Frontiers Magazine Inaugural Issue by Frontiers: Washington University Review of Health

Frontiers Magazine

Letter to the reader Frontiers Magazine was created to connect the Washington University in St. Louis undergraduate population to the exciting and innovative field of health. Some of the founding members studied public health, some biomedical engineering, and some did not have health-specific academic interests but recognized the relevance of the field. We felt that ideas related to health are far-reaching and that, at some point, every student would have an interaction with the field. Our solution: a publication that puts the issues and nuances of health into the hands of our peers. Now two years later, Frontiers is growing and thriving. This happens thanks to our many dedicated writers and editors. Health is still our uniting focus, but we have widened our topics and expanded our readership beyond the pre-med community and into the greater St. Louis population. While we will always include some of the “hard science” that permeates the medical field, we make an effort to vary the style and content of our articles, including public interest pieces to draw connections between culture and medicine. Through this first-ever print issue, build upon this vision by focusing on “bodies”. Our writers explore bodies both as they relate to health and representations of our communities. In [Un]healthy Bodies, our articles define what constitutes health, both mentally and physically; in Future Bodies, we show visions of how biological bodies might become altered or overthrown. Finally, in Contested Bodies, we explore the barriers to these envisioned futures. The biological translates to the legal, social, and political bodies that shape our world. Physical bodies, social bodies, future bodies - they are all connected. As Frontiers continues to grow in the WUSTL community, we welcome anyone who appreciates our mission, regardless of major, year, or experience. If you have any ideas for the magazine or would like to contribute as a writer, editor, or executive board member, please feel free to email us at frontiersmag@gmail.com. We hope you will enjoy the articles your fellow students have written for this issue. Happy reading, Amee Azad (Founder/Past Executive Director) Carly Herbert (Current Executive Director) Monica Lim (Co-Editor-in-Chief) Katelyn Mae Petrin (Co-Editor-in-Chief)

executive board executive director carly Herbert

director of public relations sarah burack

editors-in chief monica lim katelyn mae petrin

directors of design maya mashkovich shelby hawkins

faculty advisor seema dahlheimer

director of internal development rachana vemireddy

web editor neha prasad

director of finances victoria distasi

April 2015

CONTRIBUTORS AND EDITORS writers alex carico charlie chen luch chin dan cohen riva desai katrina farris connie gan christina ge amrita hari-raj rachel hoffman pranita kaginele megan kerstein iqra khan hongyi richard li monica lim john lin anna lin-schweitzer adam Lowenstein anna mai katelyn mae petrin neha prasad apoorva ram lily sanborn

akshay shanker katie shapiro urvi sinha maddie stewart ji-yun suh sanji suresh olivia sutton sandy tadros danny teich ben tolkin hannah walcek alex wess michael xi alicia yang kelley zhao

editors matt agritelley divya babbula usama ismail abhinav srinath maddie stewart danny teich charlie chen aashka dalal christina ge amrita hari-raj iqra khan sandy tadros cover illustrator alicia chen

ILLUSTRATors RYAN BRANDT ALICIA CHEN JENNIFER CHEN NORTH KAY TAYLOR TUTEUR SHIQI WANG anna mai

founding executive board executive director amee azad

director of public relations mahendra reddy

editors-in chief rachel hoffman olivia sutton

directors of design sydney myers

faculty advisor seema dahlheimer web editor tony wang

director of finances alex wess

Frontiers Magazine

Table of Contents [Un]healthy Bodies 5

Diabetes Epidemic

19 the footprint of our food

Katie Shapiro | shapirok@wustl.edu

Sugar Addiction

20 Happiness and Health

Lily Sanborn | lsanborn@wustl.edu

The Realities of Cancer in College Amrita Hari-Raj

American Horror Story: Superbugs Measles and Misconceptions Ji-Yun Suh | suh.ji-yun@wustl.edu

Hypochondriasis

21 Interdisciplinary Health 24 Back to Back Akshay Shanker | akshay.shanker@gmail.com

26 IUD: The next birth control Alicia Yang | aliciayang@wustl.edu

27 Own Your Own Health

Kelley Zhao

Pranita Kaginele | pranita.kaginele@wustl.edu Charlie Chen | cdchen@wustl.edu

Neha Prasad | nehaprasad@wustl.edu

Anna Lin-Schweitzer | lin-schweitzer@wustl.edu

Riva Desai | rivadesai@wustl.edu

You Are What You Feed Sandy Tadros | shtadros@wustl.edu

29 spires: Traumatic Reflections Anna Mai

Future Bodies 31

Medicine of the future Ben Tolkin | btolkin@wustl.edu

32 Facing Frankenstein: GM Food John Lin | john.lin@wustl.edu

34 from classroom to real world Connie Gan | connie.gan@wustl.edu

36 Science, Not Fiction Olivia Sutton | oliviamsutton@gmail.com

38 StL: from Brain Drain to Brain Gain Megan Kerstein

39 DIY Biotechnological Revolution Katelyn Mae Petrin

contested Bodies 41 A PRescription for Change Rachel Hoffman | rachel.hoffman@wustl.edu

43 Local controversy: Labadie Hannah Walcek

44 Medicine: Right or luxury Maddie Stewart | madelinestewart@wustl.edu

46 Dissociative Identity Disorder Michael Xi | mxi@wustl.edu

47 Finishing STrong Danny Teich | dteich@wustl.edu

49 Transforming transgender Healthcare Urvi Sinha | urvisinha@wustl.edu

51 Mind the Gap Monica Lim | monica.lim@wustl.edu

April 2015

Diabetes Epidemic Katie Shapiro

Illustration by Shiqi Wang

Frontiers Magazine We are in the midst of a global race toward development. As a consequence, we see a consequent shift in cultural norms: the symptoms of Western society are spreading to impact the rest of the world. Let’s look at India. India, among many other nations, has seen a rapid economic transition, which has corresponded to changes in day-to-day life. The typical Indian male today leads a sedentary life, probably working long hours in a call center, lab, or bank. Physical exercise such as jogging or even walking to work is out of the question—it would entail navigating a perilous traffic scheme and choking on the thick fumes of the city. His dietary habits probably follow the growing national trend of high-fat, high-calorie food consumption. The transmission of fast food restaurants from the United States to its Eastern counterparts condones this busy, nutritionallychallenged lifestyle. Our typical man probably stops at McDonald’s during his lunch breaks. But the symptoms of Westernization— these behavioral and lifestyle changes—have further consequences. The International Diabetes Foundation reports that 65 million adults in India have diabetes and expects that number to increase to 109 million by 2035. Where did this come from? Rapid urbanization and increasingly sedentary lifestyles have spurred the onslaught of obesity and diabetes, diseases that were previously deemed “Western” and associated with affluence. The result? An increased prevalence of Type 2 diabetes in developing countries. A Harvard researcher has found that globalization of the Western lifestyle has also sparked dietary changes like increased consumption of animal fat and energy-dense foods, decreased intake of fiber, and more frequent intake of fast foods.[1] Furthermore, he found that while Type 2 diabetes was once more common among adults, the rising rate of childhood

obesity has brought the disease to a younger demographic worldwide. A population’s level of obesity and consumption of high-fat foods correlates to the prevalence of diabetes and insulin resistance. But the nature of the diabetes epidemic—what makes it so extensive and threateningly unconventional—is the prevalence of diabetes in populations where obesity is not a major health problem. In fact, many third world countries suffering from widespread malnutrition have seen an increase in diabetes.

Is maltutrition, then, linked to diabetes? Israeli researchers found evidence that may suggest this. Between 1997 and 2010, the prevalence of Type 2 diabetes almost doubled in Africa. To put this in perspective, the rate of diabetes in Africa (2.4 percent) is lower than in Europe or North America (7.85 percent), but Africa – especially the rural regions – faces a severe lack of economic and medical resources for diagnosis and treatment. Looking at diabetes in low-resource countries, these researchers found that malnutrition, combined with the physical work typically accompanied by a rural lifestyle and iron or protein deficiencies, increases the prevalence of low-birth-weight newborns. GDM—gestational diabetes mellitus—can develop during pregnancy due to the increased production of hormones that inhibit efficient use of insulin. GDM and pre-gestational diabetes mean a higher chance of fetal death and various childbirth complications. In fact, untreated GDM often causes late-onset diabetes and thus later health issues for offspring. In one study conducted by these researchers, children who were very small at birth—due to the malnutrition of their mothers—typically have a reduced number of pancreatic beta cells and cannot handle insulin well, rendering them susceptible to the disease.[2] A potential cause? They suggest insufficient access to resources for nutritional and medical purposes. It’s difficult to diagnose and manage diabetes in developing countries. A family living in rural Africa may live many miles away from the nearest health clinic; even if they can make the journey there and their child shows elevated blood sugar levels, the family may lack the financial means

April 2015 for adequate treatment, or the doctor may not have the proper resources to proceed. Low income, long distances from health centers, and low educational levels inhibit proper treatment. Approximately 25 million Americans have diabetes, but through treatment and early detection we keep the disease under control. But patients elsewhere in the world face much steeper health risks from diabetes due to inhibited access to health care and supplies such as insulin, blood pressure pills, and other medicines. The costs associated with diabetes treatments are enormous. In some developing countries, diabetic patients living on one or two dollars per day would have to spend nearly 50 percent of their monthly income to purchase a single vial of insulin.

But what can explain the actual onslaught of diabetes in third world? Two hypotheses have been proposed. The “thrifty phenotype hypothesis” suggests that infants with low birth weights are more likely to develop Type 2 diabetes. The “thrifty genotype hypothesis” proposes the existence of diabetic genes persisting in populations that have undergone the transition to a modern lifestyle with an abundance of food. In the newer context, these genes become detrimental by facilitating the development of obesity and diabetes. According to latter hypothesis, populations that have faced malnutrition in the past are more prone to the development of diabetes when becoming Westernized. Europeans are less likely to possess thrifty genotypes because they evolved in environments that were less affected by the feast and famine cycles. Perhaps the diabetes epidemic in malnourished countries illustrates the clashing of ancestral genes with modern lifestyles. Type 2 diabetes, of course, is very preventable, and typically staved off by healthy eating and physical activity. But even the United States has been unable to implement these habits on a large scale – we are still a nation crushed by its obesity rates. To address the rising of diabetes in developing countries, affordable medications may need to be introduced. The treatment of diabetes also calls for medical systems that are geared toward chronic care and

foster long-term partnership between patients and a clinical team. Approaches to treatment also require a consideration of cultural beliefs on a regional basis – in some rural areas of the world, indigenous groups believe diabetic patients to be bewitched and will first consult a traditional healer over a medical health professional; similarly, in many low-income countries, obesity is considered desirable. Another approach entails the distribution of user-friendly blood glucose measuring devices, as well as inexpensive oral glucose-lowering agents. Essentially, diabetes in the developing world stems from a combination of malnutrition and modernized lifestyles. How can it be that national development (correlating to the spread of obesity, sedentary lifestyles, and Western customs) and underdevelopment (analogous to malnutrition and the lack of proper medical and financial resources) both contribute to the diabetes epidemic? We usually equate the development of a nation with advancement, but perhaps our interpretation of “development” is at fault. This word is used interchangeably with “Westernization,” but there may exist a fundamental difference. Perhaps low-income and third world countries need development, but not Westernization. After all, even the United States has been unable to tackle the diabetes epidemic due to the lifestyle choices and habits underlying Western Civilization. We see this global race toward development, but we fail to develop in a sustainable and health-conscious manner, thereby propelling the invasion of diabetes. References [1] Hu, F. B. 2011. “Globalization of Diabetes: The Role of Diet, Lifestyle, and Genes.” Diabetes Care 34 (6): 1249–57. [2] Ashwal, Eran, Eran Hadar, and Moshe Hod. 2015. “Diabetes in Low-Resourced Countries.” Best Practice & Research Clinical Obstetrics & Gynaecology 29 (1): 91–101. doi:10.1016/j.bpobgyn.2014.05.009.

Frontiers Magazine

Sugar Cravings:

Evolution, Addiction, or Both? Lily Sanborn When we think of addiction, our minds automatically jump to alcohol and illicit drugs. However, recent research has called into question whether sugar should be added to this list. There is no question that when given the option, most people choose sugary foods over healthier options, seeking out sweets despite awareness of their adverse health effects – a behavior characteristic of other addictions. This phenomenon interests many scientists, who have sought to understand just what about sweets makes them so tempting to the human brain. A January 2015 study at MIT shed new light on the neurological factors contributing to sugar preference. Focusing on a specific neurocircuit, the LH-VTA loop, which links the part of the brain that controls hunger (the lateral hypothalamus, LH) and a group of neurons central to the brain’s reward circuit (the ventral tegmental area, VTA), researchers genetically modified mice so that the circuit could be turned on and off merely by exposing the mice to different frequencies of light. The mice were then provided with a source of food pellets, as well as a source of sugar.

The results of this experiment correlated this neurocircuit with behavior that resembled addiction: when the neurons in the circuit were deactivated, mice chose to eat the pellets and stopped when full. However, when the neurons were activated, mice ate for longer periods of time and would repeatedly travel back to the sugar source, even when they had to cross an electric shocking platform to do

so. Although performed with animal models, the experiment could apply to humans because the neurocircuit performs the same functions in the human brain. Therefore, these observations of animal behavior could also demonstrate human sugar addiction. This research begs the question: what exactly happens in the brain’s reward centers when we consume sugar? As it turns out, the body’s fondness for candy and ice cream comes from multiple chemical responses that follow consumption. Studies by Dr. Yanina Pepino and Julie Mennella have demonstrated that early in life, sugar can act as an analgesic, essentially a painkiller. This goes away with development. Additionally, it is scientifically established that sugar consumption activates the body’s reward system through dopamine production. As the result of an adaptation to seek out highenergy foods and prevent starvation early in human history, our bodies evolved to respond to sugar consumption with the release of this “feel-good” chemical in the brain. Coincidentally, dopamine is the same chemical responsible for producing a “high” after consumption of illicit drugs. While this trait once provided an evolutionary leg-up, in today’s society, where candy bars line the checkout counters at grocery stores and soda is often just as readily available as water, this mental hardwiring leads to overconsumption and consequently a range of health problems, from cavities to diabetes. As is the case with drug use, increased sugar consumption causes the body to crave it even more, prompting the brain to require larger amounts of the sugar/drug to reach the same dopamine level again. These chemical changes within the brain resemble those of addiction. This raises the question: are humans addicted to sugar? Further research has investigated the potential relationships between sugar and addiction. Yanina Pepino, an assistant professor in the division of Geriatrics and Nutritional Science at the Washington University School of Medicine (WUSM),

April 2015 has found that people with family histories of alcohol addiction have increased preference for sweetness. She also mentioned that there are several anecdotal reports in the literature and some studies showing that “when trying to withdraw from drugs and come back from addiction, people many times report having an intense craving for sweetness and feel that increasing their sweet consumption can help keep them from alcohol or heroin.” Although this does not provide evidence that humans experience sugar addiction, it indicates that humans exhibit “addicted-like behavior” towards sugar. Tamara Hershey, a professor at WUSM who has studied the relationship between dopaminergic abnormalities in the brain and obesity, weighed in on the question of whether or not humans experience sugar addiction. She noted that although we are hardwired to seek out sugar, it is difficult to classify this tendency a true addiction because, unlike drugs, sugar is not a substance one can avoid consuming. Hershey reflected, “The idea has great heuristic value in that it causes us to think harder about what we mean by ‘food addiction.’ It makes us ask a lot of great questions, but it might not truly be the same as an addiction to a drug.” Sarah Eisenstein, an Instructor in the Psychiatry Department who worked on the same study, also brought up the difficulty of determining whether overeating or extremely high preference for sugar reflects a deficient or overactive reward system: “Do some people eat more because they need more than other people to feel pleasure, or is it because they are especially sensitive to pleasurable stimuli?” The answer may be different depending on the type of reward and personality of the person in question. While we may not be able to say humans are “addicted” to sugar, it is widely accepted that sugar elicits chemical responses in the brain just like those present in substance addictions. Every day when we are tempted by caloric options that seem so readily available and decide not to partake, we are fighting our basic human instincts. Somewhat ironically, these instincts are more of a hindrance than a help in today’s society.

Frontiers Magazine

The Realities of C

“

was a nearly sure bet to catch any escaped cancer cells…I knew the surgery was a major operation with its own risks…but the most motivating reason I opted not to have the RPLND was a suspicion that no one was talking about the inevitable after effects of the damaged nerves and tissue.” Ziebarth’s cancer ended up returning in fall 2012, but fortunately, “… my oncologist [was] one of the foremost experts on genitourinary cancers, and had participated on the team that cured Lance Armstrong.” Ziebarth underwent a twelve-week chemo regimen, after which he was deemed cured of testicular cancer. This is not to say students should live in fear of the impending doom that is cancer. According to Dr. Thomas Heck, co-medical director of Samaritan Breast Center and a surgeon at Gem City Surgical Breast Care Center in Dayton, OH, “Generally, patients we see are fifty years and older. As for screening, I recommend a baseline mammogram at 40 and yearly thereafter.” However, a s t h e i nt e l l e c t u a l , g lobal citizens that we strive to be with our coursework and endeavors at WashU, it is a disservice to ourselves to neglect personal care. Ziebarth’s experience is exemplary of the power of self-checking and being aware of one’s body. Although only 6 percent of the United States’ new cases of cancer occurred in those under the age of 45, this 6 percent feels enormous when it encompasses someone you know personally, especially when he or she is of college age. According to the National Cancer Institute, survival rates of cancers in adolescents and young adults (AYAs) have not improved over the last 30 years. Factors that may contribute to this trend include delayed diagnoses and the unique psychological and social needs of this age group.

“

According to the American Cancer Society, six percent of the new cases of cancer in 2013 occurred in people under the age of 45. With philanthropic endeavors such as Relay for Life and the cutting edge research at the medical school, our institution does not claim ignorance to these statistics. Yet, it is difficult to bring these numbers to life as college students. It is all too easy to live under the mantra “this could never happen to me;” but this invincibility complex is not in anyone’s best interest. Brendan Ziebarth, a junior in the College of Arts and Sciences, was diagnosed with testicular cancer in June 2012. Ziebarth eventually had a CT with contrast and an X-ray to confirm, but “I actually self-diagnosed based on a lump I felt,” he said. He initially saw a medical professional at urgent care; “The doctor who saw me performed a tactile exam of the testicle and concluded in her opinion there was nothing of concern. I insisted on getting a referral to a urologist anyway. I was sure about what I had felt.” Sure enough, the urologist diagnosed him with cancer immediately. Ziebarth believes the “atypical presentation of [his] symptoms” attributed to the initial ignorance of his cancer signs. He had surgery to remove the cancerous testicle as well as to repair a hernia he had since the age of 12. “I had caught it very early, around Stage 1a. However, [the oncologist] warned that it was hard to know if it was actually Stage 1s, in which some cancer cells escape into the lymphatic system and can come back.” Ziebarth ultimately declined an offer to have a Retropariteneal Lymph Node Dissection (RPLND), a procedure where the abdominal lymph nodes would be surgically removed through an incision from the sternum to the groin. “The procedure

It can be difficult to speak up about potential medical problems or to feel ashamed, especially during adolescence.

April 2015

Cancer in College Amrita Hari-Raj Mo s t i m p o r t a nt l y, t h o u g h , Z i e b a r t h’s experience calls us to become more aware of our own bodies and to be unafraid to speak up. It can be difficult to speak up about potential medical problems or to feel ashamed, especially during adolescence. “Those feelings of fear and shame are especially true in young adult bodies that are already undergoing significant changes and developments,” said Ziebarth. It is for this reason that Ziebarth said he is so open and detailed in recounting his experience. Ziebarth said his aunt, who is a nurse, once saw a fifteen-year-old boy with a testicle the size of a grapefruit. “I had already passed the first hurdle and conquered the fear of telling my parents and sought medical advice.” It is imperative that we not only reconcile any shame or embarrassment felt

regarding health problems, but we must also foster open dialogues that destigmatize illness and instead offer support to those that need it, he said. Most importantly, we must take ownership of our health and dutifully listen to our bodies. “It was because of my insistent advocacy for my own health and my trust in my instinct and self-knowledge of my body that I secured a referral to another professional,” Ziebarth said.

Illustration by Alicia Chen

Frontiers Magazine

American Horror Story:

Superbugs neha prasad On September 18th, 2014, President Obama issued an executive order, declaring war on “superbugs.” While antibiotics were an effective, reliable way to treat potentially fatal infections in the past, the modern misuse and overuse of antibiotics has compromised their reliability. Now, bacterial strains are becoming increasingly resistant to the few antibiotics on the market, gaining “superbug” status. Since antibiotics do not affect these superbugs, normal infections are becoming untreatable and, thus, life-threatening. Even in developed countries, only 50 percent of patients respond to some oncepotent antibiotics. These “superbugs” are gaining the upperhand in our fight against bacterial infections, and pose a serious threat to global health security. With bacterial resistance, the question is not if the strains will pick up resistance, but rather when. Antibiotics target a specific component of an essential bacterial biochemical pathway, like cell wall synthesis or folic acid metabolism. Since not all bacteria have the same DNA sequence encoding the molecules involved in that pathway, a random mutation may confer resistance to a bacterial cell against the antibiotic. The antibiotic then kills all susceptible bacteria and leaves the mutated, resistant bacteria unaffected. The bacterial cells can pass on their DNA for resistance to their progeny or to other bacterial cells it encounters through conjugation (horizontal gene transfer). Antibiotic discovery is a cat-mouse chase: as scientists develop pharmacologically active molecules, which inhibit essential biochemical pathways in bacteria, the bacteria eventually develop resistance to the antibiotic through random mutations in their DNA. Therefore, the more exposure bacteria has to antibiotics, the faster the antibiotic will select for resistant bacteria and generate a threatening “superbug”. According to the Center for Disease Control and Prevention (CDC), antibiotic-resistant infections are responsible annually for 2 million illnesses in the

U.S and $20 billion in health care costs. Not only are antibiotics prescribed for common infections like strep throat, but they are also crucial for fighting bacterial infections after surgery, transplants, and chemotherapy. Without the promise of effective antibiotics, these complicated medical procedures become unviable due to significant concern for post-treatment complications. President Obama’s executive order comprises of a plan for action that will limit and control use of antibiotics in medicine and agriculture (in order to decrease antibiotic exposure) and develop new medicines and technologies to combat the “superbugs.” In research, the plan encourages the discovery of new classes of antibiotics, vaccines, and diagnostic tools.

...the question is not if the strains will pick up resistance, but rather, when. The CDC estimates that 50 percent of antibiotics prescribed are unnecessary or incorrectly prescribed. Bioinformatics and metagenomics can be used to develop a “point-of-care” diagnostic tool that would quickly identify the type of bacteria and its particular antibiotic susceptibilities to prevent misdiagnosis by doctors. This technology would be utilized as soon as a patient walks into a doctor’s office with a bacterial infection, and by the time the visit is over, the doctor will have enough information to prescribe the most suitable antibiotic. During wartime, when bacterial infections were a pervasive cause of death on the battlefield, the antibiotic industry was born. “A short golden age of antibiotic discovery from nature followed by a subsequent golden half century of medicinal

April 2015 chemistry optimization of existing molecular scaffolds emphasizes the need for new antibiotic molecular frameworks,” reads a paper published by Walsh and Wencewicz.[1] For the last few decades, not much innovative effort has gone into overcoming bacterial resistance. Researchers, like Dr. Wencewicz of Washington University in St. Louis, are looking for new mechanisms to target these “superbugs” so that the effectiveness of these next-generation antibiotics can last longer than the current 1-2 year potency period. Yet, the shrinkage of the R&D sector of the pharmaceutical industry limits access to the expertise and cooperative facilities crucial for drug development. The effectiveness of the Executive Order depends on the cooperation of the government with big businesses, practicing doctors, farmers, and researchers. Overall, with more regulation and research, the U.S hopes to defeat the “superbugs”–perhaps once and for all.

references [1] Walsh, Christopher T, and Timothy A Wencewicz. 2014. “Prospects for New Antibiotics: A Molecule-Centered Perspective.” The Journal of Antibiotics 67 (1): 7–22.

Illustration by Shiqi Wang

Frontiers Magazine

measles and misconceptions ji-yun suh Most of us have heard denunciations of vaccinations like “Vaccinations should not be mandatory, but voluntary” or “Vaccines cause autism.” Many Washington University in St. Louis students scoff at these sentiments because science has proven that vaccinations prevent disease and protect public health. In an informal survey with a sample of WUSTL students, 100 percent of those surveyed affirmed that vaccinations were beneficial. Phrases discounting the effectiveness or safety of vaccinations are not words we would expect from two prospective presidential candidates for the 2016 election. However, Governor Chris Christie said there should be “some measure of choice” in getting children vaccinated and Senator Rand Paul asserted that there had been “many tragic cases of walking, talking, normal children who wound up with profound mental disorders after vaccines.” Such assertions, with a lack of verifiable scientific backing, are not exactly what we want to hear from potential future presidents of the United States of America. These anti-vaccination statements are problematic in light of the latest mass outbreaks of measles causing major concern in the United States. We have seen more cases of measles in the past few months of 2015 than in an entire typical year. The outbreak was traced back to Disneyland in California and spread to fourteen states during January 2015. The majority of those infected were unvaccinated. Dr. Stoner, associate professor of sociocultural anthropology with a focus on infectious diseases at Washington University in St. Louis, said that parents choosing to not vaccinate their children will cause the United States to “see a resurgence of vaccine preventable diseases, the likes of which we have never seen in our lifetime … not just measles but mumps, diphtheria, maybe even something like polio.” But why does this affect WUSTL? As seen in the survey at WUSTL, all of our students believe in the merit of vaccinations. However, with all of these recent measles outbreaks, Dr. Stoner said, “[it’s] possible that someone with measles could come back to the Midwest and spread measles. It’s highly

contagious, and it’s possible that some students would acquire measles as a result of that. This trend toward not vaccinating is creating this potential for serious public health problems. Although my guess is that most of the WUSTL student population is vaccinated and the impact would be limited, the disease can be spread to people who have been vaccinated, even if it’s less likely.” The fact is that not getting vaccinated and becoming susceptible to these diseases puts those who have been vaccinated at risk as well. More, while many of our students agree with vaccines, some of their parents have had misgivings about vaccinations. In the survey at WUSTL, 14 percent of the students surveyed admitted that their parents questioned the way that vaccines were administered. Some comments included statements such as, “My parents are skeptical of the flu vaccine because I got the flu the week after getting it” and “Parents have delayed vaccinations (especially the HPV vaccine)”. The fears that vaccines are excessive or that they might actually cause the illness are prevalent among the parents of our students, even though these claims have no scientific backing. Dr. Stoner addressed some of these ideas. When asked whether or not the flu vaccine could cause the flu, Dr. Stoner retorted that, “You can have a low grade local reaction, a low grade fever that lasts for about 24 hours. One thing it won’t do is give you the flu … That’s just not true. There’s a lot of misconception about that.” He addressed the idea that vaccinations are delayed or staggered over time by arguing that children can “get the disease during infancy during the time when they’re not covered, especially with outbreaks lately. The thing is that diseases are more severe when you get them at a young age.” Vaccines are widely accessible especially in the United States. The most tragic part of dying from a vaccine preventable disease is that it is simply so easy to prevent. Not getting the vaccine puts not only yourself but also the people around you in danger. As future parents of the next generation, we need to understand and spread the word that vaccinations are only here to help.

April 2015

+ kelley zhao Lou Gehrig. Appendicitis. Boerhaave syndrome. Hemorrhagic fever. Fibromyalgia. Parkinson’s. Cancer. The list of diseases and health conditions is seemingly endless. Each one constitutes its own list of syndromes, risk factors, death rates, and other statistics. Collectively, they make up a significant portion of the second-year medical student’s (M2’s) curriculum. First-year medical students (M1’s) attend lectures for mostly basic core science classes, such as Biology, Physiology, Human Development, and Medical Genetics. M2’s learn about all the things that can go wrong in the systems they learned the year prior. “Medical students are bombarded with new definitions, new terms, syndromes, diseases,” said Jeremy Lai, a Washington in St. Louis alumni and third-year medical student at Northwestern University Feinberg School of Medicine. It isn’t until the third year that students finally gain clinical experience and are exposed to the actual manifestation of diseases or illnesses in patients. Second year medical students are thus immersed in a stage where they have “too much knowledge and lack of experience in applying that knowledge,” according to Re-I Chin, a first-year student at St. Louis University School of Medicine.

many students have mistakenly self-diagnosed themselves with one condition learned in their first few years of medical school. Put two and two together, and what you end up with is Hypochondriasis in medical students. Or

at least, there is an increased risk of it during your first few years of medical school. According to the National Library of Medicine, hypochondriasis is the “preoccupation that physical symptoms are signs of a serious illness, even when there is no medical evidence to support the presence of an illness.” It is commonly heard that at one point in their medical education, many students have mistakenly self-diagnosed themselves with one condition learned in their first few years of medical school. In a New York Time’s article, “When Med Students Get Medical Students’ Disease,” around a startling 70 percent of students have gone to student health services complaining of symptoms. Of course, the small percentage of students who do not consult student health services must be taken into consideration as well. Hypochondriasis presents itself as a curriculum-sensitive phenomenon: medical students have a greater tendency to misdiagnose themselves during their preclinical years in medical school. “They don’t see the patients who have it, or the doctors who deal with it,” said Steven Sun, a fourth-year at University of Michigan Medical School. “One of my residents once told me M1’s and M2’s know just enough to be dangerous – to themselves and to other patients. If you don’t truly understand the disease processes, you could have misconceptions about the disease.” Lai concurs. “It becomes easy to associate our own experiences with what we’re learning.” Another possible cause of increased risk for preclinical medical students to become hypochondriacs is the unfamiliar lifestyle they must lead during the school year. Medical school and its demanding curriculum is an “immersive experience, during which your perspective is narrowed and limited,” according to Lai. As a result, with much of a medical student’s mind suddenly preoccupied by lectures upon lectures of diseases, they easily fixate on certain diseases. “We live, breathe, and talk medicine,” said Sun. What does that translate into? Students will more readily match their own current symptoms with those presented for certain diseases in lecture,

Frontiers Magazine as their lives and medicine become more and more indistinguishable. Not only does medical school cause an increase tendency to correlate life events to information learned in class, but it also commonly induces many of the constitutional symptoms that medical students readily use to misdiagnose themselves. Suffering from fatigue, weight loss, and difficulties falling asleep? Are you also a medical student? If so, there is a likelier chance of being diagnosed as a stressed medical student than being diagnosed with cancer. “Medical school is not a great time to be health conscious between work hours. It means you don’t eat right or exercise or sleep enough,” said Pham. So what’s the solution? Keep perspective. Pham said of his own experience, “When I was shadowing as an M1, my preceptor told me a lot of people have ADHD/bipolar disorder and don’t know it. They typically look like classmates who don’t get a lot of sleep and can’t remain very focused, and I thought, Well, that looks like me. What if I have ADHD and that’s why I can’t focus? Ultimately, you have to understand what’s within the range of normal, and what would be clinically abnormal.” Not only does keeping perspective mean distinguishing between normal and abnormal, but it is also rationally determining the causes behind the abnormal. A headache could be a sign of cancer, but it can also be a sign of insufficient sleep. While it cannot be concluded that all and only preclinical medical student develop hypochondriasis and absolutely no practicing doctors can have fears of having certain medical conditions, there is a decreased occurrence of hypochondriasis amongst practicing doctors. Students do learn better. “As we go further in our training, it becomes less of an issue. You become used to seeing disease and illnesses, and you learn to separate yourself more from that,” said Lai. Sun elaborated on that idea, saying, “They have more experience, so they understand the full disease process. You’ve gone through more of your training, so if you think you have something, you’re closer to being correct. There was once a neurosurgeon who woke up in the middle of the night, and realized he was having a stroke. He drove himself to the ER, and after they scanned him, lo and behold, he was having a stroke.” Of course, there are also anecdotes floating around about students who have correctly diagnosed

themselves after learning about the symptoms. Isn’t it better to be safe than sorry? Chin responded, “It pays off to be vigilant. But I wonder if the benefits ultimately outweigh the costs of worrying.” Costs not only include mental

I wonder if the benefits ultimately outweigh the costs of worrying. - re-i Chin, student and emotional ones, but also physical as well, as an excess of radiation, biopsy, and other tests may cause more overall harm than good. The best option, Chin advised, is to “bring it up to the health care provider in your medical school, whether or not your worries are warranted. If they agree with your suspicions, then they can run further diagnostic tests to support a possible diagnosis.” While there is a general consensus that hypochondriasis is by definition unnecessarily debilitating for a student, there is some level of understanding and compassion around the issue amongst classmates. “If you need help, it’s okay to ask for it. Turning to friends, family, and professional help should not be looked down upon. Each person’s reaction may be different – we’re not in an era where if you can’t handle it, you’re not cut out for it,” said one anonymous interviewee. So Lou Gehrig? Boerhaave syndrome? Hemorrhagic fever? For medical students, the fear of having these illnesses may be more common than actually having them.

April 2015

you are what you

eed

Sandy tadros When people find out I don’t have Facebook, they always look so puzzled. “Why not?” they ask. It’s been two years since I deactivated my account and, yet, I still can’t find a coherent answer to this question. More times than not, I respond with an “uhhh” until somebody changes the subject. I do think Facebook is oftentimes useless … but is that why I no longer use it? Did it make me feel lonely? Was it just that an overall bad feeling accompanied my perusing it? Research certainly suggests that social media does affect our moods and mental health. FB’s mission, according to its informational page, is to “give people the power to share and make the world more open and connected.” FB does, in fact, allow individuals to keep in touch with those in other cities and even distant countries. However, it seems this does not help the shy, the lonely, or those with low self-esteem feel a sense of belonging, despite initial speculations of its positive effects on these populations. Because these individuals do not self-disclose as much in person, researchers initially believed that shy people might share their thoughts online because it is less awkward than face-to-face interactions. Based on these predictions, Dr. Amanda Forest and Dr. Joanne Woods at the University of Waterloo conducted a psychological study on low self-esteem individuals. The results supported the idea that participants with lower self-esteem saw FB as a safer place to express themselves than did individuals with high self-esteem. Low self-esteem individuals also saw more advantages to disclosing their thoughts and feelings on FB over in person. Given this view, Forest and Woods then investigated whether or not people with low self-esteem actually did use FB to better their social lives and achieve intimacy in their relationships. Their results suggested that although low self-esteem individuals see FB as a safe place, they do not use FB more than those with high self-esteem. Further, participants who posted negative updates on FB were “less liked” by other facebook users. Given these results, is FB really living up to its mission? Maybe not as a whole, but the Wash

U Confessions page is certainly trying to build on FB’s “power to share”. The administrator for Wash U Confessions hopes to create a place where people can “turn off their filters and not worry about being judged for their honesty.” The admin states that “when so many people are posting pictures and statuses about how great their lives are, it isn’t always easy to speak up and admit that … life isn’t going so well.” Regardless of the outlet Washington University in St. Louis students have gained through the Confessions page, Frontiers’ informal campus survey still suggests that most students’ moods are negatively affected by FB as opposed to positively affected or not at all affected. I know I tend to feel a little down when I look through the Wash U Confessions page, specifically. This seems to be a common sentiment, as one post on October 27 states, “The new Wash U Confessions profile picture is really depressing. Please change it … We need that sunny background to counteract these oftdepressing confessions!”

Additionally, many students on campus have expressed a dislike for Wash U Admirers, a page intended to provide uplifting words and flattery; instead, it is regarded as a rite of passage on our campus. Recently, a friend of mine came up to me holding his phone screen so close to my face I couldn’t recognize what he was showing me. “I

Frontiers Magazine finally made it!” he screamed as I noticed there was a new post about how he is “the most attractive guy on campus” - which, by the way, I find to be a lame compliment since, according to Wash U Admirers, every guy is the most attractive guy around. Still, this instance showed me just how much we value receiving admirer’s posts on our campus.

reflect on how [social media] affects you and be honest with yourself. Even when people do get mentioned in a post on Wash U Admirers, they aren’t always completely satisfied. One survey respondent points out that “the one time [she] received a post [she] had mixed feelings – ‘yay, I’m so popular’ and ‘meh, the post just says I’m a nice person, nothing about how I look.’” Being positively affected by an admirer’s post is not a certainty and, instead, appears to be pretty difficult. What happens to those who don’t “make it”? In the words of a Wash U Confession-er from November 22: “You know its a little thing, but it kind of sucks to be a senior and never have received a

Wash U Admirer’s post. And I know that normally when people post this some kind souls offer to write one for them if the person messages them, but for me that kind of defeats the purpose.” Maybe there exists a reason for why FB sometimes saddens its users, aside from the confessions and admirers pages on our campus. In June, FB revealed that the company had altered over half a million user feeds, making them primarily positive or negative at random without user consent. The researchers found that moods were contagious; those who saw more positive posts also posted more positively and those who were exposed to negative posts appeared more pessimistic in their posts. Unless these similarities in posts are due to a desire to fit in, FB users’ moods are being affected by other posts. So is my answer to the inevitable “why not” question simply that I was a depressed college sophomore with low self-esteem and needed to delete my Facebook account to be happier? Did I just have a lot of friends who posted negatively? I don’t know but I can tell you that the change did make me happier regardless of how I felt beforehand. Think about how important Facebook and other social media outlets are to you. Reflect on how they affect you and be honest with yourself. At the very least, be mindful of how FB might be playing with your mind.

April 2015

the footprint of our food anna lin-schweitzer We all know that that an apple a day keeps the doctor away. But it also keeps our planet safe, or at least safer than a steak a day does. Food production in general is an inefficient process; the US expends roughly 10 units of fossil energy to produce just one unit of food energy. Indeed, about 10 percent of the US energy consumption goes into raising, distributing, processing, preparing, and preserving the plant and animal matter that Americans eat. Meat production, however, requires and produces a greater amount of energy. In 2006, the Food and Agriculture Organization of the UN announced that 18 percent of global emission results from the livestock industry. This is equivalent to 7.1 billion tonnes of CO2. For context, according to Rutland City Council, a single tonne of CO2 weighs as much as 10 baby elephants, an amount the Climate Neutral Group equates to flying to Paris seven times or breathing for 500 days. In a report published in the journal Climatic Change, researchers found that a meat eater’s diet releases greenhouse gas emissions approximately double that of vegan’s. This is primarily a result of the enormous amount of toxic gases produced by the livestock industry. Indeed, according to a paper by Scarborough et al., merely reducing the amount of meat subjects consumed reduces greenhouse gas emissions associated with an individual by between 920 and 1560 kg CO2-equivalent/yr. Although the livestock industry accounts for only 9 percent of the global emission of CO2, this sector also generates 65 percent of human-related nitrous oxide and 35 percent of methane. These gases have 296 and 23 times the Global Warming Potential of CO2, respectively, meaning they are even more dangerous to the environment. So where do these gases come from? The main culprits are the animals themselves, especially cattle. As cows digest, they produce methane during a process known as enteric fermentation. Another major source is manure management, including storage, which can affect how these gases are produced. The United States Environmental Protection Agency states manure management contributes to nitrous oxide levels, which rise during

the breakdown of manure and urine. The meat industry also requires massive amounts of water, both to feed its animals and to process the meat. According to the Green Monday enterprise group, beef production requires six times more water than tofu production, and even four times more than chicken. Each processing step, aside from final packaging and storage, requires water, in addition to polluting the waterways with blood, manure, fat, and other animal byproducts.

how can we make a difference when these huge industries dominate greenhouse gas emissions? How can we make a difference when these huge industries dominate greenhouse gas emissions? One way is to reduce wasted food. At least a quarter of the food grown is wasted annually, accounting for 2.5 percent of the annual US energy consumption. Merely by eating what we buy, monitoring our food spoilage, and making informed decisions about portion sizes could be more effective than expensive and controversial energy supply policies that have been proposed.[1] Another key to the problem is to reduce our meat consumption, replacing energy-intensive meats with less energy intensive fruits, nuts, beans, vegetables, and grains. You’ve probably heard about Green Monday, a new initiative spearheaded by the Office of Sustainability that encourages members of the community to eat vegetarian one day a week. Indeed, if everyone at Washington University in St. Louis, faculty, staff, and students alike, participates in Green Monday, the institution could collectively reduce its carbon emissions by as much as 5,000 metric tons per year. This is equivalent to taking 1,053 cars off the road. Even giving up meat for just one day a week makes a significant difference when done consistently and communally. references

[1] Webber, Michael. “More Food, Less Energy.” Scientific American Jan. 2012: 74-79. Print.

Frontiers Magazine

Stay Happy, Stay Healthy Pranita Kaginele When John Grace was diagnosed with cancer in the spring of 2006, he found strength in happiness. The tumor on his tongue made life very difficult and he had trouble with daily behaviors like swallowing and talking. Despite this challenge, he and his wife, Joan Raducha, found solace in small comforts of happiness. Studies have shown that emotional states affect both mental and physical health. According to a Harvard study, negative emotions like anger, anxiety, and fear can disrupt cardiac function and stability, which can lead to a faster heart rate, higher blood pressure, and the release of stress hormones. Conversely, positive emotions, including optimism and enthusiasm, lead to benefits. A study done by Laura Kubzansky, also at Harvard, suggests that a positive mental health correlates with a lower blood pressure and a normal body weight. We all know that happiness generally leads to a healthier lifestyle. But, the real question still remains: how do we become happy, and more importantly, how do we stay happy? Biology tells us that some happiness is due to genetics. However, this means the rest of it comes from our environment. Nature and nurture seems out of our hands, but we can cultivate positive thinking. According to a study by the Mayo Clinic, while 10 percent of happiness is based on our circumstances, the majority of our happiness can be fostered through our outlook, personality, and behaviors, all of which we control. Choosing to exercise, a simple habit, can have numerous positive effects. Not only does exercising help with physical health, it also plays a large positive role in emotional health. Exercise has both short-term and long-term benefits with relation to emotions. Endorphins released by exercising produce mood-enhancing effects. In addition, regular exercise has been shown to reduce depression and anger. “I exercise on a regular basis,” said Professor Tim Bono, professor and researcher of Positive Psychology at Washington University in St. Louis. “I also exercise gratitude. I think about the positive things in my life.”

Therefore, relationships are also an important indicator of happiness. Many gain their energy from others – absorbing it from the enthusiasm of those surrounding them. Happiness is similar. “People are designed to be together … we’re relational creatures,” said Pria Mahadevan, co-director of Uncle Joe’s Peer Counseling and Resource Center. “A lot of the issues we see students deal with come from problems with relationships.” Being surrounded by positive and healthy relationships creates a sense of protection and love, thus creating the feeling of happiness. Students frequently complain about not having enough time to exercise in their busy days filled with classes, homework, jobs, and clubs. Similarly, this same stress and these time constraints deter strong and happy relationships. Here at Washington University, resources, such as Uncle Joe’s and Student Health Services (SHS), can help students fix these problems. “What we often talk to students about is … self-care, helping them generate ideas on their own about what they can do,” said Kelsey Stiles, co-director of Uncle Joe’s. Similarly, SHS also offers confidential advisors and counselors, in addition to mental health and wellness workshops, about topics such as mindfulness, managing difficult feelings, and increasing self-esteem. The resources present on campus are designed to help students lead better lives. When Grace was diagnosed with cancer, instead of counting down the days he had left, he and his wife decided to look at it with a positive outlook. “We learned to see the glass half full rather than half empty,” said Grace. “In other words, we chose happiness.”[1] They learned to see the world in a different light, dancing and singing with their kids, finding beauty in the weather, and appreciating new treatments. They did not choose to have cancer in their life, but they chose their outlook, and that made all the difference. References [1] Grace, John, and Joan Raducha. n.d. “Choose Happiness: Unexpected Lessons from Living with Head and Neck Cancer.” UW Health.

April 2015

What Can Interdisciplinary Health Offer Us? Charlie chen

Illustration by Taylor Tuteur

How different disciplines influence the practice of medicine

Frontiers Magazine

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Evoke the idea of interdisciplinary science in any given room of researchers, and you will likely get as many opinions as there are disciplines. As the scientific community struggles to define what exactly can be considered “interdisciplinary,” there is also a serious discussion on whether interdisciplinary research is the latest fashion or the future of scientific inquiry. In the field of public health, interdisciplinary initiatives are undeniably appropriate given its immense scope. The question remains, though: what advantages do interdisciplinary approaches offer that traditional ones cannot? Dr. William G. Powderly, Director of the Institute for Public Health (IPH) at the Washington University School of Medicine (WUSM), weighed in with perspectives gained from his work in infectious diseases, in particular, HIV. “At the beginning, you had a situation where you had a fatal disease, where the key was to find effective treatment,” Powderly said. Over a 10 year period, extensive study into the biological and genomic structure of HIV led to the development of antiretrovirals that were very effective in controlling HIV. The development of these antiretroviral drugs is undoubtedly a scientific success, but Powderly has seen a different picture emerge after the drugs hit the market. According to a 2011 study from the Center for Disease Control, in the United States alone, an estimated 1.2 million people are living with HIV infection. Of the nearly 80 percent of people who are aware of their infection, about 50 percent have remained in the medical care system. And of the people who have remained in care, 77 percent have demonstrated viral suppression after treatment. Yet when these results are taken together, only 28 percent of all people living with HIV in the United States are able to control the infection successfully. In trying to explain these results, Powderly realized that approaching the problem of HIV from a purely biological perspective was incredibly limiting. “What you start to realize is that under the biological model, you would say you make the diagnosis, you

We actually have to address why the system doesn’t work,

- Dr. William G. Powderly

put people on treatment, and you get a successful outcome,” Powderly said. “If you take it in a broader context, you realize that the factors that lead to failure are actually not traditional biological models, but are more social.” Under what Powderly calls the “biological model,” a number of reductionist assumptions are made: first, that all people infected with HIV present themselves to the medical system, and second, that controlling HIV only involves controlling the action of the virus in isolation from the individual. In reality, while researchers and clinicians are working tirelessly to control the action of HIV, a large majority of people infected with HIV fall through the cracks of our medical system. “We actually have to address why the system doesn’t work, the reason why we don’t translate the benefit of a biomedical science into a broader healthier community,” Powderly said. “And this requires going outside the discipline of biomedical science.” To this end, Powderly cited how the insights of behavioral scientists can help investigators understand the reasons why many people do not get tested for HIV and why they do not seek care. In addition, insights from economists and political scientists can help establish and finance health care systems that work. And within the field of medicine, HIV is becoming better understood within the context of mental health and addiction; mental health specialists integrate their work with traditional HIV treatment to combat the disease more comprehensively. The organization of interdisciplinary programs makes these collaborations possible. Powderly believes these programs allow for problems

April 2015

to be addressed in a coordinated fashion across a continuum of disciplines. “You cannot mandate topdown cooperation and collaboration,” Powderly said. “But if you create a framework, if you create enough opportunities for people from different disciplines to come together around a problem, then you can use that continuum of discovery at different points to not only to advance what a particular lab or group is doing, but also look at [the problem] in its totality.” An example of such a collaborative environment is the Program of Occupational Therapy at WUSM. Its director, Dr. Carolyn Baum, stresses the importance of interdisciplinarity in her work. Baum has helped build an acute stroke database at Barnes-Jewish Hospital. For the past 16 years, every patient with a stroke that is admitted to the neurology floor at Barnes-Jewish Hospital is asked if their data can be used in the database, which now contains the data of over 18,000 patients. Reviewing this database has led to unprecedented insight that has escaped clinical literature until now. For instance, Baum has found that, contrary to what many in the medical field had previously thought, stroke is not strictly a condition of old age. Through the acute stroke database, Baum noted that 46 percent of cases are of people who have had a stroke under the age of 65. Some of those admitted are as young as 18. But the most troubling discovery Baum found concerned the 52 percent of the cases involving a mild stroke that does not affect motor performance. “They can dress themselves, they can feed themselves - all the things that rehabilitation itself was built to do, they could already do,” Baum said. In these cases, the patients leave Barnes-Jewish without citing the need for additional services. “But they have executive dysfunction, where they have trouble organizing, and sequencing, and making judgment,” Baum said. This hidden obstacle can quietly hinder an individual’s ability to transition back into the workplace and lower their quality of life back home. Since the medical system is currently unable to offer the interventions needed for these individuals to transition back into their daily lives,

Baum is working with investigators on a number of clinical trials that specifically addresses how to fix this. This intervention, first used for patients after a stroke, is now being used for women with breast cancer who have been on chemotherapy and may have suffered mild cognitive impairment from the treatment process. Providing care for these individuals, not only within the context of treating breast cancer or stroke, but also in the context of cognitive impairment after treatment, and the transition between hospital to home can improve quality of life. This intervention incorporates insights from several disciplines to properly address our current health crises. It exemplifies how interdisciplinary health can change lives.

Frontiers Magazine

How Chiropractic Stands Today Akshay Shanker After competing with the men’s Ultimate Frisbee team in the regional finals last year, I started to notice a twinge in my lower back. As a person who prides himself on staying healthy, I convinced myself that the pain was temporary; after all, I could only recall one instance when I dove awkwardly for the disc. However, no matter how hard I tried to ignore it, the prickly sensation that traveled down my spine began to hinder my ability to walk or run for extended periods of time. Eventually, one of my friends suggested that I take action. He told me that he had been going to a chiropractor regularly for three years and expected that they would make quick work of my problem. Many people, myself included, are not exactly familiar with chiropractic medicine. What is the difference between a physician and a chiropractor? Do they attack the same problem in different ways, or do they focus on different issues entirely? And ultimately, do patients view chiropractic treatment as effective? Surprisingly enough, the answers to these questions are multifaceted, underscoring tensions within the medical field and shedding light on optimal treatment methods. Although Hippocrates published texts around 400 B.C declaring that it was important to “get knowledge of the spine…[as] it is the requisite for many diseases,” the practice of spinal manipulation started to gain traction much later, in the nineteenth century, according to the American Chiropractic Association. Today, physicians and other health practitioners coexist within a larger system of hospitals, insurance companies, and related institutions. However, as Princeton University professor Paul Starr argues in his Pulitzer Prizewinning book The Social Transformation of American Medicine, the nineteenth century marked an era in which “lay, or popular medicine was an active rival of … professional medicine, with a coherent structure of its own.”[1] Through this turmoil emerged David Palmer, a magnetic healer and spiritualist well read in the medical journals of his time. After

April 2015

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What could be causing this phenomenon? In stark contrast to the doctor-patient relationship, where reported trends indicate that visits are increasingly brief and impersonal, chiropractors have been lauded for their alternative approach to medicine. Prominent review articles by Richard Cooper and Heather McKee have noted that the entire chiropractic encounter includes “sensitivity to patients as individuals, effective communication, and a holistic approach to health and disease”. An empathetic touch can therefore go a long way in assisting individuals dealing with chronic pain; while these mannerisms may not be curative, they are certainly comforting. These findings have interesting implications for health policy. Given that complementary and alternative medicine continues to report growing proportions of health expenditures, it appears that chiropractic medicine serves an important purpose for the patient population. But since chiropractic treatment for lower back pain costs more than any other treatment besides care provided by orthopedic surgeons, Americans will have to determine whether this heightened patient satisfaction is worth the extra expense. References [1] Starr, Paul. 1982. The Social Transformation of American Medicine. New York: Basic Books. [2] Cooper, Richard A., and Heather J. McKee. 2003. “Chiropractic in the United States: Trends and Issues.” Milbank Quarterly 81 (1): 107–38.

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performing his first chiropractic adjustment in 1895, he went on to establish the first school of chiropractic medicine in 1897. While medicine is concerned with the general realm of human health, chiropractic tends to focus on disorders of the musculoskeletal system—the bones and muscles that allow us to sit, stand, walk, or run]. However, this means that chiropractic treatment tends to overlap with that of acupuncturists and physical therapists. Although chiropractors may have considered their profession to be separate from medical practice in the past, Richard Cooper of the Medical College of Wisconsin argues that their recent foray “into the reimbursed world of healthcare means that … they must now prove their quality, effectiveness, and value.”[2] Unfortunately, it appears that support for chiropractic is mixed. Spinal manipulation therapy, the hallmark of chiropractic medicine, appears to offer short-term benefit in some patients with acute or uncomplicated lower back pain, but the evidence is inconclusive for patients with more chronic symptoms. Review articles published by the National Center for Biotechnology Information seem to lean toward one conclusion: chiropractic can sometimes be effective in decreasing musculoskeletal pain, but not to a greater extent than placebos or existing treatments. At the same time, however, it appears that chiropractors excel in one crucial factor: patient satisfaction. A study published in the New England Journal of Medicine found that across the board, patients who go to chiropractors report their visits as more positive in comparison to their visits with physicians or other health professionals. In addition, researchers at the University of Limburg found that patients tend to return more often to chiropractors when their symptoms reappear.

An empathetic touch can go a long way in assisting individuals dealing with chronic pain

Frontiers Magazine

IUDs: The Next Generation’s Birth Control alicia yang While “The Pill” launched a sexual revolution, the more enigmatic “intrauterine device” (IUD) has been mostly relegated to a place of distrust. However, the IUD offers liberation from taking thousands of pills over the course of five or ten years. The Pill releases estrogen and progesterone throughout your entire body; one IUD on the market releases progesterone locally in the uterus and another is strictly non-hormonal. Both have high prevention rates (over 99 percent). However, imperfect use causes much higher failure rates in the Pill. In the past few months, the American Academy of Pediatricians has joined the American College of Obstetricians in recommending IUDs as the safest and most effective birth control option for teenagers. According to Guttmacher Institute’s self-reported surveys about sexual activity, only 4.5 percent of female teen contraceptive users reported relying on IUDs in 2009, an increase of almost tenfold since 2002. In comparison, more than half reported using the pull-out method or the Pill, and almost all sexually active teenagers reported using condoms. In a Washington University in St. Louis (WUSTL) study, researchers offered teenagers free birth control and counseling, including a range of less common options like the IUD. The resulting pregnancy and abortion rates over the course of three years were less than a quarter of the national average. In a New York Times op-ed, Isabel V. Sawhill suggests that IUDs and other “long-acting reversible contraceptives” (LARCs) could reduce the rates of unplanned pregnancies among less affluent single women, who would suffer the most financially otherwise.[1] LARCs make sense economically in several senses. Brookings Institute researchers discovered that for every dollar invested in birth control, taxpayers save around five dollars. Although the 1000 dollar device is now covered by the Affordable Care Act and Medicaid, the larger issue is encouraging doctors to educate teenage girls about the benefits and options of longterm birth control. According to Shefali Luthra from

The Atlantic, since pediatricians only spend about a month on “adolescent medicine” during residency, few are adequately trained in the procedure and thus are much less likely to recommend the procedure than gynecologists are to older female patients. According to a recent study conducted by the Center for Disease Control, doctors untrained in IUD insertion are more likely to emphasize their risks to patients. Luthra also notes that lack of confidentiality and outside referrals act as obstacles. Although these may seem like minor inconveniences, the repercussions of an unplanned pregnancy—40 percent of which result from misuse of contraceptives—can change lives. Sawhill also makes the interesting assertion that young Americans should look beyond the antiquated idea of matrimony and toward “a new ethic of responsible parenthood.” Birth control is no longer an issue of lack of medical knowledge, but rather public knowledge and advocacy to help younger girls make choices and feel a sense of sexual agency. The main barriers for the IUD are not actual health concerns, but rather lingering fears due to older models such as the 1970s’ Dalkon Shield IUDs, which increased the risk of pelvic inflammatory disease. Furthermore, some doctors and providers fear that teenagers may regret their decision to use an IUD. However, the procedure for removal is simple and would give teenage girls more agency to decide when they want to start having children, if ever. Doctors and sexual education programs are now considering IUDs as a more reliable and convenient alternative to standard birth control options—for the sake of both teenage girls and public health at large. references [1] Sawhill, Isabel. 2014. “http://www.nytimes. com/2014/09/14/opinion/sunday/beyond-marriage. html?_r=0.” New York Times, September 13, Online edition, sec. Opinion.

April 2015

“Own Your Own Health” At the Touch of a Button riva desai Less than three years ago, a very dear member of our own Washington University community contracted bacterial meningitis during her freshman year. Despite her earlier vaccination against meningitis, she had contracted the serotype B meningococcal disease that, at the time, was not covered by her earlier vaccine. On May 9th, 2012, Emily Benatar lost her life to bacterial meningitis at the age of 19; WashU students mourned the loss of their bright and talented classmate who had impacted so many lives in such a short amount of time. In order to carry on her legacy, the Benatar family chooses a project each year to better the community as a whole and make a difference in at least one person’s life, affectionately referred to as the Emily’s Way project. The Emily’s Way project was born out of a commitment to honor Emily on her birthday, February 11th. Last year, they embarked on an Operation Gratitude-related project to send cards of gratitude to military personnel overseas, and ended up sending over 1600 of these cards to United States servicemen and women. Wanting to continue the success of their newly-formed tradition this year, Emily’s family has chosen a project very close to their heart—the unique and very pertinent “Own Your Own Health Info” project that encourages people to take charge of their own health by bringing the need for getting electronic access to health records to peoples’ attention. Information such as your immunization record, allergies, and current medications can be easily found using digital resources such as the Electronic Health Records website and their subsequent phone application, thus allowing you to access your own health history right at your fingertips. When asked about the reasons for which “Own Your Own Health Info” was chosen as the 2015 Emily’s Way project, Mrs. Benatar remarked, “We decided on this project because we wanted to raise awareness and help prevent future cases of meningococcal disease, and we realized that backing up a step and helping people accomplish the broader task of understanding the vaccines they’ve

had and other important health information might be a really important first step towards achieving our more specific goal.” Mrs. Benatar is touching on an important, and unfortunately common, misconceptions of how vaccinations work. Many vaccines intended to prevent a certain disease (meningococcal disease, for example) can only protect against certain strains, and the inability to access this type of information can hinder receiving proper treatment in a timely fashion. In addition, the necessity of keeping track of every vaccine one has ever received, as well as the specific strains they work against, is a daunting task for anyone—especially the always-on-the-go college student. The “Own Your Own Health Info” project hopes to alleviate this burden by making this health information more portable and accessible to the conscientious individual.

people should have immediate access to their own immunization records. But it quickly became apparent that the actual process of receiving an online version of your health records and entering them into a phone application is a fairly challenging task. Mrs. Benatar expands on a number of issues during the early stages of this project that prevented them from reaching their goal of 1100 Electronic Health Record (EHR) signups by February 11th. One of the early difficulties was the lack of doctors’ offices that had signed up for online accounts or mobile phone apps, thus preventing their patients from obtaining online health records. And for college students who do not yet have an “adult” doctor (instead meeting with doctors in or around their college and/or their pediatrician from home), it was confusing to know which doctor to go to. But by far the hardest part in

Frontiers Magazine getting people signed up was the release form that is required for obtaining an online health records account and receiving an access code to the health record apps; college students simply don’t have that kind of time, and the 1100 sign-up goal was seeming more and more impossible. To circumvent these obstacles, Mrs. Benatar decided that, at the very least, people should have immediate access to their own immunization records. She then came up with the idea of creating a GoogleDoc template for parents and kids to manually enter their own vaccinations and dates and then send this information to their phones. As the technological knowledge gap between parents and kids grew too large to ignore, however, even this re-invention of the original project became a difficult endeavor. But in a serendipitous twist of events, a new approach to “Own Your Own Health Info” was born a mere two weeks before the February 11th deadline: “I was at a party talking to a woman I hadn’t seen in years, telling her about the project, and she said ‘Have them take a picture. Make it easy.’ That changed everything.” Mrs. Benatar soon realized that having a photo of your immunization records on your phone was a simple yet easy request, and definitely a step in the right direction. But most importantly, having even a picture of your immunization records fundamentally serves the overall purpose of the “Own Your Own Health Info” project: taking personal responsibility for your own health information. This underlying mission of the project makes it all the more relevant for college students. As Mrs. Benatar put it, “Typically kids call their moms if they need to know something about their health. At some point, though, they need to take on these responsibilities for themselves. When kids turn 18 it makes sense for them to take on the responsibility of keeping track of their health records because at that point their parents no longer even have legal access to the records.” Parents and students alike should take the time to discuss the importance of knowing your own medical information, including allergies, medications, vaccinations, past surgeries, and more. Even having the knowledge that you need a tetanus booster shot in the next few months could save a lot of pain and heartbreak for yourself and your parents in the future. The “Own Your Own Health Info” project can be a jumping-off point for parents and their college-bound children to start a dialogue on

the “adult” elements of healthcare, such as finding a doctor, getting insurance, and getting access to your own records. What can you do to not only participate in the 2015 Emily’s Way project, but also take part in the growing trend of digitized healthcare? Instead of relying on your doctor’s office to offer electronic health records, you can take the initiative and fill out Mrs. Benatar’s GoogleDoc template or take a picture of your immunization records and save it to your phone. Or maybe you could go even further and talk to your doctor about setting up an online database system. Start taking an active interest in your personal health information—be the only person in charge of your own body. And if you need any more motivation to become a part of the “Own Your Own Health Info” project, Mrs. Benatar has provided some quick and easy tasks that can jumpstart your journey into becoming your own health advocate: “Get a photo of your immunizations on your phone TODAY. Let us know you did this through our website. Do this as a gift to your parents. Or at least for yourself. If possible, set up an online account with a doctor and begin the process of creating a place where all of your health information is stored. Spread the word. THANK YOU!” More information on Emily’s story and the “Own Your Health” project can be found on www.ownyourhealthinfo.com.

April 2015

traumatic reflections anna mai When one of us is traumatized, the trauma does not end when the tears dry and the blood is wiped away. Rather, the whole world becomes a reflection of the trauma faced. The people around us morph into monsters who appear to want us harm. Violence and fear permeate environments once enjoyed. Trauma’s reach is long enough to impact whole communities, and its grip is strong enough to affect generations. Post-traumatic Stress Disorder (PTSD), a debilitating condition characterized by extreme anxiety and fear, is one of the ways in which past traumas take hold of present and future lives. When describing those who may be impacted by PTSD the NIH notes that “not everyone with PTSD has been through a dangerous event. Some people get PTSD after a friend or family member experiences danger or is harmed.”[1] In this way, we recognize that the experience of trauma is a personal one which cannot necessarily be rationalized by occurrences in the immediate vicinity of the experiencer or the surrounding community. For this reason, the (inter)national events of the past nine months have left few unimpacted. From the ebola outbreaks in West Africa to the Department of Education’s public announcement of institutions undergoing open Title IX Sexual Violence investigations to the events of Ferguson, Shaw, Palestine, and Ayotzinapa, many in our community have felt shaken by the ways in which the core issues of these unfoldings were handled by the university and mass media. In a university setting, it is all too easy to sterilize the complex nexus of race, class, gender, ability, and religion at the heart of these occurrences and to treat them as a set of abstract concepts instead of as people, their lives, actions, and bodies. But when we treat these issues as ideas instead of people with pasts and futures, we lose sight of the impact these traumatic events have on the health and wellbeing of individuals and communities. We see the way in which the effects of single traumatic event are magnified across communities in the cases of Ferguson and Ayotzinapa. Following the events of Ferguson, the St. Louis Post Dispatch

published an article describing the ways in which the police brutality in Ferguson took an emotional and psychological toll not just on the residents of Ferguson who were directly impacted by the initial violence, subsequent protests and backlash but also affected people across the country who perhaps had never heard of Ferguson, MO before August 9, 2014. Similarly, Doctors Without Borders is working across Mexico helping families and community members deal with the psychological impact of the abductions and deaths of students in the state of Guerrero. The reality faced by those left to rebuild communities in these regions is one of widereaching post-traumatic stress. However, the traumas unfolding in Ferguson and Ayotzinapa are by no means unique. The systematic devaluation of life on the basis of race and class is a ceaseless process comprising countless aggressions. In the same way, sexual assault is an all too frequent occurrence that rarely receives the media outrage that it warrants. Furthermore, a report from the NIH notes that “the prevalence of Post-traumatic Stress Disorder (PTSD) in assault survivors is drastically higher than the national prevalence of the disorder,” which is to say that current therapies for sexual-assault-related PTSD do not adequately address the specific type of trauma at hand.[2] Compounding this issue, the prevalence of sexual assault on college campuses becomes more problematic through the treatment of the perpetration as “just a mistake,” an attitude which sets the precedent that sexual assault is an easily excusable offense. The Department of Education’s efforts to enforce greater transparency and accountability during sexual assault investigations on college campuses is a step in the right direction, but does little to help those for whom surviving is already an ongoing struggle to reconcile the past with the future. We are human beings, each reflected in each other. If one of us is deemed victim, the impact of their life on their community makes us all victim of the trauma they face. Our emotional capacities enable us to be reflected in each other, and we make choices everyday whether or not we wish

Frontiers Magazine to empower or harm that reflection. Harm to this reflection is perpetuated by the unwillingness to recognize the reflection of the Other in the self. Whether this otherness be defined by class, gender, race, religion, or ability, we all are impacted by trauma be it our own or another’s. However, through recognizing our own reflection in the lives of others, we can reconcile past traumas and prevent future ones from occurring.

references [1] “What Is Post-Traumatic Stress Disorder, or PTSD?” n.d. National Institute of Mental Health. [2] Chivers-Wilson, Kaitlin A. 2006. “Sexual Assault and Posttraumatic Stress Disorder: A Review of the Biological, Psychological and Sociological Factors and Treatments.” McGill Journal of Medicine 9 (2): 111–18.

Confronted by the trauma that surrounds and saturates our lives, we cannot help but ask the question: why does this happen? and when will it stop? The Spring 2015 issue of Spires magazine presents a collection of written and visual works which attempt to answer these questions. We, as the editors of Spires, are excited by this platform not only as an expression of the trauma we face, but as a call to take action and address injustice before it occurs.

this article is a selection from spires, washington university’s intercollegiate art and literary magazine. visit their page at spires.wustl.edu.

April 2015

Medicine of the Future Ben Tolkin Despite centuries of technological advancement, modern medicine treats almost all diseases with the same fundamental process. A problem is identified, then diagnosed. An intervention is performed and the patient returned to normal. This procedure works well when a virus can be easily destroyed, or a tumor simply removed, and as technology improves, medicine becomes increasingly effective in producing normal, healthy patients. When a condition is chronic, however, the procedure cannot be so simply applied. Those with mental disorders may never stop taking pills. Serious allergies can send a patient to the hospital over and over again. Diabetics have to become adept at self-medicating, managing their illness with regular treatments for years. This system could all soon change. A new concept of medicine is emerging, one that supplements the body’s own anatomy to provide treatment. The goal may no longer be for patients to leave the hospital normal, but to leave with additional systems in place to meet their specific needs. The most promising target for this sort of treatment is diabetes. Diabetics are unable to produce the hormone insulin, necessary for digesting sugars in food. Up until now, the usual treatment for diabetes requires personal injections of insulin using a pump after each meal, being careful not to give oneself too much or too little, which could lead to dangerous imbalance in blood sugar. In a healthy body, insulin is produced by the pancreas, which detects the level of blood sugar and automatically produces the appropriate amount of insulin. In January of 2013, the first successful artificial pancreas was developed by Ahmad Haidal of the Institut de recherches cliniques de Montréal, combining an insulin pump and a blood sugar sensor with a complex algorithm to continuously ensure the right levels of blood sugar. The device has yet to be made available for the public, but preliminary tests show it to be at least as effective as traditional methods, and certainly easier. However, the potential of bionic treatments goes even beyond replacing dysfunctional body parts with prosthetics.

Martin Fussenegger, professor of biotechnology and bioengineering at the Swiss Federal Institute of Technology in Zürich, is leading a fledgling movement for a new way of treating neurological disorders. The brain is an intricate set of connections between psychological and biological factors, interacting in dizzyingly complex patterns that can sometimes spiral out of control. In September of last year, Fussenegger provided proof of concept that these patterns can be augmented and regulated by new technology. Scientists grew mouse cells in a petri dish, genetically modified so that they would produce the protein alkaline phosphatase when exposed to a certain type of light. Then, a device, which contained these engineered cells and a laser that produced that specific light, was embedded into mice. Human subjects wore a headset that measured the electrical activity in their brains and sent this information by radio to the device in the mice. By mentally concentrating, the human subjects were able to raise and lower the level of protein detectable in the mouse’s blood. These experimentations may seem like a pointless exercise, but the implications of such a device could be far-reaching.Attacks of mental disorders like epilepsy or migraine are debilitating, and often unpredictable. This device could detect specific brainwave patterns before an attack and release the necessary proteins to treat them. Instead of removing an underlying problem, the patient gets a new system in their body that regularly deals with their symptoms, which essentially reverses standard models for treatment. However, promising as they may be, these bionic treatments are far away. The closest Fussenegger’s team has come to success is a method of treating allergies by detecting histamine levels the body produces before an attack and linking them to proteins that alleviate symptoms; even that procedure is only in preliminary stages. Effective bionic treatments currently remain the stuff of science fiction, but they are no longer beyond imagination. In the future, we may use medicine not simply to cure disease, but to advance the body beyond need of cure.

Frontiers Magazine

FaCing John Lin

GM Food

I am sitting across from Connie Diekman in her office at Myers. “One of my colleagues posted a picture yesterday of romaine lettuce, okay. Romaine lettuce. The label says, ‘gluten-free’, ‘lactose-free’, ‘no GM’. I think we’ve gone a bit crazy in this country, and it’s because people don’t understand food,” she says. Non-GMO. All-natural. Grass-fed. Take a stroll through any major American supermarket and you will see at least a few of these labels. They are proudly touted on cereal boxes, fruits, vegetables, meat, assuring the consumer that this is healthier or safer to eat. The proliferation of this marketing strategy suggests something about our cultural attitude toward the “natural” and “artificial”. Distinguishing a product as being grown or made “naturally” makes it sell. Why? What exactly are these labels appealing to when we read them? “There is a lot of fear in the GMO arena, and it’s a fear that is in many cases based upon miscommunications, perceptions, and lack of knowledge about science and food. That’s what really surrounds this whole topic,” Diekman says. “What worries me as a dietician is that the door has already been shut on the opportunities that GM food can provide, that the ears are closed to the conversation.” Recently, this fear of genetic modification has hindered the acceptance of new Innate™ potatoes by corporations such as Frito-Lay and McDonald’s. Although these potatoes have fewer “black spots” and lower acrylamide levels, both of which are popular undesirable traits, market leaders are hesitant to accept the crop. This hesitance suggests that confidence in public acceptance for these GMOs is low. Can this fear be found on campus? Among the students? How deeply do these beliefs penetrate?

I turned to students to understand these questions. Angela Park, a junior studying psychology, has thought about this. When I talked to her, she was unsure about GMOs and at first, could not seem to figure out why. “I have always heard people talk about [GMOs] in a negative way. For instance, they say how [GMOs] are not very natural and we don’t know the consequences for consuming these over a long period of time. I don’t know...now that I’ve actually talked about it, I think that a lot of my friends, including myself, just aren’t very aware of all of this. But at the same time, we just don’t know [about GMOs].” As she talked more, Park began to see how her views on food were shaped significantly by those around her and by how she was raised. At the end of our conversation, she said, “I think just by being in this interview I kind of realized how a lot of the things I’ve said and a lot of the ideas I’ve had were kind of notions of what I’ve grown up with and we should actually try to find out how things are for ourselves.” A preference for the “natural” is echoed by another Washington University in St. Louis student, Helen Li, a pre-med junior who is also studying psychology. “Natural is what nature has given us in the first place. It is what has been selected by evolution. If human beings stick their foot into the natural cycle, I think there are consequences, I just don’t really know what they are,” Li said. Not knowing enough about the science of GMOs is a concern that repeatedly arises in the debate over genetic modification. The most common response for those who are unsure is to avoid GMOs until people actually know whether or not they are safe.

April 2015 However, is it true that the science is uncertain? More than 2,000 studies have been conducted related to the health and environmental safety of GMOs. In regards to health, these studies have done testing ranging from the allergenic safety of GM crops to the safety of consuming transcribed DNA. A crop would not be released commercially if it did not test successfully against a database of known allergens or was found to deposit its DNA into human cells. There has not been strong evidence that GMOs pose a significant health risk. “I think the important thing for people to remember is that all the foods that are currently available that could be GM have been tested, tested, tested, and tested. They are safe. For any new item to get through the USDA and FDA, the hoops are huge. If there even is the slightest bit of concern, crops won’t be approved for sale,” Diekman says. At the end of it, the important thing is to be able to delineate the quality of being synthetic from the final product that is created. For some reason, America is afraid of the synthetic. If the encroachment of man onto nature is so precarious, it would make sense to also question the security in our beliefs on gene therapies or other recombinant genetic technologies such as the production of insulin. “So how do you think we can open our ears again?” I ask Diekman. She replies, “I think you guys are the ones that know that answer better than I do. It is in the most part your generation. “What is the worry? What is the fear? Why is there a lack of trust? How do we open this door again? And why is it so closed?”

33 Illustration by Alicia Chen

Frontiers Magazine

Solution: From classroom to Real World Connie Gan Most college students can easily name some of the most successful business people - Steve Jobs, Bill Gates, Mark Zuckerburg, Oprah Winfrey. But rarely do they act upon ideas that they have. So often I have heard, “There is just so little time, and I’m not sure if my idea is good enough to be worth it” or “This solution might help with the efficiency, but it’s not the cure to cancer” or “I don’t have an idea that I could develop, how can I get into entrepreneurship?” However, unknown to most Washington University in St. Louis students, St. Louis and WUSTL are centers of the entrepreneurship in the Midwest. St. Louis has been recognized by the St. Louis Regional Business Chamber as well as by Forbes, TechCrunch, The Wall Street Journal, and CNBC as the home to the world’s largest business plan competition and the nation’s fastest growing incubator, especially for high-tech and information entrepreneurial technology startups. And there’s only more support for those who are interested. For example, the Olin Cup Competition, founded by WUSTL’s Olin Business School, was created to give students an opportunity to develop original business plans while honing their analytical and presentation skills, which help them gain firsthand entrepreneurship experience. The Cup is awarded to those teams that best exemplify entrepreneurial spirit, strategic business thinking, and high quality deliverables. Olin School’s entrepreneurship program, the Hatchery, links students to outside entrepreneurs who have promising ideas but who lack capital, business experience, or both. Today, the entrepreneurship program at Washington University

continues into develop as one of the finest in the country. The program is expanding, creating more collaboration across campus and within St. Louis by playing a key role in the building of an innovation environment. One of such collaborations is IDEA Labs, a relatively recent bioengineering and design incubator that unites WUSTL the medical, business, engineering schools, as well as PhD programs, faculty, staff, and local entrepreneurs to tackle unmet needs in healthcare delivery and clinical medicine. The project began in 2011 when Josh Siegle and a group of medical students were presented with a patient who was mostly paralyzed after a stroke and only utilized one button to control a communication screen. The group immediately saw a better design of the computer for a patient with facility of the whole hand, not just one finger. This was essentially the first IDEA Labs project. After the initial project, the group was approached by many other patients and physicians who had suggestions of how to improve medical system. From there, IDEA Labs and its problem bank was born. Now the problem bank consists of more than one hundred and fifty problems submitted by doctors, nurses, pharmacists, and therapists. Having your own idea is not essential to becoming involved in the movement. IDEA Labs welcomes students from all majors because interdisciplinary teams are wellrounded and consider more aspects of the business plan. Graduate students, even those who are on a set career path like the MD-PhD program, take part in this program, which gives them the option of running their own company in the future. The group that placed first in IDEA Lab’s Demo Day competition last year, Data Dog, is developing a system for enhancing therapy for stress and anxiety disorders through an app and wearable technology. Moreover, they have received significant funding from venture capitalists. Beta testing of the app begins in a few weeks. In short, if you do have a groundbreaking idea, act upon it. Mentors and the Skandalaris

April 2015 Center can help develop your idea. Blake Marggraff, a senior biology major says that WUSTL has been very instrumental in the development of his entrepreneurial spirit: “WUSTL does a great job of mixing the hard sciences and challenging coursework with opportunities to expand in the directions they choose.” WUSTL’s flexibility allowed him to take many different types of classes, not just those in his major, giving him free rein to pursue his interests. Also, through WUSTL, he attended several conferences and met his future co-founders for his first company: Betaversity. Blake describes his startup as “an education technology company that began as a consultancy for engineering departments … [and] was all based on the Stanford model of learning-by-doing and design thinking.” This goal is packaged in Betaversity’s main product: BetaBox, a mobile learning lab in a shipping container with the most recent rapid prototyping technology and

design thinking methodologies. Betaversity now rents or sells BetaBoxes that have helped 20,000250,000 people, mostly university students. Those numbers only increase every day. But in reality, entrepreneurs are not geniuses who have lightbulb ideas. Instead, they are problem solvers who identify a problem they are passionate about and upon which they want to improve. They utilize resources around them to develop a solution, something WUSTL students do every day in class and in clubs. If they were to give one piece of advice to WUSTL students, both Josh Siegle and Blake Marggraff emphasize, “You may be surprised to find out that there is so much to learn outside of the classroom. Your future career may happen to be shaped more by your outside activities than class work.” Every WUSTL student can make a positive change on the world in which we live - they just need to take that first step.

Image courtesy of IDEA Labs Academic Year Timeline http://ideas.wustl.edu/about-us.html

Frontiers Magazine

Science, Not Fiction Olivia Sutton Students coming into WashU know that our faculty is studded with world-renowned researchers. Once attending the school, however, so many students become engulfed by their classes that these researchers become no more than professors. Behind the syllabi they hand out in prerequisite classes, our professors are truly pushing the frontier of medical research. Daniel Moran, Ph.D. teaches biomechanics, a sophomore-level course required for all biomedical engineering students. Yet when

Illustration by Alicia Chen

this professor is back in his lab, Moran develops technology surrounding a topic that may seem straight out of a science fiction movie: mind control. That’s right. On our campus, in our labs, there are monkeys who can play video games on computers using only their minds, thanks to Moran. If you are not convinced his that this research is scifi come to life, when approached about his research, the first thing Moran says is, “Have you ever watched The Six Million Dollar Man or The Bionic Woman?” “Our goal in the lab is to help paralyzed people,” Moran said. “For them, the problem is the wiring.” Signals in the brain can’t reach the limb due to spinal cord injury, and that disconnect is enough to render their limbs useless. “So we want to develop technology that we can implant in the human brain to figure out what they want to do.” Moran currently does this using epidural e l ect ro co r t i co g ra p hy, or EECoG, a new braincomputer interface technique. A grid of disk-like electrodes, surgically placed inside the skull, records electrical signals coming from the brain. Then, the brain’s signals are translated into directions that the computer can understand and execute. There are challenges associated with the technique. Surgery is invasive, and it can be difficult to get FDA permission to use human patients to develop this technology, even though volunteers are out there. However, in 2006, Moran showed that a young patient, hospitalized for intractable epilepsy and implanted with an electrode array, could be trained to play “Space Invaders” just by thinking about moving the spaceship.

April 2015

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eventually, we want to basically reanimate their arms, their own arms, through technology

“

- Dr. Daniel Moran The practical application of this technology is even more “Star Wars”-like. Remember Luke Skywalker’s mind-controlled prosthetic limb? Technologies like Moran’s EECoG will soon be ready for implantation in humans to help them control prosthetic limbs with the dexterity and precision of the real thing. This is a much greater endeavor. Moving a cursor in a 2D plane on a computer screen involves two degrees of freedom. Moving a robotic arm? Seven. The arm is a complex piece of equipment, after all, and the signals that go into controlling it are even more difficult to decode. “Eventually, we want to basically reanimate their arms, their own arms, through technology,” he said. Once brain signals are harnessed, they have to be translated into a signal sent to a peripheral nerve in the paralyzed limb. “For example, how do you think about going up-and-to-the-left, then convert that into muscle movement?” Moran said. Studies working to translate this signal to a physical motion are further behind, but Moran’s lab conducted a study in rats, and they are preparing to do non-human primate implant studies too. Once finished, these two technologies can work together to heal paralyzed individuals.

Moran has personal ties to his research as well. “I had a good friend I played baseball with,” he said. “Both sophomores together, both made varsity together. Then, he slid headfirst into home plate and broke his neck. He’s been in a wheelchair since he was sixteen. So when I walked into my first BME class and they asked us what we were there for, I knew to say: ‘I’m here to make neuroprosthetics for spinal cord injured patients.’” WashU professors’ lives go beyond the classroom: they are fascinating people. If not research, there is certainly something else they do that is worth asking about. If you haven’t yet, it is time to do a little research of your own and learn more about that professor behind the podium.

Frontiers Magazine

St. Louis: Moving from Brain Drain to Brain Gain Megan Kerstein Brain drain. As nefarious as this phrase sounds, it represents a real problem for the greater St. Louis community. Brain drain, also called human capital flight, is the movement of educated individuals from one geographic location to another for better working conditions. In the case of St. Louis, many graduates from Washington University in St. Louis (WUSTL) and other St. Louis universities leave the area for larger cities like Chicago. Brain drain especially affects the medical field. St. Louis City and County were selected by the Centers for Medicare and Medicaid Services to participate in a pilot project called “Gateway to Better Health.” Through this program, St. Louis receives 30 million dollars in federal funds each year to provide primary, specialty, and urgent care for uninsured and lowincome adults in the St. Louis metropolitan area (many of whom do not qualify for Medicaid). According to Robert Fruend, Chief Executive Officer of the St. Louis Regional Health Commission, the Patient Protection and Affordable Care Act (PPACA) will change the medical field. One of the PPACA’s goals includes expanding healthcare coverage of millions of Americans via Medicaid. More people will qualify for Medicaid as qualifying income thresholds are raised. After intense debate over the constitutionality of the PPACA, the Supreme Court determined that individual state legislatures can decide whether they wish to expand Medicaid. Missouri opted not to expand Medicaid, creating problems for programs like Gateway. Federal funding of Gateway will be siphoned away to other states’ Medicaid programs. With funding removed, the future of Gateway and the health of St. Louis is uncertain. Further, many doctors and other healthcare professionals now flee from St. Louis and the state of Missouri. They instead go to states that have expanded Medicaid because these states devote more funds to compensating healthcare professionals. Thus, St. Louis is on the verge of a large-scale physician shortage. There are potential solutions to the problem of Brain Drain. Within WUSTL, some initiatives are already in place to encourage students to gain

exposure to St. Louis. the Gephardt Institutes offers stipends that expose students to the St. Louis community outside of WUSTL, hopefully sparking long-term interest in the city. Recent WUSTL alumni Audrey Chan, originally from the San Francisco Bay Area, decided to stay in St. Louis. “During my years of undergrad I felt that I had not yet fully experienced what St. Louis has to offer as a city, and so that was a factor in my decision to stay,” Chan said. “Second, the different job prospects were a major factor. For me, St. Louis has more opportunities in my field versus going back to the Bay Area where WashU has not quite yet established the reputation it deserves. I would have to compete with graduates from Stanford and Berkeley that are more well-known there. Third, I like the people and the culture of St. Louis. People are very well-connected and it’s a great place to build up a network.” A group of WUSTL alumni, all sharing a love of St. Louis, stuck around in St. Louis after graduation. They formed a group called “Brain Drain.” This collective hopes to retain more young professionals in the St. Louis area by discussing ways to make St. Louis more appealing. To start off, the group created a project called CityPulse, which studies the demographics of different neighborhoods in St. Louis by using mounted cameras. CityPulse seeks to improve neighborhoods in St. Louis by tailoring developments to community-based needs. Improvements are evident in places such as Washington Avenue in downtown St. Louis, where vacant buildings have been renovated. The street is now known for its vibrant nightlife and the abundance of loft-style housing. With similar neighborhood improvements, St. Louis will become a more livable city and likely retain more professionals. Through initiatives like this, brain drain is not inevitable. St. Louis college students are at a fork in the road. We can choose to change the city by using the tools available to us and sticking around after graduation.

April 2015

Do-It-Yourself

Biotechnological Revolution Katelyn Mae Petrin I magine: Salmonella breaks out, people go mad, hundreds become ill. You, alone in your basement, have all the tools to design a simple biological test that determines the presence of Salmonella bacteria in your food; the tools to solve this particular problem, excluding the fancier machines already present in your laboratory, cost no more than $5. Problem—solved. For you, at least. Distribution might be a little more difficult; helping others is dependent on your ability to go to the internet, post about your process, and provide others with the information they need to repeat the test. Potentially, dozens, if not hundreds or thousands, could protect themselves. This is the power of do-it-yourself biology, the garage biology movement: less money, more knowledge, more change. Bergen McMurray, co-founder of Seattle’s DIYbio space, HiveBio, expands on these ideas. “It’s taking the power of information out of the hands of the elite few and putting it in the hands of the individual,” she said. “I think that’s not only going to revolutionize bioscience, but education in general.” Now that it’s cheaper to start a DIYbio laboratory than it is to develop an application, perhaps changing both bioscience and education is an achievable goal. HiveBio offers regular classes— from eyeball dissection to gel electrophoresis to introductory microscopy—to anyone who can pay a

Photo by Katelyn Mae Petrin

low fee for a few hours. They also host summer camps for both children interested in pursuing science and children with no experience whatsoever. With the help of grant money from various sources, they are increasingly able to provide more classes at lower prices. Their ideal? The ability to provide biological knowledge to anyone for free. HiveBio began as two separate quests for the same thing. Katriona Guthrie-Honea, as a mere high schooler, could not find any professional laboratory to let her conduct her own research despite the fact that she was more than competent. Similarly, Bergen McMurray, after a career change from art to neuroscience, couldn’t find places that rented space cheaply enough for her to further explore biological research. Together, they created HiveBio. HiveBio now provides laboratory equipment for anyone who wants it. “Access to spaces like this, I think, is going to revolutionize the way that medicine works because it’s going to give people the information they need to make decisions like [genome sequencing],” McMurray said. What exactly does a space like HiveBio look like? Not unlike a real laboratory: machinery clustered on counters, glassware arrayed on shelves, a few brains soaking in some chemicals on a counter. Perhaps a bit more cluttered than your average laboratory, with its limited space, and a bit more friendly, with its pamphlets and lending library, but not dissimilar. Some of the chemicals may be technically expired, but that doesn’t stop professional laboratories, either. Other DIYbio spaces include New York’s GenSpace, London Biohackspace, and San Francisco’s BioBridge. Each of these came to fruition in their own ways. Similar laboratories, each with their own individual research interests and political or scientific goals, can be found across the world. As is the case with most of these spaces, the research capacities of a space like HiveBio are minimal, but not a lot is necessary to perform biological research these days. The average high school student in an AP Biology class learns to conduct many of the

Frontiers Magazine procedures used in professional laboratories.You can buy DNA online for $0.23 per base pair. If you purchase some DNA and can use Google and a textbook to figure out gene splicing (also taught in AP Biology), you can absolutely genetically engineer a test that checks for the Salmonella in your food purchases or determine whether or not you have a particular gene in your own body. Low access to expensive equipment creates the primary barrier to biological research. Still, a one-person laboratory is purchasable on eBay for a few thousand dollars. A decently high quality microscope can be fashioned by combining an iPhone camera with a basic lens, some wood, and a few screws (about $10 of materials, maximum). With support from individual donors and the private sector, community laboratories are even more achievable. Some hackers believe DIYbio might be able to help end the ebola crisis. Others hope it hails a biotechnology revolution of a sort more dramatic than what McMurray imagines. Some fear it may enable bioterrorism. Critics say, not likely. So what can DIYbio do? It has produced genetically engineered plants that glow in the dark, cheap genetic tests, and a handful of minor biological discoveries. This may not sound like much. Strictly speaking about research and innovation, DIYbio really allows scientists to “increase the tinkerability” of biology. Tony Stark’s laboratory,

superimposed over some creaky basement beneath the city streets, is not the science fiction revolution we might imagine. It is, however, a new way of doing things. McMurray explained that traditional science is done by scientists trained in separate disciplines to adhere to strict modes of thought. A DIYbio space opens up places for scientists to work together and devise solutions that would otherwise never have occurred to them. But there are larger ideals to consider. HiveBio’s real goal, McMurray said, is to “demystify science. Fight the idea that ‘oh, science is so hard, you have to go through years of schooling before you can understand it.’ People give up before they even start.” DIYbio can also provide knowledge to communities that wouldn’t otherwise access it; change not just the way our highly trained professionals, but also children and communities, think about science; and transform the way the world of biotechnology works at its structural core. In St. Louis, we have no DIYbio laboratory. Our public schools, meanwhile, struggle significantly; over the years, they have lost accreditation and fought to regain it. Many children (and even adults) could use places to learn more hands-on science. St. Louis has biotechnology and industry. St. Louis has students. St. Louis has scientists. Perhaps if the world of science reached out to the curious and the underserved, the city might gain much.

April 2015

Physicians and Advocacy: A Prescription for Change Rachel Hoffman A doctor getting dragged away in handcuffs might be something we see in a movie, but we rarely think of it as a real-life occurrence. Dr. Charles van der Horst proves that assumption wrong. In May 2013, Dr. van der Horst, Professor of Medicine and Infectious Diseases at UNC-Chapel Hill, was arrested at the North Carolina General Assembly protesting issues including the state’s decision not to expand Medicaid. The risk of such a decision was something Dr. van der Horst said he felt compelled to stand up against. “The laws were going to lead to the deaths of about 2,000 people each year,” van der Horst said. “We [doctors] need to take care of our patients. Not just their organs, but the patients out in the community.” Physicians have a unique role to play in regard to advocacy and activism surrounding medical issues, and recent debates over the Affordable Care Act and Medicaid expansion have prompted doctors to step away from the office and make their voices heard in their communities. “We are intimately involved,” Dr. van der Horst said of physicians. “We don’t just measure patients’ blood pressure and prescribe a pill. We know that they don’t have health insurance to afford the pill, or they’re working two jobs and eating poorly because they don’t have enough money, or they’re homeless out on the streets. Once you have that information, it’s our responsibility as a physician to do something about it.” Dr. Heidi Miller, an internal medicine physician for Family Care Health Centers in St. Louis, echoes the idea that doctors play an integral role in effecting change. Dr. Miller spends half her time practicing medicine at a health center that serves patients who do not have the ability to pay for their services. She spends the other half on local projects and advocacy at the state level to provide an equitable distribution of health care. Among other movements, Dr. Miller has been involved in the call for Missouri to expand Medicaid, just as Dr. van der Horst does in North Carolina. Part of her work includes testifying multiple times at special state-level hearings about Medicaid expansion. Dr.

Miller has used these opportunities to represent her patients and tell their stories, an ability that Dr. Miller said she does not take lightly. As an example of this privilege, she cites the chance to address the misconception that patients who could benefit from Medicaid expansion do not work. “They work minimum wage, they can’t afford health insurance, and the jobs that they work are often really physically demanding,” Dr. Miller said. “I have several patients who wash cars all day. They’re bending, crouching. I have several waiters who are carrying 30-pound trays. I have patients who are house cleaners who work their bodies extremely hard. We need to tell decision makers that if you want these patients to continue to clean your houses and drive your taxis and tow your car, then they need to be healthy, and they need health coverage.” Not only do they have the unique ability to bring their patients’ voice to the forefront of social change, but physicians also hold a position of power. The white coat represents education, dedication, and a life of service for others, but it also serves to amplify doctors’ voices. Even when unsolicited, the white coat commands respect, and doctors should take advantage of this opportunity to demand justice for their patients. Doctors must recognize the invaluable role they have in the movement towards equitable healthcare access.

“It’s an integral part of being a doctor to recognize that your purpose is not just to treat the patient that’s in the exam room with you

Frontiers Magazine but to ensure that the people in our community have equitable access to care,” Dr. Miller said. “If someone spends years learning how to become a superb physician, and they learn really advanced techniques in treating disease, I’m not sure how that physician can deliver care without working to make it accessible to anybody who needs it.”

Dr. van der Horst also cites the image of the white coat as a useful tool in working toward health equity and says doctors must make use of that. But Chris Chen, a medical student at Washington University School of Medicine who has been involved with Doctors for America, says medical students and undergraduates invested in equitable healthcare play a role too.

Chen emphasizes that students are the future of the health and medical field, and that they should exercise that power. Chen cites an example of a letter to the editor he and a friend were able to publish in the New York Times. The letter surrounds issues regarding the primary care workforce, and Chen says they framed it in the perspective of medical students interested in primary care. “We were able to articulate it in an interesting way that caught people’s attention,” Chen said. “I don’t know that if you were just another doctor, even if you made the same point, it would have gotten in. You use the hook you can. Dr. Miller also highlights the importance of the student voice. She recalls bringing a medical student with her to a rally, and the legislators of the Medicaid Transformation Committee were keen on hearing his views. “They were so interested in hearing about his perspective, and his future plans, and his career,” Dr. Miller said. “The legislators are really interested in what shapes the future workforce and what drivers are there. The legislators should learn how students’ ambitions reflect the current level of resources and challenges in providing medical care.” While it may seem obvious that doctors have great insight when it comes to achieving equitable access to healthcare, legislators and policymakers often do not recognize this until physicians fight to make their voices heard. Similarly, students and patients must push for change by taking advantage of the unique niche they occupy in this movement. Whether a physician, medical student, undergraduate, or patient, each individual has a voice in the fight for equitable access to healthcare. Now, it’s up to you to use it.

April 2015

Local Controversy: Environment and Advocacy in Labadie Hannah Walcek About four years ago, Ameren, the company that provides power to 1.2 million customers across Missouri, purchased 1,200 acres of land in the Missouri floodplains. This news caught the attention of a local women’s book club in Labadie, Missouri, a small community located in the Missouri River floodplain. Ameren intended to build a 400acre, 100-foot tall coal combustion waste landfill. The women were reminded of the Tennessee Valley Authority coal fly ash slurry spill, an event where more than one billion gallons of coal ash slurry spilled, polluting the Emory River and covering 300 acres of land, houses included, in toxic sludge. With this spill in mind, members of the book club began to question the safety of building such a hazardous site in the floodplain, locally known as “the bottoms.” What began as a small group of concerned citizens transformed into a community-wide call to action with the establishment of Labadie Environmental Organization (LEO). Companies such as Ameren assert that landfills designed to hold coal ash, a byproduct of burning coal, are safe and durable, but LEO, the people of Labadie, and inhabitants of the surrounding area are concerned about its effect on the bottoms. Ameren’s representatives have argued that the landfill would be an improvement over its current wet storage methods, but according to the Environmental Protection Agency (EPA), dry landfills can also pose dangers to local drinking water and aquatic life. If the landfill were to be compromised, heavy metals in the coal ash such as lead, mercury, cadmium, and arsenic could enter the floodplain. The EPA conducted a study that demonstrated that coal ash leached arsenic at up to 18,000 parts per billion. This is 1,800 times the federal drinking water standard and over 3 times the hazardous waste threshold. One report of 31 coal ash sites found 26 sites contaminated with heavy metals and other toxins exceeding drinking water standards. It was found that some sites can contained waters with as much as 90 times the drinking water standard for arsenic. Even beyond the boundaries of the dumping ground, arsenic levels can be as high as 31 times the

drinking water standard, and contaminated water has been known to carry over a mile away from the original coal ash dump site. There are serious health concerns for ingesting water containing heavy metals resulting from coal ash leaching, such as an increased risk for cancer from arsenic. The groundwater in the floodplain is especially vulnerable to contamination because water levels tend to rise and fall seasonally, which means metals could also seep into the water table, polluting the groundwater. As a result, this could endanger the floodplain ecosystem, which includes wildlife, farmers, and locals who rely upon groundwater from drinking wells. The condition of the floodplain plays a vital role in the region’s ecosystem, economy, and public health. Determined to stand up for its community’s well being, LEO took legal action against these risks at their first hearing on December 14, 2010. The community urged Franklin County to oppose a proposition to change the county’s zoning code. The change would have allowed the construction of a coal ash landfill in an area that previously banned landfills. One of LEO’s earliest accomplishments involved catching the attention of the EPA and delaying the landfill’s construction process. LEO’s efforts have not only stifled many attempts that Ameren has made to obtain approval for constructing the coal ash landfill, but they have also managed to bring together a politically diverse community. With water and community health on the line, the people of Labadie have set aside political differences to stand together in defense of the floodplains. It is LEO’s hope to not only represent Labadie’s environmental concerns, but also pave the way for other communities now and in the future that are fighting similar battles. As Ms. Schuba said, “That’s what scares the Amerens of the world … We don’t fight for a paycheck, we fight for our children.”

Another version of this article is published through Material Monsters’ “The 2014 Missouri Exhibit: A Look at Agency Here at Home.” For more information please visit www.2014missouriexhibit.org.

Frontiers Magazine

Medicine:

Right or Luxury? Madeline Stewart Drug discovery and production is a business; its purpose is profit. However, the goods produced through this business carry much more value than the price assigned to them. They save human lives. Examining the pharmaceutical industry to ensure that access to medicine is a right afforded to all human beings, not a luxury reserved for those able to pay, is crucial. Dr. Bradley Stoner, an associate professor of Anthropology in the School of Arts and Sciences and Infectious Diseases at the Washington University Medical School, was able to offer both an anthropological and medical perspective on the current model of drug research, discovery, and production. “Since the drug discovery is embedded in the private sector, drug company’s primary responsibility is to their shareholders. It’s very expensive to bring a drug to market, and so the companies must take a big risk with the reward of being paid back in the end. However, when you have a disease like HIV that is so devastating, and the drugs are priced out of reach, you develop a two-tiered healthcare system. It’s very disheartening to those of us on the public health side.” Dr. Stoner referred to the fact that access to treatment for HIV in the form of anti-retroviral drugs (ARVs) is limited, especially for those in SubSaharan Africa, as many are patented and expensive. “In the early 2000’s, concern by international AIDS activists lowered restrictions on local production of drugs. Countries like Brazil and India were able to produce their own drugs. The problem was that these countries were not allowed to sell the drugs. There are a host of countries in Sub-Saharan Africa that have the need for the drug but not the ability or infrastructure to produce it. We rely on donor countries and international organizations to provide drugs to these countries.” Access to HIV treatment has improved: the

April 2015 cost of first line HIV treatment for one person for one year has fallen from $15,000 in 1996 to $115 in 2013, and by the end of 2013, 11.7 million people of the 35 million infected were receiving treatment for HIV.

“

Right now what’s getting manufactured are drugs for people who can pay for them

pool their resources and fund an institute for discovering drugs and bringing them to market.” Any solution to this problem must balance profit for pharmaceutical companies and access to affordable medicine for those in need. If the TPP is approved, it will favor profit for pharmaceutical companies, and decrease health equity for patients in developing countries. If access to health care is a basic human right, medicines cannot be priced at astronomically high prices that are out of reach to all but the affluent.

“

- Dr. bRADLEY sTONER

However, a potential international trade deal, the Trans-Pacific Partnership (TPP), now exists that could even more severely decrease access to medicines for those without the money to pay for patented drugs. A leak revealed that the United States is pushing for terms that would help pharmaceutical companies profit by restricting production of generic drugs. These terms include lowering the bar on what can be patented; slowing generic production by not allowing the generic producer access to the clinical trials performed by the pharmaceutical company; and extending patents, now 20 years, to at least 25 years. While HIV/AIDS is not the only disease for which this agreement would have repercussions, the global health community should be informed of its potential negative repercussions. “Right now,” Dr. Stoner said, “what’s getting manufactured are drugs for people who can pay for them; that’s why we’re seeing so many new drugs for type two diabetes and hypertension. The ugly underbelly to privatization of pharmaceuticals is this two-tiered healthcare system, where there’s a 30 year lag until it’s cheap enough for people in developing countries to afford drugs.” The implementation of the TPP will only widen the gap between the two tiers of health care. Those with the money to pay for drugs would receive an even higher level of care than those without the money to pay for patented drugs. Looking towards the future, Dr. Stoner suggested that, “a solution would be for the United States government and other OECD countries to invest more heavily in drug discovery. They could

Frontiers Magazine

dissociative identity disorder: separating facts from fiction michael xi Very few psychological disorders have captured the publicâ&#x20AC;&#x2122;s imagination like Dissociative Identity Disorder (DID). While often confused with schizophrenia, which is characterized by paranoia rather than dissociation, dissociative identity is a completely unrelated disorder. Dissociative disorders in general tend to be rare, misunderstood, and often debated among psychology experts. Many disagree about whether DID, arguably the most severe dissociative disorder, is a real disorder or an affliction created by suggestion. The DSM-5 criteria for DID has two requirements: the presence of multiple distinct personalities and the presence of true amnesia, the complete lack of memory transfer, between those personalities. Many experts, whether they believe in DID or not, acknowledge that the symptoms arise from the memories of severe trauma. While these symptoms may seem fantastical, the fact remains that reported prevalence of DID has ranged from .01 percent to 3 percent in the general population, depending on the source. This inconsistent range is a testament to the debate around defining and diagnosing the disorder. Despite its potentially high prevalence, the National Institute of Mental Health has not yet funded a single study on it. Furthermore, the majority of treatments for DID attempt to deal with the associated distress, and there are no approved, researched methods of treatment. It seems, then, that lack of information about DID prevents developments in research. On the other hand, some experts claim that DID is a figment of the imagination. Though DID is often associated with childhood trauma, the majority of childhood trauma does not result in dissociation of any kind. Furthermore, considering that the majority of diagnoses of DID come from strong proponents, some experts point out that the disorder may have been manufactured through leading questions and the suggestibility of the patient. Finally, though true amnesia is a DSM-5 requirement for DID, a study conducted in the Netherlands shows at least some memory exchange between personalities. Such

issues present doubt about whether psychiatrists should treat the disorder itself or the beliefs about the disorder. No matter where the debate leans, however, some people suffer from it. The presence of different personalities clamoring for attention and use of the body is often chaotic and frightening for those involved. Those with DID are usually unable to work and typically find themselves living disjointed lives. While the disorder does need to be better defined, the scientific debates surrounding it have little direct effect on the lives of those with DID. Media, however, has often been a powerful factor in influencing opinions and ideas about DID. Indeed, the disorder was first brought to the public eye by the books The Three Faces of Eve and Sybil, and the latterâ&#x20AC;&#x2122;s accompanying movie. These portrayals of DID were followed by an eruption of cases as well as more personalities associated with each case. While science attempted to untangle the disorder, media had already run rampant with it. Though DID is not often found in commonly read news or science articles these days, the media has not lost its fascination with it. From an episode of Psych where a man unwittingly harbors both a feminine and a serial killer identity to a more accurate portrayal of the disorder in Criminal Minds, television often takes advantage of the mystique surrounding the disorder to create drama on the screen. Often, however, DID is not as wild or as romantic as it is portrayed; like any other psychological disorder, those with it often see it as a harsh burden to bear throughout their daily lives. Learning more about DID can enable us to have a better awareness compared to media portrayals. Hopefully, time and research will enable more effective treatment. Learning more about dissociative identity disorder can enable us to have a better awareness compared to media portrayals. Hopefully, with time and research into the disorder, there will be deeper understanding into dissociative identity disorder that will allow for more effective treatment.

April 2015

Finishing Strong: Determining the Right Treatment for Dying Patients Daniel Teich “What would you do with your life if you only had a month to live?” I have had this conversation with friends before. It usually turns into a joke, where everyone tries to one-up each other with their fantasies of the craziest adventures fathomable. The joke is always based on several illogical assumptions: that we will be in perfect health throughout the month, only to die instantly in our sleep. That we will not be dealing with the pain and suffering of dying a slow death, and that we won’t be under constant surveillance of a medical professional as we slowly lose the ability to function. Let’s face it, those constraints would just take the fun out of the game. However, to millions of elderly people all over the world, this is a question they eventually have to consider. For them, fragile health limits their choices. Death is a topic that people rarely discuss, especially their own. But the end of life is an inevitable reality, and what was once a lighthearted game becomes a terrifying series of choices.

As fearful as we are of death, many of us are even more fearful of losing our independence. Spending our dying weeks, months, or even years under constant monitoring, unable to perform menial tasks such as getting dressed or using the bathroom on our own, can be a difficult lifestyle to comprehend. This is where palliative care comes in. While curative care seeks a cure for a specific disease, palliative care is geared towards addressing the symptoms and providing comfort to patients with serious illnesses. Kevin Thomas, a third-year WUSTL student, spent part of a summer working with Pallium India, an organization that provides palliative care to severely ill patients in India. Thomas described the primary goal of Pallium India as “being there for [the patients] and making sure that they’re as comfortable as possible.” Thomas treated dying patients with comforting methods such as music therapy. He was there so dying patients and their families could have somebody to talk to, and he was able to comfort people emotionally and physically. This holistic approach to treating dying patients can also be found in the United States. BJC Hospice, a branch of BJC Healthcare based in St. Louis, “treats the person, not the disease.” Hospice care is a subset of palliative care specifically for patients who are likely to die in six months or less. Dr. Joan Rosenbaum, an associate medical director and pediatric palliative care specialist at BJC Hospice, said hospice care focuses on more than a patient’s physical symptoms. “Back to the days when hospice was first described, illness was described not just in terms of abnormal physiology and physical symptoms, but the emotional, spiritual, and social parts of what makes up a person,” Rosenbaum said.

Frontiers Magazine While nearly half of all people who die in the United States are treated in hospice care, not everybody who is near death will choose this path. Ultimately, patients must make their own choice between hospice care and curative care. According to Rosenbaum, when working with a dying patient, a doctor’s main focus should be on relief from pain and suffering. They must then pose the inevitable question, “Given what you’re up against, what are you hoping for?” What is difficult about this question is that it subtly implies that a patient may not get everything they hoped for, may not have a curable disease, or may not survive. Rosenbaum said the family is often “hoping for a miracle, a cure.” When the doctor determines that a cure may not be possible, it is time for the patient and his or her family to make a decision for themselves: how should we make the best of the time we have left? Many patients will choose curative treatment based on a desire to “go out fighting” and a reluctance to give up. However, death cannot be avoided forever. Sometimes, attempts to prolong life by a few weeks simply create a few weeks extra of pain and suffering. Side effects of chemotherapy, for instance, can be severe. Simply trying to hold on to life can do more harm than good. In his book “Being Mortal: Medicine and What Matters in the End,” surgeon Atul Gawande argues for the need of a shift to palliative care for patients. He says doctors have a lot of trouble determining the physical state of a dying patient and tend to overestimate the amount of time a patient has to live by about a factor of five. Accordingly, the effects of aggressive curative treatment for these patients are unpredictable. Perhaps the most striking finding is that, along with facing an easier death, people who choose to go into hospice care may actually live longer. In “Being Mortal,” Gawande cites a study showing that lung cancer patients who spoke with a palliative care doctor ended up spending fewer days in the hospital, ceasing chemotherapy earlier, and living 25 percent longer than those who chose curative care. This opens up the possibility that continuing futile medical treatment may actively worsen the body’s condition and that the choice between a longer life and a more comfortable life may be a false dilemma. Death will come to all of us one way or another. Unfortunately, trying to fight off death for as long as possible can be counteractive. When asked about the future of palliative care, Thomas

said, “I don’t think in my lifetime we will come to the point where all diseases are curable. Until that happens, I think palliative care will ultimately grow and will be realized as more comfortable for the patient.” Perhaps it would be beneficial to think of hospice care not as a way of surrendering, but as a way of optimizing the last few months of life to live to the very fullest.

April 2015

forming gender health care urvi sinha According to National Public Radio, as of 2015, Oregon has joined a few other states in covering health services specific to the needs of the transgender community. Its Medicaid now pays for hormones, puberty delay and suppression, and reassignment surgeries. Dr. Amy Cislo, a professor of Women and Gender Studies who also teaches Transgender Studies and Gender, Religion, Medicine and Science, applauds Oregon and other states. They are, in her opinion, “trying to be progressive”. However, she said health care inequality for transgender people goes deeper than lack of access to hormones or surgeries. Even access to basic health care can be a challenge due to the medical community’s discrimination against transgender people. “[Transgender] people will go in to the doctor with a rash, and they can’t get their rash looked at because the doctor is so focused on them being trans,” said Cislo. Sayer Andrew Johnson, President of the Board of St. Louis’s Metro Trans Umbrella Group, a local transgender advocacy group, agrees. Though Johnson has undergone gender reassignment surgery, it is still recommended that he receive routine mammograms. He recalled a visit to a mammography clinic seven months ago as “humiliating and inappropriate.” Often, he finds, health professionals react similarly to his transgender identity. “[The technician was] treating me as if I had some communicable disease,” said Johnson. “Even if I did, I should have been treated with more decency.” He eventually requested a different technician. Johnson’s experience reflects a larger trend. 28 percent of respondents to a National Center for Transgender Equality (NCTE) survey reported that they had been harassed in a medical setting. Cislo believes that medical professionals do not know how to treat transgender patients while respecting their identities because most medical schools do not teach LGBT health. According to Cislo, doctors and health care workers are not trained to realize that being transgender is not a manifestation of

disease. In fact, a startling 50 percent of NCTE survey respondents stated that they have had to “teach their medical providers about transgender care.” The gap in knowledge about transgender health often causes uncomfortable relations between health professionals and transgender patients. Cislo recalls the experience of one of her friends, a gynecologist, who was “taken aback” when she entered the examination room and realized her patient was a transgender man. “It wasn’t that she didn’t want to help the patient,” said Cislo. “But ... she was unprepared … and she knows that her relations with the patient suffered as a result.” According to the NCTE survey, 28 percent of transgender people reported postponing medical care due to concerns about discrimination, and 19 percent report having been refused care because they were transgender. Johnson himself feels unsafe when visiting any doctor other than his primary care physician. Johnson refers transgender people to only three physicians in the St. Louis area. According to Johnson, he and other transgender people are especially reluctant to receive emergency care; they are worried about their safety at the hands of unfamiliar physicians and nurses. Doctors are part of a larger pattern of discrimination that transgender people face. According to Cislo, transgender people have difficulty obtaining employment both because of discrimination from employers and because of legal issues. Often, transgender people cannot be legally hired because their physical appearance does not match the gender associated with their legal documents. These forms of discrimination may seem unrelated to health care. However, almost half of NCTE survey respondents reported delaying medical care because of inability to pay. This is nearly twice the number of respondents who cited discrimination as a cause for delaying care. Compared to 14 percent of the general population, 19 percent of transgender respondents were uninsured. In this way, other forms of discrimination also prevent access to

Frontiers Magazine health care. These barriers caused by discrimination, violence, and lack of education in transgender health do not just prevent access to health care; they also increase health care needs. Unemployment and low income correlate heavily with the prevalence of HIV infection, substance abuse, or suicide attempts. Respondents to the NCTE survey reported rates of HIV infection at four times the national average. A fourth of the respondents reported misusing drugs or alcohol to cope with gender-identity related discrimination. While 41 percent of respondents acknowledged attempting suicide, only 1.6 percent of the general population reports the same. Taken together, transgendered people risk falling into poor health and failing to recover. So how can doctors and other health professionals seek to alleviate, rather than compound, the health issues faced by the transgender community? One part of the solution, believes Cislo, is that prehealth students should take courses like Trans Studies at the undergraduate level. “Knowing the history of the medical profession [when it comes to trans people], which we cover in these courses, gives insight into the many things that have been done wrong in the past and how to improve in the future,” said Cislo. Johnson emphasizes that medical professionals should learn how to treat transgender patients from transgender people themselves. Johnson’s organization, Metro Trans Umbrella Group, offers training sessions led by transgender people. Johnson believes that experiences of transgender patients could improve if doctors take the opportunity to “hear the desires, hear the support needed, straight from the mouths of the people [they] are treating.” Cislo suggests, however, that the first step may be simply a casual encounter. “Doctors in training would benefit just from having a conversation with someone who is trans in a non-clinical setting.”

April 2015

Mind the

Gap

Monica Lim Images of children’s faces greet passersby who drive past the hospital complex in Central West End–faces on banners that happily announce the “coming soon” of this important center. Smiling faces, gleaming buildings, culminating wholeness. These signs, strung across cement blocks, illustrate a vision for a more efficient, as well as elegant, St. Louis health care system. But who are the beneficiaries of these improvements? The depicted faces show no sign of distress or discrimination. Oftentimes, the invisible, underprivileged sectors of the city remain just that: unseen and not targeted enough for initiatives that may improve the quality of life in St. Louis. Traditionally, the “Gateway to the West” has been regarded as a beacon of accessibility, representative of a doorway to opportunity. However, modern-day St. Louis, as highlighted by data maps appearing on Wired Magazine, appears to be a patchwork of unconnected resources. Rather than an overlapping network of healthcare and education among the 90 municipalities, St. Louis splits by ZIP codes and neighborhoods. Instead of providing the door to opportunity, resources are locked down. A gap exists in St. Louis between resources and people, a fissure that is both physical and figurative in nature. If we all live in the same city, why are some populations more susceptible to disparities in quality of life? One of the greatest difficulties in ensuring access to resources like proper healthcare lies in targeting the right people. Most often, the unseen populations of St. Louis, such as the growing Hispanic and Latino communities, demonstrate

the effects of this multi-faceted divide in the city. Many people from these populations must navigate around this gap in order to maintain the well-being of their families. The situation of Hispanic populations within St. Louis remains largely unrecognized because Hispanics and Latinos comprise a mere 3.7 percent of the city population according to the US Census. This community represents a sector of the population that many initiatives fail to reach. Many of the statistics provided by the St. Louis Department of Health focus on comparisons between black and white populations, rarely looking at smaller minorities. As a result, new immigrants and those in the Hispanic and Latino community slip unnoticed through the obvious gaps in the system. These holes can be found across other cities, not just St. Louis. For instance, many cities with similar issues are beginning to model health initiatives after the projects of Closing the Health gap, an organization based in Cincinnati. Having worked the past summer with Closing the Health Gap, Adriana Ungerleider, a Washington University in St. Louis third-year Global Health student, plans to translate what she learned in Cincinnati to working in the Hispanic and Latino neighborhood in St. Louis. She reflects on her summer by stating that “specificity is key” in reaching communities that require aid. For example, organizations that best bridge the separation between ideals and effective change work within communities to address the specific challenges placed on marginalized populations. In the Hispanic and Latino community, one of

A gap exists in St. Louis between resources and people, a fissure that is both physical and figurative in nature.

Frontiers Magazine the greatest issues is lack of health insurance. Immigrants and minorities can easily get lost in the confusing insurance system. According to Ungerleider, registering for insurance is a complicated process, especially for a new citizen speaking a different language. For undocumented residents or those with language barriers, insurance is either difficult or impossible to obtain. Some private organizations, like Casa de Salud, provide health and mental services like referrals, screenings, and vaccines to the uninsured and underinsured. According to Executive Director Jorge Riopedre, part of Casa’s mission is to “connect people to other sources of care,” working alongside the health care system already in place to bridge the gap between services and the 90 percent of Hispanics and Latinos who are uninsured. On the other hand, the city must still

concentrate efforts on another aspect of the disconnect between resources and citizens within St. Louis: the physical divides that show up on all maps of the area. Looking at a demographic map of St. Louis reveals clear blocks for certain income levels, races and services. Just as organizations are working to connect initiatives with actual people, the city must overcome the physical barriers that prevent people from obtaining the means for an improved quality of life. As seen in the sharp distinction between various neighborhoods, St. Louis has parceled out an uneven amount of resources to various areas. This divide poses problems for those in areas lacking resources. Thinking back to her past experiences as a new student in St. Louis, Ungerleider compares an immigrant or minority possessing a language barrier with a college freshman. Freshmen and immigrants alike must depend on public transportation and friends to obtain basic services like healthcare and food markets. However, even for a well-equipped student, Ungerleider can recall spending an hour and half on a bus in transit from school to a doctor’s office in West County for a simple appointment. Because the hospitals and clinics tend to cluster in blocks in Central West End and West County, convenient lines of transportation are not always available to a variety of neighborhoods. To many people, it seems “inconceivable that inability plays as much a role as common sense,” Ungerleider said. The question of whether or not to get quality health care can be shortened to a quick decision between keeping a job and spending time in transit to a clinic. Tying in with this lack of accessibility, food deserts, areas where citizens cannot obtain healthy food stuffs at an affordable cost, play a role in health disparity. Income determines whether or not a family can afford the prices of either full groceries or convenience stores, which affects availability of fresh produce in the pantry. According to a study by Washington

April 2015 University student Madeleine Daepp, though most St. Louis ZIP codes may be located within a mile of a full-service grocery in a neighboring area, income level is the greatest barrier to healthy grocery shopping. The ZIP codes with the some of the highest concentrations of Hispanic population, 63112 and 63118, have median household incomes ranging from around twenty-five to twenty-nine thousand dollars per year. For many families in these areas, affordable and well-stocked grocery stores are not always available. This situation is not exclusive to immigrants or Hispanic and Latino populations, and varying income levels and access to healthy food play a large role in the general well-being of wide variety of citizens. In essence, physical discontinuities stop the flow of resources to a spectrum of communities. However, in light of these issues, the city is not idle. St. Louis works alongside private organizations such as Casa de Salud to alleviate the disparities caused by income and racial differences. One section of the 2014-2017 Community Health Improvement Plan provided by the St. Louis Department of Health recognizes how diabetes affects a disproportionate amount of the Hispanic population, with diagnosis being over 66 percent higher in Hispanics and Latinos than whites in the city. According to St. Louis University Hospital, these statistics are largely due to availability of healthy produce as well as predisposition by genetics, tying back to the issue of food deserts. The St. Louis Department of Health plans to implement the City’s Obesity Plan through the Healthy Eating, Active Living Partnership, which includes an emphasis on active living, healthcare access, and social marketing. Moreover, with the high number of universities in the St. Louis area, research about health interventions is underway. A constant flow of feedback must insure that measures are implemented effectively within the community. The social marketing objective of the City’s Obesity Plan follows this logic. The goal is to find tried-and-proven ways to “market interventions and change behavior through media/marketing”. Additionally, the city is looking into ways to improve transportation, such as plans for extending metro lines. As of now, the city continually refines its plans for attacking both figurative and physical gaps in St. Louis. Overall, while the health and quality of life disparities in St. Louis depend on a variety of factors like predisposition and income, much of

Specifically targeting the invisible victims of disparities is the only method that will lead to health solutions. the issue stems from problems with accessibility and specificity. Specifically targeting the invisible victims of disparities is the only method that will lead to health solutions. St. Louis and private organizations together are making strides in this direction. Riopedre of Casa de Salud emphasizes “collaboration” as the vital goal. The director wants people to know that Casa stands in solidarity with all neighborhoods and “serves a wide range of minorities, anyone who is uninsured.” We want movement and exchange between people. Health issues in St. Louis are not limited to a certain population; rather, as stated earlier, numerous neighborhoods make up the city. Many and all faces of St. Louis should be on the banners proclaiming change. The patchwork map of St. Louis still has far to go before the contributions of private citizens, researchers, and public officers can knit the city together along a common need for improved access to healthy living. However, with a more intimate look at the people of St. Louis who we claim to be aiding, perhaps we will reach a point where the unseen will be pictured on banners as the beneficiaries of our ongoing initiatives.

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