Yale Global Health Review Vol. 5, No. 1 by Yale Global Health Review

WINTER 2018

THE YALE

VOL. 5, NO.1

GLOBAL HEALTH REVIEW

RELIEF:

A COMPARISON OF MEDICAL RELIEF EFFORTS IN AREAS RECENTLY AFFECTED BY NATURAL DISASTERS BY TOMEKA FRIESON Zoriah, Flickr

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LETTER FROM THE EDITORS WINTER 2018 VOL. 5, NO. 1

Dear Readers, We are very excited to release our first issue as the new executive board! We hope that our publication can serve as a platform for discussions about global health in the Yale community and incite change. The articles in this issue cover a wide range of topics in a diverse array of countries around the world. We begin by examining pressing issues in global health, such as access to clean water and the opioid epidemic, and then move to Latin America, Mexico, Puerto Rico, Haiti, and Yemen. Key themes examined in this issue are women’s health, the limitations of healthcare in developing nations, and advancements to improve healthcare and disaster relief in developing nations. This issue’s feature article especially focuses on comparing disaster relief efforts in areas affected by hurricanes and monsoons in 2017. We’d like to sincerely thank our staff members for their hard work. Releasing this issue would not have been possible without the dedication and passion of our writers, editors, and publication and design team. We’d also like to thank you, our readers, for taking the time to read our work and think critically about how to drive the frontier of global health efforts forward in the future. For more information on global health, please visit our website at yaleglobalhealthreview.com. Better yet, to get involved, send us an email at yaleglobalhealthreview@gmail.com. All the best, Katarina Wang and Nancy Lu

Editors-in-Chief Katarina Wang Nancy Lu

OUR TEAM Webmaster Cathy Xue

Senior Editors Cassie Lignelli Colin Hemez Eli Rami Krista Chen Rebecca Slutsky Sarah Householder Associate Editors Annabelle Pan Drew Gupta Minh Vu Sarah Spaulding Copy Editors Debbie Dada Dhiksha Balaji Erica Lin Marisa Peryer Max Ackerman Mohamed Eltoum Nathan Chang Tomeka Frieson YALE GLOBAL HEALTH REVIEW

Online Editor Matthew Pettus Production & Design Team Elizabeth Qian-Wang Marisa Peryer Mohammed Eltoum Sunnie Liu Wenzhen Zhao Yasheen Gao Staff Writers Debbie Dada Eleanor Cook Hannah Verma Indira Flores Jenesis Duran Kristi Wharton Matthew Pettus Rachel Jaber Chehayeb Rohan Garg Tomeka Frieson Yasheen Gao

ABOUT US The Yale Global Health Review is the premiere undergraduate-run publication at Yale University covering topics in health. We feature original research, thoughtful commentary, and balanced reporting with a global health focus. Our goal is to bridge scholarship and practice, connect students and faculty, and bring together voices from across a spectrum of disciplines and sectors. The YGHR is a hub for discussion and engagement on all issues relevant to global health – in print and online, at Yale and beyond. SPONSORS We would like to thank the Yale Global Health Leadership Institute, Yale Global Mental Health Program, Yale China, the Yale School of Public Health Admissions Department & the Yale Undergraduate Organizations Committee for their support.

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CONTENTS GLOBAL HEALTH TODAY

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GLOBAL HEALTH TODAY

p. 6

LATIN AMERICA

p. 9

Water Security: Novel Techniques in Increasing Access to Clean Water Around the World By Jenesis Duran

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MEXICO Cultural Interpretation of Somatic Symptoms: Mexican American Explanatory Model of Type II Diabetes By Debbie Dada p. 13

p. 19

p. 22

p. 31

Stigma and the Opioid Epidemic By Yasheen Gao

Latin America: Understanding Teenage Pregnancy By Eleanor Cook

TECHNOLOGY

Global Health Efforts Poised to Take Off with Novel Drone Technology By Rohan Garg

UNITED STATES

Turing Pharmaceuticals: A Price Raise, a Name Change, and an Outrage By Indira Flores

PUERTO RICO

Defining the Future of Puerto Rico: An Analysis of Hurricane Maria By Matthew Pettus

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FEATURE ARTICLE Relief: Is There a Difference in How We Rise? A Comparison of the Medical Relief Efforts Among Areas Recently Affected by Natural Disasters By Tomeka Frieson p. 25 HAITI

p. 35

YEMEN

p. 41

A Malnutrition Crisis: Its Past, Present, and Future By Hannah Verma The Yemen Civil War and its Effects on Civilians By Kristi Wharton

GLOBAL HEALTH TODAY

Women's Health: The Basis for Global Health

By Rachel Jaber Chehayeb p. 37

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Water Security:

GLOBAL

Novel Techniques in Increasing Access to By Jenesis Duran Clean Water Around the World

he necessity of water cannot be denied. Consisting of over 60% of the human body by mass, it is the sustainer of life and vitality. As ubiquitous as water seems, in today’s world over 40% of the global population suffers from water scarcity, with around 783 million individuals worldwide lacking access to clean water.1 In addition, a current average of 3.4 million people die from waterborne illnesses every year.2 This is the same number of people who die of diabetes.3 And in spite of the incredible technological advancements in today’s world of water treatment, from an individualized LifeStraw to nationalized reverse osmosis, the number of countries classified as water-scarce is expected to rise from 31 to 54 by 2050.4 This is in large part a result of our increasing population, which will imply an additional freshwater demand of nearly 64 billion cubic meters per year.5 The gravity of this situation demands global attention and cooperation in order to thoroughly implement effective water treatment techniques around the world. The importance of water security has

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drawn concern from both developing and developed nations alike. But they generally have very different approaches to the problem, for a key reason: the use of water is dramatically greater in the developed world than in the developing world. Developed countries use an average of 450 liters of water a day per person, whereas the average person in developing countries uses 20 liters of water.2 A variety of sources categorize developed and developing nations under different precepts. For example, the World Bank classifies countries into low, middle, or high income status based on the gross national income per capita. A developing nation is thus considered one that has a gross national income per capita of $4,085 or less.6 The United Nations classifies development based on gross national income per capita, a Human Assets Index, and an Economic Vulnerability Index.6 Countries in the Middle East and Africa are most susceptible to the effects of water scarcity due to their climate. It is important to note that the definition of water security is often described as global access to safe water at an affordable cost, whilst ensuring

environmental protection.7 In order to understand how water security functions in the modern world, we can consider historical methods of water treatment and how they have evolved. Initially, each country relied on its own methods for treating water. For example, the hand-dug qanat tunnels provided 70% of water and 50% of Iranian irrigation in the 1980s.7 These tunnels were underground channels that transported water from underground water sources to the surface level. Over time, however, nations began to substitute individual national practices with international policy. In 2002 the universal right to water was affirmed by the United Nations. The following year, the Chief Executives Board (CEB) for the United Nations established the UN Water agency to coordinate on all freshwater and sanitation related issues. The General Assembly then proclaimed an International Decade for Action, “Water for Life”, campaign that would last from 20052015.1 This project would result in the provision of safe drinking water for nearly 1.3 billion individuals in developing countries.

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Despite the progress made, issues still persist around the world. As of 2015, the World Economic Forum’s Global Risk Report deemed the ensuing water crisis a part of the top ten global risks that threaten economic growth.8 The water crisis has even been prioritized by the UN as a part of its Goal 6 sustainable development plan.1 Just recently, the United States, which is widely recognized as a developed country, has grappled with the water crisis in Flint, Michigan, and the current harrowing aftermath of the 2017 hurricanes. In the developing world, due to the lack of access to safe water and sanitation, Sub-Saharan Africa alone has encountered economic loss estimated to be around $28.4 billion a year.5 In the Middle East, control over the Jordan River and the effects of the Six-Day War between Syria and Israel in 1967 have caused ongoing tensions in this region over the notion of water security.7 Countries in the Gulf Cooperation Council (GCC) have experienced difficulties with their water supply due to population and economic growth, urbanization, and industrialization. It seems as if the common denominator that bridges the gap between these vastly different nations is the pursuit of water

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Reverse osmosis desalination plant.

security. In order to resolve this issue, global collaboration and novel techniques must be established. Ongoing novel techniques include technologies and policies that have been found to be both beneficial and effective. This includes desalination techniques that now comprise of an additional greenhouse solar energy-based desalination method. In Tanzania financing has been allocated towards the acceleration of solar water pumping.9 Reverse osmosis is also a technology that is widely used. In addition, the investment in foreign land for food and the production of genetically modified organisms (GMO) have served as beneficial short-term methods. The goal has been to genetically modify plants to make them resist drought and transpire less.6 Beneficial policies that have contributed to water security include the efforts of the Millennium Development Goals, The Global Water Partnership, and the Integrated Water Resources Management plan (IWRM).

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Millennium Development Goals.

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For countries with adequate resources, one effective form of water treatment is desalination. Since the planet consists of 70% salt water, the desalination method is widely used.8 The cost of desalination,

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As ubiquitous as water seems, in today’s world over 40% of the global population suffers from water scarcity, with around 783 million individuals worldwide lacking access to clean water.

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however, has prevented it from being used more frequently. The most important users include countries in the Middle East and in North Africa, as well as the United States.10 In Israel alone, the cost for this method is 53 cents per cubic meter. An estimated 12,500 desalination plants were being used in 2002 in 120 countries. The production of these plants was about 14 million cubic meters of fresh water per day.10 The greenhouse solar energy-based desalination method uses

solar energy to desalinate seawater. Meanwhile, desalination plants convert seawater to drinking water on ships and in arid regions by using the natural properties of the water cycle. Even more effective than desalination is reverse osmosis. Reverse osmosis is a technology that is used to remove contaminants from water by pushing water under pressure through a semipermeable membrane.11 Reverse osmosis is an effective method for producing demineralized or deionized water. This novel technique was first commercialized in the United States in the 1960s, but it wasn’t widely used until twenty years later due to its expense. The cost since then has decreased significantly. In California the average residential monthly charge was $36.39 per 1500 cubic feet of drinking water.12 Despite the decrease in cost, the method of reverse osmosis is still seemingly unaffordable for developing nations. In order to establish a more equilateral approach that is separate from individual technologies, effective policies, like the Millennium Development Goals (MDGs), have been implemented across borders. A specific objective of this plan was to indicate water and sanitation as a part of overall environmental sustainability. The goal was to “halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation.”5 This proportion was monitored by observing the proportions of those using improved water sources and improved sanitation facilities.

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The common denominator that bridges the gap between these vastly different nations is the pursuit of water security.

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Mehmet Bilgin

Disaster response and relief efforts in Puerto Rico afterr Hurricane Maria.

The MDGs were established by the World Health Organization in 2000. The eight goals were agreed and collaborated upon by a total of 191 UN member states. Another policy that has contributed to global water security has been the Integrated Water Resources Management (IWRM) approach. This approach is in accordance with the definition of water security in that it seeks to manage water resources in an equitable manner that doesn’t compromise environmental sustainability.8 The three pillars of this approach include creating environmental sustainability legislation, establishing institutional framework for effective implementation of said legislation, and the provision of necessary management tools for these institutions.8 It is important to note that the IWRM, unlike the MDGs, is a long-term initiative, rather than a short-term pursuit. Challenges that are to be expected fall within the realm of social, political, economic, and ecological concerns. Socially, it will be challenging to inspire empowerment and participation in developing communities to take charge over this pre-

Wikimedia

Simple schematic of reverse osmosis.

U.S. Department of Defense

dicament. This is in part due to the political influence of certain world leaders who have led their communities to rely solely on the government’s power. Economic challenges include accountability for costs. The most affected regions are developing countries that are unable to afford the expensive desalination and reverse osmosis technologies. This issue, along with the costs of providing effective structures and management resources, should be considered. Lastly, ecological challenges will include the abundance of fresh water, which is limited, and the risk of climate change and its associated natural disasters. The failure to exercise appropriate concern over these matters may result in extensive negative repercussions. In addition, the World Business Council for Sustainable Development has estimated that the total cost of water and sanitation infrastructure may be as much as $200 billion per year.5 The following quantities will only increase upon negligence. Fortunately, the World Health Organization (WHO) has estimated that for each $1 investment in safe drinking and water sanitation, a return of $3-$34 is received.5 The negative and positive effects of this predicament should serve as an incentive to increase global collaboration and the search for novel techniques. Only then will we have the ability to establish a global foundation for long-term water security. www Jenesis is a first-year in Davenport College from Washington D.C. She hopes to study History of Science, Medicine, and Publc Health and Neuroscience. She can be contacted at jenesis.duran@yale.edu.

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US Department of Defense

GLOBAL

Stigma and the

Opioid Epidemic

By Yasheen Gao

Max, a young man, was similarly prescribed Vicodin® when he injured his back.2 Instead of taking two pills a day as was prescribed, he took a few more and began to enjoy how the pills made him feel.2 He quickly became dependent on the highly addictive drug. He went to different doctors to get pills, sometimes lying about his pain to obtain the prescriptions. A local pharmacist became suspicious of the num-

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ber of Vicodin® prescriptions she filled for Max, and began denying them to him.2 These are stories of isolation, shame, and stigma. There are few happy endings. Sadly, Victoria and Max’s stories reflect common narratives of victims of the opioid epidemic-- a deeply stigmatized issue which is compounded by the marginalization of those affected. The opioid epidemic is a serious public health crisis that has been particularly compounded by stigma. Opioids are the driving force behind drug overdose, which is now the leading cause of accidental death in the United States.3 In 2015, there were 20,101 overdose deaths related to prescription pain relievers and 12,990 related to heroin.3 These figures reflect a dramatic increase over the past few decades as the number of deaths has quadrupled from 1999 to 2008.3 Much of this morbidity can be attributed to the severe stigma surrounding opioid addiction, which negatively impacts treatment, access, and utilization. Thus, 80% of opioid-addicted patients are unable to receive the treatment they need to recover from their addictions.4 Furthermore, studies have shown that as morbidity

increases from opioid addiction, public discourse scrutinizes physicians who prescribe opioids, which in turn causes physicians to prescribe fewer pain medications.5 Though fewer prescriptions seems helpful on the surface, the lack of access to pain relievers has led opioids users to resort to dangerous recreational drugs such as heroin, which has seen a large increase in usage rates in recent years.6 The shame and subsequent neglect of opioid addiction in social, political, and clinical worlds on the backdrop of a worsening epidemic demands a rethink

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hen Victoria, a young woman from San Antonio, went to her doctor, she thought that back pain was the extent of her medical problems. Her doctor prescribed Vicodin® to cope with the pain.1 Victoria was aware that Vicodin could be addictive, but she never imagined that it would impact her. That was something that happened to other people. But Victoria quickly became addicted. Her doctor cut her off the medication, which only meant that she was now dealing with back pain and an addiction-- without help.1 As a result, she experiences heavy withdrawal symptoms and begins using heroin. That causes her to lose her job, damage relationships with family and friends, and lose status as a valued member of her community. 1

In 2015, there were 20,101 overdose deaths related to prescription pain relievers and 12,990 heroin overdose deaths.

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stigma reduction measures.

Centers for Disease Control

The U.S.'s opioid epidemic is worsening. Pictured are the overdose deaths involving opioids per county in 2015.

ing of addiction from negativity and stigma to acceptance and rehabilitation. Stigma is both deep-rooted and long-standing. Defined as a set of negative beliefs towards a person or group of people, stigma has been condemned as a fundamental cause of discrimination and injustice by the World Health Organization.8 Like many forms of injustice, stigma finds its way “under the skin”. Stigma is a fundamental cause of health outcomes, leading to physical sickness and mental illness. Not only that; stigma disrupts the social networks of those affected by stigmatized conditions like addiction. For example, it can lead to a reduction in self-esteem and increase disputes among family members.8

At its extreme, stigma can take away a person’s life. In the scope of opioid addiction, addicts are given pejorative labels like “junkies” and “crackheads”. This shaming comes from both external sources like the media, and internal sources like family and friends. Furthermore, the National Institute on Drug Abuse’s survey on drug use has indicated that between 94% and 99% of adults in the United States disapprove of heroin use. Even frequent users of ecstasy and other drugs shame those who use heroin9. The social stigma surrounding opioid users makes it increasingly difficult for them to seek much needed help and care. Stigmatization makes it difficult for opioid users to recover from addiction, which implicates public health officials to create multi-level

One strong example of how stigma can reduce intervention can be found in a clinical setting, where physicians might provide inferior care to addicted patients because they too view their choices as immoral and incorrect. In an article from AMA wire, Dr. Patrice A. Harris, the chair of the AMA Task Force to Reduce Opioid Abuse, states that “Unfortunately, we still have a lot of people who think that people who have substance use disorders have character flaws, or that having an addiction is a moral failing. What makes the problem worse is the lack of care that healthcare professionals tend to provide towards opioid users.” 4 Although some may claim that physicians are helping the opioid epidemic by refusing to prescribe pills, this action must be coupled with an awareness that opioid users should get treatment for addiction rather than being neglected altogether. Moreover, it is evident several years into this epidemic that patronization by physicians is not enough to curb addictive behaviors. Thus, the doctors stigmatization of their own patients only serves to reduce the utilization and effectiveness of care. For the physician, treating addiction patients implicates them morally and legally.5 Opioid prescriptions are increasingly legis-

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Between 94% and 99% of adults in the United States disapprove of heroin use, even once or twice, and even frequent users of ecstasy and other drugs have a tendency to stigmatize the use of heroin.

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pexels.com

Prescription pain-relievers are a pressing issue in the opioid epidemic.

lated in state and federal governments. On one hand, physicians are obligated to provide pain relief for individuals who need it. On the other hand, there is a significant risk to prescribing pain relievers as patients can become addicted, which in turn implicates the prescribing physician in iatrogen

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or out of the state and updates them whenever controlled substances are dispensed.4 Furthermore, they can help to identify the need for special counsel or other treatment for an opioid use disorder.4 Simpler interventions such as adapting a more forthright approach towards physician-patient interaction and medication-driven treatment for substance approach have helped to reduce stigma and provide more access to care in the healthcare system for opioid users.4 A study showed that heroin deaths decreased by 37% with the introduction of Buprenorphine, an alternate medication for addiction.12

Mehmet Bilgin

Heroin dose deaths are decreasing as a result of MAT and medication.

ic harm. Possible consequences for physicians include risks of under prescription and over prescription, overdose liability, and third-party liability. When physicians under-prescribe pain medication, they may face loss of licensure and monetary consequences. However, over prescription can have more severe consequences. Between 2004 and March 31, 2016, over 240 criminal cases involved convicted physicians.10 In one such case, a physician was found guilty in a Court in Pennsylvania for continually prescribing controlled substances to individuals that were dependent on drugs.10 He was sentenced to fourteen years in prison, followed by twenty years of probation as well

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When even healthcare providers seem to neglect patients with opioid addiction, the barriers towards treatment and rehabilitation appear to be even more insurmountable.

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National Institute on Drug Abuse

as being ordered to pay a $30,000 fine.10 Physicians are also liable to be sued or to be legally responsible for overdoses and other issues related to pain relievers that they may have prescribed. They may also be liable for the dangerous or illegal behavior that may have resulted from their prescription of pain relievers, even though they may have not participated in the violent behavior themselves.10 For instance, a physician in Nevada was convicted of second degree murder for prescribing controlled substances to young adults without a medical reason.10 As a result of his overprescription, several young adults overdosed and died. The physician was sentenced to serve ten years in prison.10 These past examples clearly indicate that physicians can face serious consequences regarding the prescription of pain relievers. These serious consequences cause doctors to prescribe opioids less often, which sometimes means that people who need pain relief cannot get treatment and those who seek medical opioids for addiction will find unsafe sources. Thus, physicians must turn towards constructive treatment of addiction patients, rather than disengaging from the issue to avoid personal liability. A few suitable methods of treatment and preventative changes have already been proposed by medical professionals. These methods have been centered on improving the physician-patient stigma that has existed for so long. Prescription Drug Monitoring Programs (PDMP) have been created to inform physicians about whether a patient receives opioid prescriptions in

Along with medication, behavioral therapy, known as Medication Assisted Treatment (MAT), provides a “whole patient” approach that has also been shown to be an effective treatment for opioid addiction.12,13 MAT has been shown to decrease opioid use and deaths as well as criminal activity within participants.12,13 More innovative approaches are being researched as well, including developing a vaccine that would prevent opioids from reaching the brain.11 These solutions are centered on giving physicians better tools that encourage them to interact and connect with patients addicted to opioids. Hopefully, these tools will help reduce the issue of stigma in the medical community in a positive and healthy way. As the opioid crisis has spread, stigma has deepened. This public health crisis will no doubt require sober policy-making and fundamental social change. Stigma is not just an unfortunate side effect of an otherwise-serious disease. Stigma makes people sicker and can sometimes even kill them. Stigma keeps patients from accessing treatment, keeps doctors from providing the best care, and keeps families from supporting loved ones through addiction. Even though PMMPs and different approaches to treatment have lessened the stigma in doctor-patient relationships, many providers and patients are unable to access these types of treatments. If one thing is clear, it is that this crisis will persist unless serious efforts are made to mitigate the harmful effects of stigma. www Yasheen Gao is a first-year in Pauli Murray College studying Molecular, Cellular, and Developmental Biology. Yasheen is from Atlanta, Georgia. She can be contacted at yasheen.gao@yale.edu.

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LATIN AMERICA

LATIN AMERICA: Understanding Teenage Pregnancy By Eleanor Cook

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urrently, over one tenth of births worldwide are to girls aged 15 to 19 years old.1 Although this number has been decreasing globally for the past few decades, there is one region in which fertility, meaning the number of births per women, has remained stagnant or even increased among teenage girls. In several countries in Latin America, teenage girls have experienced an increase in fertility, even though their older peers have been reproducing with less frequency.2

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wealthier peers, which means that often those teenagers who give birth are those least financially capable of supporting a child. The poorest quintile of the population could have fertility rates of up to five times those of the richest quintile in Latin American countries.2 Becoming pregnant almost automatically puts girls on a path to poverty rather than success, and often leaves them dependent on othersâ&#x20AC;&#x2122; support. Adolescent pregnancy in Latin America

is thus an issue that merits considerable attention, but in order to try to solve the problem, it is important to understand its origins. A particularly revelatory situation is that in Guatemala. In 2012 alone, there were 61,000 pregnancies among teenage girls, just under 4,000 of those girls were 11 to 14 years old, and 35 were 10-year-olds. This marked the highest teenage fertility rate in Latin America. These numbers do not show signs of improving, either. From

Complications during childbirth are the second most prominent cause of death among 15 to 19-year-old girls.

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Teenage pregnancy is not a problem in the abstract. It has proven negative effects on both the mother and the child. Globally, complications during childbirth are the second most prominent cause of death among 15 to 19-year-old girls.1 Infants born to teenage mothers are also at increased risk of being born premature and underweight.3 Research of girls and young women in Latin America specifically has found that adolescent mothers had a greater risk of postpartum hemorrhage, puerperal endometritis, operative vaginal delivery, episiotomy, low birth weight, preterm delivery, and small-for-gestational-age infants. Adolescents aged 15 or younger were at greater risk of maternal death, early neonatal death, and anemia compared with their older counterparts.4

Beyond merely health-related problems, however, are social and socio-economic concerns regarding both mother and child. In the first place, many of the pregnancies that occur in adolescent girls are unwanted. Although many teenagers who become pregnant have already dropped out of school, of those who have not, a majority stop pursuing their education upon becoming pregnant, and the vast majority of those who do so never return to school.5 Even for those who try to continue their schooling, there exist obstacles to those who wish to remain enrolled beyond the extra work of balancing motherhood with education, such as expulsion from school for being pregnant. Furthermore, poor adolescent girls are more likely to become pregnant than their

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In Guatemala, the rural Western plateau and Northern regions are home to mostly indigenous communities. The regions are also among the poorest and the least accessible.

2000 to 2010, pregnancy rates in Guatemala remained stagnant.6 In a country which guarantees reproductive healthcare, it may seem counter-intuitive that the incidence of teenage pregnancy should be so high, and yet there exist many social structures in place which prohibit girls’ access to the healthcare they are promised.7 One particular barrier to girls receiving reproductive care is the stigma that surrounds it. Guatemala is a predominantly Roman Catholic nation8, which means that the Catholic Church’s ban on contraceptive use often dissuades girls from using effective methods of protection during intercourse. Furthermore, even for those who do seek contraception, cultural influences beyond religion prevent them. Often, in order to acquire birth control, a girl must be accompanied by a man to a health center, making contraceptives inaccessible at those centers for many women.7 Poverty, especially in rural areas is also a factor in teenage fertility, which has led especially to significantly large fertility rates among indigenous populations. After regimes that systematically oppressed them and a civil war that lasted longer than 30 years in which many found themselves in the crossfires, three quarters of indigenous individuals live in poverty, especially in Guatemala’s rural Western plateau and Northern region. The marginalization of indigenous, especially Mayan, populations in Guatemala has led to widespread poverty in their communities. Such poverty means that families, who struggle

to support their children, look to marry off their daughters as soon as possible, so that someone else may be responsible for the girl, and may help support the rest of the family. This means that girls marry young, and thus reproduce young.7 Contributing to rampant rural poverty, but also partially as a result of it is widespread illiteracy and an inadequate education system in Guatemala. Around a quarter of the country is illiterate, and only 30% of rural, indigenous girls enroll in secondary school. Furthermore, Mayan girls are disproportionately likely to drop

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It is largely girls in rural areas, a disproportionate number of whom are indigenous, who fall through the cracks.

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out of school compared to other populations, such as girls from urban areas.7 While pregnancy often causes girls to drop out of school, the negative dynamic also works the other way around. Girls who have dropped out of school are more likely to marry early and have children. This means that those already at a disadvantage pedagogically are those who end up most burdened by teenage pregnancy, as well.9 Another significant problem in Guate-

mala is sexual assault. Around a third of the approximately 4,000 10 to 14-year-old girls who became pregnant in Guatemala in 2012, were raped by their fathers. In 2009, Guatemala tried to address the problem of sexual assault against girls by outlawing sexual relations with girls under the age of 14 with the passage of the Law Against Sexual Violence, Exploitation, and Trafficking of People. This law also requires that a report be filed for every pregnant girl who goes to a hospital or medical center. What the law fails to catch, however, are pregnancies in girls who do not seek treatment at a hospital during their pregnancy. Again, it is largely girls in rural areas, a disproportionate number of whom are indigenous, who fall through the cracks, as they are less likely to visit a hospital than girls living in urban areas.9 This means that, in many instances, the only way perpetrators of sexual assault face punishment is if they are reported. Although 10,000 people report being raped in Guatemala each year, many instances go unreported.10 Furthermore, filing a report does not necessarily mean bringing a perpetrator of sexual assault to justice. As a result of the 2009 law, 20 men were convicted of rape in 2013,9 however many cases do not reach this point. In a particular instance of violent sexual assault, one girl describes how she was guaranteed safety as long as she did not press charges. Were she to bring the incident to court, she was told that her rapists would kill her family.10 Faced with inadequate structures to guarantee the wellbeing of victims and their families, even girls with the opportunity to report sexual assault may be deterred from doing so for fear of unwanted ramifications. Although each country’s teenage pregnancy problem is slightly different, they often show similar trends. Both Ecuador and Colombia are among the 40 countries with the highest fertility rates.11 In Ecuador, from 1990 to 2001, the fertility rate among 15 to 19-year-olds increased from 13.5 to 16.3 percent of girls with the age group.2 More recently, however, political stability has led to increased investment in healthcare. The government has worked to make healthcare accessible and free for everyone, and healthcare use has certainly increased.

U.S. Department of Defense

By creating a more welcoming environment, health facilities are able to attract and care for more young people.

Nonetheless, a considerable number of teenage girls still become pregnant. A 2013 report found that 21% of women in Ecuador from the ages 20 to 24 had given birth before the age of 18. This is less than Guatemala’s 24 %, but is still high.11 Although use

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of contraceptives in Ecuador has increased significantly in the past two decades, have rates of intercourse among adolescents has, as well. Contraceptive use is also not consistent in many instances, and many girls report not using a condom during their first sexual encounter.5 Often, this is because contraceptives as basic as condoms are simply not available to the teenagers.12 In Colombia, where one in five women aged 20 to 24 were found to have given birth before 18, unprotected sex occurs frequently among teenagers, as well. In addition to lack of access to contraceptives, ignorance is also a catalyst. Urban myths claim that girls cannot get pregnant during their first sexual encounter, or that girls cannot become pregnant if they perform intercourse while standing. Believing erroneously that their risk of pregnancy is low, teenagers take fewer precautions during intercourse.12 Both in Ecuador and Colombia, pregnancy can also be used as an escape, as a way for a girl to gain status. Girls in Colombia at risk of gang violence will sometimes seek to become pregnant with a member of a gang in order to secure her own protection, and to escape expectations of performing gang-related activities herself.12 In Ecuador, becoming pregnant can be a way to escape abusive families.13 Sexual assault is also a significant problem in countries beyond Guatemala. Many Ecuadorian women report having experienced sexual violence in their lifetimes, and many cases certainly go unreported. There exists a culture in which girls often do not feel the right to say no to sexual advances.5 Girls are especially powerless in their relations with older male family members, including fathers. Like in Guatemala, rape by male family members is a significant force driving up rates of teenage pregnancy in Colombia. Furthermore, indigenous groups in Ecuador, like in Guatemala, tend to be less healthy on average. With regards to teenage pregnancy specifically, a study in 2004 found that the proportion of girls ages 15 to 19 in the Orellana province, which has a significant indigenous population was more than four times that of the same age group in the most populous province, Guayas.5 Given the situations in these countries, it is important that action be taken. Currently, much of the need being addressed is by private organizations. Doctors Without Borders, for example, tells of a clinic it

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Impoverished Guatemalan girls are often married offed to support the rest of the family.

runs in Guatemala City intended specifically for survivors of sexual assault.10 Other groups focus on educating adolescents about reproductive health and pregnancy.7

Ecuador, as a model, however, demonstrates the need for differentiated care, specifically for teenagers when it comes to reproductive healthcare in Latin America.

One model for government action which has proven successful is a national program established in Ecuador in 2007. The program focused on providing healthcare specifically for adolescents, distinct

The government in Bogotá, Colombia has taken another approach and is pushing efforts to combat ignorance about reproduction. They have trained 1,000 youth leaders, and plans to train many more, to talk with their peers about and inform them on sex and sexual health. The government is also using cultural phenomena, such as television shows, to encourage discussion about teenage pregnancy and safe sex. As more attention is paid to the problem of teenage pregnancy, in Colombia, rates have decreased. The World Bank noted a marked improvement in Colombia from 2000 to 2010,6 and last year, the number of pregnant teenagers in Bogotá was reported as just over three fifths of what it was in 2010.12

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Health facilities established trusting relationships between teenagers and health professionals, and the number of young people who sought reproductive healthcare rapidly increased.

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from that for adults. By establishing an environment with assured respect, confidentiality, and friendliness, such facilities established trusting relationships between teenagers and health professionals, and the number of young people who sought reproductive healthcare rapidly increased. Unfortunately, in 2011, the government pushed instead for integrated family health care, which meant a drop in support for adolescent-specific services.5

Although private initiatives can make a difference where they operate, it is mostly broad government action that seems to make a dent in the overwhelming quantities of teenage pregnancy in Latin America. Legislation, education, and increased access to healthcare have proven helpful in Guatemala, Ecuador, and Colombia. The underlying politics and causes of teenage pregnancy, however, are different in every country, but these efforts to combat teen pregnancy rates in Latin America are promising. www Eleanor is a first-year in Pierson College on the pre-med track. She can be contacted at eleanor.cook@yale.edu.

MEXICO

Cultural Interpretation of Somatic Symptoms: Mexican American Explanatory Model of Type II Diabetes By Debbie Dada

INTRODUCTION

ype II diabetes is a leading health concern that is often viewed as a “disease of modernization” because of its prevalence in developed countries, most notably, the United States of America.1 This illness is particularly prevalent among Mexican immigrants living in America; over one in every ten Mexican-Americans is diagnosed with type II diabetes. As of 2014, 13.9% of Mexican-Americans were diagnosed with type II diabetes, a rate 1.5 times higher than the national average.2 Chronic diabetes can have debilitating effects on one’s life, and puts individuals at a greater risk for many other illnesses.2 Given the scope of the disease, it is important to understand how the experience of diabetes differs between ethnic groups and how group experiences of diabetes are mediated through social and cultural forces. This article will aim to address the research question: how do the beliefs and cultural markers of Mexican immigrants in America inform their explanatory model of type II diabetes? This article employs secondary resources to investigate the Mexican American cultural interpretation of the experience of diabetes. This study aims to determine the different systems of knowledge and cultural traits relevant to the production of their explanatory model through an idealist approach. This model is then compared with the mainstream North American model for the etiology of diabetes through discussions of syncretism, which is the amalgamation of distinct aspects of different cultures to make something new. This is done in order to evaluate the effects that their cultural beliefs have on their view of the disease. This analysis will use socio-cultural anthropology and medical anthropology lenses, the latter subfield being: “the cross-cultural, pan-historical study of health and sickness.” 5 The emic mental domain, as theorized by Marvin Harris, is an approach to anthropological inquiry where the observer attempts to “get inside the heads” of the population and learns the rules and categories of a culture.3 This is most effective in understanding the cultural values of Mexican-Americans, so it will be employed. The idealist theoretical perspective is most appropriate

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in the exploration of interpretivism within the Mexican-American culture, and is defined as: “focusing primarily on the activities and categories of the human mind (for example, beliefs, symbols and rationality), and seek explanations for the human condition in terms of them.”4 PREMISES AND LIMITATIONS Since this study aims to look at the views of Mexican-Americans, it is important to note that the beliefs and cultural markers discussed are largely particular to this specific subculture. Therefore, it would be erroneous to generalize the conclusions made in this investigation to all other Hispanic populations living in America. I also recognize that within these treated populations there will be differing beliefs among individuals. Although this serves to bring about a greater understanding of the Mexican-American culture as a whole, it cannot be assumed that every individual in this subculture holds these beliefs. It is important to note that the studies analyzed were drawn from 1984-2008. The studies consulted were conducted over the span of many years and focus on only certain aspects of the explanatory model. This provides a limitation, as it is difficult to provide an analysis of the change in the attitudes and beliefs of the Mexican-American population through a diachronic perspective. It is key in the treatment of Mexican-Americans to recognize that Mexico itself is a large country, filled with diverse histories and beliefs. This is especially important considering the syncretism of indigenous and European belief systems (as a result of colonialism) surrounding illness and health. This is very relevant in analyzing the interplay of the different religious healing rituals associated with each ancestry. Finally, as the pieces of ethnographic material used include a lot more quantitative data than qualitative data (from methods like participant or non-participant observation), the extent to which the observer can affect the results is rather limited. It is important to recognize that in the presentation of the ethnographic material there may arise issues of accurate representation (due to selectivity bias, assumptions, etc.). I have tried to limit this as much as possible by drawing on a wide variety of sources from reputable journals. BACKGROUND Mexican-Americans constitute a subcul-

ture within the United States because they have distinct beliefs and practices. For this reason, it is beneficial to understand the mainstream American explanatory model of diabetes in order to properly compare the model produced by Mexican-Americans. Diabetes is a disease wherein the pancreas does not produce enough insulin or the body resists insulin causing blood glucose levels to rise higher than normal. This puts patients at greater risk of having a stroke, high blood pressure, central nervous system diseases and depression.2 It is best managed through exercising regularly, eating healthy and avoiding stress. This model, purely biomedical, relies on a secular and scientific belief system accepted by mainstream America. COLLECTED EVIDENCE KEY IDEAS FOLK ILLNESSES Folk illnesses, also known as culture-bound syndromes, are defined as “illnesses created by personal, social and cultural reaction to malfunctioning biologic processes and are understood only within defined context of meaning and social relationships.”6 These are relevant to their explanatory model of diabetes so it is important to have an understanding of what they are and the role they play in their culture. These exist in a variety of forms within many cultures and have been the subject of anthropological inquiry for decades. Susto is one the most commonly referenced folk illness within Latin America and Mexico, and is believed to be a significant fright or an illness derived from such a fright.1, 6,7 During such an event, the spirit is believed to leave the body for a moment, and this can cause other illnesses to form or bring forth certain symptoms directly, such as: “listlessness, lack of appetite, depression and withdrawal, diarrhea, nightmares, and headaches.” 6 Intense emotions like susto can be experienced over a longer period of time or in a specific event. Some of the other significant and intense emotions believed to be associated with folk illnesses include stress or anxiety known as nervios, extreme anger known as corteja, as well as intense sadness known as tristeza.1 Some other folk illnesses are mal de ojo, which is evil eye and empacho, which is a type of stomachache caused by eating low quality foods or eating at the wrong time of the day. Each folk illness has distinct consequences in the lives of those who experience them. It is important to note

who experience them. It is important to note that these illnesses can exist only within the belief systems produced by the culture and for this reason are largely specific to certain cultural groups. HOT AND COLD THEORY The hot and cold theory, although not often implicated in the Mexican-American explanatory model of diabetes, is key in gaining a holistic understanding of how Mexican-Americans view and comprehend illness in general. This theory “classifies treatments, foods, bodily states, and illnesses as predominantly either hot or cold… The goal is to maintain a bodily equilibrium of hot and cold forces.” 8 The hot and cold discussed has no reference to actual temperature and is instead arrived at as a result of metaphysical features. For example, tropical fruits are cold, and wheat products are hot.6 An imbalance of the hot and cold forces is believed to cause sicknesses. Their belief in this theory speaks to their reliance on culturally significant symbols in understanding how to view the world. This relates directly to the interpretive approach to understanding culture as postulated by Clifford Geertz. This postulates that “culture is lived experience integrated into a coherent, public system of symbols that renders the world intelligible.” 5 The concepts of hot and cold can be viewed as symbols according to the defi-

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experience. In this section, I will be detailing the explanatory model of type II diabetes as put forth by a combination of six different studies. First, I will provide ethnographic context for studies discussed, then form an explanatory model including etiology, experience, and treatment. These studies in particular were chosen because of the wide range in ages, locales, and economic statuses represented. The first five studies took place with 3,722 first and second-generation Mexican-American immigrants who had diabetes, had a family history of diabetes or knew somebody with diabetes ranging from teenagers to seniors. They made on average between $420 and $1600 each month and the majority had less than eight or over twelve years of schooling. These studies took place in Illinois, Texas, Washington, Ohio and the Southwestern United States in 2008, 2004, 2003, 2000 and 1984. The sixth study 10 was done in 2012 in Guadalajara, Mexico with 36 participants, the majority of whom were married elderly women with six years of schooling earning between 2000 and 4000 pesos monthly. It was chosen even though it was not done with Mexican immigrants because the beliefs of Mexicans still living in Mexico is very relevant to comparative discussion of syncretism between explanatory models of Mexican-American immi-

The majority of participants across all studies implicated susto in some way as a cause of diabetes in general, and often as a cause of their own diabetes.

nition used by Victor Turner as “a blaze or landmark, something that connects the unknown with the known”.9 These symbols help people make sense of unknown illnesses by associating them with a culturally understood idea of hot and cold which can relate to other familiar and comprehendible bodily states or foods. In this way the Mexican-American culture creates meaning for these symbols. EXPLANATORY MODEL By evaluating the belief systems native to Mexican cultures and the effect of the acculturation of many mainstream American ideals, we are able to see that the Mexican American explanatory model of diabetes is specific to their culture and has been arrived at as a direct result of the interplay of the aforementioned two. This example of cultures in contact renders the Mexican-American explanatory model of diabetes unique to the Mexican-American life

grants and mainstream America. ETIOLOGY & EXPERIENCE

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Most participants were aware of the biomedical explanation for the onset of diabetes with some noting having taken classes after their diagnosis and others being taught by their physicians.6, 12 For this reason, we cannot simply conclude that their alternative explanations for the onset of diabetes are due to a lack of knowledge and are simply attempts to have some sort of a concrete idea about what is causing their symptoms. Instead, we can see that their explanatory model is directly dependent on the different cultural markers and beliefs specific to the Mexican American culture. A key similarity between the explanatory model of the mainstream culture and that of the discussed subculture is the appreciation, at least to an extent, of the biomedical explanation of the onset of diabetes.

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Curandero conducting ritual in Santa Fe, New Mexico Flickr

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The majority of participants across all studies implicated susto, in some way, as a cause of diabetes in general, and often as a cause of their own diabetes. Their model incorporates susto because the prevailing belief system concerning health in Mexico is not secular, unlike the mainstream American health system, but rather is a combination of Catholicism and types of divination. This is exemplified by the fact that most participants in the study in Mexico itself noted experiencing susto or nervios at some point in their personal lives as well as the fact that the hot and cold theory is an established element of the Mexican as well as Mexican-American health experience.6, 10 Susto is seen as such a culturally significant concept because of its ability to make sense of experiences and symptoms experienced both in the natural and the supernatural, seeing as susto along with other folk illnesses often implicate forces like witchcraft in their origin.14 Furthermore, it is important to note that the Mexicans saw susto as a folk illness in and of itself, outside of its function in bringing on diabetes. This contrasts with the beliefs in some of the studies with Mexican American participants, where the meaning of susto simply is the frightful event or set of conditions that bring about chronic stress that cause diabetes.6 The presence of the symptoms of susto (other than the onset of diabetes) varied greatly between studies. This unique understanding of susto shows some level of conformity to the mainstream model as this strips susto of much of its connotations dealing with

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es between believing susto causes diabetes and that it is caused by biomedical reasons is that it reduces the agency of the individual. There is nothing one can do to prevent susto, which leaves people powerless, whereas the biomedical model asserts that the agency of the individual (in controlling their diet, exercise habits, etc.) results in the meaningful, though negative, change of his/her life. One of the Mexican-American participants explained her “vulnerability to diabetes in terms of her distressing life experiences associated with migration: she was alone, economically dependent, and in need of social support.” 1 That being said, when asked to rank the most significant causes of diabetes in most studies the biomedical and traditional origins were generally viewed as parallel.12 Of the studies that explicitly asked participants to rank causes, susto or a larger context of intense emotions (as will be discussed later) was ranked first once, second to diet once and last once.6, 11,13 The other most frequently high ranked causes were heredity, weight and a lack of self-care. This is direct evidence of the syncretism of the prevailing American belief system in regards to health, biomedical, and the prevailing Mexican system, traditional. This leads us to the varying presentation of susto or coraje in different people’s diabetes narratives as one specific frightening or marking event or a set of circumstances in which these emotional states are prevalent. An example of the latter can be seen

... They use their explanatory model of diabetes as a means by which to communicate personal circumstances that are only appropriate to be discussed in the private sphere, in the public sphere.

the supernatural. This functions to make their explanatory model more compatible with that of the physicians that they might encounter. Across three studies, participants keenly described their experience that caused diabetes as a very traumatic event; for example, a woman a woman explained, “my rage (cortaje) is like a mark, one that stays with you.” 1, 11, 12 Another, described their susto experience twice almost identically nearly a year apart, showing just how traumatizing it was in their life. 6 It is also interesting to note that one of the key differenc-

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with a man named Jorge who attributed his diabetes to his unfortunate living situation and lack of economic stability. He believes that if it is difficult for you to “to pay rent, electricity and water. Food. If one doesn’t have any food to eat that’s bad. You are left traumatized. That is one powerful reason that causes you to have diabetes.” 1 Many also believed that further experiences of susto or coraje after being diagnosed could exacerbate diabetes symptoms. A participant in reference to experiences with her son-in-law explained “he makes me so mad. That’s when my sugar was up a lot. When I get mad, it’s dangerous.” 12 Further-

more, women were more likely to report acute stressors within the domestic world whereas men were more likely to report stressors “outside of the home.”1 This is relevant to the discussion of the organization of space and place with regards to gender relations within the Mexican American culture where women have more power within the private sphere and males are to have more power in the public sphere. This makes women more vulnerable to stressors within the family and private sphere than men are. 10 It is reasonable to conclude that in their lives diabetes through susto or other intense emotional states can serve as a way to express “social suffering and emotional distress.” 1 In this way, diabetes can be viewed as an idiom of distress, which can be defined as “somatic language for expressing distressing experiences in a culturally meaningful way.” 14 This means that they use their explanatory model of diabetes as a means by which to communicate personal circumstances that are only appropriate to be discussed in the private sphere, in the public sphere. In this way, they are able to communicate distress without transgressing social norms. In the Mexican-American culture this includes a stigma around mental health issues as well as the open discussion of realities like abuse.14 Therefore if someone is to experience one of these they use their explanation of the etiology of their diabetes as a justification for discussing taboo topics in the public sphere. This is also consistent with the finding that participants who thought that they had experienced susto at some point in their lives “had more symptoms and were physically sicker than” others who had not. 6 This can also be seen as specific to the Mexican-American experience of immigrating from Mexico to America because of all the uncertainty and stress (nervios) associated with acculturation, the formation of “transcultural identities and migration.”11 Diabetes specifically is well suited to be an adequate idiom of distress within their culture because of its prevalence within the Mexican-American community as well as the fact that traumatic experiences (in which susto, corteja or other intense emotions originate) pervade their day-today lives just like the chronic illness does. TREATMENT Within the three studies that spoke to the Mexican-American response to diabetes, all revealed an integration of the biomedical

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and traditional system.6, 11, 13 This meant that participants used the medicine and advice prescribed by their doctors (similar to mainstream America) in conjunction with home remedies or consulting healers known as curanderos. These healers are respected members of the Mexican-American community that have ritualistic cures for “illnesses known for generations” and so they often provide a deeply personal alternative to the often impersonal experiences participants have with physicians. The only group asked to rank the effectiveness of the different treatments put diet, regulation, natural remedies and pills as the most important, in that order.11 In interviews, many described their reliance on curanderos for treating certain illnesses like susto, minor pains and mal de ojo while using physician alone for major pains.13 Participants were more likely to rely on home remedies and curanderos if they “recently immigrated, visited the physician often, or lacked health insurance.” 11 The curanderos treatment of diabetes was very ritualistic, usually involving a combination of herbal remedies and consisting of one of two therapies: 1) internal consumption teas prepared with indigenous herbs and prayers; and 2) ritual which often included stylized manipulation of raw eggs, palm leaves, and a variety of incantations.”1 Mexican-Americans are more likely than “African-Americans, Asian-Americans and non-Hispanic whites” to use home remedies to “augment the treatment of diabetes.” 11

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Glucose level testing of a diabetic patient.

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ment. This draws light on the fact that there are different religious belief systems present among Mexican-Americans. It must be noted as well that the evident Catholicism is likely a result of the European colonialist roots in Mexico and has stayed central to the Mexican-American belief system.

The participants did not only seek out curanderos and physicians in the event of a diagnosis of diabetes, but many also turned to Catholicism. One woman recounted in reference to Catholicism: “a prayer that you offer to God, in which you talk to God with all your heart whatever you want to tell Him, that is what will help. But using a stone or an egg, that will not help, because God does not need us to offer him anything.”6 Here, the Catholic ritual of prayer is believed to be another viable form of treat-

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Regardless of whether they turned to Catholicism, home remedies or curanderos, many Mexican-Americans decided to exercise agency by taking the ongoing treatment of diabetes, at least partially, into their own hands. This can be seen as a result of the socially acceptable way of managing one’s health care in Mexico where “self-diagnosis and prescription without supervision are common practice.”11 In this way we see another effect of acculturation where they moved from being largely responsible for

their own healthcare to following doctors’ orders while also keeping elements of their care within their control. CONCLUSION After evaluating the Mexican-American explanatory model of diabetes, it is clear that its many elements and intricacies occur as a result of the distinctive experience that Mexican-Americans have in life as determined by their culture. With discussion of the specific belief systems, gender relations, symbols and systems of knowledge accepted by the Mexican culture in contact with the American culture, we can see that they result in an interesting interchange that create the Mexican-American culture. This culture, informed by ideas of acculturation, syncretism, and conformity, brings forth a unique interpretation of the somatic symptoms of diabetes that form the Mexican-American explanatory model.

www Debbie Dada is a first year in Pierson college. Debbie hails from Toronto and hopes to major in Global Affairs with pre-med requirements. She can be contacted at debbie.dada@yale.edu. yale.edu.

TECHNOLOGY

Global Health Efforts Poised to Take Off with Novel Drone Technology

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By Rohan Garg With the help of drones' enhanced imaging capa-

bilities, epidemiologists can respond to changing disease reports more quickly and efficiently, illustrating the potential for drones to advance epidemiology research.

rones have long been associated with violence and destruction. Used frequently as a tool for surveillance and bombings in military conflicts, drones have inadvertently killed countless civilians and deteriorated civilians’ mental health in warzone populations. Recent technological developments in healthcare, however, suggest that drones may soon serve the polar opposite purpose: saving lives. In particular, drones have demonstrated promising potential as a means of mapping disease epidemiology, delivering medical aid to patients, and diagnosing individuals in remote areas with greater efficiency. Drones are already helping researchers to make strides toward mapping infectious disease epidemiology. At the forefront of these novel research efforts is Chris Drakeley, Professor of Infection and Immunity at the London School of Hygiene and Tropical Medicine. Drakeley and his team have been actively monitoring an emerging Malaysian outbreak of Plasmodium knowlesi malaria, which can occur in humans but is hosted and transmitted by long-tailed macaques, a type of monkey.1 In order to investigate the geographical distribution

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of malaria-carrying macaques, Drakeley’s team conducted 158 survey flights with commercially available drones in the Sabah region of Malaysia, where epidemiologists had observed a recent upsurge in Plasmodium knowlesi malaria incidence.2 These drones were programmed to track the movement and behavior of individual macaques from roughly 300 meters above ground. After compiling and synthesizing macaque population data from all flight trials, the team successfully identified the areas where the risk of acquiring Plasmodium knowlesi malaria was highest. In this fashion, aerial drone-produced images offered valuable insights into the geographical distribution of malaria that could be subsequently used to inform policymakers about potential methods for the optimal distribution of antimalarial supplies across the Sabah region of Malaysia. With regards to disease mapping, drones are likely to provide a more useful epidemiological portrait than the traditional method of satellite imaging does. Aerial surveys that use satellite imaging are severely limited in their abilities to provide detailed environmental mapping or frequent monitor-

Delivery drones are unmanned aerial vehicles that are used to transpo

ing of wildlife movement. Drone-produced images, on the other hand, allow for “the mapping of small geographical areas at user-defined time points and spatial resolutions.”2 With the help of drones’ enhanced imaging capabilities, epidemiologists can respond to changing disease reports more quickly and efficiently, illustrating the potential for drones to advance epidemiology research. Beyond the context of academic epidemiology research, drones might be pragmatically used to deliver emergency medical aid to patients. In several developing nations plagued by poor infrastructure and impassable roads, it is often inefficient or impossible for hospitals to attend to medical emergencies by means of an ambulance or a similar ground vehicle. Accordingly, international agencies are exploring the po-

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ort packages of food and other goods.

tential of drones to transport medical supplies. The United Nations Population Fund (UNFPA), for example, has spearheaded a pilot project aimed at delivering contraceptives and life-saving medicines to women in rural Ghana. Urban drone operators pack a transport drone with medical supplies and guide it to remote areas inaccessible to cars. Here, local health workers receive and distribute the supplies. Dubbed “Project Dr. One,” this initiative has already reduced average delivery times from two days to thirty minutes.3 “Drones not only overcome infrastructural challenges of poor roads, heavily forested areas, or deserts, but can also slash the time needed to wait for life-saving medicines and other supplies”, explains Renee Van de Weerdt, a senior advisor at the UNFPA.2 By avoid-

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Although developing nations might come to mind as a first choice for the deployment of medical drones, Zipline’s efforts in both Rwanda and the United States emphasize that the use of drones for medical deliveries are beneficial in so called first-world countries as well.

ing the inefficiencies and hindrances associated with poor infrastructure, drones not just reach rural communities, but they also reach rural communities far more quickly than a ground vehicle possibly could. In response to the cost-effectiveness and efficiency of Ghana’s Project Dr. One, several neighboring African nations have expressed interest in establishing similar nationwide initiatives, signaling a global

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ripple effect in the movement toward drone delivery programs. Indeed, the deployment of medical drones is already underway in the United States. Zipline, a medical drone startup based in Silicon Valley, announced last August that, with interest from the Obama administration, it sought the Federal Aviation Administration’s regulatory approval for three projects designed to bring medical

supplies to underserved communities in the United States.4 These initiatives would bring medical supplies to Smith Island in Maryland, Native American reservations in Nevada, and the San Juan Islands in Washington.5 Having already instituted successful blood delivery programs in rural Rwanda, Zipline hopes to now target rural and remote communities in the United States where health inequalities often go unnoticed. Although developing nations might come to mind as the first choice for the deployment of medical drones, Zipline’s efforts in both Rwanda and the United States emphasize that the use of drones for medical deliveries are beneficial in so-called developed countries as well. Drones are not only revolutionizing the way that healthcare solutions are delivered, but also transforming the way in which medical diagnoses are conducted across the world. In Bhutan, for example, the rugged mountainous terrain and an extremely low ratio of 0.3 doctors for every 1000 people has necessitated a telemedicine system.1 In cases where doctors need blood or other biological samples for accurate medical diagnoses, however, the existing telemedicine framework is insufficient, and it often takes several days for samples to travel from the patient to a doctor. In order to address this issue, startup Matternet partnered with Bhutan’s health ministry and the World Health Organization to pursue an investigative project involving the transport of diagnostic specimens via drones. During its testing period, Matternet successfully flew drones that carried dummy blood samples between a remote clinic and the capital city of Thimphu, located fifteen kilometers away.6 Through this pilot study, Matternet validated the usefulness of drones in delivering blood samples for medical diagnosis in Bhutan, and now seeks funding from Bhutan’s government for a nationwide project in the country. Matternet has further demonstrated the potential for drone delivery of blood samples in Malawi. Through a partnership with UNICEF to conduct a trial with infants, Matternet successfully flew blood samples from rural clinics to Lilongwe, the capital of Malawi.1 The pilot projects in Bhutan and Malawi highlight the way in which drones can be used to accelerate medical diagnoses by transporting biological samples more quickly from patient to doctor. Yet many scientists note that we must proceed with caution towards the transport of biological materials. Timothy Amukele, assistant professor of pathology at Johns Hopkins University, has taken the lead in investigating

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If I were walking to a clinic in northern Cameroon and saw a drone, my first thought might be, ‘Am I about to be collateral damage in a Nigerian government strike on Boko Haram?’ not ‘Look at that stunning breakthrough in medical logistics.’

the ways in which biological samples might be altered during drone flights. “Transporting blood or other biological samples is not like transporting a book or shoe,” Amukele explains. “They are much more fragile.”4 Amukele conducted preliminary tests in which he flew 168 healthy blood samples for roughly forty minutes at a field location in Maryland. These samples were paired with 168 other samples that were kept stationary. After the flight trials, more than thirty of the most common chemistry, hematology, and coagulation tests were performed on all of the samples. Statistical analyses led Amukele to the conclusion that the transportation of blood samples via drones does not affect the accuracy of routine medical tests.7 The full adoption of drone transport of diagnostic specimens, however, will require similar studies for other types of specimens, laboratory tests, and environmental conditions. Moreover, the use of drones in healthcare initiatives will require the development of firm international regulations concerning aviation policy and the consent of rural populations where drones might deliver supplies. Given that a multitude of countries—such as Nigeria, Israel, Iraq, Pakistan, and the United Kingdom—are also currently using drones for lethal strikes in military operations, it is imperative to establish international norms for drone usage and to educate rural populations about the role of drones in healthcare interventions.

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As observed by public health specialist Belinda O’Donnell, “If I were walking to a clinic in northern Cameroon and saw a drone, my first thought might be, ‘Am I about to be collateral damage in a Nigerian government strike on Boko Haram?’ not ‘Look at that stunning breakthrough in medical logistics.’”8 In order to maximize the efficacy of medical drones and to comply with basic ethical standards, global health leaders must take into account the public perception of medical drones and develop programs to educate communities, all prior to actually launching drone delivery programs. The notion of advancing global health with the use of drones is clearly not perfect. Drones will not fully solve the global shortage of healthcare workers, and they require a robust system of cooperation between urban hospitals and rural community leaders. Extensive efforts, however, are indeed underway to remedy these issues. Very soon, drones will serve the purpose they were always meant to serve: saving lives.

www Rohan Garg is a first-year in Branford College interested in the fields of global health and economics. He can be contacted at rohan.garg@yale.edu.

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Turing Pharmaceuticals: A Price Raise, a Name Change, and an Outrage By Indira Flores

s of September 2017, notorious ‘pharma bro’ Martin Shkreli has taken up residence in a federal prison in Brooklyn, New York.12 After bragging that he would only ever be sent to a luxurious, low-security ‘Club-Fed’ for his earlier convictions of fraud, he was sent to a federal prison for a completely separate reason: posting a message asking his followers to try to “grab” a strand of Hillary Clinton’s hair for him. These Facebook posts, after being deemed as potentially threatening to Clinton by the judge ruling over his case, resulted in Shkreli’s imprisonment without bail. During this time, Shkreli was originally meant to be quietly awaiting his sentencing, scheduled for January of 2018, after being convicted of one count of conspiracy and two counts of fraud for his hedge fund dealings. Perhaps the reason why Shkreli has demonstrated such aggressive hostility toward Clinton is because she is an influential public figure who, like most American citizens, vehemently condemned him for increasing the price of Daraprim, a medication used to fight parasitic infections, by 5000 percent overnight in 2015. Shkreli’s recent incarceration has provided an opportunity to re-investigate the timeline of the Daraprim outrage and review the effects that it still has today.

The story of the complications surrounding Daraprim begins in February of 2015. During this month, Shkreli officially launched Turing Pharmaceuticals, named after famous computer scientist Alan Turing.6 Shkreli served as the company’s chief executive officer. The company was initiated by the acquisition of three medical products from Retrophin Inc, another pharmaceutical company that Shkreli had originally founded. Several months later, in August, Turing Pharmaceuticals purchased exclusive rights to pyrimethamine, the drug marketed as Daraprim, in the United States from Impax Laboratories. When Impax Laboratories owned

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the rights to Daraprim, its cost was $13.50 per pill. Once Turing Pharmaceuticals gained ownership of the drug, they dramatically raised the price to $750 per pill—a 5000 percent increase. This marks the beginning of the controversy. By September, major news networks had begun reporting on the price increase, bringing it to the attention of the general public. It was at this time that Clinton also began making an enemy out of Turing Pharmaceuticals and referring to them as proof of the corruption that permeates the pharmaceutical industry to amass support for her own drug plan while campaigning for the 2016 presidential election.11 This frustrated the leaders of other American pharmaceutical companies, who claimed that Turing was not representative of the industry as a whole and feared that the villainous image of “big pharma” would begin spreading through the population like the viruses these companies produce drugs to treat. With so many different groups of people affected and angered by this situation, it was no surprise that Shkreli felt justified in beginning to refer to himself as

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Once Turing Pharmaceuticals gained ownership of the drug, they dramatically raised the price to $750 per pill-a 5000 percent increase.

“the most hated man on the Internet.”

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In November of 2015, Turing Pharmaceuticals announced that the company would be changing the price of Daraprim to $375 per pill for hospitals.5 The Clinton campaign suggested that the pres-

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In September 2017, Shkreli was sent to federal prison.

idential candidate’s open criticisms and condemnation of the company was in part responsible for Shkreli’s decision to reduce the price. Although Turing reduced the drug’s cost to half the level it had originally set, it still marked a 2500 percent increase from the price that the pill had originally been when Impax Laboratories owned it. December of 2015 marked an even more significant change for Turing Pharmaceuticals and its founder: Martin Shkreli was arrested. However, it was not related to the controversial price hike of Daraprim or for any business he conducted as CEO of Turing Pharmaceuticals. He was actually arrested on securities fraud charges; the investor reportedly paid off his hedge funds’ money-losing investors using the funds of his prior pharmaceutical company, Retrophin.10 Immediately following his arrest, Shkreli resigned as chief executive officer of Turing Pharmaceuticals. The man who was previously the board chairman of the company, Ron Tilles, was announced as Shkreli’s replacement.2 Medical providers and patients who were required to take Daraprim were hopeful that this would result in a return to the original price of the drug, but no such price drop occurred. Shkreli himself was not indicted for dramatically hiking the price of Daraprim. However, around the same time that he was arrested, the news that Turing Pharmaceuticals was undergoing investigation by the US Federal Trade Commission was released.2 The FTC began conducting their investigation of the company to determine

if the Daraprim price hike might be connected to antitrust violations. In February of 2016, Shkreli and other representatives from Turing attended a House Oversight Committee hearing on rising drug prices in the US.4 They claimed that the company’s decision to raise the price of Daraprim was ethical and reasonable because the additional profits earned would be used to fund further drug research. They also claimed that the uninsured, low-income users of Daraprim would benefit from the funds of

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...[Leaders of the pharmaceutical industry] feared that the villainous image of "Big Pharma" would begin spreading through the population like the viruses these companies produce drugs to treat.

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an assistance program put in place by the company, and approximately 67 percent of the people who use Daraprim would only be paying pennies per pill due to a discount offered through Medicare and Medicaid. This still left patients who did not qualify for the assistance program, as well as hospitals and insurance companies, paying up to $30,000 for a single bottle of the Daraprim pills.4 In the end, Turing Pharmaceuticals was not forced to shut down business or lower the price of Daraprim; the company came out largely unscathed, save for a tarnished reputation. Perhaps in an attempt to

relinquish their baggage from the past, in September of 2017, the company changed its name to Vyera for all business conducted in the United States. However, the baggage has not completely disappeared, as the price of Daraprim remains high. Daraprim has been a life-saving drug since its beginnings over six decades ago, so its price changes have certainly affected its users. The common name for the drug is pyrimethamine.3 The drug is most commonly prescribed to treat toxoplasmosis, an infection caused by a virus that may invade human tissues and damage the brain. In certain less common cases, the drug is used to treat acute malaria. Although an estimated twenty-three percent of adults in the US have toxoplasmosis and do not require treatment, individuals with diseases such as HIV and AIDS who have weakened immune systems are especially susceptible to the infection.1 These patients are typically prescribed two to three pills every day for a period lasting from several weeks to several months. The price hiking of Daraprim actually began even before Turing Pharmaceuticals purchased the rights to the drug. Before 2010, rights to the drug were owned by the company GlaxoSmithKline, who priced it at just one dollar per pill.8 Then, when the company Impax Laboratories and its subsidiary CorePharma acquired rights to the drug, they raised the price to $13.50 per pill in order to increase their profits. In 2015, Turing bought the rights to Daraprim from CorePharma, which is

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when they hiked the price up to $750 per pill. These price hikes most directly affect patients who require Daraprim to recover from infections. Those who are not covered by the company’s assistance program or who otherwise lack adequate health coverage cannot afford to pay such an outrageous amount of money for the medication. Considering that these patients are typically individuals who also have diseases such as AIDS, they are already paying large amounts of money each year to treat the symptoms of those diseases and others that accompany them. To take the full course of their Daraprim prescription as recommended by their doctors would cost them an additional $336,000 to $634,500 per year, depending on the weight of the patient.9 As the prices of drugs such as Daraprim increase, those who are required to take these drugs are not the only ones affected. The pharmaceutical companies expect health insurance providers to shoulder the majority of the additional costs. Health insurance providers in turn claim that this justifies the rising costs of insurance premiums and copays for everyone—including both those health insurance holders who use the more expensive drugs and those who do not. In a free market system such as that of

the United States, it may seem surprising that a single company can raise the cost of a drug so dramatically and have no apparent competitors marketing similar drugs at lower prices. The issue is that the disease that Daraprim treats, toxoplasmosis, does not need to be treated as often as many other diseases do. The demand for this drug is somewhat low when compared to the demand for other drugs, so other pharmaceutical companies have not viewed pyrimethamine as a lucrative drug to devote resources to begin producing; there is no generic version of the drug available in the United States. This is why Turing Pharmaceuticals was able to purchase exclusive rights to the drug and essentially have a monopoly over its production so they could raise its price dramatically while still retaining its consumers. One pharmaceutical company, Imprimis, markets a pyrimethamine/ leucovorin capsule as an “option… for individualized compounded medications in the face of drug prices that have recently significantly increased”—a thinly-veiled jab at Turing and their Daraprim price spike.7 Although the Imprimis capsule is significantly less expensive than Daraprim, priced at under ten dollars per pill, it is also not nearly as effective.

Fortunately, the implications of Turing Pharmaceuticals’ Daraprim price hike have not had harmful consequences on a global scale. In other countries, pyrimethamine still remains available at the price of only one or two dollars per pill because Turing only has rights to distribute the drug in the United States.8 Medical professionals from around the world have been very willing to send the drug to American doctors whose patients could no longer afford it after the price hike.

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In other countries, the same drug that was marketed here for $750 was being marketed for less than ten dollars per pill.

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The entire situation involving the sudden rise in the price of Daraprim by Turing Pharmaceuticals calls attention to some startling issues with the pharmaceutical industry. Firstly, there are issues with the people who are leading the pharmaceutical industry in the United States. The fact that someone with motives as questionable as Shkreli’s could found, lead, and abandon several different biomedical and pharmaceutical companies is a major point of concern. Additionally, there is an issue with the role of monopoly in the American pharmaceutical industry. The United States has tried to place regulations on monopolies and trusts, and the FTC investigation and subsequent Congressional hearings seemed as though they might enforce those regulations, but both of these governmental actions resulted in more questions than answers, and no real progress resulted from them. In other countries, the same drug that was marketed here for $750 was being marketed for less than ten dollars per pill; there was no Turing Pharmaceuticals monopolizing health insurance providers or consumers of the drug abroad. These findings explain and warrant the recent rise in calls for reform of governmental regulations on “Big Pharma” in the United States. www Indira is a first-year on the pre-med track in Grace Hopper College with a potential major in Molecular, Cellular, and Developmental Biology.

Activists protest against Martin Shkreli outside the lobby of Turing Pharmaceuticals in New York City.

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She can be contacted at indira.flores@yale.edu.

FEATURE ARTICLE

US Coast Guard members cleaning up rubble from a razed Puerto Rican home as a result of Hurricane Maria. 25

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RELIEF:

IS THERE A DIFFERENCE IN HOW WE RISE? A COMPARISON OF THE MEDICAL RELIEF EFFORTS AMONG AREAS RECENTLY AFFECTED BY NATURAL DISASTERS BY TOMEKA FRIESON

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U.S. Department of Defense

ugust 25, 2017, was a day of unanticipated shock and grief for many Americans. Texas had been struck by Category Four Hurricane Harvey and, during those next four days, would experience extensive damage to its people, places, and infrastructure all across its southern region. 1 On August 29, 2017, when the torrential rains terminated, and the totality of damage could be determined, it was surmised that Hurricane Harvey’s 52 inches of rainfall—greater than waist-high on many individuals—and subsequent extensive flooding had left in its wake 12,700 destroyed homes and 190,300 others with varying degrees of damage; 738,000 individuals applying for financial assistance from the Federal Emergency Management Agency; 10,000 citizens trapped in their flooded homes or highways; 37,000 Texans in shelters; 180 billion dollars in damage; and 82 citizens dead as of September 17, 2017. 2,3 In light of Hurricane Harvey’s categorization as the most catastrophic hurricane to have taken place in the United States to date, there is no doubting that human health, sanitation, and medical needs were impacted by this natural disaster. Rather, the question remains the extent to which Texans’ medical needs have been fulfilled by volunteer and relief efforts across the nation. The adverse impact upon Texas citizens has been—and currently continues to be—expansive, especially in terms of physical and mental health, sanitation, and other public health issues. Short-term worries for recipients and responders of the flood relief efforts include the introduction of malicious microbes and mosquito-borne diseases due to a prolonged presence of stagnant water; outbreaks of E. coli infections or similar diseases as a result of scarce availability of food or potable water; presence of mold on consistently wet, non-waterproofed infrastructures; lack of proper sewage drainage; and mental health conditions, such as post-traumatic stress disorder and depression, as well as other public health issues. 4 The widespread presence of floodwaters has restricted access to medications for individuals in constant need of a prescription, especially for those living with hypertension, diabetes, and/or asthma. Since Texas has the lowest health insurance rate in the country, resources by which individuals could access those medications are, consequently, extremely limited. Referring to Hurricane Har-

vey’s impact on public health in Houston and its surrounding cities, author Peter Hotez in an interview with the Washington Post deemed the Gulf Coast (the area of the US where Hurricane Harvey’s destruction took precedence) as “America’s vulnerable underbelly of infectious disease,” a phrase that reigns true if taking into account the citizens’ generally low socioeconomic status, high levels of transportation, and the ever-increasing effects of climate change evident within the region. 4 Despite its characterization as a region of lower socioeconomic status, Texas, and particularly Houston, the city most drastically affected by Hurricane Harvey, is still situated within the United States, one of the world’s most developed countries, and, as such, possesses designated funds particularly allocated toward disaster relief aid. Exactly two weeks earlier and 8,700 miles around the world from Houston, Texas, citizens of Bangladesh were experiencing the peak of what turned out to be a heart-wrenchingly deadly early monsoon season that left over 1,200 dead; nearly 1,500,000 acres of farmland partially damaged; and close to 25,000 acres of farmland completely destroyed by floodwaters.5,6 Similar to the devastation caused by the catastrophic flooding in southern Texas, the impact of the natural disaster on the public health of Bangladeshi citizens was immense: as of August 31, 2017, 51,000 Bangladeshis had been displaced; children had been unable to attend school indefinitely; citizens lacked clean drinking water; individuals became more susceptible to mosquito-transmitted diseases such as malaria, Japanese encephalitis, and dengue, due to presence of stagnant water; and the food was so scarce that even farmers were left with nothing.6,7 With this degree of devastation, the need for aid in Bangladesh was the same—if not greater—than that of Texas. But with 32% of Bangladeshis living below the national poverty line and no developed country, such as the United States, to either economically or materialistically support the impoverished country, the question became how, when, from where, and at what time would aid be received from any outside volunteer or relief organization. 7 September 20, 2017, the day that Hurricane Maria made landfall in Puerto Rico, proved to be a horrific and infamous day in Puerto Rican history. The ultra-pow-

IBangladeshi children in their floating schoolhouse in the wake of the

erful Category Four hurricane and ensuing torrential rainfall and flooding was one of the worst to have ever occurred, leaving an initial 1.87 million people without sanitary drinking water; 8,800 in refugee shelters; 49 dead as of October 20; and the island’s 69 hospitals pining for functionality amongst the numerous power outages and blocked roads.8,9 With 30 percent of people on the island still at a loss for even the most basic necessity of clean water as of October 19, a humanitarian crisis of drastic proportions immediately ensued.9 Aside from the overbearingly dire need for potable water, limited food, fuel, cell service, and electricity for life-saving or diagnostic hospital equipment left the island in a situation in which help was desperately needed.10 In addition, there was a similar aftermath to what was experienced by both Texas and Bangladesh: a deadly bacteria outbreak of leptospirosis linked with the lack of running water took hold in some hospitals around the island.9 Yet

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e devastating August 2017 monsoon.

despite Puerto Rico’s dire need for assistance and the island’s status as a commonwealth of the United States, Puerto Rico’s disaster relief efforts have been some of the most criticized to have ever occurred—be it that the aid delivered was late in arriving, or not enough monetary resources were dedicated toward staving off total mayhem in the first place. This left the US commonwealth still, quite literally, in the dark and much volunteer and relief work to be done in order to get the island back to its normal functionality. The purpose of this article is to investigate the absence or presence of disparities amongst relief efforts for natural disasters in less developed countries, such as Bangladesh, as compared to more developed countries, such as the United States—and where Puerto Rico, a developing US commonwealth, fits into the overall picture in the quickness and completeness by which the island

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received disaster relief aid. In order to best elucidate the global health impact and potential relief disparities between the three territories’ governments, human geographical terms, such as more developed country (MDC) and less developed country (LDC) are referred to in order to emphasize the fact that disparities in government economies may lead to disparities in healthcare access. Then, focus will be placed on the medical aid and resources provided in each of the three public health-economic events. For instance, while Texas, Bangladesh, and Puerto Rico were all affected by drastic flooding that adversely affected the territories in similar ways, this article aims to find any disparities in the relief responses and aid received and surmise the potential impact of this factor on the territories’ future prosperity. What’s more, this article not only investigates the quantity of organizations that responded in each instance, but also how the same organizations responded in

each of the three different cases. In general, the resources through which disaster relief aid is accomplished differ between more and less developed countries. MDCs, for example, enjoy higher per capita incomes and, consequently, have excess capital, or funds, that can be allocated toward disaster relief programs, such as the US’s Federal Emergency Management Agency, or FEMA. For LDCs, on the other hand, capital is scarce and, while the countries’ governments may be able to allocate a small percentage of the country’s resources toward a disaster relief fund, any unexpected natural disasters, such as what occurred in Bangladesh, may quickly deplete that fund, forcing the LDC governments to search outwardly for financial aid in their time of need. In addition to the economic differences between the two country categories, characteristics of the MDC’s and LDC’s food production and supply culture can come

into play in terms of natural disasters and their global health impact. Because MDCs typically have adequate sources of, and may in some cases experience an overconsumption of, food, damages to the food supply by sudden natural disasters would not permanently debilitate the country or lead to mass malnutrition. Such is not the case for LDCs, though, in which food supplies are generally low, farming is for subsistence, and malnutrition is not a rare occurrence. When unanticipated catastrophes hit these areas, damages to the food supply can be devastating and cause even more loss of life. Furthermore, because MDCs are, as their name describes, more developed, these countries typically have much greater access to medical care and greater levels of sanitation as compared to LDCs, where overcrowding and little sanitation may already provide the grounds needed for the spread of infectious diseases.11 Comparing MDCs to LDCs, then, there is reason to wonder whether areas struck by disasters governed by MDCs receive aid and have needs addressed at a generally faster rate than those of LDCs. However, in analyzing the Texas-Bangladesh situation in particular, a complication exists that may serve as a divergence from the general trend of MDC versus LDC access to aid: both the Texan and Bangladeshi floods occurred at the same time on different sides of the world and medical aid, consequently, had to be divvied amongst the two disasters. The question still remains, though, whether, in the wake of having to split disaster relief resources, one country still received more aid or resources than the other. In other words, is there a fundamental difference in how we rise from the devastation of natural disasters in terms of administered relief efforts? In the case of Texas’s Hurricane Harvey flood, disaster relief aid came predominantly from within the United States, a phenomenon that occurred not only because the United States is an MDC, but also because, as the Washington Post article entitled “Dozens of Countries Offered Help after Hurricane Katrina. After Harvey, Not So Much,” suggests, the currently charged political climate may have deterred some foreign countries from offering money or supplies, instead only extending condolences to those affected.12 Nevertheless, the internal disaster relief effort for Texas’s natural disaster was quite profound: rallying the

support of the local, state, and federal governments, Texans received aid from 300 volunteer organizations; rescues for over 122,000 individuals; medical care for over 5,000 patients; over six million meals and bottles of water collectively; thousands of hygiene kits, blankets, and cots; and aid from numerous federal organizations, such as the Department of Defense and the Environmental Protection Agency. Particularly of interest is the response of the American Red Cross, which provided over 900,000 meals and

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Two boxes of food divvied amongst eight people does more than enough to explain why Puerto Rico is still in the midst of an extreme humanitarian crisis.

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1 million snacks, deployed more than 3,000 volunteers and 171 emergency response vehicles, and supported more than 100,000 Texans with over 45 million dollars in financial aid for the provision of immediate needs.13

On the other hand, in Bangladesh, the medical response and relief efforts were much more of a local and international effort than a federal one. Internationally, organizations such as UNICEF’s Children’s Emergency Fund, Save the Children, and UK-based Oxfam made great contributions by providing hygiene kits, solar lamps, and fleece blankets for those in need and equipping more than 180,000 victims with food and clean water.14,15 Furthermore, under the guidance of the Red Cross’ partner, the Bangladesh Red Crescent, food was distributed to over 20,000 flood victims.16 In spite of this, local aid remained the primary source for disaster relief in Bangladesh. Because local organizations were particularly able to understand the degree to which the catastrophic floods had wreaked havoc upon the country’s public health, sanitation, and economic institutions, and being so close to the source of devastation, they were able to focus their resources on the particular needs of individuals devastated by the monsoon floods. The truth of the matter, however, is

that in being backed by an MDC who has a federally recognized and well-constructed plan of action for disaster relief, Texas’s prosperity in terms of individuals’ public health will be better off in the long-run. For Bangladesh, on the other hand, volunteer organizations are still struggling to find enough clean water to provide the victims. Bangladesh started off in conditions much less conducive to rapid recovery should a natural disaster strike, and when one finally did, the resources and aid just were not in place in order to aid in a swift recovery following the devastation. On account of these two disparate outcomes as a result of available aid, the question becomes: where does Puerto Rico, as a developing territory that is also a commonwealth of a more developed country, fit into the grand scheme of disaster relief response? CNN reports that even though Puerto Ricans are provided with 10,000 containers worth of food, water, and medical supplies, access to these resources is very limited since the trucks that need to transport them to where they need to be are significantly impeded by totally razed infrastructure and destroyed roads. And even with this, fuel shortages and damaged cell towers additionally prevent drivers from reaching their destinations. In other words, the supplies are where they should be—but can’t be where they need to be. In lieu of the lack of access to supplies, then, local efforts were made by gas stations and supermarkets to ration out grocery products as much as possible.17 And while organizations such as the Red Cross are on the ground to facilitate relief efforts by distributing food and bottled water, two boxes of food divvied amongst eight people does more than enough to explain why Puerto Rico is still in the midst of an extreme humanitarian crisis. Many Puerto Rican citizens point out that there really exists no structural organization in the distribution of relief supplies; most of the matter is left up to the serendipity of those who happen to be around when supplies are rationed.18 In terms of volunteer forces on the ground in order to help ease the burden of devastation, organizations such as United for Puerto Rico, UNICEF, Save the Children, and One America Appeal are doing what they can to funnel money and supplies

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to the areas that need them most. 19 On an international level, furthermore, the response is quite strong, with Puerto Rico receiving aid from numerous global organizations aimed at reducing the burden of people living within natural-disaster-torn areas. Red Cross volunteers, for example, are continually distributing hygiene and sanitation kits along with highly sought-after food and water, yet emergency shelters are still needed by many in the Puerto Rican population.20 Federally, the US’s FEMA has approved for more than 500 million dollars in assistance to be distributed throughout various sectors of Puerto Rico, whether it be for critical and immediate assistance, sanitation amelioration, or small business improvement.21 All in all though, much of the aid being rendered has yet to fully reach its recipients. So how do you categorize the relief efforts of an island where the supplies are readily available, but not readily accessible? Does the response to Puerto Rico’s natural disaster more closely fit the mold of an LDC response, an MDC response, neither, or both? After investigation, it can be concluded that the case of Puerto Rico is truthfully a middle ground, one in which aspects of both LDC and MDC responses come into play to create the situation currently observed throughout the country. Specifically, in terms of Puerto Rico’s economic status and the amount of aid the people of the island truly receive, Puerto Rico mimics much more closely the

model of a less developed country, one in which the island’s economy must look to external sources to obtain sufficient aid and relief, and in which infrastructure—the washed away roads and lack of widespread electricity in particular— prevents the extensive distribution of aid for even the most basic needs, such as potable water. On the other hand, Puerto Rico’s disaster relief request initiative can be said to mimic that of an MDC in terms of the publicity and global recognition rendered to the cause. Similar to what happened after the extent to which floodwaters had decimated southern Texas following Hurricane Harvey had been realized, American media quickly recognized and made an effort to publicize the destruction caused by Hurricane Maria’s floodwaters in Puerto Rico. In simply talking about the devastation that had occurred in the US commonwealth so readily and openly, more citizens in both the United States and abroad became aware of the situation and were, consequently, willing to send money and supplies to aid in relief efforts.

foreseen (yet can be mitigated by human behavior that reduces the progression of climate change), preparedness can—and, consequently, should—be. In fact, in the cases of both Bangladesh and Puerto Rico, the issue at hand was not the governments’ improper allocation of monetary funds toward disaster relief and emergency aid, but rather a general lack of resources available in order to do so in the first place. A possible solution to this plight would be to institute a baseline disaster preparedness module in even the least developed of countries in order to ensure that territories around the world had a least some funds allocated toward relief should disaster strike. Turning this solution into a reality, though, may pose a challenge since its establishment requires the cooperation of other countries to channel funds and resources into preparedness for those who have yet to establish a plan. In increasing disaster preparedness, we could increase disaster response and, in turn, more quickly and effectively improve the health and prosperity of victims after such crises.

If Puerto Rico is a commonwealth essentially stuck between two worlds and, just like Bangladesh and Texas, is in dire need of supplies and financial assistance, what is the next step that we can take to ease the burden of destruction caused by natural disasters and prevent as catastrophic of repercussions in the future? Firstly, it must be asked why and how these catastrophes occurred in the first place. And while the onset of severe meteorological events cannot always be

Nevertheless, we can all immediately play a part in contributing to the rehabilitation and relief of individuals living within natural-disaster-torn areas of Texas, Bangladesh, and/or Puerto Rico, as well as others. Food, bottled water, proper sanitation, and shelter still remain highly sought-after in each of these areas, yet less developed regions such as Puerto Rico and Bangladesh are experiencing particularly catastrophic hardship due to a decreased access to financial amenities, as well as washedout infrastructure that prevents even an adequate distribution of relief supplies. Consequently, to find out what we each can do to minimize the negative impact of these natural disasters on the citizens of these territories and help motivate disaster preparedness efforts in the future, visit https://reliefweb.int/organizations#content for a comprehensive list of relief organizations. Any aid rendered is a step toward future prosperity. www

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US troops helping a woman in need in the aftermath of Hurricane Harvey.

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Tomeka Frieson is a first-year in Berkeley College with the prospective major of the History of Science, Medicine, and Public Health. She can be contacted at tomeka.frieson@yale.edu.

PUERTO RICO

YALE GLOBAL HEALTH REVIEW

Defining the Future of

PUERTO RICO: An Analysis of Hurricane Maria BY MATTHEW PETTUS

An officer assisting with relief efforts in the aftermath of Hurricane Maria looks over San Juan, Puerto Rico. VOLUME 5, NO.1 NO. 1

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pproximately 105 miles off the coast of the Dominican Republic lies a small island in the northeast of the Caribbean Sea. On September 20th, Puerto Rico was hit by Hurricane Maria, a Category 5 hurricane. The major national disaster left the densely-populated island in a state of shock, chaos, and emergency. As the tenth strongest Atlantic-based hurricane, it mirrored the damage from Hurricane Irma (landfall on 9/6) throughout the northeast Caribbean. This is a unique issue not only because of its time sensitivity, but because of Puerto Rico’s fragile condition as well, meaning that any assistance the island receives has the potential to alter its developing identity and role in international affairs. The destructive wake of Hurricane Maria has left Puerto Rico in a state of self-insufficient isolation, with the potential to degrade even further via public health epidemics, infrastructural issues, and lack of access to quality resources. Furthermore, as disclaimer, we should initially establish that although the immediate situation in Puerto Rico is dire, it may improve by the time this article is published; however, the implications related to public health and policy remain highly relevant. 1 Puerto Rico’s history with epidemics could speak to the potential for the emergence of another disease. We can predict the course of action for Puerto Rico by examining other developing nations’ states post-natural disaster. Thus, it is necessary to employ a historical analysis throughout this article in order to determine the archipelago’s rate of infectious disease. The circumstances that historically led to the island’s prevalence of cholera, dengue, and, most recently, Zika, will be discussed in the latter half of this article—their determinants are fairly similar. Though post-Maria problems are only beginning to appear in Puerto Rico, its effects are suitable for the emergence of a parasitic or viral disease. The aftermath of a natural disaster is a ripe time for epidemics: it is primarily environmental factors that would play a role in the potential emergence of an infectious disease. Destroyed homes have forced people into close proximity in the form of community shelters. Moreover, affected Puerto Ricans are not prioritizing their health as much as they would otherwise (e.g. by not washing their hands or consuming standing water from the

roadside), exhibiting a lack of sanitation which thus facilitates the likely emergence and spread of disease. Additionally, said standing water is also a prime breeding ground for mosquitos, sources of parasitic diseases such as hepatitis A and enteroviruses. This notion is corroborated by the past examples of the largescale earthquake in 2010 in Haiti as well as Hurricane Katrina in 2005 in New Orleans, Louisiana, through which enteric epidemics arose. In January of 2010, Haiti was struck by formidable earthquake, which killed and wounded thousands, while leav-

Organization, they made significant progress in repairing the nation’s infrastructure. 3 Another example of a disease outbreak stemming from a natural disaster is the rampant general health issues throughout New Orleans in the aftermath of Hurricane Katrina. While infectious diseases like tuberculosis and West Nile virus played a role in affecting the citizens, chronic diseases and inability to access health resources were more prevalent. Because it was difficult to access crucial health screenings, immunizations, and reproductive health services,

The ruins left in the aftermath of Hurricane Maria at Barriada Belgica, Ponce, Puerto Rico.

ing millions homeless. Several parallels can be drawn between the aftermaths of both Haiti post-earthquake and Puerto Rico post-Maria, especially because conditions in each nation were similar before the natural disasters. Haiti’s economy and government were unstable and corrupt, and when combined with the earthquake, the subsequent living conditions were ripe to facilitate an epidemic. 2 Because of this, Haiti experienced a devastating cholera outbreak that affected more than 700,000 people. However, they were resilient, and along with third party organizations like the Center for Disease Control and the World Health

several issues developed over time, such as: eye and ear infections, sexually transmitted infections, and hypertension. Several disaster-related clinics were established in New Orleans to combat these, and slowly but surely, the communities affected by Katrina have progressed back to normal over the course of several years.4 Moreover, infrastructural issues primarily characterize Puerto Rico’s label as a developing nation. Broadly, these issues manifest themselves as: a general lack of access to quality resources, and a powerless government; they have also

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been intensified by the wreckage caused by Hurricane Maria. For example, it is necessary to address the direct effects of Hurricane Maria, rather than the indirect effects and potential future resulting from it. The destruction from the hurricane rapidly deteriorated Puerto Rican society and lifestyle. Homes were upended, people were separated from their families, trees were stripped, and roads were destroyed by wind and rain. This left the surviving citizens in a state of uncertainty—a period of paranoia where there seemed to be no hope of recovery. Sever-

The little water that exists on the island is contaminated, so naturally people are drinking less, bathing less, and flushing toilets less, potentially causing public health issues like dehydration, generally bad hygiene, and cholera. The lack of water goes in tandem with the nationwide lack of power. Much of the island has blacked out, as weakened the energy grid—as of October 15, 85% of the island had no electricity.6 This is one of the most significant ways that they are isolated to the outside world—nobody can leave, communicate, or stay hygienic on the island at this time. Puerto Rican Governor Ricardo Rosselló has stated

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al fled the island to escape the tragic conditions. However, those who couldn’t afford to were left to deal with the harsh reality of Hurricane Maria. When describing the battle for survival, Leyla Santiago, a CNN Reporter with family in Puerto Rico, details, “The struggles are everywhere. And where there is help or supplies, there are lines, always lines. Some days, it would be people lining up for gas. And then for food at the supermarket. The longest lines were now to use the ATM.” Other more significant struggles for resources stem from previously existing infrastructural issues on the island.5

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that power should be restored to 95% of the island’s energy grid by December 15, but of course no guarantees can be made.7 Moreover, because the Puerto Rican health care system is so ineffective, the lack of power and resources has put a large strain on hospitals, who are trying to deal with public health issues before it turns into a crisis. Firstly, hospitals are exceeding capacity simply due to the amount of people who need aid. Mobile clinics have begun to be created, but are not as effective since caretakers are not comprised of medical professionals but

rather humanitarian aid workers and volunteers. This is mainly because of the shortage of doctors in Puerto Rico. This shortage was exacerbated by Hurricane Maria in that some doctors are not well enough to practice, so the few hospitals on the island—that people can access— are understaffed. As an example, emergency room wait times have skyrocketed in the struggle for resources on the island. 8 Furthermore, the Puerto Rican government isn’t able to take action because it is bankrupt and seemingly corrupt. Thus, Puerto Ricans have been relying on local government and private organizations to aid them in their time of need. Additionally, because jobs were also destroyed by Maria, it is going to be very difficult to rebound into success after this tragic setback. In order for a tragedy of this magnitude to occur again, Puerto Rico’s infrastructure needs to be rebuilt in a more modernized way—perhaps with the aid of larger entity as well. 9 Combined, these infrastructural issues make it difficult to accomplish any sort of reform in a weather-torn Puerto Rico, and illustrate the necessity of a third-party solution. It is well known that President Trump is not doing much to help rebuild Puerto Rico—he has thus far declared a State of Emergency and given them aid in the form of food. However, it seems that most of Puerto Rico’s aid in the near future will be from third party organizations like United for Puerto Rico, ConPRmetidos, the American Red Cross, and several others. You can help by donating to any organization that directly provides humanitarian aid to Puerto Rico. In light of the US response to Puerto Rico’s situation, statehood for the island is once again being heavily debated. This could potentially alter the course of any future tragedies that come its way, as well as help Puerto Rico to rebuild its infrastructure. Natural disasters would not have effects as adverse as these if it were a developed nation, so let’s help it become exactly that. 1 www Matthew Pettus is a sophomore in Saybrook College. He is a prospective Cognitive Science major. He can be contacted at matthew.pettus@yale.edu

HAITI

A Malnutrition Crisis: Its Past, Present, and Future BY HANNAH VERMA

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n early 2010, a massive earthquake decimated the Republic of Haiti. As one of the most poverty stricken nations in the world, it lacks the resources both to prepare for natural disasters and deal with the aftermath. The result? 1 in 5 children are malnourished. Approximately 50% of the population lives on less than one dollar per day.1 Only 50% of people have access to what is known as “an improved water source,” such as a hand pump or well, meaning that the rest are forced to rely on untreated lakes and rivers.2 These statistics represent only a small portion of the challenges faced by Haitian citizens. Investment and development efforts prior to the 2010 earthquake have since resumed, and have made an impact, but recent natural disasters have interrupted any progress. Haiti is especially vulnerable to these storms, due to its location in the heart of the “hurricane belt.” As a result, the malnutrition crisis remains, and will remain, a crucial issue in Haiti until further intervention.

Haiti’s population is largely centered around its youth, with over half of its population under the age of 20.3 Of its roughly 10.6 million inhabitants, most towns are concentrated in Haiti’s coastal regions and urban areas, with 60.9% of people living in urban cities.4 The population is 95% African American, while the remaining 5% are “mulattoes” (mixed ethnicity) or white.5 The mulatto population, long considered the Haitian elite, tends to face less of these hardships. Rural areas face a poverty rate significantly higher than urban areas, along with a lower median income.6 This economic inequality is accompanied with a host of discrepancies in other crucial areas, including access to sanitation, water, food, and jobs. In rural areas, health outcomes are greatly affected as well; the prevalence of underweight children and lack of knowledge on HIV exceeds that of urban areas by a wide margin.7 Malnutrition wreaks havoc on Haiti’s population. The greatest victims are, unfortunately, the ones who are least able to tolerate it: children. The USAID reported that less than 50% of children under the age of six months are breastfed and less than 20% of children between six months and twenty-three months of age receive appropriate nutrition.¹ Mothers who are malnourished and underweight are unlikely to be able to deliver milk to their children, creating a cycle of undernourishment. And after birth, children are chronically malnourished, stunted, and underweight. 13 Malnutrition in Haiti is also stratified regionally. The highest rates of malnutrition are in the Southeast and Center regions, 29% and

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28% respectively, and the lower rates of malnutrition are in the West, Nippes, and Metropolitan regions, with rates of 17%, 17%, and 15%, respectively.1 The cities with the lowest rates are all major trade centers or urban centers, further highlighting the relationship between geography and inequality. Malnourishment at a young age has ripple effects that extend throughout one’s lifetime. It reduces the ability to work at full capacity, slows cognitive development, and thus affects school performance and earning potential.13 Decreased productivity reduces potential to move up the economic ladder. This can doom one’s children and future generations to a repeated cycle of poverty and malnutrition as well. An overall lack of infrastructure and development is compounded by these eco-

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The Haitian government has proved unable to provide all of the support its citizens need, whether it be infrastrure or agriculture loans.

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nomic disparities. Without access to clean, safe drinking water, rural Haitians more easily succumb to infectious water b r u n t of enormous tropical depressions, cyclones, hurricanes, and storms. These factors can destroy an entire year’s worth of crops, and in turn destroy remaining infrastructure as well.12 Through the process of deforestation, the roots of once sturdy trees are eradicated, leaving nothing to hold the topsoil in place. This erosion increases the likelihood of flooding and damage from storms, which in turn increases food prices and make crops even more difficult to grow.

In early 2017, the Haitian government relied on the Copenhagen Consensus Centre to diagnose the most pressing issues and develop comprehensive, cost-effective solutions. The CCC used a benefit-to-cost ratio (BCR) to evaluate major issues, such as infectious disease, and the proposed solution. Because the BCR did not take into account the nutritional benefits of increased sustainability farming, the government prioritized other, more efficient (as calculated by the BCR) projects instead.15 Consistently, a weak Haitian government has proved unable to provide all of the support its citizens need, whether it be infrastructure or agricultural loans. Though Haiti still faces constant agricultural and health crises, the country, in conjunction with several partner nations, has made progress in addressing these issues. Through the Haitian government’s Nutrition Strategic Plan, the nation-

al Commission for the Fight Against Hunger and Malnutrition works with several agencies, including the Haitian Red Cross, to meet three goals: 1) to improve access to food; 2) to invest in the agricultural industry to increase crop yields; and 3) to deliver essential services such as healthcare and sanitation.1 US government intervention consists of USAID programs, such as Feed the Future, which focuses on rural agriculture, and the SPRING project, which aims to help pregnant women and young children. To improve agricultural production, a potential change could be consolidating both private sector and public investment, with the private sector checking the public sector’s lack of accountability and direction, and the public sector decreasing market entry barriers to increase competition, driving down the overall costs of goods and services. After the 2010 earthquake, foreign aid from countries, such as from the United States, was heightened and used rather effectively; since then, global awareness of and support for Haiti has seemed to die down.14 Even after further development, many who live in Port-au-Prince dwell in flimsy shelters, vulnerable to yet another storm that will surely hit Haiti in the coming years. Haiti is not the only country in the hurricane belt, but it seems to get hit the hardest, a result of its lack of a coping mechanism and disaster mitigation. The damage sustained from each natural disaster will set Haiti further back in its quest to eradicate hunger and sickness. Especially with the effects of climate change, it is more crucial than ever that Haiti is able to manage the infrastructure needed to prevent irreparable harm. By strengthening the agricultural sector through existing programs such as Feed the Future partnership,1 Haiti can work towards sustainable farming practices. Past efforts by the Haitian government have been successful; from 2006 to 2012, rates of stunting decreased from 28.5% to 22.2%.14 However, until Haiti formulates stronger policies for improving food security and reducing economic inequality, its workforce, made of malnourished citizens, can never thrive. To fully escape the shackles of poverty, Haiti must focus on feeding its hungry. www Hannah is a first-year in Branford College studying History of Science, Medicine, and Public Health She can be contacted at hannah.verma@yale.edu.

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GLOBAL

Women's Health:

The Basis for Global Health BY RACHEL JABER CHEHAYEB

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he diversity of biological, environmental, social and governmental factors that contribute to shaping overall population health and the extent of interconnectedness of these factors make trade-offs between interventions and decisions of resource and fund allocation exceedingly difficult. Nevertheless, women’s health perseveres as an accurate indicator of and contributor to overall health levels. Investing in women’s health, from reproductive health provision through access to family planning services to acknowledging the role of gender to reducing women’s NCD burden and gender-based violence, has huge positive externalities that are far-reaching in time horizon and scope of impact; adopting a women’s health approach to global health is a tremendously effective and sustainable manner to shape global health, with current and intergenerational benefits outweighing those of more vertical approaches. Family planning services through boosting reproductive health greatly shape global health

Family planning services (FPS), key components of reproductive health, have far-reaching impacts on several determinants of global health. One of the ways women’s health indirectly shapes global health is through contributing to economic growth. Merely meeting one third of the need for family planning in Nigeria, Kenya and Senegal could pull up income per capita by 8 to 13 percent.1 Access to abortion services has comparable overall influences on the economy: the drop in overall education levels and subsequent decreased economic productivity of children post 1967 in Romania was traced back to the abortion ban.1 These results are significant given the role of higher GDP per capita on increasing life expectancy and on decreasing the rate of disease and mortality.1 The use of family planning services greatly suppresses the probability of delivering low birth weight babies,1 hence contributing to overall improved health in the long run. These far-reaching effects are evident upon analyzing progress after twenty years of implementation of the Family Planning and Maternal Child Health (FPMCH) program in Matlab, Bangladesh. Mere access to these services caused child mortality to drop by 20% and a quantifiable increase in wealth and education levels. Families were hence able to invest in key sanitation and preventative measures like access to clean water, leading to a reduction in neglected tropical disease incidence. Child weight, nutrition

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and immunization status all showed improvements,2 as did the health of family members in general, including elderly living in the households. Furthermore, each prevented birth increases female labor force supply by two years, leading to more overall economic growth.2 Climate change experts claim that in the long run family planning services could significantly impact the deceleration of climate change.3 These factors collectively corroborate the tremendous impact of investing in women’s health on overall health. Moreover, according to WHO estimates, 100,000 maternal lives would be saved annually if women could avoid unwanted pregnancy.4 Putting aside all the aforementioned benefits of access to FPS, this mere reduction is on its own substantial given the hefty societal costs of maternal mortality. Current maternal health levels determine the overall health status of the next generations Maternal mortality and morbidity are directly correlated to losses in social and economic development and decreases in health levels. Each maternal mortality de-

creases GDP per capita by $0.36, a significant drop given that a country’s economic growth contributes to 40% of reductions in infant mortality, a core health-related sustainable development goal.5 GDP drops also imply a drop in healthcare spending, hence a decrease in overall healthcare services’ provision.1 Aside from maternal mortality, exposure to maternal undernutrition or famine in utero has far-reaching effects on literacy, income, and even adult risk of hypertension and sub-optimal glucose tolerance later on in life. Maternal obesity was observed to increase risk of neonatal deaths in 27 separate African countries.1 Lower maternal height and lower maternal weight were respectively linked to worse child health and low birth weight,1 hence exhibiting the spillover effect of maternal health on the future, creating a “vicious cycle”. Aside from mothers’ physical health, mental health is also of critical importance. Postpartum and maternal depression have exorbitant consequences, from both a health and development perspective. The latest lancet series on early childhood development (ECD) stresses both the importance of nurturing care on early childhood development, and the long term conse-

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Community health volunteers

quences the proper formation of neuronal synapses and brain development have on children achieving full potential.6 Besides its potentially harmful impact on ECD, a mother’s poor mental health has possibly fatal long run impacts on a child through being a risk factor for malnutrition, stunting, infectious diseases, diarrheal disease and disordered or insufficient immunization.1 In the most extreme case of maternal mortality, there is an amplified risk of infant mortality, a revealing causation given that paternal mortality does not alter the risk of infant mortality.1 Maternal orphans tend to have lower educational attainment and extreme economic difficulties that further fuel the cycle. Women’s health, however, extends beyond mere maternal health and has larger health implications, particularly upon considering the rapidly growing global health burden of non-communicable diseases (NCDs). A women’s health focused approach is key to reducing the overall NCD burden As non-communicable diseases continue to pose a growing global health threat, contributing to 60% of deaths,7 both targeting NCDs in women and targeting women’s health in general prove to be arguably the most effective approaches of dealing with these challenges. Cancer is the leading cause of death among women, leading to huge losses in disability adjusted life years and having traumatic impacts on children and families due to a mother’s prolonged suffering.8 Debt accrued due to women’s cancer causes extreme financial difficulties that have negative impacts on heath.8 According to the International Agency for

Research on Cancer, approximately 3.3 million women died from cancer in 2008 worldwide.7 Investing in women’s health and cancer treatment partially alleviates the costs of maternal mortality, psychological trauma and economics losses that reduce access to healthcare. These costs highlight the importance of focusing on women’s health: evidence suggests that increasing available studies on women’s health and NCDs and including more women in research would greatly effect health outcomes overall.8 Women’s health also affects NCD incidence and progression throughout the population. As mentioned earlier, prenatal malnutrition is highly correlated to subsequent risk of hypertension. A pregnant woman’s intake of one recommended daily allowance (RDA) of multiple micronutrients would lead to lower chances of chronic disease development in her child.8 Besides long term investment, educating women about NCD prevention and promoting healthy lifestyles in women causes a mirroring of induced changes and reduced NCD incidence in entire communities as a whole.9 Hence, the global strategy for women’s and children’s health states stresses the importance of gender empowerment and the integration of women’s care with other services when targeting NCD reduction.9 This prioritization, or even consideration, of women’s health, unfortunately, is not always the case. Investing in women’s health is secondary to investing in infectious disease control Investing into infectious disease control, particularly into HIV/AIDs, is frequently portrayed as a more effective approach to

global health promotion, with Bill Clinton, for instance, having announced that HIVAIDS programs, through strengthening infrastructure and generating positive benefits, would be ideal starting points to improving global health.10 These claims have proved to be misguided, with indicators like prenatal care, maternal health and even basic vaccinations plummeting as an effect of the centralization of infectious disease programs.10 In practice, vertical programs have proved to divert healthcare workers away from basic primary care provision towards infectious disease control, hence inducing neglect of other vital elements of health.10 Despite the volatility of infectious disease patterns, the health status of women continues to act as a stable measure of a well-functioning health system.10 Furthermore, maternal health itself plays a role in controlling infectious disease spread. In Kwa-Zulu Natal province in South Africa, the spread of extensively drug resistant TB was traced back to failed treatment completion due to an ailing health system that was over-focused on battling HIV.10 On the other hand, targeting the improvement of women’s health is a more sustainable approach, as it encompasses the improvement of health infrastructure that would allow for improved preparedness to combat emergent infectious diseases, while also indirectly inducing a drop in the spread of sexually transmitted diseases. Poor mental health in women, for instance, has repeatedly been linked to depressed use of contraception and hence increased risk of contraction of HIV among other STDs.11 In this context, a women’s health-based approach to global health has hence become the equivalent of a prevention-focused, sustainable long-term approach to global health and development, as opposed to a series of narrower short-run “symptom” targeting approaches. The above mentioned hyper-focus could also occur within the realm of women’s health, as in the case of neglect of gender-based violence. Violence against women is a human rights issues as opposed to a global health threat Gender-based violence, that predominantly affects women, is seldom considered a public health issue.12 This is noteworthy given the huge global burden of violence: data accumulated from several sources stress the contribution of violence to injury and ill-health, with one out of every five healthy days of life lost to women of reproductive age being traced back to gender-based victimization.12 Female-focused violence also impedes social and econom-

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ic development and hence impedes progress in health indicators. Physical violence during pregnancy has been correlated to suboptimal birth outcomes, like premature birth and low birth weight, in addition to an increased burden of mental disorders, all of which impact mother and youth.12 Several costly intestinal disorders have been linked to abuse in women, with violence in general decreasing available resources due to costs of treatment.12 Violence against women also significantly reduces use of contraception due to “fear of mail reprisal” thereby reducing the success of family planning services while increasing the risk of STI contraction, thereby driving progress to a standstill.12 In this case, the trauma of abuse experienced by mothers has proved to be intergenerational, deeply impacting children who witness it psychologically.12 This impact of violence, alongside the impact of diseases and biological responses in general, varies with gender in nature and severity, a phenomenon that is unfortunately often disregarded. There is not much merit in adopting a gender-based approach to health The unique needs of mothers and women in general are often undermined, with common assumptions including that what

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benefits the child benefits the mother,13 and that progression and risk of disease are rather identical among men and women. These beliefs divert resources away from gender-specific research that could contribute greatly to global health. In fact, men and women exhibit distinct trajectories of illness with women, for instance, being much more likely to develop post-traumatic stress disorder as a result of child abuse.11 Sharp variations in depression rates and rates of drug abuse between genders are apparent, with a large proportion of DALYs due to neuropsychiatric illness being traced back to women.11 This sizeable burden stresses both the importance of emphasizing women’s health to reduce the global burden of DALYs and the importance of developing a deeper understanding of gender differences in designing specific cost-effective approaches. Traditional association of particular diseases with gender has been contributing to differences in quality of treatment, with women receiving lower quality diagnoses and treatments for cardiovascular diseases, due to CVD being traditionally associated with men.14 Gender-based interventions would surely be more effective in reducing the global burden of disease than the “one-size-fits-all” policy currently in place.15 In fact, Vera- Regitz- Xshrosek claims that incorporating gender-specific

analysis into medical research and the development of distinct treatment approaches could reduce treatment prices in the long run while improving overall global health across genders, with the continuation of non-gender specific therapy being the least favorable to overall health in the long run.15 In conclusion, women’s health is at the heart of global health, with the current status of women’s health being a rather accurate mirror of both current and future global health levels, and a reflection of the quality of existing health infrastructure and services. This importance of women’s health merits a channeling of investments and global efforts towards improving not only reproductive and maternal health, but also the health of women outside the realm of motherhood, coupled with a need for increased research into gender-based health differences. The impact of gender-based violence on overall health is simple proof of the hefty cost of neglecting a contributing factor to women’s health. A women’s health-focused approach to health is hence both sustainable and all- inclusive, equating women’s health to global health. www Rachel is a sophomore in Pauli Murray College. She can be contacted at rachel.chehayeb@yale.edu.

The Yemen Civil War and its Effects on Civilians

n a country plagued by civilian casualties, potential famine, and a cholera outbreak, the Yemeni civil war rages on between the Houthi rebels and government forces, with the citizens of Yemen stuck in the middle. The Houthis’ goal is to end government corruption—and to end Western influence—while ultimately creating a modern democracy. Yet, the war between the rebels and the government continues to compromise the safety of the people of Yemen through famine, disease outbreak, and a dilapidated healthcare system. In 2011, towards the end of Yemeni President Saleh’s reign, the Houthi rebels initiated several rebellions against the leader. Beginning in February of that year, the revolution in Egypt sparked a series of protests against the current president. In March, President Saleh offered to step down from his position, but the Houthi rebels and their supporters rejected the offer, and the protests continued for several months until June, when opposition forces launched a missile into the presidential palace. The severely-injured president, suffering from a collapsed lung and burns on over 40 percent of his body, was taken to Saudi Arabia for three subsequent months to receive treatment. Shortly after his return, he signed over his executive power to Vice President Abdu Rabu Mandur Hadi, still retaining the presidential title until the official handover ceremony in February of 2012.1 This transition of power was meant to serve as a source of stability, easing the country’s political turmoil. However, because Hadi failed to solve many of the issues at hand, the unrest was not resolved. Throughout the beginning of his presidency, Hadi struggled with many aspects of the presidential position, failing to address a separatist movement in the south, attacks by al-Qaeda, or the problems of unemployment and food insecurity. What’s more, the situ-

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ation was not improved by the loyalty that many military officers still showed toward former President Saleh. Capitalizing on the new president’s weaknesses, Houthi rebels took control over the Saada province in northwestern Yemen. In September of 2014, the rebels entered the capital city of Sanaa, setting up roadblocks and street camps. Just a few months later, the Houthis surrounded the presidential palace, forcing Hadi to flee abroad in March of 2015.2 These events culminated in a war that would result in civilian casualties, famine, disease outbreaks, and a healthcare system too weak to adequately address these issues. By March of 2017, upwards of 7,600 people had been killed, and another 42,000 injured. Of these, nearly 5,000 deaths and 8,000 injuries were civilians.2 Dr. Tankred Stoebe, former President of Doctors Without Borders—also known as Médecins Sans Frontières (MSF)—said that they saw more than 800 casualties per month at the hospital he worked at in Taiz, and the majority of them were women and children. In fact, in February of 2016, the doctors at Al-Jumhori, a hospital in Saada, were presented with one of these tragic cases. A young woman arrived at the hospital with 60 percent of her body covered in burns. Her home, located in the Razeh district of the Saada province, had been hit by an airstrike. Because travel was highly dangerous at the time of the attack, her family had to wait a week before bringing her to the nearby health facility. However, the injuries were too severe for the clinic to handle. They had to transport her to Al-Jumhori five hours away. By the time she got there, she was septic and suffering from severe organ failure. “We did what we could,” said Dr. Mariela Carrara, a doctor working with MSF, “but there was no hope.” Some people made it to the hospital in time for a more prom-

YALE GLOBAL HEALTH REVIEW

ising outcome. During Dr. Carrara’s first couple of days, a young couple was rushed into the hospital. Their home had been hit by an airstrike and although the husband had suffered only minor injuries, the wife was missing almost all of the soft tissue in both of her arms. The doctors quickly got to work and began preparations for amputation. Explaining that the couple had already lost their four children, the husband begged for the doctors to try their best to save her arms. Fortunately, the doctors successfully treated the wounds, and the wife even endured a successful enough recovery to later return to the hospital to thank Dr. Carrera.3 Since not all victims are able to access health facilities with ease, though, relief workers in the area strive to treat as many patients as possible. In fact, workers at MSF facilities work 16-hour days, taking breaks in the basement of the facilities, where they sleep on shared mattresses. The danger of the immediate area means they cannot leave the facility, and they must always be ready for incoming patients. Workers have said that they know patients are coming in when they feel the ground shake. The airstrikes are generally deadly, yet even in cases where the attacks are not completely fatal, victims are left in critical conditions with severe injuries. In addition, the frequency and unpredictability of airstrikes cause individuals to question the safety of the facilities. The risk of travelling to health

care facilities, and the lack of definite safety while there, discourage people from seeking health care altogether, leading to an overall higher propensity for fatal injuries.3 Increasing restrictions on food and fuel imports poses yet another problem for the civilians of Yemen, for around 90 percent of the country’s food supply is imported. Currently, however, the country’s northern ports are controlled by the Houthis, and the southern ports by government forces. Due

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Due to widespread government corruption, much of the food and other necessities coming into the country through these ports do not ever even make it to the citizens most in need. Cholera is spreading across the country at dangerous rates, leaving nearly 2,000 dead and infecting close to 800,000 people.

to widespread government corruption, much of the food and other necessities coming into the country through these ports do not ever even make it to the citizens most in need.8 This, combined with the dangers of travelling, makes it difficult for people to access adequate food supplies needed for their families. As a result, more than 17 million people are currently considered food insecure, 6.8 million of which are considered severely so. In addition, approx-

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This woman fled with her family after a Saudi offensive in her village and since has had to sleep in the open outside Harad.

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imately 3.3 million women and children who are either pregnant or breastfeeding are acutely malnourished. Some young mothers face malnutrition so severe that they are no longer able to breastfeed, leaving their babies without proper nutrients as well. Additionally, 462,000 Yemeni children under the age of five face severe acute malnutrition.4 While visiting an area of Yemen where major aid agencies can no longer operate, reporter Nawal al-Maghafi encountered a

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severely malnourished boy. He was eighteen months old, but weighed about as much as a six-month-old baby, and could not walk or talk. Moreover, he was lactose intolerant, so his body could not digest normal milk. Before the war, the formula he needed was readily available, but since the war has continued to decimate basic supplies, it has become very difficult to get his formula, exacerbating his now life-threatening condition. Nearby, a four-year old boy was brought to the hospital with diarrhea and a fever. He was diagnosed with an infection that his body could not fight off because he was malnourished, yet all he needed was an antibiotic. However, due to the lack of medical supplies in hospitals, the doctors could not give him the medicine he needed, and he died shortly after being admitted. “Poverty has always affected Yemen, but now there’s a risk of losing an entire generation,” explained Nawal al-Maghafi.2 Lowered immune systems as a result of malnutrition is also a growing concern. Although a major problem among children, the issue is also becoming more prevalent in adults. Cholera is spreading across the country at dangerous rates, leaving nearly 2,000 dead and infecting close to 800,000 people.4 Just a few years ago, the disease was nearly eradicated in Yemen, yet is currently infecting an average of 5,000 people per day.5 As a result of the war, millions of citizens have been cut

off from clean water, and waste collection has ceased in major cities. The worsening hygiene and sanitation conditions have left thousands susceptible to infection.6 In fact, one of these victims was presented to Dr. Stoebe, the former MSF president, when he was working in an emergency room. A family came in with a pregnant mother who had cholera. When she arrived at the hospital she was already very sick and required immediate IV fluids. Shortly after, however, she began experiencing cramps, and her baby was prematurely born the following day. Nevertheless, the baby required ventilation for an hour and a half, and remained unstable for several days. Eventually, though, the mother and her child were able to be reunited. “It was just pure luck that we could save both mother and child,” said Dr. Stoebe.4 However, had it not been so difficult for the family to get to a health facility in the first place, they likely would have avoided the health risks altogether. By November of 2016, only 45 percent of the country’s 3,500 health facilities were functioning. MSF was providing healthcare in 12 hospitals and supporting 18 other healthcare facilities throughout the country at the start of the war in March 2015.7 By February of 2016, however, three MSF healthcare facilities and one ambulance had been hit by airstrikes, leaving eight dead and hundreds of thousands deprived of access to emergency medical care.3 Now, even those within close proximity of hospitals perceive the medical facilities as unsafe, and often are afraid to attempt the journey until it is too late to receive proper treatment. The 30,000 government health employees who occupy these facilities and are essential in the fight against the cholera epidemic have not seen payment in nearly a year.5 Dr. Stoebe stresses the importance of the issue: “We are having really a lot of trouble getting enough resources coming into Yemen, enough doctors, nurses…. [We need] international aid workers to help out because the local system is on the brink of collapse.”4 Health employees are not the only workers affected by the war. One man, a teacher with a pregnant wife and five children, reveals that although he retains his job as a teacher, he has not received payment in eight months. As a result, his family is faced with hunger and the threat of eviction. All over Yemen, college graduates and other highly educated people find themselves

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Many camp residents are malnourished children.

no longer receiving a salary or altogether unemployed. In addition, there are little to no jobs in the private sector as a result of the rapidly deteriorating economic situation, leaving many of these people without work.8 Despite the abysmal state of the war-torn country, there are several groups working in Yemen to fight the various hardships the country faces from the war. MSF helps to treat tens of thousands of injuries resulting from the war, and throughout the country, they have 1,600 staff members on duty. In fact, in 2016 alone, more than 32,900 patients received treatment in MSF facilities for wounds resulting from intentional physical violence.7 Mona Relief is an organization fighting against the current hunger crisis in the area. They presently have 380 people working in Yemen delivering food baskets to families in need. These baskets can each feed a family of six for up to a month. Despite the noble work of the organization, though, more aid is needed; this group alone only assists three million of the seventeen million individuals suffering from hunger.8 The World Health Organization (WHO) and its partners are also working to put an end to the cholera epidemic. They have been setting up cholera treatment clinics, rehabilitating the dilapidated health facilities, and delivering medical supplies to the area. Currently, data shows that more than 99 percent of people with suspected cholera who can access health services are

surviving. However, the WHO also reports an estimate of nearly fifteen million people that are unable to receive basic healthcare. The country’s healthcare crisis is far from over. While these efforts are improving the lives of millions of people, they are not enough to get Yemen back on its feet. The country needs a political resolution. There will be no end to civilian casualties until fighting and airstrikes cease. Additionally, unless the ports are opened up, and food can be transported throughout the country again, the country will be pushed into famine. The cholera epidemic will continue until the living and sanitation conditions improve. All of these issues have one common solution: an end to the civil war. With Houthi rebels control the northern region of Yemen and government forces in control of the south, though, it is difficult to imagine a resolution in the near future. With the help of international organizations, however, food distribution, health facility access, and increased amounts of supplies can help put an end to many of the hardships that plague Yemen. www Kristi Wharton is a sophomore in Branford College majoring in History of Science, Medicine, and Public Health. She can be contacted at kristi.wharton@yale.edu.

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REFERENCES

Jenesis Duran 1. Water. (n.d.). Retrieved from http://www.un.org/en/sections/issues-depth/water/index. html. 2. Lewis, K. & Yacob, L. (Eds.). (2004). Water Governance for Poverty Reduction. Retrieved from http://www.undp.org/content/dam/aplaws/publication/en/publications/environment-energy/www-ee-library/water-governance/water-governance-for-poverty-reduction/ UNDP_Water%20Governance%20for%20Poverty%20Reduction.pdf. 3. Diabetes kills 3.4 million people every year: WHO. (2012). Retrieved from http://www. unmultimedia.org/radio/english/2012/11/diabetes-kills-3-4-million-people-every-yearwho/. 4. Achieving Water and Sanitation Services for Health in Developing Countries. (1970). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK50770/. 5. Water in a Changing World. (n.d.). Retrieved from http://www.unesco.org/fileadmin/ MULTIMEDIA/HQ/SC/pdf/WWDR3_Facts_and_Figures.pdf. 6. Water Security in Developing Countries. (2013). Retrieved from http://12.000.scripts.mit. edu/mission2017/water-security-in-developing-countries/. 7. Gürsoy, S. I. & Jacques, P. J. (2014). Water security in the Middle East and North African region. Retrieved from http://www.kysq.org/docs/WatSec_ME.pdf. 8. The Water Challenge. (2017). Retrieved from http://www.gwp.org/en/About/why/ the-water-challenge/. 9. Projects & Operations. (2017). Retrieved from http://projects.worldbank.org/ search?lang=en&searchTerm=&mjsectorcode_exact=WX. 10. Perlman, U. H. (2016). Saline water: Desalination. Retrieved from https://water.usgs. gov/edu/drinkseawater.html. 11. Ultrapure Deionized Water Services and Reverse Osmosis Systems. (n.d.). Retrieved from http://puretecwater.com/reverse-osmosis/what-is-reverse-osmosis#reverse-osmosis-performance-trending-and-data-normalization. 12. Seawater Desalination Costs. (2011). Retrieved from https://watereuse.org/wp-content/ uploads/2015/10/WateReuse_Desal_Cost_White_Paper.pdf. Yasheen Gao 1. Stoeltje, M. 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