buffelgrass was originally introduced in the United States to provide forage for cattle and then to prevent soil erosion. However, it spread out of control and has overtaken much of the desert region of the American southwest (Discover the Impacts of Invasives, 2019). The highly flammable grass has grown over the fire-resistant desert, contributing to the increasing incidence of major wildfires in the area. These resulting fires directly threaten human life and property and cause declining air quality. In places like South Africa, invasive trees like black wattle and cluster pines use five times more water than native trees and are taking an enormous toll on the nationâ&#x20AC;&#x2122;s water supplies (Wild, 2018). In 2018, Cape Town nearly became the first major city to run out of water, forcing strict water usage restrictions. As climate change prolongs droughts and causes more wildfires, invasive species increase the damage. However, most media attention has been given to invasive species as vectors of disease. They have perhaps the most noticeable impact on human health, as increasing globalization means that epidemics can now cross oceans in a day. Invasive species arrive every day in ship ballasts and airplane holds, and the pathogens they carry with them hitch a ride as well. The Norway rat, or brown rat, is perhaps the most prolific invader, originating in

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northern China and spreading to every continent except Antarctica. It is not only a carrier of diseases like bubonic plague, typhus, Weilâ&#x20AC;&#x2122;s disease, toxoplasmosis and trichinosis, but also carries parasitic mites and fleas (Invasive Species & Disease). Other species like zebra mussels are hosts for roundworm, which humans pick up through eating improperly cooked fish or drinking roundworm infested water (Crowl et al., 2008). The most famous example in recent memory is the Asian Tiger mosquito, which carries Zika, chikungunya and dengue viruses. The warmer temperatures brought on by climate change have allowed it to flourish in its introduced environment (Asian Tiger Mosquito). Its range in the United States now extends as far north as the Great Lakes region, and outbreaks of diseases previously rarely found in the continental U.S have become more frequent. Invasive species clearly take a massive toll on human life, property and infrastructure. However, history is littered with misguided attempts to resolve these problems. In 1883, in an attempt to control the rat population that had accidentally been introduced to Hawaii, European plantation owners released mongoose into the island (Boissoneault, 2016). However, as mongoose are diurnal and rats are nocturnal, the mongoose instead devastated the islandsâ&#x20AC;&#x2122; native bird population. Today in Hawaii, conservationists are attempting to control the spread of the invasive strawberry guava tree by introducing the Brazilian scale, an insect that feeds exclusively on strawberry guava trees. The strawberry guava produces fruit at such a high rate that it outcompetes native trees, forming vast monocultures that

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drastically impact the watershed (Boissoneault, 2016). However, the strawberry guava is also grown as a crop and Hawaii residents worry about their own trees and fear that the insect meant to control it will create larger problems just as the mongoose did in 1883. As with the lionfish and other invasive species discussed, every proposed solution comes with its own set of risks. Additionally, many people are resistant to attempts to control species that are beneficial for humans in the short term like the strawberry guava tree or buffelgrass. Ultimately, conservationists must somehow walk the knife’s edge of controlling invasive species with a “do no harm” mentality.

References [1] Asian Tiger Mosquito. (n.d.). Retrieved from https://www.invasivespeciesinfo.gov/profile/ asian-tiger-mosquito [2] Boissoneault, L. (2016, May 19). When Invasive Species Become Local Cuisine. Retrieved from https://www.theatlantic.com/ science/archive/2016/05/hawaii-invasive-species/483509/ [3] Crowl, T. A., Crist, T. O., Parmenter, R. R., Belovsky, G., & Lugo, A. E. (2008). The spread of invasive species and infectious disease as drivers of ecosystem change. Frontiers in Ecology and the Environment, 6(5), 238–246. doi: 10.1890/070151 [4] Discover the Impacts of Invasives. (2019, February 26). Retrieved from https://www. invasive-species.org/stories/ [5] Invasive Species & Disease. (n.d.). Retrieved from https://wilderness.net/learn-about-wilderness/threats/invasive.php [6] Wild, S. (2018, November 2). South Africa’s invasive species guzzle precious water and cost US$450 million a year. Retrieved from https://www.nature.com/articles/d41586-01807286-0

Washington University Review of Health

Unnatural Selection: Targeting Cancer With Evolution Writer: Akshay Govindan | Editor: Ryan Chang | Illustrator: Angela Chen

hile most people might think of fitness as a measure of athleticism or time spent at the gym, evolution gives the word a much different meaning. In evolutionary theory, the term “fitness” describes the ability of an organism to reproduce and survive in its environment (Orr et. al, 2009). As time goes on, organisms acquire mutations in their DNA which change their genotype and impact their fitness. This phenomenon of differences in genotype affecting fitness is called natural selection (Orr et. al, 2009). Since the advent of modern genetics, fitness and natural selection have been used to describe populations of organisms in natural ecosystems, from Darwin’s famous finches to humans. Recently, scientists have begun using these same ideas on smaller ecosystems, like groups of cells in the human body, leading to significant advances in medical research. A key area of research where evolutionary theory is being applied is cancer. Cancer originates from mutations in the DNA of somatic cells, which are cells that do not play a role in reproduction (Dagogo-Jack et. al, 2018). In particular, the disease is initiated by certain early “driver” mutations that significantly contribute to cancer progression and proliferation. Each cell can be modeled as a “parent”; when it divides, it passes down its DNA footprint to its offspring. As the disease progresses and more cells divide, differences in fitness result

in cells with certain traits surviving, while others die off. This creates a diverse environment, composed of cells with different mutations and gene expression levels (Fittall et. al, 2019). On a broader scale, a diverse tumor environment results in a cancer that is more heterogeneous, with distinct “clones” that share a parent cell (Ben-David et. al, 2019). A consequence of tumor heterogeneity is that clones may respond differently to treatments. Multiple studies have shown that heterogeneity, and cancer evolution in general, promote drug resistance in two distinct ways (Dagogo-Jack et. al, 2018). First, pre-existing clones that are drug-resistant may survive treatment while clones that are drug-susceptible die off. After treatment, the cells in these drug-resistant clones rapidly divide, resulting in a tumor dominated by drug-resistant cells (Dagogo-Jack et. al, 2018). Alternatively, some cell

subpopulations can enter a “persister” state in which cell growth is limited (Ramirez et. al, 2016). This is evolutionarily advantageous since many cancer treatment options target cells that quickly divide (Ramirez et. al, 2016). After entering this “persister” state, these cells can acquire even more mutations which can result in the formation of multiple drug-resistant clones (Dagogo-Jack et. al, 2018). As a result, conventional treatments like chemotherapy may actually result in a cancer that is more difficult to treat. Current research aims to understand both the specifics of tumor heterogeneity as well as how to take advantage of this phenomenon in treatment. Scientists, including those at Washington University, are developing complex algorithms that statistically infer the clonal structure of tumors from the frequencies of mutations they possess (Miller et. al, 2014). The general method relies

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on the idea that low mutational frequencies are more likely to be found in subclones that developed later in time, while higher mutational frequencies are likely more prevalent in clones that contributed to disease initiation (Miller et. al, 2014). By clustering these mutational frequencies, the algorithm can designate clones and ultimately show the clonal structure of a tumor sample. Furthermore, computational advances have enabled the discovery of the evolutionary history of cancers, such as the when the driver mutations occurred in time (Fittall et. al, 2019). In more clinical settings, physicians are beginning to evaluate how to use ideas from evolutionary theory to inform therapy. One approach known as adaptive therapy focuses on selectively eliminating a portion of drug-sensitive cells instead of targeting the whole tumor (Gatenby et. al, 2009). This allows for the population of drug-sensitive cells to compete with the population of drug-resistant cells and therefore, limit the growth of the drug-resistant cells. The end result is a tumor that is overall more responsive to treatment since it is not dominated by drug-resistant cells, but instead still has a small, stable population of targetable, drug-sensitive cells (Gatenby et. al, 2009). An alternative approach targets driver mutations, which are present in the founders of the cancer cell population, and therefore are also in the offspring of these founder cells. Understanding the evolutionary history of a cancer allows for the identification of key driver events in the founder cells of the cancer. Targeting multiple driver mutations eliminates cells in multiple clones and therefore, increases the possibility of eliminating the tumor

(Fittall et. al, 2019). By using innovative therapies which exploit the evolutionary history of cancers, groups of cancer cells can be selectively targeted to improve patient survival. The application of evolutionary theory to populations of cells has led to major advances in medicine. In the area of cancer, researchers have developed new perspectives on the disease, tools to understand cancer progression, and innovative

forms of therapy. Similar ideas can be applied in areas such as immunology, where immune cells must rapidly evolve to successfully combat an infection. The development of novel antibiotics relies on understanding how evolution results in groups of bacteria which respond differently to drugs (Nesse et. al, 2008). Future cancer therapies will surely evolve in order to catch up to the cells they target.

References Ben-David, U., Beroukhim, R. & Golub, T.R. Genomic evolution of cancer models: perils and opportunities. Nat Rev Cancer 19, 97–109 (2019). https://doi.org/10.1038/s41568-0180095-3

Nesse, R. M., & Stearns, S. C. (2008). The great opportunity: Evolutionary applications to medicine and public health. Evolutionary applications, 1(1), 28–48. https://doi.org/10.1111/ j.1752-4571.2007.00006.x

Dagogo-Jack, I., Shaw, A. Tumour heterogeneity and resistance to cancer therapies. Nat Rev Clin Oncol 15, 81–94 (2018). https://doi. org/10.1038/nrclinonc.2017.166

Orr H. A. (2009). Fitness and its role in evolutionary genetics. Nature reviews. Genetics, 10(8), 531–539. https://doi.org/10.1038/ nrg2603

Fittall, M.W., Van Loo, P. Translating insights into tumor evolution to clinical practice: promises and challenges. Genome Med 11, 20 (2019). https://doi.org/10.1186/s13073-0190632-z

Ramirez, M., Rajaram, S., Steininger, R. et al. Diverse drug-resistance mechanisms can emerge from drug-tolerant cancer persister cells. Nat Commun 7, 10690 (2016). https:// doi.org/10.1038/ncomms10690

Gatenby, R. A., Silva, A. S., Gillies, R. J., & Frieden, B. R. (2009). Adaptive therapy. Cancer research, 69(11), 4894–4903. https://doi. org/10.1158/0008-5472.CAN-08-3658 Miller CA, White BS, Dees ND, Griffith M, Welch JS, Griffith OL, et al. (2014) SciClone: Inferring Clonal Architecture and Tracking the Spatial and Temporal Patterns of Tumor Evolution. PLoS Comput Biol 10(8): e1003665. https:// doi.org/10.1371/journal.pcbi.1003665

Washington University Review of Health

Starting Today Writer: Hei-Yong Lo | Editor: Daniel Berkovich | Illustrator: Yu Xin Zeng

fter graduating from WashU, I entered an MD/ PhD program. As most students who decide on this path, I was excited and eager. With strong academic achievements and even stronger hopes and dreams, nothing could stand in my way. Yet, in only three years, I have witnessed multiple students (some with better grades and bigger dreams) delay progress. A few have left the program. One got dismissed. The common thread? Mental health. Mental health is something that we are told to work on. Unfortunately, we are often not given too much guidance or resources to do so. Most Universities and programs are seeking to improve mental health amongst their students and some take pride in their happy community (Eva 2019, Lipson 2019). But how do we tackle something so large and as amorphous a concept as “mental health”? I’ve wrestled with this question for years until I came across a peculiar thought: how could I hope to achieve a state of being healthy without a means of accurately assessing how far I’ve come? Perhaps a good place to begin is to ask whether we can more accurately assess our mental health state beyond Good or Bad. To assess tangible things is often simple. Since a young age, we have been given marks to assess achievement. Starting with stars in kindergarten, to grades throughout college, and ultimately awards, publications, and salaries as we

graduate, we are surrounded by quantitative means of measuring success. But when it comes to mental health, we may not be as experienced. In fact, accurately measuring mental health is a scientific problem (and one that researchers are actively working on!). Some of these questionnaires are being used clinically, such as the PHQ9 questionnaire to screen for major depression and suicidal thoughts. However, those usually catch more severe symptoms of major depression (Levis 2019, MDcalc 2019). Why is measuring our mental health so important? Because for a task as large as improving mental health, we need an accurate way to assess progress. There exist mental health screening tests though they have varying degrees of success (Tannenbaum 2009, Wei 2016). This may be due to the fact that the definition of baseline mental health is subjective and personal. The point of all of this is to say that if we want to improve mental health, we need to be able to measure how we are progressing, and this scale is something that we have to determine for ourselves. What would a scale look like? When defining a scale, use indicators such as certain concrete behaviors or patterns of thought. On a given “good” day, write down some thoughts and compare them with those on a “bad” day. Those are some baseline thoughts. Then analyze behaviors. What are some

routines? What causes habits to change? Finally, ask what mentally health looks like you, specifically? Is it making time to run? Calling your parents? Two measures I have: when I am happy, I look forward to making dinner and I am more likely to listen to sad music before I even realize I am down. In other words, we discover our scale by being cognizant of our behaviors and thoughts. Once we have organized our thoughts and behaviors, it becomes easier to identify when something changes. The earlier we can identify that something is wrong, the more empowered we are to tackle it. These practices have helped me throughout stressful transitions to medical school and then to graduate school. Both present with their own set of challenges. Being cognizant of changes in my behavior helped me know when to seek help from various peers and mentors who helped me workshop possible solutions. I’ve found that relying on friends and mentors has helped me through most of my concerns, as long as I reach out. Lastly, do not be afraid of seeing your healthy mental state change. As we take more responsibilities, our scale will change, but the goal is to be at a healthy state of mind despite high workloads. Defining a baseline for mental health can be very hard to do on your own. Additionally, some problems cannot be solved by peers or mentors. For those instances,

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consider reaching out to experts such as counselors, psychologists, or psychiatrists. Many universities have free mental health services and screenings (Siceloff 2017, Scott 2019). Seeing an expert regularly (even when things are going well) is a great habit to develop. No matter what career we choose, having the experience and available tools will serve us well. For readers, a great resource for those struggling with depression is the book Feeling Good: The New Mood Therapy by David Burns (Burns 2012). It covers a number of cognitive distortions and warning signs for depression particularly well (which have helped me greatly). WashU has improved their efforts greatly since I have graduated. They have introduced better mental health services, such as Let’s Talk (free walk-ins for appointments with MHS counselors) and TAO (Therapist Assisted Online - an interactive web-based program to help overcome common mental health concerns) (WUSTL 2019). Take advantage of these structured programs when they exist, but seek to develop your own long-term system. Choose something sustainable you can lean on even in times of great stress. Each of us is traveling a long journey, often winding in unexpected ways. To tackle challenges along the way requires constant effort. The earlier we start thinking about how we measure our own unique happiness and sadness, the earlier we can identify issues and seek the remedies to solve them. Why wait?

References Burns, David. Feeling Good. https://www. goodreads.com/work/best_book/1892311feeling-good-the-new-mood-therapy. 2020 Eva, Amy L. How Colleges Today Are Supporting Student Mental Health. Greater Good https://greatergood.berkeley.edu/article/item/ how_colleges_today_are_supporting_student_ mental_health. 2020 Levis, B., Benedetti, A. & Thombs, B. D. Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis. BMJ 365, (2019). Lipson, S. K., Abelson, S., Phillips, M. & Eisenberg, D. Prepared by the healthy minds network research team: 14. 2019 PHQ-9 (Patient Health Questionnaire-9). MDCalc https://www.mdcalc.com/phq-9-patienthealth-questionnaire-9.

Siceloff, E. R., Bradley, W. J. & Flory, K. Universal Behavioral/Emotional Health Screening in Schools: Overview and Feasibility. Rep. Emot. Behav. Disord. Youth 17, 32–38 (2017). Tannenbaum, C., Lexchin, J., Tamblyn, R. & Romans, S. Indicators for Measuring Mental Health: Towards Better Surveillance. Healthc. Policy 5, e177–e186 (2009). Wei, Y., McGrath, P. J., Hayden, J. & Kutcher, S. Measurement properties of tools measuring mental health knowledge: a systematic review. BMC Psychiatry 16, 297 (2016). Wustl. Let’s Talk. Students https://students. wustl.edu/lets-talk/ (2018). Wustl. Therapy Assistance Online (TAO). Students https://students.wustl.edu/therapist-assisted-online/ (2018).

Scott, Emily Goodman, Peg Donohue, Jennifer Betters-Bubon. The case for universal mental health screening in schools. Counseling Today https://ct.counseling.org/2019/09/the-casefor-universal-mental-health-screening-inschools/ (2019).

Washington University Review of Health

Why Antibiotics are Not the Answer to Everything: Urgent Cares and the Rise of Antibiotic Resistance Writer: Alyssa Hyman | Editor: Casey Connelly | Illustrator: Elena Bosak

any people go to an urgent care center when experiencing a relatively minor health issue. Flu tests and strep cultures yield the same results no matter where they are administered, so many people, including college students, opt to go to a more convenient place where the wait time will be shorter. Those who enter an urgent care center often do not leave empty-handed; they are given a prescription to fill. Urgent care centers get extremely busy when an illness like the flu is going around; this means doctors must see large numbers of patients in a short period of time. In order to satisfy the patient, a doctor will frequently prescribe an antibiotic, as the core mission of urgent care “is to ‘give patients what they want when they want it’” (McKenna, 2018). While it may be well-intentioned, this practice of handing out pills with abandon led to a problem: antibiotic resistance. Antibiotic resistance is becoming increasingly problematic throughout the world and is now a major health concern in the United States. A recent study uncovered that close to 3 million US citizens experience an infection due to antibiotic resistance each year (Cohut, 2018). Antibiotic-resistant bacteria, or “superbugs,” “cause 35,000 deaths per year in the country” (Cohut, 2018). Superbugs are more deadly than regular bacteria because there are fewer means to eradicate them. The antibiotics that are typically used are no longer efficacious once

someone has built up resistance to the medication. When an individual has a bacterial infection and the bacteria are superbugs, he or she faces higher health risks and often experiences poorer expected health outcomes (Cohut, 2018). Antibiotic resistance occurs when antibiotics are overused. An antibiotic should only be taken for bacterial infections, yet many individuals take them for viruses and other maladies (Cohut, 2018). As a result, “good” bacteria in the body are killed off, threatening the delicate balance between helpful and harmful bacteria in the human body. When an individual unnecessarily takes an antibiotic, antibiot-

ic-resistant bacteria can take over more easily, which increases the number of strains of these so-called superbugs (Cohut, 2018). According to the World Health Organization (WHO), antibiotic resistance is currently “one of the biggest threats to global health, food security, and development today” (Cohut, 2018). It is important to note that while antibiotic resistance occurs naturally, the overuse of antibiotics accelerates this process, thus increasing the magnitude of the problem. As mentioned, urgent care centers exacerbate the issue of antibiotic resistance by writing unnecessary prescriptions in order to satisfy

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their patients. A study conducted by the CDC analyzed 2014 data and found that “among patients who visited urgent care centers for antibiotic-inappropriate respiratory problems like bronchitis, flu or asthma, nearly half (45.7%) were incorrectly prescribed antibiotics” (Pifer, 2018). Alarmingly, when a patient expresses interest in being prescribed an antibiotic, a doctor is more likely to prescribe it; it is unsurprising, then, that 39 percent of urgent care visits end with an antibiotic prescription, even though far less should (Pifer, 2018). Pressure to satisfy a patient’s desires may seem innocent, but most patients are not trained the way their providers are, and to have such power over the treatment plan is dangerous.

References

Not much, if anything, can be done to combat superbugs once they develop; instead, efforts need to be made to prevent the creation of the superbugs in the first place. The WHO has issued statements saying that antibiotics cannot be shared, taken unnecessarily, or disposed of carelessly (Antibiotic resistance, 2018). The WHO has also mentioned that whenever an antibiotic-resistant infection is seen, it should be reported in order to prevent other individuals from contracting it (Antibiotic resistance, 2018). Antibiotic stewardship interventions are needed to prevent superbugs. “Antibiotic stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms” (Antimicrobial stewardship – APIC, n.d.). By increasing physician awareness

of the appropriate time to prescribe an antibiotic, drug efficacy and patient safety will increase. The Urgent Care Association (UCA), has begun to make efforts to combat the antibiotic resistance crisis. The group has teamed up with the Antibiotic Resistance Action Center (ARAC) “to better understand challenges and opportunities within the urgent care delivery system” (Urgent Care Collaborating to Address Antibiotic Resistance, 2019). Together, the groups authored a Commitment to Antibiotic Stewardship, in order to “improve antibiotic stewardship among medical providers and to educate patients” (Urgent Care Collaborating to Address Antibiotic Resistance, 2019). This recent commitment to antibiotic stewardship will hopefully bring changes to the way urgent care centers prescribe antibiotics, and will in turn help prevent future superbugs from forming.

Antibiotic resistance. (2018). Retrieved 10 February 2020, from https://www.who.int/newsroom/fact-sheets/detail/antibiotic-resistance Antimicrobial stewardship - APIC. Retrieved 10 February 2020, from https://apic.org/professional-practice/practice-resources/antimicrobial-stewardship/ Cohut, M. (2018). What is the state of the antibiotic resistance crisis?. Retrieved 10 February 2020, from https://www.medicalnewstoday. com/articles/327050.php#1 McKenna, M. (2018). Urgent Care Clinics Come To an Antibiotics Mea Culpa. Retrieved 10 February 2020, from https://www.wired.com/ story/urgent-care-clinics-come-to-an-antibiotics-mea-culpa/ Pifer, R. (2018). Nearly half of antibiotics inappropriate in urgent care, CDC study says. Retrieved 10 February 2020, from https://www.healthcaredive.com/news/nearly-half-of-antibiotics-inappropriate-in-urgent-ca re-cdc-study-says/528061/ Urgent Care Collaborating to Address Antibiotic Resistance. (2019). Retrieved 11 February 2020, from https://blogs.cdc.gov/safehealthcare/urgent-care-antibiotic-resistance/

Washington University Review of Health

A “Vegetable-less” Campus Writer: Ricky Illindala | Editor: Soyi Sarkar | Illustrator: Jennifer Broza

ost people agree that vegetables are an important part of a person’s diet. Vegetables provide many vital nutrients and minerals that power everyday bodily function and long-term healthy living. However, access to fresh vegetables can sometimes be limited, especially so on college campuses, such as our own. With limited access to fresh vegetables, both in raw and cooked with meals, is it possible to survive without eating vegetables? In order to answer the question, people must first understand the role vegetables play in our body. Vegetables are a plentiful source of two important vitamins: vitamin A and vitamin C. Vegetables that are yellow or orange in color tend to be a plentiful source of vitamin A while green vegetables tend to have a large supply of vitamin C. Both of these vitamins function as antioxidants, which are chemical compounds that can boost the body’s immunity and protect against potentially toxic free radicals. Additionally, healthy intake of both vitamins have been correlated with a reduced risk for different cancers (USDA, 2020). On top of these general functions, both vitamins play a role in niche, but absolutely vital, specific body functions. Vitamin A is a fat-soluble vitamin that has many vital roles in eye function, tissue health, and immunity. The role of vitamin A in eye function is an especially important multidimensional role of the

vitamin. When needed for eye function, vitamin A is predominantly stored as retinyl esters, which can be converted and used in the function of retinal pigment epithelial (RPE) cells and mammalian eye development (Pem and Jeewon, 2015). Curiously, vitamin A also plays an important function in gene expression. Vitamin A can be converted into retinoic acid, which then binds to retinoic acid or retinoid X receptors on transcription factors within the nucleus. Retinoic acid is also known to influence promoters as well as signaling pathways, allowing it to regulate the function of over 500 retinoid-responsive genes. (Higdon et al., 2015) Unlike vitamin A, vitamin C is a water-soluble vitamin that cannot be synthesized within a human, further emphasizing the importance of consuming foods with vitamin C content. Vitamin C is vital in wound healing. It is used in the biosynthesis of collagen, which is an essential material used in knitting wounds closed and supporting blood vessel walls (Higdon et al., 2018). During the synthesis of collagen, vitamin C acts as a cofactor in the enzymatic reactions that produce collagen. It can serve this function due to its unique redox potential. Vitamin C is a potent reducing agent that preserves enzyme-bound metals in a reduced state, aiding oxidases that function in the synthesis several vital biomolecules, including collagen. Vitamin C also has an ability to enhance the intestinal

absorption of nonheme iron, which is the form of iron found in plant sources (Harvard T.H. Chan, 2019). This increases the overall iron intake of individuals by enabling them to absorb more iron into their bloodstream. Vegetables also serve as an important source of dietary fiber, potassium, and folate. Fiber can be fermented in the colon, improving gut health and creating fatty acid chains with anticarcinogenic properties (Mayo Clinic, 2018a). Potassium is important for maintaining and lowering a healthy blood pressure. Folate helps in red blood cell formation, but also can prevent brain and spine birth defects if taken during pregnancy (USDA, 2020). On a college campus with limited access to and convenience of fresh vegetables, intaking the recommended nutrients for healthy function can often prove difficult. However, even without the recommended daily intake of vegetables, students can still find new ways to receive the necessary vitamins and minerals for regular bodily function from other kinds of foods. Vitamin A is consumed as two primary forms in food: preformed vitamin A and provitamin A carotenoids which come from animal sources and plant sources, respectively. However, both forms are ultimately metabolized into retinol, an active form of vitamin A, making them interchangeable (NIH,

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2020). Commonly accessible sources of preformed vitamin A include dairy products, such as milk and eggs, liver, fish, and fortified cereals. A tasty choice for vitamin A is ice cream. One soft serve cup of french vanilla ice cream can provide 31 percent of your recommended daily intake of vitamin A, but itâ&#x20AC;&#x2122;s high sugar content makes it a less healthy option (NIH, 2020). Of the two vitamins, encountering healthy sources of vitamin C proves to be a much tougher ordeal. Vitamin C can not be synthesized

within humans, further emphasizing the need to incorporate vitamin C-rich foods in oneâ&#x20AC;&#x2122;s diet. The best sources of vitamin C are fruits and vegetables, with the most common sources of fruits including citrus fruits, tomatoes, and potatoes (NIH, 2019). Whether you detest the acidity of citrus fruits such as oranges or the sourness of tomatoes, there are still plenty of options available at WashU that include at least 1-2 of these ingredients. Making the effort to pick up just one 12 fluid ounce bottle of Minute Maid orange juice every morning is

a convenient source for over 100 percent of your recommended daily intake of vitamin C (Coca Cola, 2019). When it comes to fiber, potassium, and folate, vegetables-haters still have hope in finding other sources of these important nutrients. When it comes to fiber, fruits and grains can provide the most consistent source of fiber. High-fiber foods within these categories include staple food items such as apples, bananas, and oranges, in the fruit group, and spaghetti, rice, and

Washington University Review of Health

bread, in the grains group. Another less common, but very high source of fiber are black beans and baked beans (Mayo Clinic, 2018). Folate can be found in fortified grains and cereals, and orange and tomato juice. With such few sources for folate, it is not surprising that most people do not intake the recommended amount of folate (Harvard Health Publishing, 2018). On the other hand, people can be more confident in working potassium into their diet. Potassium can be found in a wide variety of foods, including meat, milk, fruits, and grains (Harvard Health Publishing, 2018).

Although these alternative sources exist to make up for the nutritional value of vegetables, there are still long-term benefits of vegetables that should not be overlooked. They have a uniquely low calorie density that turns them into ideal weightloss food. The large number of antioxidants and other beneficial plant compounds in vegetables is correlated with a lower risk or type 2 diabetes, heart disease, and some anticarcinogenic properties (Petre, 2017). Would it be possible to survive without eating vegetables? The

References Harvard Health Publishing. (2018, November 14). Listing of vitamins. Harvard Health. https://www.health.harvard.edu/staying-healthy/listing_of_vitamins Harvard T.H. Chan. (2019, September 16). Iron. The Nutrition Source. https://www.hsph. harvard.edu/nutritionsource/iron/ Higdon, J., Drake, V. J., Angelo, G., Delage, B., Carr, A., & Alexander J. Michels. (2018, December).Vitamin C. Linus Pauling Institute. https:// lpi.oregonstate.edu/mic/vitamins/vitamin-C Higdon, J., Drake, V. J., Delage, B., Ross, A., & Libo Tan. (2015, March). Vitamin A | Linus Pauling Institute | Oregon State University. https://lpi.oregonstate.edu/mic/vitamins/ vitamin-A Mayo Clinic Staff. (2018a). How to add more fiber to your diet. Mayo Clinic. https:// www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/fiber/art20043983 Mayo Clinic Staff. (2018b). How much fiber is found in common foods?. Mayo Clinic. https:// www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/high-fiberfoods/art-20050948

NIH. (2020, February 14). Office of Dietary Supplements—Vitamin A. https://ods.od.nih.gov/ factsheets/VitaminA-HealthProfessional/ NIH. (2019, July 9). Office of Dietary Supplements—Vitamin C. https://ods.od.nih.gov/ factsheets/VitaminC-HealthProfessional/ Pem, D., & Jeewon, R. (2015). Fruit and Vegetable Intake: Benefits and Progress of Nutrition Education Interventions- Narrative Review Article. Iranian Journal of Public Health, 44(10), 1309–1321. Petre, A. How Many Servings of Vegetables Should You Eat per Day? (2017, November 26). Healthline. https://www.healthline.com/nutrition/servings-of-vegetables-per-day The Coca Cola Company. (2019). Minute Maid Orange Juice, Original - 12 fl oz. /content/ Productfacts-Refresh/us/en/products/minutemaid-orange-juice/original/12-oz USDA. (2020). Nutrients and health benefits | ChooseMyPlate. https://www.choosemyplate. gov/eathealthy/vegetables/vegetables-nutrients-health

answer is definitely “yes”. Most, if not all, of the vital nutrients found in vegetables also have other non-vegetable sources. However, the nutrient amounts and variety found in other foods is significantly less than what is found in vegetables. Not only do vegetables provide a significant source of nutrients that contribute to everyday health, but they also have antioxidants and other compounds that can provide long-term disease prevention benefits. When vegetables appear as an all-in-one package for healthy living, it makes little sense to go through the effort of scavenging for such nutrition elsewhere.

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Get Busy Living Or Get Busy Dying Writer: Jihoon Kiel | Editor: Anhthi Luong | Illustrator: Elena Bosak

y College Writing assignment is due in two weeks. Feeling confident with the time remaining, I casually dismiss it and decide to watch the final game of the World Series only to see the Nationals defeat the Astros in disappointment. One week later, I check the assignment again and decide to postpone it. Instead, I explore outside as the second snow appears outside St. Louis, Mo. Finally, with three days remaining and with not a single word typed, I check the assignment and realize I have neither the research nor the ideas planned to formulate my dream essay. I decided to work in Olin, only to find myself looking up more BTS songs for my playlist on Spotify. I end up working back in Bear’s Den the next couple of days, and with the remaining time I had left, I briefly skimmed over several articles about technological devices, drafted the essay with a large list of errors and turned in my assignment onto Canvas with revisions still in progress at 11:59 p.m. on the final day the essay was due. Feeling relieved that the burden of writing was temporarily gone, I sink back into my chair and doze off with both satisfaction and dread. I would later ask my professor for an extension on my revisions, and after he agreed, I quickly made the necessary adjustments on my paper and turned it in. Now, I was fortunate to have an extension at the time, but I was pushing procrastination to a level many of us dread.

However, whether we want to admit it or not, almost all college students and individuals in general struggle with procrastination. According to a study, around “80 percent to 90 percent” of college-age students experience some form of procrastination, and “95 percent” of all individuals in general wish to overcome it (Preston, 2018). The study suggests we desire to resolve procrastination, but what exactly causes it, and where do we even begin? While the biological causes of procrastination remain extremely new, according to recent studies, when an individual experiences an unpleasant task or assignment, the brain is conflicted between the prefrontal cortex and the limbic system. The prefrontal cortex is an extremely sophisticated part of the brain that has developed over time to help moderate thoughts and actions. Such planning by the prefrontal cortex is involved with personality expression, decision making, social behavior and cognitive function (Siddiqui et al., 2008). How effectively the prefrontal cortex functions mainly corresponds to the current task or situation. If the task appears pleasant and easy to follow by the individual, the prefrontal cortex delivers the option to complete the task immediately. If the task is unpleasant or very complicated, the prefrontal cortex simply delivers the pass option, delaying the work in favor of more pleasant activities.

In contrast, the limbic system primarily moderates unconscious thoughts and desires in the brain (Swenson, 2006). Should an event or stimulus appear pleasing to an individual, the limbic system unconsciously activates and predetermines the individual’s actions in favor of the stimulus. In terms of psychology, this type of behavior and cognitive function can be explained through Sigmund Freud’s concept of the id, ego, and superego. The id represents the unconscious and uncontrollable desire and thought (Cherry, 2019). The superego represents the system of higher level thoughts and actions and moral judgement while the ego represents the balance between the superego and the id (Cherry, 2019). When individuals procrastinate, the superego and ego will consciously remind them of an important task while the id will often push the assignment away instinctively in favor of a lesser task. Although the causes of procrastination remain complex, procrastination can be combated with the simple use of mindfulness. Instead of a medical procedure or prescription, mindfulness, present-centered attention and awareness, effectively reduces procrastination among individuals. Practices, such as, meditation and simple questioning out of curiosity, improve performance and well being by targeting both the mind and the individual to be more self-conscious (Spencer & Seaver, 2019). Simply having more self awareness allows the individual

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to better understand his or her situation and the tasks currently present. These types of practices appear so simple, yet they help treat everyday difficulties and neuropsychiatric disorders, such as, depression, burnout, loneliness and anxiety that many college students and adults experience. Even with continuous studies and existing treatments, people still struggle to remove procrastination and often allow it to return. Individuals complain that they can not resolve procrastination due to a lack of motivation, desperation, energy and time. Time, however, provides a clear explanation for why people should fight against procrastination. Time can categorize procrastination into two forms. The form many people are aware of involves the use of deadlines such as papers, exams

Practices, such as, meditation and simple questioning out of curiosity, improve performance and well being by targeting both the mind and the individual to be more selfconscious (Spencer & Seaver, 2019).

or applications. This type of procrastination is short-term as it occurs very briefly in people before they eventually forget and move on. The other type of procrastination occurs long-term. At first, it seems very similar to procrastination in the short-term, but a huge difference involves the removal of the deadline. The deadline functions as a physical factor that causes humans to experience dread or desperation as it approaches closer. Without a deadline, individuals lose the automatic and sudden response of fear that occurs during procrastination. Now the question then becomes what are we procrastinating long-term? Maybe thereâ&#x20AC;&#x2122;s that one thing in life you always wished you could achieve. Maybe it is a ques-

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tion, a hobby, a desire to serve others, a dream destination to travel, a dream career or an apology. Whatever it is, we can’t wait idly by and hope and wish it could happen. A lot of times, individuals are reluctant to take that first initial step because they fear social judgement or a lack of qualifications. People value a need for confirmation and approval from others in order to justify their actions and thoughts. As a result, individuals instead put off a task, feeling unwilling to accept failure or be humiliated. Really, however, we are doing ourselves a disservice by living in that mentality. We have to make our desires happen. We are quite literally on the clock to make

an impact whether individuals act selfish or selfless. As people have often said in cliches or general statements, “all things come to an end.” While we believe we have a lot of control for the future, in reality, we only have a minimum control for the present. No matter how talented, skilled, appealing or resilient we are, we have no say when things will end. Just look at some examples: John F. Kennedy, Whitney Houston and Kobe Bryant. The bottom line is that we must address whatever continues to make us ponder immediately, perhaps today and right now after reading this work. If not, well at least start considering it soon.

Reference Chatterjee, Ushri, Goyal, Nishant, Kumar, Devvarta, Siddiqui, Aleem, Siddiqui, Shazia V. “Neuropsychology of prefrontal cortex.” Indian Journal of Psychiatry, vol. 50, no. 3, July 2008, pp. 202-208. US National Library of Medicine, doi:10.4103/0019-5545.43634. Cherry, Kendra. “Freud’s Id, Ego, and Superego.” Verywell Mind, 2019. Preston, Camille. “How Procrastination Affects Your Health.” Thrive Global, 2018. Seaver, Maggie, Spencer, Amy. “Want to Train Your Brain to Stop Procrastinating? Read These Tips From a Neuroscientist.” Real Simple, 27 August 2019. Swenson, Rand. “Review of Clinical and Functional Neuroscience.” Dartmouth Medical School, 2006.

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Can Phage Therapy be the solution to antibiotic resistance? Writer: Ben Lieberman | Editor: Shubanjali Minhas | Illustrator: Grace Kim

hen Alexander Fleming accidentally discovered that fungal spore contamination killed off the bacteria growing on his petri dishes in 1928, it started off the era of antibiotics. Further research led to discoveries of New antibiotics in the 1960s and 70s as the “golden age of antibiotics” (Furfaro, 2018). Suddenly, no bacterial infection seemed untreatable. Everything including cancer treatment, dialysis, organ transplants and surgeries today require antibiotics. They are an irreplaceable component of modern medicine (CDC, 2019). The 2019 CDC Report on antibiotic resistance lists five urgent threats, two new threats and three threats on the watch lists. It highlights the urgency to address new antibiotic resistance mechanisms. The literature shows evidence of horizontal gene transfer between strains of unrelated species to create new Multidrug Resistant (MDR) infections (CDC, 2019). Millions of Americans now have an antibiotic resistant infection resulting from unnecessary use of antibiotics and bad stewardship in hospitals and care centers, overuse of common antibiotics in animal feed for American agriculture and exposure in daily life. The question is not if but when MDR infections can

become widespread and overwhelm our antibiotic treatment regimens. What can be done in the face of the prospect of a threat only getting worse overtime? One novel solution is bacteriophages, or viruses who prey exclusively on bacteria. These viruses are around 3 billion years old, killing off bacteria wherever they exist. They have been in an evolutionary arms race for billions of years with their bacterial hosts, playing an important role in keeping bacterial populations under control (Criscuolo, 2017). Phages work by infecting cells by binding to the cell surface, injecting their DNA or RNA genome into the cell, and producing copies of themselves. After the cell is filled with new phages, the viruses break open the

Suddenly, no bacterial infection seemed untreatable. Everything including cancer treatment, dialysis, organ transplants and surgeries today require antibiotics.

cell with lytic enzymes and spread to infect further bacteria. Thus far, phage therapy has been in development for diverse strains, including Salmonella, Mycobacterium Tuberculosis, E. coli, and Acinetobacter baumannii, among others (Iftikhar, 2019). Although harmless to us, they can kill off bacteria very quickly. In 1919, French-Canadian microbiologist Félix d’Herelle first discovered and experimented with bacteriophages and thought up phage therapy as a possible treatment. The first time it was used in humans was on four children who recovered from dysentery. With the introduction of antibiotics and their ease of use and widespread success, phages were put on the backburner until the 1980s when phage display and other techniques were developed. These are now used as a technique to find successful molecules against pathogens. The leading centers have historically been in the former Soviet Union states and satellite states of Georgia and Poland (Criscuolo, 2017). But recently, UC San Diego’s School of Medicine opened up its first phage lab in June 2018 as the “first dedicated phage therapy center in North America, bringing innovative research and clinical practice to the field of medicine” (Center for Innovative Phage Applications and

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Therapeutics). These labs believe that phage therapy may be a step forward in the struggle against bacterial infection. All of these new centers have applied new microbiology techniques to emphasizing phage therapy development. Some of these developments have gotten the approval of the FDA and are going into early-stage clinical trials. Many applications involve biofilm (Criscuolo, 2017) and lysins (Furfaro, 2018) as well live viruses in treatment. All of these possible options mean that MDRs might not be an untreatable phenomenon, whose subsequent could mean a dark end to the clinical miracles of antibiotics. But these techniques must be developed in concert with completely novel classes of antibiotics. Currently, The CDC reports antibiotic research

makes up only 2 percent of current pharmaceutical research, with very few drugs coming out since 1980. There are also issues with the current phage therapy technology that must be overcome before it can become a safe, practical, and effective method of treating bacterial infection. First, the phages are difficult to isolate and prepare as a treatment solution. They require heavy doses and do not always replicate as quickly as desired. Phages can lead to immune reactions despite being harmless. Phages must be specific and some do not work on every strain of a certain bacterial infection. They can only target bacteria which have certain surface antigens that are not present in every specimen . So many can involve immunity to phages just like antibiotics by

simply becoming unrecognizable (Iftikhar, 2019 & Reindel, 2017). Nonetheless, phages are a promising solution that can be strain-specific solutions to MDR infections. There are reasons why phages never became an equal to antibiotics and were more work than the effort was worth. New efforts should be made on antibiotic development. Perhaps billions of dollars should not be poured into phages with other antibiotic efforts producing more practical fruit. But phages are a potential solution and should not be dismissed as a scientific curiosity; nor should phages be considered an historic dead end in our efforts to eliminate infection. Maybe they do not deserve special consideration. But they do deserve to be taken seriously.

References Furfaro, L. L., Payne, M. S., & Chang, B. J. (2018). Bacteriophage Therapy: Clinical Trials and Regulatory Hurdles. Frontiers in Cellular and Infection Microbiology, 8, 376. https://doi.org/10.3389/ fcimb.2018.00376 CDC. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2019 Criscuolo, E., Spadini, S., Lamanna, J., Ferro, M., & Burioni, R. (2017). Bacteriophages and Their Immunological Applications against Infectious Threats.

Journal of Immunology Research, 2017, 3780697. https://doi. org/10.1155/2017/3780697

Retrieved February 19, 2020 from www.sciencedaily.com/releases/2019/09/190924104108.htm

Center for Innovative Phage Applications and Therapeutics. (n.d.). UC San Diego School of Medicine. Retrieved February 19, 2020, from https://medschool.ucsd. edu:443/som/medicine/divisions/ idgph/research/center-innovative-phage-applications-and-therapeutics/Pages/default.aspx

Iftikhar, N. (2019, January 14). Phage Therapy: How It Works, Pros and Cons, Availability, and More. Healthline. https://www.healthline. com/health/phage-therapy

The Hong Kong Polytechnic University. (2019). New class of antibiotic candidates for fighting against superbugs. ScienceDaily.

Reindel, R., & Fiore, C. R. (2017). Phage Therapy: Considerations and Challenges for Development. Clinical Infectious Diseases, 64(11), 1589â&#x20AC;&#x201C;1590. https://doi. org/10.1093/cid/cix188

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COVID-19: What Went Wrong? Writer: Shuyu Lin | Editor: Morgan Leff | Illustrator: Yixuan Chen

any things happened since the discovery of the novel coronavirus and the appearance of Coronavirus disease 2019 (COVID-19) in Wuhan, China. As of 24:00 on Feb 20,there are 75,465 identified cases of COVID-19 nationally, 62,662 of which are in Hubei province (NHC, 2020). Wuhan with more than 9 million residents is completely shut down. Panic and xenophobia are spreading across the border (Wernau and Chin, 2020). China fights hard in a so-called “People’s War” against the epidemic (Jia and Zhang, 2020). As a veteran of public health crisis, China has been running a national surveillance system for Pneumonia of Unknown Etiology (PUE) since the severe acute respiratory syndrome (SARS) outbreak in 2003 (Feng et al., 2020). Chinese Center for Disease Control and Prevention (CCDC) sent high-profile virologists and public health experts to Wuhan by the end of December (CCDC, 2020). More than 4.5 billion yuan ($645 million) of financial aid has been distributed directly to Hubei province by the National Ministry of Finance (Xinhua News Agency, 2020). A number of 21,569 healthcare workers and 189 medical teams have been relocated to Hubei by February 12th (Xinhua News Agency, 2020). However, the situation in Wuhan and Hubei is a disaster. Though both the public and central government are pouring countless donations and supplies to Hubei, medical supplies are running low in almost all major hospitals in Wuhan. The public has

questioned the disproportionate and delayed allocation of public donations by one of the government-designated dispensers, the local Red Cross charter (Chen et al., 2020). Medical workers are exposed to the hazardous environment usually with insufficient protective gears and lack of knowledge, resulting in 1716 cases of infections and 6 deaths by February 14th including one of whistleblowers, Dr. Li Wenliang (Murphy et al., 2020). Wuhan municipal government has shut down public transport since January 23rd, and at least 48 cities in China have implemented certain lockdown policies (Bhatia, 2020). This public health crisis continues to escalate as this article is written, while the local government and even the central government remain unable to control the situation. So, what went wrong?

Are scientists to be blamed?

Interestingly, all of the leading virologists and public health experts in China have faced harsh criticism on the internet. One popular opinion is that they had prioritized publishing their research results in high-caliber international academic journals rather than working to contain the disease, which allows them to reap the benefits of bolstered academic credentials while

paying no attention to the people’s safety in Wuhan. An inferno of controversy struck all social media when the director-general of CCDC, virologist George F. Gao, co-authored an article analyzing the early transmission patterns of COVID-19 on January 27th in New England Journal of Medicine (Feng et al., 2020). This academic accomplishment was treated as evidence of his malfeasance. A document published by the Ministry of Science and Technology on January 29th seemed to support this argument by asking scientists “not to focus on publications until epidemic prevention and control tasks are completed” (MST, 2020). It appeared that scientists were indeed the ones to blame. However, that is simply not true. In fact, the CCDC is an agency under the National Health Commission (NHC) with no authorization to make or override policies and administrative decisions made by the local government (CCDC, 2020). Think about it as a government-sponsored think tank that provides important intelligence support but is not entrusted with decision making. Furthermore, if the municipal government in Wuhan decides to down the city, they are changing the lives of countless people. The Wuhan government needs to consult specialists in not only medicine but commerce, finance, and manufacture to optimize their decision. Drawing from the data procured by the CCDC, local government and party branches can act to contain this public health crisis.

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The assumption that scientists should do everything also neglects the specificity of expertise. Scientists may be virologists and epidemiologists by training, but are not familiar with policymaking and administrative procedures. Therefore, they can help in the decision-making process but not redirect society to contain the disease with administrative orders.

2020). Dr. Shi Zheng-li and her team, who successfully tracked the origin of SARS coronavirus in 2017, published their research about the possible origin and functioning mechanism of the SARS-CoV-2 on January 23rd (Shi et al., 2020). By sharing the data and research results, they fostered global collaboration to combat the public health crisis.

The scientific community around the world recognizes the outstanding contributions of medical experts in China who rapidly responded to the emergency. A team of scientists in the CCDC released the genome sequence of the novel coronavirus online on January 10th (Zhang et al,

Is COVID-19 hard to treat in clinical practices?

In short, yes. On a molecular level, the virus SARS-CoV-2 shares many similarities with the 2003 SARS-CoV. The novel coronavirus, SARS-CoV-2, matches 79.5% of the sequences identified in the 2003 SARS-CoV (Shi et al., 2020). They both use spike (S) glycoprotein to bind a cell entry receptor called angiotensin-converting enzyme 2 (ACE2) in order to enter the host cell. However, SARS-CoV-2 has a higher affinity to the receptors, which possibly contributes to its strengthened ability to spread amongst humans. In clinical practice, things get trickier: there is no known effective

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anti-virus treatment. The virus may trigger a severe immune overreaction called a cytokine storm, which results in acute respiratory system responses and life-threatening symptoms. It takes time to figure out how exactly a novel virus triggers a cytokine storm. Dr. Wang Leyao, a virologist by training and a specialist for human microbiome and lung diseases in Washington University School of Medicine, expressed her concerns “Normally, viral respiratory infections can be self-controlled…there is no solid study yet on the pathology of this disease. It is long-term research to go.” Unlike bacteria, there is no medicine available to hunt down the virus without hurting all other cells. However, some medications for viral infections may prove useful. The treatment plan issued by the CCDC recommends Lopinavir/ ritonavir, which is a combination of drugs used for HIV/AIDS. Clinical trials have been launched in Wuhan and Beijing to investigate the efficacy of Remdesivir, an antiviral drug developed for Ebola and MERS that “incorporates into nascent viral RNA chains and results in premature termination” (Xiao et al., 2020). It takes time to figure out the effectiveness of treatments.

Unlike bacteria, there is no medicine available to hunt down the virus without hurting all other cells. 30

What should we be concerned about in addition to medicine? The National Health Commission (NHC) has been running a bottom-up surveillance system of Pneumonia of Unknown Etiology (PUE) since 2004. The procedures require all clinicians to directly report PUE online, which may stop the local government from concealing the actual situation of PUE. Though many researchers expressed concerns about the effectiveness and the awareness of the system among clinicians (Li et al., 2019), it did work. The surging number of patients with COVID-19 was noticed by the CDC on different levels by the end of December (Feng et al., 2020). But after the first week of January, they lost control. Suspiciously, no new cases were confirmed by the Wuhan Municipal Health Commission for five days from January 11th to 15th, when Lianghui, the two most important political conferences in Hubei, took place (WMHC, 2020). Then, the number surged. Government officers in Wuhan and Hubei were late at every step of the way as anticipated due to the top-down accountability philosophy. They tend to prioritize the satisfaction of their superiors rather than the well-being of their citizens, implementing campaign-style extreme policies to prove their ability to control the situation. Additionally, the lack of civic participation resulted in a spectacle

on social media. Therefore, the lack of civic engagement in China deserves more attention. Currently on Washington University’s campus, COVID-19 does not impose health concerns. As of January 27th, no cases of COVID-19 have been identified in Missouri (DHSS, 2020). There’s no need to wear disposable surgical masks or even N95 medical masks, as Dr. Henry Huang in the Department of Microbiology of Washington University School of Medicine clarifies. “If it’s a raging epidemic like inside China, then [wearing masks] makes some sense,”Dr. Huang says, “there’s a very limited and defined role of the masks.” Masks may catch certain percent of pathogens when someone sneezes on you, while most people neither have the skills to safely take off a N95 mask. In general, washing hands is helpful in terms of flu prevention considering how often we touch our faces and eyes with our pathogen-carrying hands.

They tend to prioritize the satisfaction of their superiors rather than the well-being of their citizens. After all, a tragedy is happening in China. Every single life counts. Every single family counts. Please join me in remembering what is happening in Wuhan, concerning Chinese citizens, and mourning the loss of lives.

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References “About Us.” Chinese Center for Disease Control and Prevention, 2020. http://www.chinacdc. cn/en/. Bhatia, Gurman. “Under China’s Lockdown, Millions Have Nowhere to Go.” Reuters. Thomson Reuters, February 14, 2020. https:// graphics.reuters.com/CHINA-HEALTH-LOCKDOWN/0100B5EF3LJ/index.html. CCDC. “The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) in China.” The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) in China, February 17, 2020. Cheng et al. “Xinhua Headlines: China Penalizes Derelict Officials in Coronavirus Fight.” Xinhua News Agency, February 5, 2020. http://www.xinhuanet.com/english/2020-02/05/c_138755872.htm. DHSS. “Recent News.” Missouri Department of Health & Senior Services, January 27, 2020. https://health.mo.gov/news/newsitem/uuid/2c92c814-9953-41fd-87126b12ee494558/dhss-provides-update-on-novel-coronavirus-ncov. Jia, Denise, and Zhang Fan. “In Depth: The ‘People’s War’ Against the Epidemic in 16 Cities Across Hubei.” Caixin Global, February 17, 2020. https://www.caixinglobal.com/202002-17/in-depth-the-peoples-war-against-theepidemic-in-16-cities-across-hubei-101516420. html. Li, Qun, Xuhua Guan, Peng Wu, Xiaoye Wang, Lei Zhou, Yeqing Tong, Ruiqi Ren, et al. “Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia.” New England Journal of Medicine, January

29, 2020. https://doi.org/10.1056/nejmoa2001316. MST. “The Ministry of Science and Technology Proposes That Scientific Researchers Must Carry the Burden and Invest in Scientific and Technological Tasks, and Write Thesis on the Front Line of Fighting the Epidemic.” Ministry of Science and Technology of People’s Republic of China, January 29, 2020. NHC. “Feb 21: Daily Briefing on Novel Coronavirus Cases in China.” National Health Commission of the People’s Republic of China, February 21, 2020. http://en.nhc.gov.cn/202002/21/c_76740.htm. Wang, Manli, Ruiyuan Cao, Leike Zhang, Xinglou Yang, Jia Liu, Mingyue Xu, Zhengli Shi, Zhihong Hu, Wu Zhong, and Gengfu Xiao. “Remdesivir and Chloroquine Effectively Inhibit the Recently Emerged Novel Coronavirus (2019-NCoV) in Vitro.” Cell Research, February 4, 2020. https://doi.org/10.1038/s41422-0200282-0. Wernau, Julie, and Josh Chin. “China Urges Calm Over Virus During ‘Critical Period.’” The Wall Street Journal, January 26, 2020. https://www.wsj.com/articles/china-urges-calm-over-virus-during-critical-period-11580045718. WMHC. “Wuhan Municipal Health and Health Commission’s Report on Pneumonia of New Coronavirus Infection.” Wuhan Municipal Health Commission, January 12, 2020. WMHC. “Wuhan Municipal Health and Health Commission’s Report on Pneumonia of New Coronavirus Infection.” Wuhan Municipal Health Commission, January 16, 2020.

Xinhua News Agency. “The Ministry of Finance Pre-Allocated 8 Billion Yuan for the Second Batch of Epidemic Prevention and Control Subsidies.” Xinhua News Agency, February 15, 2020. http://www.gov.cn/xinwen/2020-02/15/ content_5479470.htm. Xinhua News Agency. “In Accordance with the Deployment of the State Council, the Ministry of Finance Has Allocated 1 Billion Yuan in Emergency Prevention and Control of Pneumonia in Hubei Province for New Coronavirus Infection.” Xinhua News Agency, January 23, 2020. http://www.gov.cn/xinwen/2020-01/23/ content_5471917.htm. Xinhua News Agency. “National Health Commission: More than 20,000 Medical Staff from 189 Medical Teams Have Been Sent to Support Hubei.” Xinhua News Agency, February 13, 2020. Yu, Gao, Xiao Hui, and Flynn Murphy. “Coronavirus Has Infected More Than 1,700 Medical Workers.” Caixin Global, February 14, 2020. https://www.caixinglobal.com/2020-02-14/ coronavirus-has-infected-more-than-1700-medical-workers-101515540.html. Zhang et al. “Severe Acute Respiratory Syndrome Coronavirus 2 Isolate Wuhan-Hu-1, Complete Genome.” NCBI GenBank, January 2020. https://www.ncbi.nlm.nih.gov/nuccore/ MN908947. Zhou, Peng, Xing-Lou Yang, Xian-Guang Wang, Ben Hu, Lei Zhang, Wei Zhang, Hao-Rui Si, et al. “Discovery of a Novel Coronavirus Associated with the Recent Pneumonia Outbreak in Humans and Its Potential Bat Origin,” January 23, 2020. https://doi. org/10.1101/2020.01.22.914952.

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Gene Therapy: A Possible Cure for Hemophilia Writer: Rehan Mehta | Editor: Annie Feng | Illustrator: Jennifer Broza

ver the past century, the development of treatments for hemophilia has seen remarkable progress. People with hemophilia in the early 1900s had a life expectancy of 13 years, while today, most patients with hemophilia can expect to live a nearly normal life (National Hemophilia Foundation, 2014). Back then, there was no way of storing blood and victims often died of excessive and prolonged bleeding. The discovery of blood clotting factors and a way for scientists to derive these clotting factors led to the development of a preventive treatment (National Hemophilia Foundation, 2014). Recent advancements include clotting factors that last longer and can be made without human or animal blood. Despite these advancements, the majority of people with hemophilia in the world receive little to no treatment, resulting in high morbidity and mortality rates (Young, 2012). The development of gene therapy serves as a potential cure for hemophilia, eliminating the need for continuous treatment, thus offering hope for wider access to treatment. Hemophilia is an inherited bleeding disorder that severely reduces the ability of blood to clot, causing prolonged external and internal bleeding. In hemophilia, the normal clotting process is disrupted due to defects in the genes responsible for producing clotting factors. These clotting factors are essential since they stop bleeding and let the wound heal. The two most common

forms of the disease are hemophilia A, which is caused by a deficiency in clotting factor VIII, and hemophilia B, which is caused by a deficiency in clotting factor IX (American Society of Gene & Cell Therapy, 2019). The severity of hemophilia is determined by how much of the clotting factor is in the patientâ&#x20AC;&#x2122;s blood and can be classified as mild, moderate or severe. About 60 percent of those with hemophilia have the severe form of the condition (Indiana Hemophilia & Thrombosis Center, n.d.). Patients with severe hemophilia have a complete absence of clotting factor VIII or IX, resulting in spontaneous bleeding that can cause permanent damage to the joints and soft tissues. Those with mild or moderate hemophilia are less likely to experience spontaneous bleeding and generally experience prolonged bleeding from injuries.

The standard treatment for people with hemophilia involves the regular administration of exogenously derived clotting factors. While this treatment has significantly improved quality of life and life expectancy for individuals with hemophilia, its effectiveness is limited due to the need for frequent infusions, the development of inhibitors and the high cost of treatment. Factor concentrates have relatively short half-lives, resulting in the need for two to three infusions administered intravenously per week. Factor VIII has a half-life of 8-12 hours, while Factor IX has a half-life of 18-24 hours (Young & Kizilocak, 2019). Patients also develop inhibitors to factor concentrates, which reduces the efficacy of infused clotting factors. An estimated one-third to one-fifth of people with severe hemophilia A develop inhibitors sometime in their lives (National Hemophilia Foundation, 2014). These inhibitors are a result of an immune response to the factor concentrates and destroy the foreign clotting factor before it has a chance to stop the bleeding, making treatment more difficult. Another complication is the significant financial costs associated with factor concentrates, resulting in variations in access to standard treatment around the world. One study designed to assess the cost of severe hemophilia in Europe, reveals that the average annual cost per patient across five countries in 2014 was estimated to be around $200,000 (Oâ&#x20AC;&#x2122;Hara et al, 2017). The high cost and need for frequent

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injections explain the ineffectiveness of treatment, especially in less developed countries. Gene therapy works by inserting a functional version of the defective gene into a cell using a viral vector, enabling the cell to produce the missing clotting factor. In terms of treating hemophilia, several different gene delivery vehicles have been tested, but the most success has been found in using a recombinant adeno-associated virus to deliver the clotting factor gene (Willard, 2018). These viruses have been designed to be safe since all pathogenic genes have been removed. The vector is delivered to a patient’s liver cells, since the FXIII and FIX clotting factors are naturally produced there. This then enables the liver cells to produce and secrete functional clotting factors into the bloodstream, helping prevent future bleeding (American Society of Gene & Cell Therapy, 2019). The results of several clinical trials using adeno-associated virus gene therapy to treat hemophilia have been promising and have sparked a race towards a cure. At present, a handful of pharmaceutical companies have gene therapy products being assessed in phase three clinical trials, meaning it might be available as a treatment soon (Willard, 2018). One trial involving 15 adults with severe hemophilia A with a follow-up found that the mean annualized rate of bleeding events decreased by over 90 percent and the median use of exogenous clotting factor was reduced from 138.5 infusions to 0 infusions per year (Pasi et al, 2020). Additionally, the follow-up revealed that three years after the gene therapy, sufficient levels of clotting factor

XIII remained in the subjects to allow for normal clotting (Pasi et al, 2020). Another trial involving 10 adults with severe hemophilia B has shown similar results with a 90 percent reduction in bleeding episodes. A long-term follow-up at six years has shown stable clotting factor IX expression and no latent toxicity in the subjects (Batty & Lillicrap, 2019). These results are encouraging and have proven gene therapy can effectively treat hemophilia.

groundbreaking therapeutics and has proven to be a viable and effective treatment option that can potentially be utilized to treat other diseases.

While the future of hemophilia patients looks bright, several questions still remain about the mechanisms and long-term safety of gene therapy as a novel therapeutic means. Vector-induced liver inflammation, for example, remains a challenge that is not yet fully understood, and can be harmful to subjects (Evens et al, 2018). Liver inflammation occurs when the liver cells are attacked by a pathogen, resulting in possible liver damage and impaired liver function. Additionally, controversies about gene therapy increasing the risk of oncogenesis, a process transforming normal cells into cancerous cells, remain unresolved (Evens et al, 2018). On the bright side, these problems are not inherent to gene therapy; they are inherent to the vector. By improving the vector design, safety risks can be significantly reduced. Despite these challenges, treatments for hemophilia have come a long way and there is hope for a cure on the horizon. The most significant benefit of gene therapy would be in the developing world, where access to clotting factors is limited. How gene therapy is priced will ultimately determine its availability to patients. Nevertheless, gene therapy has led the way into a new age of

History of Bleeding Disorders. (2014, March 4). National Hemophilia Foundation. https:// www.hemophilia.org/Bleeding-Disorders/History-of-Bleeding-Disorders

References Batty, P., & Lillicrap, D. (2019). Advances and challenges for hemophilia gene therapy. Human Molecular Genetics, 28(R1), R95–R101. https://doi.org/10.1093/hmg/ddz157 Evens, H., Chuah, M. K., & VandenDriessche, T. (2018). Haemophilia gene therapy: From trailblazer to gamechanger. Haemophilia, 24(S6), 50–59. https://doi.org/10.1111/hae.13494

Inhibitors and Other Complications. (2014, March 4). National Hemophilia Foundation. https://www.hemophilia.org/Bleeding-Disorders/Inhibitors-and-Other-Complications Kizilocak, H., & Young, G. (2019). Diagnosis and treatment of hemophilia. Clinical Advances in Hematology & Oncology: H&O, 17(6), 344–351. National Hemophilia Foundation. (n.d.). National Hemophilia Foundation. Retrieved February 21, 2020, from https://www.hemophilia. org/National-Hemophilia-Foundation O’Hara, J., Hughes, D., Camp, C., Burke, T., Carroll, L., & Diego, D.-A. G. (2017). The cost of severe haemophilia in Europe: The CHESS study. Orphanet Journal of Rare Diseases, 12(1), 106. https://doi.org/10.1186/s13023017-0660-y Pasi, K. J., Rangarajan, S., Mitchell, N., Lester, W., Symington, E., Madan, B., Laffan, M., Russell, C. B., Li, M., Pierce, G. F., & Wong, W. Y. (2020). Multiyear Follow-up of AAV5-hFVIII-SQ Gene Therapy for Hemophilia A. New England Journal of Medicine, 382(1), 29–40. https:// doi.org/10.1056/NEJMoa1908490 Severity of Hemophilia | Indiana Hemophilia & Thrombosis Center. (n.d.). Retrieved February 21, 2020, from https://www.ihtc.org/severity-of-hemophilia/ Willard, D. (2018, October 1). Breakthroughs in Gene Therapy for Hemophilia. ASH Clinical News. https://www.ashclinicalnews.org/spotlight/breakthroughs-gene-therapy-hemophilia/ Young, G. (2012). New challenges in hemophilia: Long-term outcomes and complications. Hematology, 2012(1), 362–368. https://doi.org/10.1182/asheducation. V2012.1.362.3798344

Washington University Review of Health

What’s Your Healthcare Plan?: Universal Healthcare Around the World Writer: Vaibav Nandeesh | Editor: Sophia Xiao

ith the 2020 Democratic presidential primary season coming into full swing, candidates are putting forward a variety of policy proposals that tackle an important issue on American voters’ minds: healthcare. Democrats won control of the House of Representatives in 2018 in part due to their healthcare policy, so its rise to the forefront of primary debates is not surprising as it could be the key to winning the presidency. From Elizabeth Warren and Bernie Sanders’s “Medicare for All” plan to Pete Buttigieg’s public option plan dubbed “Medicare for All Who Want It,” voters have a wide array of options from which to choose. With over 28 million Americans lacking health care coverage in 2018, the current American system has failed to do what every other developed nation in the world has achieved: universal healthcare (US Census, 2019). To get a sense of perspective on the candidates’ proposals, we should examine the healthcare systems of other nations throughout the world and understand the similarities and differences between them. No two countries completely share the same healthcare system, and the variety of systems out there indicate that no single perfect formula exists for implementing universal healthcare in America.

Take Canada for instance, a country with universal healthcare that Democratic presidential candidate Bernie Sanders has frequently referenced. Even though he has repeatedly praised the Canadian model, his Medicare for All proposal (S. 1804) significantly differs from it. His plan would make Medicare a national health insurance system administered by the federal government for people of all ages. In contrast, Canada does not employ a national health insurance system as healthcare is administered by the provinces (the Canadian equivalent of states) which are financed from money grants allocated by the

With over 28 million Americans lacking health care coverage in 2018, the current American system has failed to do what every other developed nation in the world has achieved: universal healthcare (US Census, 2019).

federal government with basic requirements that the provincial healthcare plan be universal, comprehensive and have a not-forprofit motive (Norris, 2018). Medicare for All also differs from the Canadian model as it provides coverage for dental care, vision care and pharmaceutical drugs, none of which are covered by the Canadian public healthcare system. These aspects of healthcare are left to private insurance companies, which are used by 75% of Canadians (Chen, 2018). While Medicare for All advocates such as Warren and Sanders promote the elimination of private insurance, other universal healthcare countries such as the Netherlands maintain the use of private insurance companies, albeit under different conditions. The Dutch government funds the healthcare system through public money while its administration and management is done by competing private insurance companies who use these funds. Residents of the country are required to opt into one of these private health insurance plans that are usually priced at 1,421 euros (roughly $1500) per year, far less than the average health insurance premiums of $7,188 per year in America (Aldermen Dagblad, 2019; Kaiser Family Foundation, 2018). Just like in Canada, the basic health insurance plans offered by the

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Dutch system do not include vision and dental care, which Sanders’s Medicare for All covers. Down under in Australia, Pete Buttigieg’s “Medicare for All Who Want It” finds familiar territory. With a hybrid public-private healthcare system, Australian residents have the option of opting into Medicare--Australia’s universal public health insurance program--or using private health insurance. Medicare operates in a similar way to that of Canada’s healthcare system as the states receive the funding from the federal government and provide the healthcare services (Department of the Prime Minister and Cabinet, Australian Government, 2014). What is unique to Australia’s system is that it provides incentives to encourage the use of private insurance through tax rebates and upholds a penalty surcharge for high income earners who don’t opt into a private health insurance plan. The country’s Lifetime Health Insurance program gives Australians who switch to a private health insurance plan before the age of 31, lower premiums for life (Australian Tax Office, 2019). Regardless which universal healthcare country you choose, the country’s spending per capita on healthcare remains staggeringly less. America spends over $10,000 per person for less healthcare coverage while other developed countries achieve universal coverage for nearly half that price tag (OECD). Whether it be a president who supports Medicare for All or a president who supports a public option, it is clear that there lies a long road ahead of them as they must try to confront the inefficacies that plague America’s current healthcare system.

References US Census Bureau. (2019). Health Insurance Coverage in the United States: 2018. Retrieved from https://www.census.gov/library/publications/2019/demo/p60-267.html Medicare for All Act of 2017, S. 1804, 115th Congress. (2017) Retrieved from https:// www.congress.gov/bill/115th-congress/senate-bill/1804 Norris, S. (2018). Federal Funding for Health Care. Retrieved February 14, 2020, from https://lop.parl.ca/sites/PublicWebsite/default/en_CA/ResearchPublications/201845E#a3 Zoveel zal de zorgpremie volgens het kabinet stijgen. (2019). Retrieved February 14, 2020, from https://www.ad.nl/politiek/zoveelzal-de-zorgpremie-volgens-het-kabinet-stijgen~acb82b29/ Kaiser Family Foundation. (2019, October 8). 2019 Employer Health Benefits Survey Section 1: Cost of Health Insurance. Retrieved from https://www.kff.org/report-section/ehbs2019-section-1-cost-of-health-insurance/ Department of the Prime Minister and Cabinet, Australian Government. (2014). Roles and Responsibilities of Health. Reform of the Federation White Paper. Retrieved from https://ahha.asn.au/sites/default/files/docs/ policy-issue/rotf_issues_paper_3_-_roles_and_ responsibilities_in_health.pdf Australian Tax Office Website https://www.ato.gov.au/Individuals/Medicare-levy/Private-health-insurance-rebate/ Lifetime-health-cover/ OECD https://data.oecd.org/healthres/health-spending.htm

Washington University Review of Health

Tapeworms and Tumors: How Repurposed Medicine Can Cure Cancer Writer: Haley Pak | Editor: Frank Lin | Illustrator: Lily Xu

he “cure for cancer,” in modern day, has become synonymous with an unattainable miracle- like finding the Holy Grail or the meaning of life. Light quips of, “Maybe that kid will grow up to cure cancer,” pepper heavily into daily vocabulary. It’s common knowledge that cancer’s unpredictability, its diverse range of physiological targets, and difficulty to detect make it nearly impossible to consistently treat. However it’s very likely that a cure for most variations of cancer may already have been found: in repurposed parasite medication. Repurposing medication is not a new concept. Due to the explosive cost of healthcare and medication’s increasing inaccessibility, cancer researchers have studied the possibilities of a single medication working to treat multiple illnesses. The Anticancer Fund, a non-profit cancer research organization, published a policy paper open to the public where they stated, “New cancer treatments are being developed by the pharma industry, but the process of bringing these drugs to the market is slow and expensive. A largely untapped, affordable and safe treatment approach is to reuse available licensed non-cancer drugs as new anticancer treatment,” (Anticancer Fund, 2017). As can be expected, reusing medication has its

risks. Patients who self-medicate without consulting a professional risk suffering unintended adverse effects. However, in the case of Joe Tippens, a U.S. patient who was diagnosed with lethal lung cancer in 2016, the only consequence was becoming completely cancer free after only three months of taking the most unlikely of medicines: a dog dewormer medication. Joe Tippens, who had been diagnosed with terminal cancer for nearly a year, stumbled upon a veterinary forum after being told he would only have three months left to live. He learned of how common dog deworming medication was effective in experiments on rats with cancer, and how a doctor with four-stage brain cancer tested it on himself and saw his cancerous cells disappear after six weeks of taking it. After doing more research, he found that the primary ingredient in the drug, fenbendazole, actively starves malignant cells and kills them. Determined to try anything, he took fenbendazole-based dog deworming medication for three months and eventually was confirmed on a PET scan to be completely cured. Tippens also uploaded his testimony on Youtube, which went viral and sparked a major international movement towards using the repurposed drug. However the Korean Ministry of Food and Drug Safety urged caution after

witnessing the explosive growth in dog-deworming medication sales in Korea, stating that, “If patients take fenbendazole after their physical strength has been weakened from chemotherapy, side effects can occur,” (“Dog Dewormer Gets Scarce amid Rumors of Efficacy in Cancer,” 2019). He also strongly urged cancer patients not to take the drug based on one testimony as not enough studies had been done to assess its effectiveness on humans. While quality control is a valid concern, cancer researchers across the world in the last couple of years have found numerous connections between deworming drugs and the decline of cancerous tissue. In 2017, Norwegian scientists found that NTZ, a common anti-parasite drug, killed cancer cells by decomposing activated beta-catenin. Professor Karl-Henning Kalland of the University of Bergen and leader of the research team who discovered this phenomenon stated, “We discovered that this specific substance is blocking the signaling pathway in the cancer cells… It is not often that researchers discover a substance that targets specific molecules as precisely as this one,” (“Parasite Killer Too Found to Be Effective Cancer Treatment Candidate,” 2018). Additionally, Kalland’s team discovered that reducing beta-catenin enhanced the body’s central immune system, providing a

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new candidate therapies and speed up the pipeline of available therapeutics redirected for targeting cancers,” Cheok stated (“Tapeworm Drug Could Be an Effective Treatment for Certain Cancers, 2019).

minimal side-effect natural defense against cancerous cells. In the same year, University of California San Francisco published a paper detailing how a common deworming pill could reduce cancer from a lethal illness to a chronic one by targeting a host of genes at the same time instead of a single unpredictable mutation. Bin Chen, PhD, a faculty member and researcher in Pediatrics in the Institute for Computational Health Sciences, explained how he analyzed 274 genes regulated in cancerous tissues and, in looking for drugs that targeted those genes, found that common deworming pills were highly effective in destroying cancerous tissue. “We found these disease genes were reversed after six weeks of treatment in a patient-derived tissue in a mouse model,” said Chen. He also added that, “... finding molecular signatures for diseases then looking for drugs that work against those signatures is a promising way of treating patients who may each have a different set of cancer mutations and might not respond to drugs that just targeted them one at a time,” (“Deworming Pill May Be

Effective in Treating Liver Cancer,” 2017). Cancer is difficult to treat because it’s derived from unpredictable mutations that could permeate any area of the body. By using a drug that could target multiple genes at once, Chen remains optimistic about the future of multiple types of cancer treatment. Parasite medication, in its many forms, has resurfaced multiple times in its role as a repurposed medication. It was discovered in 1950 and since then, has been found effective in attacking bacterial infections to inhibiting cancer pathways. Just recently in 2019, a team from Singapore’s A*STAR Institute of Molecular and Cell Biology found that the drug niclosamide, which is found in anti-parasitic medication, actively kills p53-defective cancer cells by raising metabolic stress. Essentially, it has the ability to specifically target cancer cells yet still spare healthy cells that carry a differing wild type p53 gene. Chit Fang Cheok, lead researcher of this study, remarks how the U.S.’s Food and Drug Administration has already approved the use of repurposed medication. “This can help to reduce cost and time in developing

What can be concluded from all of this? The takeaway isn’t that all common medications may hold some secret cure to deadly incurable diseases. Blind self-medication may result in harmful side effects, and still isn’t advised. However, with the support of dedicated research teams across the world, common medications have found new purpose in defeating devastating diseases and may hold the key to making treatment more accessible and more reliable.

References The Anticancer Fund. “Policy Paper on Repurposed Drugs.”Anticancerfund.org. n.d., n.pag. Web. 12 February 2020, https://www.anticancerfund.org/sites/default/files/attachments/ policy_paper_on_repurposing.pdf “Dog Dewormer Gets Scarce amid Rumors of Efficacy in Cancer.” Korea Biomedical Review, 24 Sept. 2019, www.koreabiomed.com/news/ articleView.html?idxno=6489. “Parasite Killer Too Found to Be Effective Cancer Treatment Candidate.” NFCR, 28 June 2018, www.nfcr.org/blog/blogparasite-killer-found-effective-cancer-treatment-candidate/. “Deworming Pill May Be Effective in Treating Liver Cancer.” Deworming Pill May Be Effective in Treating Liver Cancer | UC San Francisco, 13 Feb. 2020, www. ucsf.edu/news/2017/03/406321/deworming-pill-may-be-effective-treating-liver-cancer. Keown, Alex. “Tapeworm Drug Could Be an Effective Treatment for Certain Cancers.” BioSpace, BioSpace, 19 Feb. 2019, www.biospace.com/article/tapeworm-drug-could-bean-effective-treatment-for-certain-cancers/.

Washington University Review of Health

Physicians on FaceTime: The Future with Telehealth Writer: Maya Patel | Editor: Hannah Chay | Illustrator: Lily Xu

one are the days of unreliable WebMD searches and hour-long waits for a 10 minute doctor’s appointment: the new wave of online medicine is solving a myriad of today’s frustrations. While technology has played a role in healthcare for decades, specific remote services have not found a particular popularity until now, as the technology wave has fully washed over us. In 2020, telehealth will take the form of anything from video chats with your doctor to safe abortions at home, revolutionizing medicine for both patients and providers. As defined by the Health Resources Services Administration, telehealth is “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration” (“What is Telehealth?,” 2019). Video conferences, administrative meetings, and the interpretation of medical imaging and tests are all included in telehealth. Telemedicine falls under the broader scope of telehealth and refers solely to remote clinical services. From an economic standpoint, the growth of telehealth services will benefit the vast majority of Americans who suffer the burden of healthcare costs, from copays to transportation. The cost of transportation will be cut out when patients

opt for the telehealth alternative to visiting physicians in person. Time spent traveling to and sitting in waiting rooms would be removed, therefore eliminating the need for patients to take time off work for appointments. With the convenience of telehealth, conditions can effectively be diagnosed and treated earlier on, allowing people to seek preliminary treatments before they grow costlier (“Why Virtual Care is the Future,” 2019). Proactive medical care is beneficial for health outcomes, however, there is a potential

drawback for an excessive number of doctor video chats. In an article for Wired, author Sara Harrison highlights this caveat, noting that “a bunch of new visits, even virtual ones, also means a bevy of new bills that someone has to pay” (Harrison, 2019). This could apply to taxpayers or, more specifically, those who receive insurance through their employment. While several components of healthcare are inaccessible to certain denominations in the U.S.,

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telehealth services have been working to counteract these restrictions. Resistance against abortions and providers like Planned Parenthood have made access to abortion clinics very limited in several parts of the country. A second Wired article on the implications of telemedicine brings to light the fact that “in 27 US cities with populations greater than 50,000 people, there’s no abortion clinic within 100 miles” (Rogers, 2019). Telemedicine has solved this issue in part by allowing women to receive safe, effective abortion pills in the mail. The process is relatively simple: the patient calls a clinic then has an ultrasound to confirm the gestation time before ordering and receiving the pills. The only complication lies in governmental regulations since the pills must be “mailed to an

This could apply to taxpayers or, more specifically, those who receive insurance through their employment. address in the state where the provider is licensed,” but the issue can be circumnavigated by finding the nearest provider, even if they practice in an adjacent state (Rogers, 2019). Telehealth allows for convenient access to healthcare across fields of medicine, from women’s health to mental health services.

I had the opportunity to talk to Dr. Jacques Jospitre, co-founder of telepsychiatry service SoHoMD, which is based in New York. A pioneer in the industry, Dr. Jospitre works alongside his team of professional therapists and psychiatrists to hold appointments with their patients via video conference. Following an appointment, the physicians are able to follow up with future conversations and assist in filling prescriptions. Over the phone, Dr. Jospitre tells me that he started this business because he recognized that access to treatment was limited for the working class, and private practitioners and Medicaid clinics provided very little to support mental health. He explains that 80% of the information he uses to diagnose patients comes from their history, so diagnoses can be made more efficiently by relaying the patient’s history ahead of time and spending the majority of the appointment working out a treatment or solution.

References What is telehealth? How is telehealth different from telemedicine? (2019, October 17). Retrieved from https://www.healthit.gov/faq/ what-telehealth-how-telehealth-different-telemedicine Why Virtual Care Is The Future. (2019, April 9). Retrieved from https://www.globalmed.com/ why-virtual-care-is-the-future/ Harrison, S. (2019, December 20). Got the Flu? These Doctors Really Want to See You-Virtually. Retrieved from https://www.wired.com/ story/got-the-flu-these-doctors-really-want-tosee-youvirtually/ Rogers, A. (2019, June 5). Telemedicine Makes It Safe to Get Abortion Drugs in the Mail. Retrieved from https://www.wired.com/ story/telemedicine-makes-it-safe-to-get-abortion-drugs-in-the-mail/

Sara Harrison points out that as more patients schedule their first appointments via video conference, more people will realize they love the experience for its effectiveness and will “come back for more medical care on demand” (Harrison, 2019). Though telehealth services are increasing in popularity, it is unlikely that technology will ever fully take jobs away from physicians. Most telemedicine still requires a face-to-face interaction with a real medical professional, or at least the clinical expertise that can only come from years of specific training.

Washington University Review of Health

Alexandra Laufer

Haley Pak

ILLUSTRATION FEATURE

Grace Kim Haley Pak 40

Spring 2020

Pre-Existing Conditions: Another Possible Change in American Healthcare? Writer: Rishi Samarth | Editor: Dany Matar

he Patient Protection and Affordable Care Act (otherwise known as Obamacare) is one of the most integral pieces of health policy crafted in recent American history. According to the National Conference of State Legislatures, 32 million Americans, or about 10 percent of the United States’ population, have received healthcare coverage through a series of consumer and social protections (Healthcare.gov, 2010). One of the most famous and recognized provisions allowed individuals who currently had medical conditions to enroll in a health insurance plan, otherwise known as pre-existing medical conditions. Through the creation of the Open Enrollment Period with the Healthcare Exchange, The Affordable Care Act forced insurance plans to cover these conditions. Currently, Texas vs. U.S., a lawsuit by 20 Republican governed states, is making its way through the judicial system, aiming to remove such protections and threatening the health coverage of millions of Americans (KFF, 2020). Pre-existing conditions are described as “a medical illness or injury that you have before you start a new health care plan” (Cigna, 2018). The main reason why health insurance companies dubbed this term was to protect from insurance

fraud and to maximize profits (Hendren, 2013). Without these lists of conditions, it is very possible that an individual can go without any health coverage until they are in dire need of healthcare. An example would be an individual who is pregnant only obtaining health insurance before having children. However, these lists of

Pre-existing conditions are described as “a medical illness or injury that you have before you start a new health care plan” (Cigna, 2018). conditions often include chronic conditions requiring little medical expenditure, such as anxiety, sleep apnea and even acne. Pre-existing conditions previously applied to both individuals who received healthcare coverage through their employers or through government plans and those who purchased coverage directly from companies. Individuals who had such conditions were either denied health coverage outright, or were placed

on waiting lists or charged exorbitant amounts. Employer plans tended to cover pre-existing conditions, but others looked through the health histories before deciding coverage and prices. Some states created “high-risk pools” to cover individuals who had health conditions that needed immediate treatment (Commonwealth Fund, 2017). These pools were limited, often had waiting lists and still left many to pay for their healthcare out-of-pocket (The Guardian, 2017). Due to the ACA, these policies of combing through health histories and denying insurance coverage based on an individual’s health are currently not in effect, yet this safety is currently under attack. In recent years, The Trump Administration has attempted to repeal the Affordable Care Act multiple times,

Employer plans tended to cover pre-existing conditions, but others looked through the health histories before deciding coverage and prices. 41

Washington University Review of Health

the most famous of which was the American Health Care Act of 2017 (or the AHCA). After these attempts failed, the administration quietly supported efforts such as Texas vs. U.S., which aim to weaken the foundational policies of the ACA through removing protections for pre-existing conditions. Approximately 40 percent of Americans have a pre-existing medical condition, and many would be negatively affected by the lack of these fundamental protections (KFF, 2020). The majority of these individuals live in lower-income and rural areas of the countries, an demographic that already has trouble accessing healthcare in the first place. It is unclear exactly how the repeal of these protections would affect healthcare coverage, as the defini-

tion of a “pre-existing condition” is not a medical or scientific one, but a lack of healthcare coverage has been shown to have detrimental effects on one’s life (KFF, 2020). With a Supreme Court currently leaning conservative, these protections may possibly be removed (FiveThirtyEight, 2019). However, certain Democratic candidates for the presidency, such as Bernie Sanders and Elizabeth Warren, have proposed a Medicare-for-All policy that removes the system of purchasing health insurance in favor of automatic health coverage (Washington Post, 2019). Currently, the question of if insurance plans will cover individuals with pre-existing conditions depends on our current and future politicians and the Supreme Court.

References Ameliatd. (2019, October 7). Is The Supreme Court Heading For A Conservative Revolution? Retrieved from https://fivethirtyeight.com/features/is-the-supreme-court-heading-for-a-conservative-revolution/ Hall, J. P. (2017, March 29). High-Risk Pools for People with Preexisting Conditions. Retrieved from https://www.commonwealthfund. org/blog/2017/high-risk-pools-people-preexisting-conditions-refresher-course Musumeci, M. B. (2020, January 29). Explaining Texas v. U.S.: A Guide to the Case Challenging the ACA. Retrieved from https:// www.kff.org/health-reform/issue-brief/explaining-texas-v-u-s-a-guide-to-the-case-challenging-the-aca/ Patient Protection and Affordable Care Act - HealthCare.gov Glossary. (n.d.). Retrieved from https://www.healthcare.gov/glossary/ patient-protection-and-affordable-care-act/

Popovich, N., Harris, R., Diehm, J., & team, G. U. S. interactive. (n.d.). Here’s how Obamacare covered Americans with pre-existing conditions. What happens next? Retrieved from https://www.theguardian. com/us-news/ng-interactive/2017/jan/26/ obamacare-what-next-healthcare-preexisting-conditions Private Information and Insurance Rejections. (2013). Econometrica, 81(5), 1713–1762. doi: 10.3982/ecta10931 Tolbert, J., Orgera, K., Singer, N., & Damico, A. (2020, February 10). Key Facts about the Uninsured Population. Retrieved from https://www.kff.org/uninsured/issue-brief/ key-facts-about-the-uninsured-population/ Where 2020 Democrats stand on Medicarefor-all and other health-care issues. (2020, February 12). Retrieved from https://www. washingtonpost.com/graphics/politics/policy-2020/medicare-for-all

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