Yale Global Health Review Vol 4 No 3 by Yale Global Health Review

SPRING 2017

VOL. 4, NO. 3

An Examination of the Opioid Crisis: Methods of Mitigating Pain By Nancy Lu p. 9

Chris Schwarz/Government of Alberta

LETTER FROM THE EDITORS SPRING 2017 VOL. 4, NO. 3 Dear Readers, We’re thrilled to share with you the Spring issue of the Yale Global Health Review! While global health may conjure mental images of distant countries and continents, it is important to recognize that domestic issues in the United States are very much part of this dialogue. Our feature article, “An Examination of the Opioid Crisis: Methods of Mitigating Pain” by Nancy Lu, critically examines the opioid epidemic in America. By widening the perspective beyond the United States, we observe the stark disparities that exist in different countries, often falling across socioeconomic lines. Beyond the United States, we hope that this issue serves as a platform to engage in discussion about topical, international issues. Global health is a multi-faceted field and our publication tries its best to allow readers to view these complex challenges from a variety of angles. We have included experiences from students doing fieldwork in Asia, from epidemiological studies in Bangladesh to qualitative research in India on a wearable technology originally developed in a Yale class. Other pieces investigate palm oil deforestation in Indonesia, health disparities in the Pacific Islands, and much more. On a final note, this is our last issue as Editors in Chief. As such, we’d like to take a moment to sincerely thank each and every member of this publication. From our meticulous writing and editorial staff to our production and design team that makes each page come to life and to our business team critical in funding all of our endeavors, we are humbled by your passion for this publication. Although we are sad to be stepping down, we are confident that this publication is in good hands. We are excited to see the Yale Global Health Review continue to play a critical role in the future, raising awareness about global health issues both for the wider Yale community and beyond. For more global health, visit our blog at yaleglobalhealthreview.com. Better yet, to get involved, send us an email at yaleglobalhealthreview@gmail.com. All the best, Jessica Schmerler & Kai DeBus OUR TEAM Editors-in-Chief Jessica Schmerler Kai DeBus Senior Editors Anabel Starosta Ohvia Muraleetharan Rebecca Slutsky Associate Editors Elijah Rami Hannah Krystal Katarina Wang Krista Chen Minh Vu Sarah Householder Copy Editors Annabelle Pan Dhikshitha Balaji Katarina Wang Krista Chen Nancy Lu

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Senior Online Editor Holly Robinson Online Editors Al Nurani Carlin Sheridan Devyani Aggarwal Dhikshitha Balaji Production & Design Team Amber Tang Holly Zhou Michelle Cheng Business Team Ahmad Hassan Dhruva Gupta Spencer Briney Staff Writers Akhil Upneja, Colin Hemez, Elijah Rami, Emma Phelps, Holly Robinson, Laura Michael, Matthew Pettus, Nancy Lu, Sarah Spaulding

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.

VOLUME 4, NO. 3

CONTENTS

HEALTH PERSPECTIVES

p. 3

HEALTH POLICY

p. 5

Indigenous Responses to Violence Against Women By Emma Phelps

Failure to Fund: The Mexico City Policy’s Impact on Global Health By Caroline Tangoren

Ramon Llorensi

ON THE COVER An Examination of the Opioid Crisis: Methods of Mitigating Pain By Nancy Lu p. 9

p. 21 p. 23 p. 26

FIELD WORK

Bangladesh: In Practice By Sreeja Kodali

HEALTH TECHNOLOGY

p. 12

INTERVIEW

p. 15

GLOBAL HEALTH TODAY

p. 18

Digital Health in the Context of China’s Healthcare System By Megan Lam Q&A With Gregg Gonsalves: Global Health Justice Now By Karina Xie Coinfections: Managing a Dynamic Network of Diseases By Colin Hemez

HEALTH POLICY

A New World Health Organization: The Search for a Director-General By Matthew Pettus

FIELD WORK

White Male Suicide: The Exception to Privilege By Laura Michael Flickr

p. 31

FIELD WORK

Why International Agreements Won’t Solve the Health Crisis of Palm Oil Deforestation in Indonesia By Akielly Hu

DISEASE EPIDEMIOLOGY

The Epidemic of Drug-Resistant Tuberculosis By Sarah Spaulding p. 29

FIELD WORK

p. 36

GLOBAL HEALTH TODAY

p. 41

GLOBAL HEALTH TODAY

p. 49

HEALTH PERSPECTIVES

p. 53

A Qualitative Analysis of Accredited Social Health Activists’ Experiences in Udaipur, India By Sara Locke

Zika as a Catalyst for Reproductive Rights Reform in Latin America By Gracie Jin CIFOR

GLOBAL HEALTH TODAY

A Legacy of Imperialism: Health Disparities in the Pacific

By Erica Kocher p. 45

The Rise of Hospice Care in China By Evaline Xie

CRISPR/Cas9 and the Future of Global Health By Akhil Upneja

HEALTH PERSPECTIVES

Andrea Wiglesworth

ALASKA: Violence Against Indigineous Women

very February 14th, indigenous women call attention to missing and murdered Native American and Alaska Native women. This year, Yale Sisters of All Nations, a group of indigenous women at Yale, held an art exhibition in the Ezra Stiles Art Gallery in collaboration with Yale Native American Arts Coalition. The show commemorated missing women through various community-produced pieces. At its center were four shawls, every one representing a stage of life: infancy, adolescence, adulthood and old age. Each shawl was made by a different indigenous woman at Yale, displaying traditional designs from four different nations; hanging together they symbolized pan-indigenous solidarity.1 The exhibition mourns the shameful violence against Native women, and seeks to heal with a message: “sisters, aunties, mother, and grandmothers… you are remembered, you are loved, you are missed.”1 This artwork highlights the fact that indigenous women in the United States and Canada go missing and are murdered at a higher rate than women of any other racial or ethnic group. 61% of Native women in the United States have been assaulted at least once, often by a non-Native.1 One in three indigenous women in the United States are raped over the course of their lifetime.1 First Nations women account for

By Emma Phelps only 4% of the female population, but represent 16% of murdered women.2 Violence against Native women constitutes a critical public health issue. Just last year, The National Institute of Justice released a study of American Indians and Alaska Natives that examined rates of sexual violence, physical violence by intimate partners, stalking, and psychological aggression by intimate partners, and found that 84.3% of the women studied had experienced some form of violence, and 55.5% had experienced physical violence from an intimate partner.3 In fact, 82% of men surveyed had also been the victims of violence.3 According to the CDC, intimate partner violence often leads to severe consequences for victims’ mental and physical health. Women who have been attacked are more likely to suffer from depression, chronic pain, and difficulty sleeping than non-affected women.4 They are also much more likely to report physical symptoms, such as musculoskeletal and genitourinary disorders and respiratory illness.4 Although the response to violence cannot only occur in the domain of public health, the CDC seeks to prevent violence against women. The extremely high rates of violence against indigenous women date back to colonialism and land dispossession of Native communities. Contrary to some Western

depictions, violence against women is not traditional in Native cultures. Most violence against Native women is perpetrated by non-Native men.6 Many Native societies are matrilineal and hold women in high regard, giving them distinctly important social roles.7 Settlers stole Native lands using physical violence, including explicitly gendered violence, and imposed heteropatriarchy on Native societies.8. White settlers frequently assaulted Native women as part of a genocidal campaign intended to clear the land. Centuries later American society still contains still contains traces of a sexualized, dehumanizing perception of Native women, a perception that becomes terrifyingly concretized in today’s high rate of attacks on Native women.5 This violence is not simply due to the actions of individual men; rather, these assaults represent ongoing colonialism and disrespect of tribal sovereignty.5 White American hostility towards Native Americans has expressed itself in diverse outlets over hundreds of years. Efforts to destroy indigenous cultures and forcibly assimilate Native children began in the early 1800s, when residential boarding schools in the United States and Canada separated Native children from their families and banned them from speaking their Native languages in order to “kill the Indian in the child.”8 As late as 1978, 25% of all Indian

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children in the United States lived in boarding schools, foster care, or non-Native adopted homes.5 These boarding schools were sites of well-documented and rampant sexual, physical and emotional abuse. Even the simple removal of children from their homes tremendously injured traditional familial ties. The intergenerational trauma inflicted by the boarding school system continues to haunt Native communities: many of those who were once forced into boarding schools did not learn traditional parenting models later developed mental illness, both of which have been shown to negatively affect their children.9

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binary has had serious consequences for Two Spirit health: Two Spirit indigenous people are today more likely to be sexually or physically attacked than both heterosexual indigenous women and white lesbian women. Transgender indigenous women are especially disproportionately attacked. Yet public discourse almost entirely fails to acknowledge these injustices, as well as the inadequacy of services to help indigenous transgender and Two Spirit people who have suffered attacks.10 Native survivors of violence suffer particular legal disadvantages in pros-

Because only tribal sovereignty will defend Native women from sexual assault, protection of Native women is inseparable from the protection of tribal sovereignty.

A less discussed but equally damaging Western intrusion to Native culture is the imposition of a rigid gender binary. This strict structure particularly impacted Two Spirit people, who use a pan-Indian identification that describes a variety of non-binary gender roles found among indigenous nations and trans-gendered Native people. As a result of forced integration into heteronormative Western culture, these populations are currently at an elevated risk for gender-based violence.10 Before colonization, two-thirds of the over 200 indigenous languages spoken in North America are thought to have contained a term for individuals who were neither men nor women.10 Colonial efforts disregarded these worldviews, imposing gendered power dynamics and compelling Native peoples to conform to a Christian, patriarchal family model, or else be deprived of their human rights.10 The enforcement of a gender

Andrea Wiglesworth

“Clipped Wings” by Mallory Isburg (Lakota) on the left evokes the lives cut short by violence against indigenous women.

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ecuting their attackers. Federal laws set the maximum sentence in a tribal court to one year.5 In addition, tribes often do not have the authority to prosecute crimes committed on tribal land, because sexual violence falls under the Major Crimes Act, which lies under federal, not tribal, jurisdiction.5 This is particularly pernicious because federal attorneys decline to prosecute in 75% of the cases brought to them that involve crimes on tribal land.5 Without real legal authority, tribes are often unable to act aggressively, or even adequately, to punish violence against Native women. Therefore protection of Native women from physical and sexual assault is inseparable from the protection of tribal sovereignty. But simply increasing the amount of federal policing on reservations is not the answer. Already, Native American men are incarcerated at four times the rate of white men, and Native American women are incarcerated at six times the rate of white women.5 Native Americans are more likely than any other racial group to be killed by the police.5 In order to preempt this, some tribes have launched “community restorative justice projects,” aiming to keep the punishment of Native offenders within the tribe.5 These programs, however, may pressure victims to simply reconcile with their attackers in order to preserve their own place within the community. Activists are currently at work to create systems that hold perpetrators properly accountable without promoting mass incarceration. Grassroots efforts that demand acknowledgement of missing and murdered Native

women (such as the artwork featured in the article) have succeeded in opening discussion on the topic at the national, state, provincial, and tribal levels. Some states have begun to release reports on the topic, and to fund interventions.6 Several of these focus on the need for improved data collection, noting that violence against indigenous women is seriously underreported because many victims have little faith that their attackers will be prosecuted.6 People are also pushing for better services towards preventing violence against Natives and helping Native survivors. Ending violence against indigenous women requires more than just training staff at traditional domestic violence shelters on cultural competency training. There are some organizations that are now tirelessly working to remedy the current situation, such as the National Native American Boarding School Healing Coalition (NABS) that helps Native communities fraught with intergenerational trauma.11 Another good example is the indigenous-led organization National Indigenous Women’s Resource Center (NIWRC), which promotes policies that protect both tribal sovereignty and women’s health; another one is the Native American Women’s Health Education Resource Center (NAWHERC) which puts these sorts of policies into practice. The NAWHERC promotes traditional women center projects such as birth control, domestic violence and sexual assault initiatives. However, their agenda also includes affordable healthcare, nutritional security, the right of Native nations to determine tribal membership, the rights of Two Spirit people, and an end to coerced sterilization. NAWHERC understands that violence against Native women requires a combination of improved social services, housing, healthcare, economic development and respect for tribal sovereignty. The indigenous women who run NAWHERC express their demands simply as “the right to live as Native women.”

www

Emma Phelps is a sophomore in Grace Hopper College majoring in Ecology and Evolutionary Biology and Ethinicity, Race, and Migration. She can be contacted at emma.phelps@yale.edu.

Wikimedia

FIELD WORK

FAILURE TO FUND: The Mexico City Policy’s Impact on Global Health

By Caroline Tangoren

n January 23rd, just two days after the historic Women’s March on Washington demonstrated popular support for women’s rights, President Trump signed an executive order to reinstate the Mexico City Policy, dealing a horrible blow to women’s health globally.1 Broadly speaking, this hot-topic policy prevents any international non-governmental organization (NGO) that provides or promotes abortions from receiving United States government funding. The Mexico City Policy, also known as “the Gag Rule,” has come and gone since its creation in 1984 under the Reagan Administration.2 Unfortunately, the policy has become a high-profile piece of legislation in both international and domestic abortion politics. Many have argued, quite convincingly, that the Mexico City Policy is a gross violation of human rights enumerated in the United States Constitution and international law, as well as an illegitimate form of donor control.3 Even ignoring these more political issues, however, objective review of the Mexico City Policy demonstrates its failure: it has been unsuccessful in bringing about the desired reduction in abortions, and has negatively impacted healthcare provision for unrelated issues including child immunization, HIV prevention and treatment, and prenatal care.4 The consequences of these funding restrictions were evident, particularly for marginalized female populations, when the policy applied to a mere 6% of all US global health funding.4,5 As the Trump Administration expands these funding restrictions to all global health aid, the detrimental health outcomes previously seen may only be exacerbated.6 The Mexico City Policy under the Trump Administration must be met with newfound opposition from legal and public health scholars. Advocacy, employing

both ethical and empirical arguments, is vital to repealing the Gag Rule and protecting decades of progress in global health. The Mexico City Policy’s Historical Origins The first serious restrictions on foreign family planning aid came in 1973 with the Helms Amendment. This statutory ban, passed shortly after the Roe v. Wade decision made abortion legal in the United States, banned all US funds from the Foreign Assistance Act from paying for the performance of abortion as a method of family planning. The ban did not extend to abortion in cases of rape, incest, or threat to the life of the mother. While the Mexico City Policy has remained a controversial issue over the decades, there has been very little political discourse on the Helms Amendment.7 In the 1980s the Reagan administration was put under considerable pressure from anti-abortion and, in extreme cases, anti-family planning constituents to push the Helms Amendment even further. The result, announced at the 1984 International Conference on Population in Mexico City, was a set of serious restrictions on US family planning aid. The United States delegate stated that “the United States does not consider abortion an acceptable element of family planning programs.” As such, the United States would no longer contribute to any NGOs that “perform or actively promote abortion as a method of family planning in other nations.” The US cited the call for “legal protection for children before birth” under United Nations Convention on the Rights of the Child as a motivating factor for such restrictions.8 Ironically enough, in 2017 the United States is

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now the only state in the entire 193-state UN system that has yet to ratify the Convention on the Rights of the Child.9 The Mexico City Policy, or Gag Rule, consisted of three major restrictions. First, no USAID money could go to groups using even non-US funds to promote or provide abortions, or conduct research to improve abortion methods. The Gag Rule also prohibits aid recipients from lobbying, even withnon-US funds, for the liberalization or decriminalization of abortion. There could also be no public education campaigns on the benefits or availability of abortion as a family planning method. Finally, health workers in USAID-funded NGOs could not actively promote abortion as an option for their patients/clients. They could not refer women to an abortion provider in countries where abortion is legal in circumstances other than rape, incest, or life-threatening conditions.10 There are important nuances in the Gag Rule worth highlighting. First, these restrictions apply only to abortion as a family planning method, and do not apply to abortion in the case of rape, incest, or threat to the life of the mother. Furthermore, the restrictions previously applied only to funds awarded for family planning, not to grants for any other global health programming, such as HIV prevention and treatment. Additionally, NGOs that received USAID funding are not permitted to work with NGOs that do not follow the Gag Rule’s restrictions. For example, NGOs receiving contraceptives from the US are not allowed to distribute them in clinics that provide abortions.11 The gag rule on lobbying applies to prochoice groups only; anti-abortion groups have no such limitations on speech or political activism. Finally, physicians, nurses, and other family planning counselors are able to “passively respond” to clients’ specific questions about abortion. They cannot, however, initiate the conversation nor offer information outside the scope of the client’s questions. Such questions can only be answered after the provider is sure the client is pregnant and that said client has already decided to have a legal abortion. While the exceptions to provider silence were designed to lessen the most significant Gag Rule controversies, many NGOs feel abiding by the Mexico City Policy would still force them to compromise their ethics.10 The Mexico City Policy stayed in place from 1984 until 1993, when President Clinton rescinded it. During the Clinton administration, political turmoil surrounding the policy

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grew. President Clinton threatened to veto any bill put forward containing similar foreign aid restrictions. Anti-abortion leaders in Congress slowed down legislation on issues ranging from foreign assistance appropriations to trade in attempts to gain bargaining power on this particular issue. This fighting had substantial negative consequences for governmental functioning, including a government shutdown and delays in UN dues payments from 1995 to 1999. Finally, a compromise was struck: Republicans supported the repayment of almost $1 billion the US owed to the UN, and the Smith Amendment was passed. The Smith Amendment was a more tempered version of the Mexico City Policy in which foreign NGOs were subject to the same restrictions regarding abortion. Those that refused to comply, however, could still receive up to $15 million in funding.3

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The policy previously applied to only the family planning and reproductive health funds, a mere 6% of the global health budget. President Trump expanded the policy to include all US global health assistance in all agencies and departments.

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The Smith Amendment remained in effect until President Bush took office in 2001. President Bush reinstated the Mexico City Policy on the anniversary of the Roe v. Wade decision, and expanded the policy to include State Department funds used for family planning overseas. Importantly, however, the Bush Administration chose not to extend the policy to HIV/AIDS funding. The continued limitation on the policy suggests even proponents of the Gag Rule believed it had at least some negative health consequences. Furthermore, the restrictions on abortion lacked support when more generally applicable threats such as HIV/AIDS seemed to be involved, rather than threats to women’s health, alone. The policy remained in place until President Obama took office in 2009, at

which point he, like Clinton, rescinded the policy.3 In January 2017, President Trump reinstated and drastically expanded the Mexico City Policy. The policy previously applied to only the family planning and reproductive health funds, a mere 6% of the global health budget.12 President Trump expanded the policy to include all US global health assistance in all agencies and departments, not simply US family planning aid through USAID and the US Department of State. The current agencies and departments affected by the policy include USAID, the State Department, the Center for Disease Control and Prevention and the National Institutes of Health (under the Department of Health and Human Services), and the Department of Defense.13 Furthermore, abortion laws globally are relaxing such that many countries allow legal abortions in cases outside the GagRule-approved situations of rape, incest, or threat to the life of the mother. In 2017 more NGOs may face situations in which Gag Rule restrictions limit discussions of legally permitted medical procedures.3 The expansion of the policy’s application and the relaxation – albeit limited – of abortion restrictions in foreign nations means more NGOs than ever will be put in a difficult position in choosing whether to comply with the Mexico City Policy’s restrictions. The Global Gag Rule’s Impact on Health When the Mexico City Policy was first enacted in 1984 and when the policy was reinstated in 2001, NGOs were immediately thrown into what many viewed as a lose-lose situation: rejecting the restrictions would cause a serious drop in funding, reduced service provisions, and poor health outcomes, while adherence to the policy prevented full disclosure of health information and options to clients, again resulting in poor health outcomes.10 While there is a lack of robust literature on the impact of the policy, available information overwhelmingly shows the validity of this catch-22. The Mexico City Policy has failed to reduce the number of abortions.3 Instead, it has resulted in decreased access to contraceptives, increased rates of unwanted pregnancies, increased abortion rates, and reduced access to non-abortion health care for hundreds of thousands of people around the globe.4, 14 Decreased Access to Contraception The US government is the largest purchaser and distributor of contraceptives internationally, and USAID is key in assisting the estimated 225 million women who have an unmet need for modern contraception.15

However, as demonstrated during the last active period of the policy, the Gag Rule severely reduces the availability of contraceptive use.3, 4, 13 A study of 20 Sub-Saharan African countries, for example, shows significantly different growth rates in the prevalence of contraceptive use for countries depending on the amount of USAID funding they received. If a country received more USAID funds than the average African nation, it was considered to have high-exposure to the Mexico City Policy. If it received below average funding, it was considered to have low-exposure. After the Mexico City Policy was reinstated in 2001, contraception use prevalence in low exposure countries grew 1.8% faster than contraception use prevalence in high exposure countries, reaching statistical significance.13

its services. This was particularly impactful given Planned Parenthood’s key role in distributing contraceptives to smaller NGOs and government health centers. Proponents of this policy often say USAID could simply collaborate with other NGOs who comply with the Gag Rule to keep contraception access up.4 However, research suggests that these other NGOs may be less effective and experienced than larger aid recipients, such as Planned Parenthood in Zambia, and also may be more limited in their geographic reach.3

unwanted pregnancies and, both tragically and ironically, contribute to an increased demand for the very procedure the policy seeks to eliminate.

Increased Rates of Abortion When the Mexico City Policy was first in place from 1984 to 1992 there was no evidence that it reduced the incidence of abortion.3 Instead, as previously mentioned, the decreased access to contraception may have contributed to increased abortions in Romania and other Central and Eastern European nations with legal abortion Wikimedia such as Albania, Armenia, and Moldova.4, 16 The increase in abortions during active Gag Rule times was well quantified in the aforementioned study on Sub-Saharan Africa, as well.13 Low exposure countries had relatively consistent abortion incidences, From 2001 to 2008, ranging between 10 and USAID stopped supply20 induced abortions per ing contraceptives to any 10,000 women-years from NGOs in 16 developing 1994 to 2008. High expocountries in Africa, Asia, sure countries, however, and the Middle East. Many saw an exponential growth of these countries suffered increase when the Mexico from very high rates of City Policy was reinstated HIV.4 For example, the in 2001 (Figure 2). Further Lesotho Planned Parent- The Mexico City Policy has decreased access to contraceptives as the US government is the largest analysis found women in hood Association (LPPA) purchaser and distrubtor of contraceptive services internationally. a high exposure country received 426,000 condoms after 2001 were 2.55 times and similar quantities of IUDs and oral conEven if the Planned Parenthood Associa- more likely to have received an induced abortraceptives from 1998 to 2000. When the Gag tion of Zambia had accepted the Gag Rule, tion than women in a low exposure country, Rule was put back in place in 2001, howev- the situation may not have been much better. even after controlling for women’s place of er, LPPA was ineligible for USAID-provided NGOs in Romania, for example, accepted residence, education attainment, and use of contraception. LPPA was the only recipient the Gag Rule and were forced to terminate contraceptives, as well as funding for famiof USAID supplies, and thus from 2001 to their partnerships with abortion providers ly planning and reproductive health from 2008 no NGO in Lesotho received family during the Bush Administration. Abortion sources other than the US.13 These numbers planning aid or contraception supplies from is legal in Romania and very common: there include both safe and unsafe abortions, with the US government. This cutoff occurred at a is a substantial lack of family planning ser- the health and economic consequences of the time when one in four Lesotho women were vices, and the health system pays physicians latter being particularly extreme. The World HIV positive.4 more for providing abortions than contra- Health Organization estimates that five milception. The Mexico City Policy forced the lion women are admitted to hospitals as a In 13 other developing nations, USAID division between these preventative and re- result of unsafe abortion every year in develstopped supplying contraception to the lead- active approaches to unwanted pregnancies. oping countries.17 The annual cost of treating ing providers of family planning services, Thus women who received abortions had major complications from unsafe abortions such as Planned Parenthood Association more limited access to quality counseling is approximately $680 million, thus putting of Zambia, who refused to follow the Gag or contraception to prevent future unwant- significant strain on developing nations’ fiRule.4 While the Planned Parenthood As- ed pregnancies. Research suggests this sep- nancial resources and health infrastructure.18 sociation of Zambia does not even provide aration, driven by the Mexico City Policy, abortions, it refused to limit its counseling actually contributed to increases in induced Maternal Mortality and General Health or referral information. This was particular- abortions.3, 4 It is thus reasonable to assume Services Impact ly important to the organization, as Zambia that the expansion of the Mexico City Policy The negative impacts of the Mexico City permits abortions under more liberal circum- under the Trump Administration will result Policy do not end with unwanted pregnanstances than the Gag Rule, including risk to in a reduction in contraception use, regard- cies and abortion. Instead, the Gag Rule forcthe health of the mother. Thus, the Planned less of whether or not NGOs accept or reject es noncompliant NGOs to lose significant Parenthood Association of Zambia faced a the Mexico City Policy. Such a reduction in funding and scale back vital health services. 24% budget cut, and was forced to scale back contraception use will drive up the rate of It allows abortion politics to dictate issues

YALE GLOBAL HEALTH REVIEW

from HIV prevention to child immunization to malaria treatment.4, 19 As Trump’s expansion subjects even more funds to the Mexico City Policy’s restrictions, the consequences of the policy beyond 2017 may be even greater than in previous decades.

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The Gag Rule forces noncompliant NGOs to lose significant funding and scale back vital health services.

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Most obviously, the policy hurts maternal health. The scaling back of family planning services and closure of clinics reduces women’s access to prenatal and postnatal services. This in turn reduces the likelihood of women having a skilled birth attendant present during delivery, and increases the risk of maternal death during childbirth. Nepal, for example, had the second highest maternal mortality rate in the region (527 maternal deaths for every 100,000 live births) when the Mexico City Policy was reinstated in 2001.20 Many organizations refused to submit to the Gag Rule during this time because Nepal had some of the strictest abortion laws in the world: women could be imprisoned for seeking or receiving abortions for any reason whatsoever. The Ministry of Health was actively calling on NGOs to join in advocacy work and the expansion of abortion services, and thus NGOs refused to curtail their political activism to receive USAID funding. This activism ultimately resulted in the 2002 liberalization of abortion laws to make exceptions for rape, incest, and risk to the life of the mother. Even after 2002 NGOs felt continued education on unsafe abortions and health consequences was vital to fully realize the new law, and thus many continued to reject to the Gag Rule.15 From 2001 to 2008, Nepal lost approximately $100,000 per year in USAID funding. Due to significantly reduced budgets, many NGOs eliminated mobile clinics providing prenatal and postnatal care, among other reproductive services unrelated to abortion.21 Paradoxically, the Mexico City Policy even negatively impacts the health of women who carry their pregnancy to term.

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The consequences of the policy are not limited to women, either. For example, the Family Planning Association in Kenya refused the Gag Rule restrictions and lost so much funding it was forced to close clinics serving 19,000 people. Marie Stopes International Kenya, a leading family planning organization with a particularly strong presence in marginalized rural areas, closed clinics serving over 300,000 men, women, and children. It laid off one fifth of its staff and increased client fees, as well. These clinics provided much more than family planning services: they provided malaria treatment and screening, HIV testing and counseling, and child immunizations.4 Ethiopia provides another poignant example of the reduced access to healthcare due to the Mexico City Policy. Organizations such as the Family Guidance Association of Ethiopia refused to curtail their public awareness campaigns on abortions. The Family Guidance Association of Ethiopia does not provide abortion services; however it frequently speaks to policymakers about the thousands of lives lost annually due to unsafe abortions. Its commitment to educating policymakers on this serious public health issue cost the organization over half a million dollars in USAID funding. As a result, the Family Guidance Association of Ethiopia closed several healthcare centers and clinics serving over 300,000 women and 229,000 men in urban Ethiopia. Rural areas were additionally hurt with the reduction or elimination of community-based distribution programs. These programs were often the only source of family planning services, HIV information, and health referrals in the most remote areas of the country.22 As clinics close and are forced to concentrate limited resources in particular programs or geographic regions, the Mexico City Policy exacerbates issues of inequitable access to quality healthcare on both a local and global scale. Moving Forward: The HER Act This article puts forth substantial evidence that the Mexico City Policy is, bluntly, a failure. It fails to promote US values abroad, such as free speech, political engagement, and gender equality. It fails to improve, or even maintain, healthcare access for men, women, and children. It even fails to achieve its main objective to reduce induced abortion rates. The Mexico City Policy imposes the conservative views of a minority of Americans on hundreds of thousands of individuals around the globe.3, 23 With the consequences of the Gag Rule evident, policymakers have mobilized against these ineffective funding restrictions. Within

24 hours of Trump’s executive order expanding the Gag Rule, Vermont Senator Jeanne Shaheen and New York Representative Nita Lowey introduced the Global Health, Empowerment, and Rights (HER) Act in the Senate and House of Representatives, respectively.23 The HER Act strives to permanently repeal the Mexico City Policy, stating that foreign NGOs shall not be ineligible for foreign aid “solely on the basis of health or medical services, including counseling and referral services, provided by such organizations with non-United States Government funds.” Organizations are also free to use non-United States Government funds for advocacy and lobbying activities.23 While the Act has overwhelming Democratic support, it has important support from Republicans such as Maine Senator Susan Collins as well. The HER Act has been read twice and referred to the Committee on Foreign Relations, before hopefully returning to Congress for a vote.24 Given the obvious inefficacy of the Mexico City Policy, the passing of the HER Act is vital for global health improvements and the realization of women’s reproductive rights. Regardless of the Policy’s discriminatory nature, violation of international law, and financial coercion of foreign NGOs, public health analyses alone demonstrate the Gag Rule’s failure. It reduces women’s access to contraception, increases rates of unwanted pregnancies, and actually contributes to increased abortion rates, all while putting unethical limitations on compliant healthcare providers’ free speech and professional judgment.3, 21, 23 Noncompliant NGOs are forced to reduce or eliminate health services, causing negative health outcomes unrelated to abortion and exacerbating inequality issues both within and across countries.4 The United States is the largest funder and implementer of global health projects in the world.5 With such power comes a responsibility to objectively evaluate policy outcomes and respond accordingly. Hopefully the recent HER Act will inspire such reflection and reverse these ludicrous funding restrictions. Then the United States may be able to use its wealth and international influence on global health to promote, rather than hinder, progress. www

Caroline Tangoren is a junior Global Health Scholar and Global Affairs major in Timothy Dwight College. She can be contacted at caroline.tangoren@yale. edu.

HEALTH POLICY

An Examination of the Opioid Crisis: Methods of Mitigating Pain By Nancy Lu

n January 27, 2017, the image of the Florida couple passed out in their car with a 2-year old toddler in the backseat bore deeply into the hearts of parents, people nationwide, and even addicts themselves.1 Here was one image with a clear representation of the havoc that addiction could wreak. The image would serve as one of many wake-up calls to the American people - the opioid epidemic was in full swing, and thousands of innocent children, family members, and friends were the ones suffering. In a world where people of developing countries often die due to the lack of painkillers, it is a cruel twist of irony that Americans die precisely of the opposite problem: an excess of opioid medication. The multifaceted solutions to the problem are necessarily complex, but will in many ways determine the trajectory of healthcare for years to come.

CBS News

A Florida couple passed out in their car with their toddler in January of this year shows the dangers of addiction.

Opioids are drugs that interact with the nervous system to reduce pain. They fall into two broad categories: opiates which are derived from the opium plant and synthetic or semi-synthetic drugs. Examples of opiates includes morphine, and the latter category include oxycodone, hydrocodone, fentanyl, and many other drugs that may be even more potent. Though they were initially intended only to treat pain, opioids are widely abused because of the euphoria associated with high levels of the drug. Tolerance and eventual dependence on the drugs is often the result. The United States is the world’s largest consumer of the global opioid supply. In fact, Americans consume approximately 80% of the world’s supply.2 This is not necessarily surprising due to the American emphasis on pain management. The consequences, however, are dire. From 2010 to 2014, there was nearly a twofold increase in the number of overdoses from opioids, a statistic which remains constant across almost all races, ages, and income levels.3 On an average day in the United States, approximately 78 people die of an overdose. The staggering statistics beg for a solution to the problem.4 So how did the opioid epidemic spread to the epic proportions that it embodies today? Perhaps the first step is taking a look at the history of the drug and what led to its widespread use. Opioids have long been part of both American and world history. Touted originally as a “miracle drug” or “wonder drug,” Veterans, especially of the Civil War, had already been using the drug as a potent pain reliever, but commercial use skyrocketed in the early 1900s.5 This was partly as a result of Bayer’s invention of heroin in 1898. Users quickly became addicted and found that the drug’s effects could be amplified through injection. Kimberly Johnson, the former director of the Substance Abuse and Mental Health Services Administration notes that there was a need for these drugs: “They are effective pain relievers, and that’s what they were being used for,” Johnson said. “There weren’t many other options.”5 Soon after, however, people started to understand the drastic effects of the drug, and heroin was outlawed in 1924.

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Outlawing heroin, however, was certainly not the end of the opioid problem. Throughout the 1940s and 1950s, physicians needed to treat an influx of severely injured World War II veterans.5 This demand led to an increase in the use of nerve blockers as an effective pain management method. It was not until the 70s, when Percocet and Vicodin, two extremely addictive painkillers, came into the marketplace, that doctors began to shy away from prescribing uncontrolled dosages of these drugs. Unfortunately, there were still those who believed otherwise. In the New England Journal of Medicine, for example, Dr. Hershel Jick and Jane Porter wrote that “the development of addiction is rare in medical patients with no history of addiction” after a thorough analysis of 11,882 patients.6 This conclusion, of course, implied that the opioid addiction was not something to be taken too seriously in those who had no history of addiction. The introduction of OxyContin, an even stronger painkiller, into the marketplace in 1996, once again fueled the falsehood that opioids were not that dangerous. In fact, According to the statistics from the National Institute of Drug Abuse, the number of prescriptions for the drugs increased by 2 million every year during the first several years of OxyContin’s introduction.5 By then, when physicians realized the extremely dangerous nature of the drug and its potential to serve as a gateway into illicit drugs, it was too late: the normalization of such drugs had already been created. Interestingly, while America has a widespread drug problem due to overuse, many people in developing countries face the opposite problem due to lack of proper medication. In such countries, people often spend the ends of their lives in excruciating pain from illnesses like cancer. According to the International Narcotics Control Board, approximately “92% of all morphine, an opioid commonly used to control the pain caused by cancer, in consumed in America, Canada, New Zealand, Australia, and part of western Europe.”7 These regions of the world contain less than one-fourth of the world’s population. As Canadian professor Benedikt Fischer, a prescription-drug misuse expert at the University of Toronto’s Center for Addiction and Mental Health said, “It’s an absurd situation...We’re spraying [opioid] from a fire-hose while the majority of the world doesn’t have them.”7 Obtaining opioids for people in the rest of the world is often tedious, and in

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some cases nearly impossible. Not only are pain-relieving medications and people authorized to provide such treatment scarce in rural areas, but also numerous other issues are at play. As Dr. Gayatri Palat, a researcher of pain medicine at the MNJ Institute of Oncology and Regional Cancer Center, notes, doctors themselves themselves not well-trained in pain medicine, and thus are understandably wary of the process. Dr. Palat even notes that there may be fear of stigma against prescription, saying that “[Doctors are] afraid it will cause addiction in healthier patients or respiratory depression in those with terminal illness.”7 Because of this prevailing attitude, patients in extreme pain, such as terminal cancer sufferers, often cannot even get access to morphine. Pain relief in such situations is not a priority for healthcare professionals and in a larger sense for the government. For developing countries, the emphasis is on life-threatening epidemics rather than dying comfortably. Meg O’Brien, the managing director of global cancer treatment at the American Cancer Society puts it succinctly: “No one gets in trouble if, at the end of the year, pain relief has not been procured.”8 Thus, the opioid problem seems to be a unique problem facing developed countries, especially the United States, and much of the rest of the world waits with bated breath to see if solutions will decrease access to important medications. Researchers are eagerly looking for solutions to the problem and are tackling the issue from many different angles, including education, medication to reverse overdoses, and drug rehabilitation centers. One promising lead has been the invention of naloxone, or Narcan, its brand name. Administration of naloxone to someone who has overdosed will often help him or her regain consciousness within several minutes. Thousands of people are revived by naloxone every single day, and many consider it a “wonder drug.” Naloxone cannot be abused and has no ramifications if mistakenly administered to someone who has not overdosed on opioids.9 People revived by naloxone often wake up woozy, disoriented, and craving more drugs. Still, naloxone gives emergency responders the time to advise treatment options. Naloxone was originally used exclusively in medical settings, but the drug has gradually been moved out into rural areas, where access to immediate medical care is more costly and time-consuming for

an issue where time is of critical importance. Lawmakers have paid attention as well. Forty-seven states--all except Montana, Kansas, and Wyoming--have laws that make obtaining naloxone easier. The accessibility of such drugs “reflects the relatively humane response to the opioid epidemic, which is based largely in the nation’s white, middle-class suburbs and rural areas, a markedly different response from that of previous urban-based drug epidemics.”9 Instead of using mass incarceration and a punishment-based system which was common when drugs were considered a problem of African American communities, officials are instead taking a more compassionate approach.

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Opioids have long been part of both American and world history. Touted originally as a “miracle drug” or “wonder drug”... commercial use syrocketed in the early 1900s.

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This was even reflected in the July 2016 Democratic National Convention. Senator Jeanne Shaheen (D-New Hampshire) made an impassioned plea, noting how the opioid epidemic has ravaged communities in her state.The statistics have worsened exponentially: in 2013, there were 192 overdoses; in 2014, 326 overdoses; and in 2015, overdoses. Shaheen’s main message of potentially requiring all emergency responders to carry naloxone received thunderous applause from the present delegates.1 Critics of naloxone note that what appears to be a panacea to the problem of overdose is really an illusion. Naloxone does not treat the core problem of addiction. While there is no doubt that the death toll from opioids would be higher without it, naloxone may provide a false sense of security to users. In fact, naloxone may even increase the risk of users trying to get high in the first place. Melissa Tucci, a heroin user, has been revived seven times through naloxone and she is not alone.9 As Governor Paul LePage of Maine writes, “Naloxone does not truly save lives; it

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Senator Jeanne Shaheen and Hillary Clinton at the July 2016 Democratic National Convention.

merely extends them until the next overdose….[We have] created a situation where an addict has a heroin needle in one hand and a shot of naloxone in the other, which produces a sense of normalcy and security around heroin use that serves only to perpetuate the cycle of addiction.9” But Tucci notes that naloxone is not pleasant for someone revived from an overdose. Withdrawal symptoms begin almost immediately, and Tucci, in an interview with the New York Times says, “I hate it...When I start withdrawing, I vomit, you get diarrhea, you sweat profusely, your nose will run, you sneeze and have runny eyes, and you ache so bad you can’t even walk.”9 When revived, some addicts are angry that they have been treated with naloxone--while naloxone reverses the overdose, it also eliminates the euphoria and leads immediately into withdrawal. Another possible solution to pain management includes medical marijuana. Some evidence suggests that medical marijuana is effective for chronic pain. Prescribing medical marijuana instead of opiate-based painkillers may be a viable solution. Dr. James Feeney, a surgeon in Connecticut, firmly believes that this substitution would be much safer in the long run, and more pleasant for patients as well. He is conducting his own study at Saint Francis Hospital and Medical Center in Hartford, Connecticut.11 One of the the big obstacles that researchers face is that marijuana is still classified as a Schedule I drug, which makes obtaining the drug extremely difficult.12 Currently, the best place for researchers to obtain it is from the University of Mississippi which grows limited amounts. Licensing requirements for researchers are also extremely strict. Yasmin Hard, a researcher licensed to study marijuana, is specifically interested in THC, the active component of marijuana, and whether isolating the compound can help create a potent pain reliever.11 She is also running a study determining whether this substance can help heroin users stop using heroin. The continued research into this field should be able to provide some answers. The politics of medical marijuana are certainly very complicated, but many states, such as West Virginia which has been hit hardest by the opioid epidemic, have taken a rational and algorithmic view of the issue.13 Because many healthcare professionals are not well-versed in pain management, an advisory board of both specialists, non-specialists, and health insurance experts was set up which codifies a step-

by-step approach to treating pain. At the lowest level of risk, there are topical creams with acetaminophen. The four categories of treatment then proceed from least potent to most potent. This algorithm directly tackles the issue of lack of education amongst the community. In addition, the inclusion of health insurance providers encourages them to not deny coverage to practices that may not be considered “standard.” For example, alternative pain methods to painkillers are often denied coverage currently due to unproven efficacy. Having a state-approved algorithm system could possibly change this situation. The multifaceted approaches to treating the national opioid problem will most likely need to be applied to other nations as well. One current crisis in the developing world is tramadol, an addictive synthetic painkiller that remains largely unstudied and unregulated.14 As an inducer of hallucinations and delusions, the drug is extremely damaging to users’ nervous systems. Tramadol is the developing world’s counterpart to heroin, and will likely need to be regulated by governments in the same way. However, these governments tend to succumb easily to bribery and are generally less organized, making such regulations difficult to enforce. Ultimately, in order to provide adequate care and truly solve the opioid epidemic, we must remember and follow the words of the current Surgeon General, Vivek Murthy: “...we must stop seeing addiction as a moral failing and start treating it as the chronic illness it is, one that demands our skill, urgency, and compassion.”15 Educating those who find themselves in the ever-tightening grip of addiction is certainly the first step. Continuing to administer naloxone and finding other innovative treatments, like medical marijuana, is also crucial. Identifying solutions to this problem with compassion and understanding is of utmost importance not only because the rest of the world is watching, but also because we have a duty to help those who cannot help themselves. www Nancy Lu is a freshman in Davenport College majoring in Molecular, Cellular, Developmental Biology. She can be contacted at nancy.lu@yale.edu.

YALE GLOBAL HEALTH REVIEW

HEALTH TECHNOLOGY

CHINA:

Digital Health in Context of China’s Healthcare System By Megan Lam China’s “Medical Ruckus”

arch, 2012: Li Mengnan, 17, walked into the First Affiliated Hospital of Harbin Medical University in Northern China. He carried a four-inch fruit knife. He impaled the first person he encountered in the neck, injured several medical staff, and then unsuccessfully tried to kill himself before fleeing the scene. Wang Hao, a 28-year-old intern in the rheumatology department, died from the attack. May, 2016: Dr. Wang Jun, an ear, nose, and throat specialist at the Shaodong County People’s Hospital in Hunan, was busy with patients. Suddenly, a blow to his head resulted in him being one of the latest fatalities in China’s growing number of violent attacks against healthcare workers.1 The assailants were family members of a patient waiting to be treated by him and his colleagues. They purported that doctors did not appear to care or be vigorous enough in their treatments. Such cases have grown to earn their own terminology: yinao ( ), directly translated as “medical ruckus.” The name itself is a testament to how the country’s citizens perceive China’s current healthcare system. China currently faces a double burden of communicable and non-communicable diseases.2 Respectively, these include infectious diseases like hepatitis B, dysentery, tuberculosis, and sexually transmitted infections, as well as non-communicable, “rich world” diseases, such as stroke, cancer, heart disease, and diabetes.3 China has the largest diabetic population globally, with many more at risk.4 Furthermore, a host of systemic issues makes facing the growing disease burden even more challenging: shortages in medical staff, overcrowding, lack of privacy during visits, violent incidents, poor doctor

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satisfaction rates, and strained patient-doctor relationships. Rural patients – such as Li Mengnan – are expected to travel great distances to urban regions, only to find themselves on long wait lists to receive expensive treatments they cannot afford at tertiary hospitals. Though most Chinese citizens are insured, healthcare is still a large expense with 40% of costs paid out-of-pocket or via premiums.5 Current issues are further exacerbated by China’s rapidly aging population and quackery of counterfeit drugs, which adds pressure on a healthcare system already bursting at its seams and disreputably fragmented. Though modern reforms have promised expanded insurance coverage, access to and costs of services have hardly improved. In reflection of Premier Li Keqiang’s statement at the National People’s Congress on March 13th 2014, modern challenges might be rooted in previous policy.3 Insight into these roots is vital in addressing the issues that plague China’s healthcare system, and to guide developing health systems henceforth. The Roots: Barefoot Doctors to Nationalized Healthcare The Chinese healthcare system today appears to have regressed. As early as the 1950s, the government avowed primary healthcare a priority.6 In 1964, there were more doctors in China attending the urban population of 8.4 million than there were for the entire rural population of over 500 million. Chairman Mao Zedong addressed this issue, stating “in health and medical work, put the stress on rural areas.”7 By the end of that decade, one million people were trained in rudimentary medicine, which involved a 3 to 6-month long training programme on identifying and treating common complaints by a combina-

tion of basic Western and traditional Chinese medical techniques. They were called the “barefoot doctors,” providing frontline medical care to hundreds of millions of rural villagers.8 By the 1970s, China accomplished a deed unparalleled across the developing world at the time: near-universal provision of primary healthcare via the Cooperative Medical System. Commitment to universal healthcare at the governmental level and the perceived success of barefoot doctors inspired a chain of programmes in the same vein. A testament to this is the World Health Organization’s launch of the “Health for All” programme in 1978, which gave rise to a global primary healthcare movement. In 1985, however, the Chinese government began prioritizing economic development and introduced a market economy. This led to the official withdrawal of support for the barefoot doctor programme. Despite more recent attempts to overcome the numerous healthcare challenges, such as by expanding health insurance, rural migrants and the disabled continue to lack access due to barriers, a significant one being cost.9 After the dismantling of the barefoot doctor system, healthcare was no longer a universal public good. Instead, it became something individuals chose to consume or not based on their socioeconomic status or geographic proximity to affordable healthcare. The Hope According to a Deloitte 2016 report, China’s healthcare market is burgeoning.10 Annual expenditures are projected to hit $896.7 billion by 2019, with spending growth between 2015-2019 estimated to be 8.8% annually. Still, projection of capital resources

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In a recent systemic review by Hsu and colleagues, there is inspiring evidence to suggest that the development of mHealth solutions parallels current unmet healthcare needs.

does not equate to better resource allocation. One method of change is to have policymakers continue efforts honing in on healthcare. For instance, reducing unnecessary drug usage, reforming public hospitals, and channelling private capital into the healthcare provision and insurance sector might yield benefits. Another viable force for improvement is through innovative technologies and care models – specifically, mobile health (i.e. mHealth) and wearable devices, which are changing care delivery pathways. The commercial possibilities and potential growth is reflected in the current worth of China’s 4.55 billion RMB (approximately $662 million USD) mHealth market.11 mHealth can be defined under the umbrella of electronic health (i.e. eHealth); specifically, it entails medical and public health practices supported by technology such as mobile phones, patient monitoring devices, personal digital assistants, and various other wireless devices. mHealth exploits what these devices have to offer for healthcare purposes, such as via short messaging services (SMS) or sensor-based applications and global positioning systems (GPS).12 In the past decade, there has been great interest in harvesting and optimizing the use of new technological advances to innovate in the global health realm. Though mHealth is still in its infancy in China, many remain hopeful. As the Chairman of China Mobile, Wang Jianzhou, noted, “By making full use of innovative technology and business models…it is possible to raise the level of healthcare in society, which is very important for promoting the sustainable development of the whole of mankind.”13 The Potentials In a recent systemic review by Hsu and colleagues, there is inspiring evidence to suggest that the development of mHealth solutions parallels current unmet healthcare needs. Focusing only on medical-related apps (i.e. excluding broad health-related apps, such as weight loss or menstrual cycle

management), the authors reviewed the 234 most downloaded apps, analysing various key features. Indeed, most the apps had a primary mHealth initiative of medical care access, indicative of the demand. Additionally, disease-specific apps were reflective of current disease prevalence in China. There are several conditions that set up the potential success of mHealth in China. For instance, the Chinese Central Government has been heavily investing in the development of mobile broadband coverage. The spread of this coverage led to increased rural Internet usage, making technology more accessible and economical. According to the China Network Information Center, 78.9% of rural Internet users rely on mobile phones, as opposed to laptops or personal computers. Because China is so populous, this figure represents 27.9% of Internet users in the world.12 China is not only the most populated country, but also the world’s fastest growing and largest online population – more than double that of the United States. Thus, if mHealth is widely disseminated, it could reach millions. The potential of mHealth has also evidenced itself in other developing areas, such as various countries in Africa and India, where mHealth solutions are put in place relatively rapidly in emerging markets compared to developed countries out of urgency.16 Additionally, China Mobile established a partnership with the University of Cambridge to launch an ambitious set of pilot mHealth studies in the Guangdong, Guizhou, and Tianjin provinces.16 The programmes were called Medical Link, Medicine Link, Vaccine Link, and Patient Link. The purpose of these pilots was multifaceted: to deliver medical, health, and wellness information via SMS, improve access to doctors via SMS communication, provide vaccine-related information for families, aid in self-diagnosis, create a caller operating system for appointment bookings and a better system for managing patient information, allow for mobile video consultations, provide remote diagnosis and infectious disease tracking, and enable ra-

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dio-frequency identification tracking for drugs.17 The success in these pilots was largely due to strong telecommunications infrastructure, multidisciplinary partnership, and the potential as a creative care solution to close the urban-rural divide in healthcare. The use of technology could also provide a different medium for patients and doctors, serving as a health education platform for the public or a method of task-shifting for healthcare workers. NEC Corporation

of America Another potential use is to speed up and simplify hospital operations. Tencent’s WeChat – a key smartphone application communication service (i.e. app) that has influenced the Chinese’s digital behaviour – launched a Smart Hospital Service in 2015, which has been embraced by over 1,200 Chinese hospitals. This adoption has increased efficiency by moving various processes onto the same platform. This means that patients are able to have a better grasp of their appointments and payments and have hospital navigation at their fingertips. This app ultimately addresses the overcrowding-induced chaos that hospitals often face. Additionally, patients are even able to read and receive medical reports on the app.18 Digital Health Challenges

To deduce the success of digital health based on the development of telecommunications infrastructure and number of users, although tempting, would be a logical fallacy. Reforms at the state-level can be a lengthy process, so what would be more immediately helpful are investments from private enterprises. Large private enterprises have begun making a mark in the digital health market. For example, search engine Baidu Inc. built a smartphone application for cli-

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Cambridge advised to avoid “interacting with the humongous thing,” referring to the public healthcare system.22,23 An example of such independence from the public health care system can be seen with the private insurance company Ping An Insurance Group, which launched a parallel telemedicine branch (Ping An Good Doctor) which complements its internal insurance system. The app offers a plethora of services: free diagnosis, 24-hour online consultations, an online mall selling over-the-counter medication and medical devices, healthcare-related articles, a microblog discussion forum, and even gift cards for medical services such as health exams and gene testing.24 The app currently has a reported 77 million registered users, with a daily consultations count as high as 250,000. The proportion of users that suffer from the aforementioned unmet needs, however, are unknown.

nicians to provide online consultations; Tencent Holdings Ltd. invested in various digital health start-ups; Alibaba’s health information technology branch aimed to bring hospital services online and to develop an online pharmacy.19 Founder of Alibaba Group Holding Ltd., Jack Ma, expressed the same interests and ambitions of creating a better public healthcare system, with the explicit goals of better hospitals, cheaper drugs, and healthier people. When it comes to the big picture, the goals and vision all seem to align. However, the current role and relationship between public and private enterprises regarding the healthcare system remains unclear. According to Charles Hsu of Crosswave Management, “state-owned enterprises…are being sidestepped surprisingly fast by entrepreneurial ventures that are truly innovating.”20 Conversely, a recent Bloomberg report noted that the hopes and digital health dreams of Chinese tech tycoons are just not materialising.20,21 Given all the benefits that digital health solutions present, from the technology perspective, it can be easy to be complacent and say that mHealth is the future. How-

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ever, many do not take into consideration the intricacies and traditions of the current healthcare system: in order for mHealth to be widely adopted for public healthcare, current habits need to be broken. One of the biggest challenges the industry faces is the lack of insurers willing to collaborate with China’s dominant state-level hospitals and government insurance policies. The current outlook of China’s healthcare system is a conservative one, which is a reimbursement-driven model that does not recompense for innovative services. As put by Global Healthcare Leader at PWC, Dr. David Levy, “The problem is this enormous medical infrastructure that is very conservative and resistant to change. In most emerging markets, you have a lot of the drivers of innovation without the barriers.”22 Thus, the challenges do not ultimately lie in innovation and technologies. Rather, it is the lack of proper infrastructure to support and sustain these innovations that obstructs further possibilities. Not everyone, however, supports such reform. Current debates have spawned about whether digital health solutions should integrate with the governmental system. Professor Ian Leslie from University of

Notably, this piece only focused on mHealth out of a profusion of other possible digital health solutions. The convergence of mobile networks with increasing bandwidth capacity for data, the proliferation of lowcost smart devices, and cloud computing foster new opportunities to better the delivery of health care. The conceptual reach of mHealth is great. With China’s current healthcare system and its role as a developing country, there are great potentials for digital health solutions to proliferate. Conceptually, mHealth offers itself as a viable option which could address big issues, such as the current poor access to care exasperated by China’s rural-urban divide, or video consultations for those less able to travel long distances to a tertiary health provider. In order to capitalise on the potential of digital health, there must be further emphasis on the cross-pollination of the private and public sector and the sustainability of this relationship, as well as the possibility of tailoring technology with cultural sensitivities. Taking all the above into consideration, perhaps digital health solutions will become the new barefoot doctors.

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Megan Lam is a student at the Yale School of Medicine. She can be contacted at megan.lam@yale. edu.

houstondwiattorney.net

INTERVIEW

Global Health Justice Now: An Interview with Gregg Gonsalves

regg Gonsalves (PhD) is a longtime HIV/AIDS activist who started working with ACT UP in 1990 and founded the Treatment Action Group. He now teaches at the Yale School of Public Health and Yale Law School, where he is the Co-Director of the Global Health Justice Partnership. The Yale Global Health Review had an opportunity to sit down with Dr. Gonsalves and discuss his work towards global health justice, gaining insight on both the importance of such interdisciplinary work and the tools used to solve global health challenges. How did you transition from the early stages of activism to your current work? When I started working for ACT UP, I dropped out of college and committed myself to HIV/AIDS activism. In 1996, we had an international problem because drugs were not available around the world. It took a long time to get scientists and policymakers working together to get drugs to people and make sure people with HIV got the support they need. At the same time, I worked on educating communities on HIV and TB. I applied to Yale to ask for a financial aid package that would let me complete my college degree. At Yale, I studied biology, and a group of students and I started a Global Health and AIDS Coalition. We protested Obama when he didn’t keep his campaign promise on HIV and AIDS. And then, after college, I was going to go to Paris for a PhD, and do more benchwork research, when I was approached by two people— Albert Ko, who works on leptospirosis, and Jerry Friedland—both of whom are here at the School of Public Health. They asked

By Karina Xie me to stay at Yale to launch a new initiative merging science, public health, and justice. Then we recruited Ally Miller from the University of California at Berkeley and we formed the Global Health Justice Partnership. We work on Ebola, the United Nations’ role in cholera in Haiti, drugs in Connecticut, tuberculosis in prisons. We believe public health problems are also social justice problems. Fixing people’s health is not just one problem. Doctors and epidemiologists have only part of the tools. If you’re building a house, you need all the tools.

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faculties and senses to answer questions. Interdisciplinary work is very hot right now but also very hard. When you apply for a grant from the National Institute of Health, it’s very biomedically oriented. But you may also need some expertise from the law. We have a lecture at noon today with two lawyers and two epidemiologists on the panel, and they’re discussing the cholera epidemic in Haiti. Law won’t answer every question on refugees and immigrant rights, or every question of sexual violence and rape in Cape Town, South Africa, but

Public health problems are also social justice problems. Fixing people’s health is not just one problem. Doctors and epidemiologists have only part of the tools. If you’re building a house, you need all the tools.

Can you describe your work with the Global Health Justice Partnership? The Global Health Justice Partnership aims to promote and protect people’s health. We want to bridge the worlds of health and human rights by answering questions ranging from HIV to refugee and immigrant health. We use the tools of science to answer some questions, but we also describe the world around us using tools of sociology. We figure out a problem about the real world. If there’s a problem, what’s the expertise we need and how can we get the people we need? To put it together, we bring people from different departments. They come into the office and use all their

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neither can science. That’s why we’re bringing people from different backgrounds to work together. Can you tell me more about your project on sexual violence against women in Cape Town?

Women have to go and use the facilities. They’re living in shacks in townships, and if they want to go to the bathroom, they have to walk three blocks to go to a portable toilet in the middle of the night, and they’re subject to sexual violence. So we did a model of the city of Cape Town, showing how the city pays a lot of societal costs in terms of violence against women. And we

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What is a woman’s risk a function of? The function of the distance between her house and the toilet, how long she walks, how often she has to use the restroom, the level of crime in the immediate area? Then you can set the parameters: X equals this, Y equals that. And you have a formula that shows the less you have to walk, the less sexual violence you face.

showed that if we have more toilets, we have less sexual violence. And that makes intuitive sense. Instead of walking five blocks, they walk across the street, and there’s ten times as many toilets. And so we put that model together with a friend of mine from the Social Justice Coalition. When we were done with the study, we sent it to the Social Justice Coalition, and they sent it to the city of Cape Town, where advocate groups put it in the newspapers. We wanted to bring to the surface and address the first-person reality of these women in the township, and of other people on the ground and in the front lines. Whether they’re women facing sexual violence or miners with TB, we ask, “What’s the problem, how can we address it with all the tools—public health and science and managing resources?” When you use modeling, even if you can’t address something in an experimental way, you can still simulate it. How are mathematical models used in global health?

Infectious disease modeling has a long history that stretches back into the 20th century. The people I study with come from a field called operations research. There’s David Paltiel, who’s down the hall, and Ed Kaplan, who’s at the SOM [School of Management], who’s written on in vitro fertilization, HIV prevention, and public housing. Ed is a genius. If there’s a problem, he thinks, “I can make it into a mathematical model,” which allows him to say something important in a great analytical, quantitative way. Ed teaches a course here called Policy Modeling which is at the SOM. Ed’s really powerful. He can answer questions about people— about in vitro fertilization, terrorism, about HIV prevention—with these simple mathematical models. He can formulate it in a way that means something in the real world, like the toilet and sexual violence paper. What is a woman’s risk a function of? The function of the distance between her house and the toilet, how long she walks, how often she has to use the restroom, the level of crime in the immediate area? Then you can set the

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parameters: X equals this, Y equals that. And you have a formula that shows the less you have to walk, the less sexual violence you face. Ed teaches you how to translate policy questions into mathematical terms. Ed has taken a field that has been used for military and even business and supply chains and has used it for the public good. He has been an important mentor in teaching me about looking at health policy through mathematical modeling. Do mathematical models produce direct effects on health policy? A friend of mine, Bernard, gave a talk a few days ago about health and politics, specifically the smoking ban in China. Cigarette production in China is more than the next 25 to 30 countries combined. Bernard showed that the pollution created by smoking is fifty times worse than Beijing on a smoggy day. People continue to smoke despite knowledge of all the data correlating lung cancer with smoking. What he had to do was to

Peaceful sit-in to demand climate justice from Prime Minister Harper in advance of UN climate negotiations.

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craft an argument to the Chinese government that would focus more on the politics of China and less on the health outcomes. Bernard crafted a method meant to appeal to the government, which didn’t want a two tier system where the elite could smoke in their offices and everybody else couldn’t. Joe crafted this method to determine what other evidence was needed so that Beijing as well as Shanghai could institute a smoking ban. Health policy work in China was about creating a message using what smoking means in terms of society. Scientific evidence is just one piece of the mix; you need clever communications people, and you need activists to push the government to do the right thing. At the same time, you use scientific tools to answer these very important questions.

Wikimedia Commons

Protest in South Africa by Social Justice Coalition demanding safe and dignified sanitation.

What do you see as the intersection between science and politics? Climate change is one place where scientists have done their work measuring carbon dioxide levels and temperature changes in countries around the world. A lot of climate scientists feel their work is incredibly political. There was all this climate data that scientists downloaded from NASA before the Trump administration because they realized that science is not neutral. Even if the science is rigorously proved, it may not convince the BPA [Bonneville Power Administration]. Science is one part of the puzzle. With climate science, public health, reproductive health, you’re in in the world, on the edge of wars, entangled with politics. What is the role of raising the voices of individual people in achieving global health justice?

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Political mobilization is a potent force in changing health and public health law. The resulting public health measures produce architectural changes, such as better sanitation and ventilation, which work to improve the lives of people over the course of a century.

Think about all the social advancements in the U.S. and around the world. Women’s rights, civil rights, and gay rights were achieved by people saying, “Enough. I want the right to vote. I want my vote to count. I want to get married.” One thing about HIV is that the drug is really expensive anywhere outside of the US, and especially for people Asia and Africa. People in Thailand, Brazil, and South Africa said they would fight for these medicines. They would fight these drug companies. They would fight the US. And now ten million people are on these HIV drugs while a couple hundred thousand were on them in 2000. All the HIV activism in South Africa was done by poor women in the township who were arguing for better sanitation. They had been involved in a history of political struggle. They had overthrown the white Apartheid government and weren’t powerless. In 1996, newspapers were flooded with articles about how HIV had new medicines that raised people from their deathbeds. At the same time, many people in South Africa were watching their neighbors and their friends die. Ordinary people started saying this wasn’t right and got together to ask, “What can we do about this?” Then lawyers and doctors came into the mix and said, “With the law you can sue the drug company, and from the medical side, you can definitely deliver these drugs even if you don’t have a HIV specialist.” Then 40,000 South African women from the township marched on the South African Parliament. They fought and they won. Political mobilization is a potent force in changing health and public health law. The resulting public health measures produce architectural changes, such as better sanitation and ventilation, which work to improve the lives of people over the course of a century.

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projects going on right now. One is on drug pricing in CT and MD, one on maternal health in Georgia, and one on abortion and the Zika virus in Colombia, Costa Rica, and Brazil. There’s a drug pricing bill that’s going to happen in Connecticut over the next few weeks, so law students are doing research on drug costs, debates around drug pricing, and the legal ramifications. Over spring break, one team is going to South Africa, one is going to Georgia, one to Latin America. They’re talking to minors, doctors, lawyers, and government officials. Our students are sitting in classrooms, but they’re also going outside. They’re running along with current events with outside partners. What is informing the future direction of your projects? I’m thinking about what’s happening now politically and what effect it’s going to have on people’s health. A lot of people are looking at the Affordable Care Act and Medicaid. I’m interested in what’s going to happen now to the health of migrants, immigrants, and refugees, and if can we measure that in the short term. I’m drawing inspiration from people like Forrest Crawford, who works just downstairs, measuring hate crimes with stochastic modeling. Public health has given clinical medicine and basic science the need to be public.

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Can you tell me more about your course on global health justice? The purpose of the course is to help students work with people in the field. We want to give students a connection to the outside world, to achieve health equity through real world work. We have three

Karina Xie is a sophomore in Davenport College majoring in Molecular, Cellular, and Developmental Biology. She can be contacted at karina.xie@yale.edu

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GLOBAL HEALTH TODAY

Coinfections:

Managing a diverse network of diseases By Colin Hemez

SuSanA Secretariat

hen it comes to infectious diseases, the presence of one usually means the presence of many. Differences in environment, socioeconomics, and even genetics all conspire to leave some populations with high burdens of many diseases and other populations with low burdens of few diseases. This inconsistent distribution unfortunately results in many cases of coinfection, where an individual is infected with two or more distinct pathogens. Many HIV-positive individuals develop tuberculosis; several patients with hepatitis B also acquire hepatitis D; lots of those infected with intestinal worms have a more difficult time fighting viral infections like the flu.

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Of the approximately 25 million individuals infected with HIV in Africa, half are estimated to also be infected with at least one soil-transmitted helminth species.

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Recent evidence suggests that coinfections are most common in regions with high burdens of infectious disease, including underdeveloped nations, tropical regions, and urban slums. In Africa particularly, of about

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25 million HIV+ individuals, nearly half are estimated to also be infected with parasitic worms, also known as helminthes.1 Numerous diseases—including malaria, helminth infections, sexually-transmitted infections, and tuberculosis—are highly comorbid with HIV spread.2 In many parts of sub-Saharan Africa, coinfection is even seen as the norm, although specific epidemiological data on the prevalence of HIV, malaria, and helminth is limited and often inconsistent. Given the great diversity of infectious diseases that exist in different parts of the world, the highly localized patterns with which they occur, and the lack of detailed data on how coinfections alter the disease outcomes of patients, what can health workers and public health officials do now to manage coinfection networks in a rapid and effective way? Though the precise methods through which to minimize coinfection are often contested, it is indisputable that public health officials have an enormous and diverse number of strategies from which to choose. Some believe the answer lies in distributing more vaccines or prophylactic drugs. Sometimes quarantines are the most effective at preventing disease spread. In some environments, improving a community’s access to clean water could do the trick. But financial and human resources are always limited, and variation in coinfection type, prevalence, and severity all contribute to the effectiveness of various programs. Trying to generalize and universalize pub-

lic health procedures is difficult because of how complex coinfections can be. The broadest and likely most effective strategy would be to collect detailed and reliable epidemiological data, which can then used by local officials to apply specific strategies to specific scenarios: in other words, collect data, then divide and conquer. But even at a small scale, coinfections can still be immensely complex. A good example for studying how coinfections play out in a community is the aforementioned situation in sub-Saharan Africa, where coinfection with HIV, malaria, and helminths are widespread. The coinfection between helminths and HIV demonstrate the key principle that im-

SuSanA Secretariat

Toxocara larva hatching

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munological responses to co-infection play a significant role in the severity and spread of disease. Helminths impair cell-mediated or specific immune responses, which are crucial for developing immunity to all infections.3 Cell-mediated responses are responsible for the body’s production of antibodies, which is utilized in vaccination, so people who have been infected with helminths respond less to vaccines. So coinfection with parasitic worms undermines current and future vaccine campaigns against HIV, malaria, and other diseases. Currently, at least one helminth species is endemic (regularly infects the people) of sub-Saharan Africa, with helminth infection prevalence ranging from 20% to over 50% for the region.4 As a result, vaccination programs in Africa against all kinds of pathogens often have sub-optimal outcomes. To maximize the efficiency of their programs, public health officials must weigh the importance of targeting each disease. For example, for some areas with high rates of malaria or HIV coinfected with helminths, it may be more prudent to pursue helminth eradication rather than communal vaccination, as helminths decrease the effectiveness of vaccination programs. Or, a simultaneous treat-and-prevent program that offers both vaccination and deworming may be the most effective. To determine which is better must be decided on a local, case-by-case basis. On another level, it is also important to pursue a better scientific understanding of the coinfection. The immunological

The risk that an individual infected with HIV transmits the virus to another susceptible person is strongly associated with the amount of virus in the blood; a ten-fold increase in a patient’s viral load is associated with around a 2.5-fold increase in transmission probability” (Abu-Raddad, Patnaik et al. 2006).

effects of helminth infection on HIV risk are poorly understood, especially as they vary depending of the species of helminth involved.3 Helminths interfere with the body’s immune response in order to live for years, decades, and sometimes even lifetimes within a foreign host. The strategies that different helminths use to tinker with immune responses, however, are extremely diverse; they depend on a particular species’s life cycle and its targeted organ. Helminth infections, for the most part, could be either immunosuppressive or immune activating. In cases of immunosuppression, the helminth will secrete molecules into the host’s bloodstream that actively reduce the strength of a normal immune response. This could lead to decreased concentrations of helper T cells, aka CD4+ lymphocytes, in the bloodstream, making HIV transmission (or the establishment of an HIV infection in a previously uninfected person) more difficult. But the helminth infection can also have the opposite effect, increasing CD4+ lymphocyte levels and making it easier for

SuSanA Secretariat

Collage of various helminth eggs

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HIV to replicate itself, transmit to another individual, and establish a new infection. The problem of HIV/helminth coinfection demands more basic research into the specific immunological effects of infection by different worm species, as well as localized mapping of helminth species prevalence within sub-Saharan Africa. A different but similarly consequential coinfection is that between malaria and HIV; this one is slightly more complex. The reason why malaria infection increases the spread of HIV is rooted in the fact that an HIV+ individual’s ability to transmit the virus to another person is strongly associated with the amount of virus she contains in her blood. Specifically, a ten-fold increase in a patient’s viral load is associated with around a 2.5-fold increase in transmission probability.5 So infections that increase viral load in HIV-positive patients, either by creating environments in the body that favor virus replication, or by increasing levels of HIV’s preferred cellular host (CD4+ lymphocytes) in the blood plasma, are thus likely to increase HIV transmission and incidence. The Plasmodium parasites that cause malaria appear to do just this, inducing more rapid HIV replication in the bloodstream and increasing the propensity for individuals coinfected with both HIV and malaria to transmit HIV. Strategies to control malaria in HIV-positive patients (such as rapid malaria diagnosis, treatment with artemisinin combination therapy, and prevention through prophylaxis) are therefore likely to reduce the prevalence of HIV in malaria-endemic regions. Public health officials must keep in mind the codependency between malaria and HIV when targeting either. Another vitally important and even less intuitive consequence of the body’s immunological response to malaria is that even vaccines against malaria can trigger an increase in HIV transmission. This is because even partial Plasmodium antigens, fragments of the parasite that do not cause illness and are used in vaccines, appear to enhance

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HIV replication.6 This is likely because the immune system still generates a gradual response to the presence of chopped up Plasmodium, which may be less extreme than its response to the live parasite, but still is enough to produce the inflammation that HIV exploits. The macroscopic effect of this microscopic phenomenon is that the largescale use of some malaria vaccines can lead to spikes in HIV incidence. A strategy that counters this is offering HIV pre-exposure prophylaxis (PrEP) to individuals receiving malaria vaccines, especially in regions with high HIV prevalence, to prevent them from contracting HIV. However this comes with additional costs, which must be weighed against the benefits by public health officials. Aside from complexity arising from immunological responses in the host, the life cycles of the pathogens involved in coinfection play a large role in disease outcomes where coinfection is the norm. Helminths and Plasmodium parasites both have complex life cycles. Both have numerous life stages, both have multiple infection cycles within the body that invade different tissues, and both are highly dependent on the environment for transmission (helminths because they are often transmitted via the soil in poor-sanitation areas, and Plasmodia because they require the presence of female Anopheles mosquitoes for transmission from one vertebrate host to another). The dynamics of co-infections with worms and malaria are thus likely to be even more complex.

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Skeletal structure of the helminth worm.

keep the host’s immune system in a state of perpetual activation, priming the host to combat a malaria infection when it arises.8 However, schistosome infection only showed a protective effect against malaria at an extremely low parasite burden. The study also found that about two-thirds of children who tested positive for S. mansoni infection also had parasite burdens that far exceeded the levels that they believed were beneficial against malaria. At these levels, helminth infection is more detrimental on malarial disease than it is beneficial, and it is not realistic to expect that schistosome prevalence could reduce malaria prevalence in a region. Nonetheless, the finding that S. mansoni appears to be immune activating is an important one, as it could influence the coinfection dynamics between S. mansoni and other pathogens in regions with high schistosome burdens.

The ability of the immune system to respond to non-living threats forms the basis of some of the world’s most effective vaccines, which make use of antigens rather than live pathogens to train a person’s immune system to recognize the live pathogen should it one day invade the body.

Sometimes the infections can actually have antagonistic effects on each other, with one reducing the likelihood of another’s transmission. For example, a survey of Senegalese children found that individuals with very low-intensity but persistent infections of Schistosoma mansoni, a type of helminth transmitted via contaminated waterways, had a lower risk for malaria infection after controlling for sex and season.7 This suggests that schistosomes may

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The same study also found that schoolage children are at the highest risk for coinfection with Plasmodium and one or more helminth species.9 Except at the extremely low (and rarely observed) worm burdens that seem to be protective against malaria, schistosome infection exacerbates symptoms of anemia that often result from recurring malarial episodes. Populations at the highest risk of anemia (namely, children and pregnant and nursing mothers) would

benefit from integrated strategies that seek to control malaria and helminths simultaneously. Strategies to control the co-infection network of HIV, malaria, and helminths must be tailored to the specific epidemiological circumstances of local areas. But international cooperation in formulating a disease control program is critical to building a foundation for local programs to build from. Public health officials need to consider the current and future impacts of different interventions, keeping in mind the impact of coinfection on the effectiveness of some programs. Because of the diverse consequences of helminth infections, some countries may benefit more from implementing aggressive anti-helminth campaigns rather than vaccination projects in the short term. Also, widespread data collection is essential for tracking the spread of disease and formulating interventions that meet the demands of local disease burdens. Coinfection networks are complex, and researchers are only just beginning to elucidate them using more accurate and detailed epidemiological data. New insights are sure to come; it is essential that as they do, public health workers integrate them into their fight against coinfection.

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Colin Hemez is a junior in Ezra Stiles College majoring in Biomedical Engineering. He can be contacted at colin.hemez@yale.edu.

FIELD WORK

BAN In P

GLA

ract

ice

ast summer I had the immense privilege of travelling to Dhaka, Bangladesh to assist in the implementation of a new epidemiological study from Boston Children’s Hospital (BCH) at the National Institute of Neuro-Sciences (NINS). The study, funded by the National Institutes of Health (NIH), investigates the relationship between epidemic arsenic poisoning and the occurrence of spina bifida, a group of birth defects distinguished by spinal cord malformations. The World Health Organization has called current arsenic poisoning in Bangladesh the “largest mass poisoning of a population in world’s history.”1 Maitreyi Mazumdar (MC ’91), the study’s principal investigator and a pediatric neurologist at Boston Children’s Hospital, hypothesized that arsenic increases the risk of spina bifida. I joined the research team to learn how global health research works in practice. Global health research in practice requires a great deal of internal mechanics, of unpacking broad aims into protocols, records and record-keeping systems. For example, to measure maternal arsenic

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levels, one must know what biological samples to take and then document protocols on how to properly collect, label, package, and ship samples. To conduct ethical research, one must apply to institutional review boards, compile informed consent training material, and train new staff in said material. To collect information from subjects, questionnaires must be written in such a way that collects information and ensures accuracy. To enable future replication, detailed daily records of activity are needed as well as an effective system of navigating through said records. But beyond the internal mechanics, understanding and addressing external factors is crucial to global health research in practice. Research, especially global health work, doesn’t occur in a vacuum. Everything beyond the hospital, such as national unrest and holidays, affected our work. One external factor was a rise in extremist violence in Bangladesh against vocal liberals and foreigners. In April 2016 alone, the editor of Bangladesh’s first LGBTQ magazine and a friend, an outspoken law student, and an

By Sreeja Kodali

English professor were hacked to death by assailants in separate incidents. 2 Foreigners had also been killed recently: an Italian aid worker and Japanese farmer. 2 The US State Department in the spring issued strong warnings against visiting Bangladesh, including bans on visiting public areas, using public transportation, or walking unattended. 3 These stipulations made finding accommodations and travelling to the hospital more difficult. Our research team and hosts in Dhaka took several measures for our safety: we travelled exclusively by car, escorted by local research staff members. We only travelled to hospitals and back to our hotel, which was a closed complex with full-time security and metal detectors upon entry. Just days after I left Dhaka, a bakery in the diplomatic district of Dhaka was attacked by armed militants and 28 people, including Bangladeshi, Italian, Japanese, Indian, and American citizens, were killed. 4 We had planned a second trip to Dhaka and NINS however in light of the attacks I could not return – global health research practice is not immune to international unrest.

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Another external factor was that our trip to Dhaka occurred during Ramadan, the holy month when Muslims fast from sunrise to sunset in honor of the Prophet Muhammad’s first revelation in the holy Quran. 5 Despite the sweltering heat, many of our collaborators did not eat or drink water all day in observance of Ramadan. Nevertheless, they graciously served us water, fruits, and lunch despite their inability to eat or drink for many more hours. Ramadan affected the execution of our study because hospital workdays were cut short, halving the number of working hours we had. With so much to do but only half the time, we learned how to be maximally productive in half a workday.

trusting relationships was the most important part of bringing the project to life. Not only were we building relationships, but we were also creating an equal partnership based on mutual respect. BCH brought research experience and funding while NINS brought cases, local infrastructure, and deep clinical experience in spina bifida.

But global health research in practice is more than the internal logistics that comprise it or the external circumstances that shape it; the core of practicing global health research lies in the people who move it forward and their collaboration. Executing global health research involves many different roles on a single team: investigators, coordinators, field workers, and assistants like me. It also involves cross-cultural and language differences that come from transcending international borders. Cultivating

At first, I was surprised at how much of our trip included of meeting people, eating together, and conversing, as opposed to squeezing in extra training sessions or laboratory visits. How could chatting over fresh fruits be more productive than extra office time? How could home-cooked dinners be more than an indulgence? They were, however, all indispensable to our research. Prior to the trip, we were strangers embarking on an international, expensive commitment for the next several years. Like any serious relationship, we needed

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Research, especially global health work, doesn’t occur in a vacuum.

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to build trust and understanding, if this was going to work out. We needed to pave avenues for open communication and to discuss both our common and personal goals, doubts and concerns, and vision for the next several years. Part of creating this relationship was opening ourselves to and honoring cultural practices, such as accepting hospitality. Altogether, global health research in practice can look quite different from its research proposal counterpart. Global health research in practice is broken down into protocols, standardized procedures, and meticulous organization. It is molded to accommodate national holidays and unrest equally. And global health research in practice is enabled by the sharing of ripe mangoes, sweets, and tea, which is far more than a social exercise and rather a necessity for scientific cooperation.

www Sreeja Kodali is a junior in Saybrook College majoring in Molecular Biophysics & Biochemistry. Contact her at sreeja.kodali@yale.edu.

Dhaka has the largest number of rickshaws and is known as the Rickshaw Capital of the World. Pictured below is a glimpse of regular street traffic.

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HEALTH POLICY

A New World Health Organization The Search for a Director-General

By Matthew Pettus

r. Margaret Chan, Hong Kong-Canadian physician and Director-General of the World Health Organization (WHO), will be leaving her position this June, after a ten-year term. This means that the World Health Assembly must commence the search for a new Director-General, someone who can poignantly address the intersection between policy, global health, and economics. Historically, the role has had a large influence on the future of global health efforts in America, so, needless to say, this is an important decision with many implications for future disease prevention and proliferation.1

cade. Her term began in 2007 and was extended after reelection in 2012. Chan has several notable accomplishments on her resume, including handling numerous viral outbreaks like Zika and Ebola, spearheading the response to the swine flu outbreak in 2009, and, as of late, increasing access to the meningitis vaccine in Africa by making it more affordable and eliminating infrastructural barriers.3 Going forward, she has said that her primary concern for the World Health Organization’s future is that “[Her] successor needs to continue to address the financing of the WHO. There’s no two ways about it.”3

The Director-General of the World Health Organization is responsible for the arduous tasks of managing the finances for the WHO, spearheading the implementation of policy recommendations for all facets of global health (epidemiology, infrastructure, poverty, environmental health, etc.), and managing all of the departments within the WHO. In addition, the Director-General is responsible for leading the response to certain crises when they arise, such as the Ebola virus crisis.2

How a new Director-General will manage the finances of the WHO is seen as one of the most important deciding factors for selection, in addition to whether he or she will be able to negotiate a better budget. Currently, the WHO relies on both member state dues, which are guaranteed, and voluntary donations, which are decreasing in size every day.4 The change in leadership this May has the power to fundamentally change the future trajectory of the WHO.

As the outgoing Director-General, Dr. Margaret Chan has ardently worked alongside the rest of the WHO for an entire de-

For such a complex and nuanced role, the election process for Director-General is surprisingly straightforward. Over the span of

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eight months, replacements are nominated, a forum is held for candidates to present their ideas to member states, WHO’s Executive Board narrows the list down to 5 candidates, the candidates are interviewed and further narrowed down to a list of three. Lastly, the final three move on to the World Health Assembly election in May where the new Director-General is elected.5 As of January 2017, the final five candidates were: Tedros Adhanom Ghebreyesus, 51, of Ethiopia; Dr. Sania Nishtar, 53, of Pakistan; Dr. David Nabarro, 67, of the United Kingdom; Dr. Flavia Bustreo, 55, of Italy; and Dr. Philippe Douste-Blazy, 65, of France. The initial favorite was Dr. Flavia Bustreo, as she is currently the Assistant Director-General of WHO and leads the Family, Women’s, and Children’s Health Department. The close second, Dr. Philippe Douste-Blazy, was a foreign affairs and health minister, who founded UNITAID, an organization that works to prevent, diagnose, and treat HIV. However, both candidates were eliminated after the interview round and did not advance to the final three.6 In February 2017, the pool of five candidates was narrowed down to three:

Dr. Sania Nishtar, Tedros Ghebreyesus, and Dr. David Nabarro. Dr. Sania Nishtar is a former Pakistani Health Minister and cardiologist. She has had extensive experience in the political realm, serving in the interim Pakistani Cabinet of 2013 and overseeing public health, education, and science in Pakistan. She is particularly knowledgeable in the field of public health, as demonstrated by her establishment of a health policy nonprofit, which has since been overtaken by the Clinton Global Initiative. In addition, what separates her from her competition is that she has diligently explored peacemaking as a discipline, and poignantly used her status to address the tense India-Pakistan and US-Pakistan relations. She has accomplished this through working with the Aman ki Asha Initiative, the Aspen Institute, the Global Advisory Council of the Pakistan American Foundation, and the US-Muslim Engagement Initiative.6, 7 Tedros Adhanom Ghebreyesus is an Ethiopian politician with much relevant knowledge in the field of public health. He served as the Minister of Health in Ethio-

pia for seven years, and as the Minister of Foreign Affairs for four years. Accomplishments and highlights from these positions include gaining immense ground on malaria research, increasing access to health services in impoverished communities, increasing the availability of medical doctors, and improving gender equality. He also managed West Africa’s response to the Ebola virus epidemic, and in doing so, augmented the International Health Regulations regarding disease outbreak and led the African Union Response Team. After his tenure as a board chair on the Global Fund to Fight AIDS, Tuberculosis, and Malaria, he was nominated to be the African Union’s candidate for the Director-General of the World Health Organization.6, 7 Dr. David Nabarro is a British endocrinologist who currently serves as Special Adviser to the UN Secretary-General on the 2030 Agenda for Sustainable Development and Climate Change. Previously, he served as the Special Envoy to the Ebola crisis in Africa, and he is currently leading the response to the cholera outbreak in Haiti. He has prior experience with the World Health Organization, serving as Project Manager

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The headquarters of the United Nations, the World Health Organization’s governing body, in Geneva Switzerland.

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to eradicate malaria at the beginning of his career. He also cofounded the Global Fund to Fight AIDS, Tuberculosis, and Malaria. In addition, he has worked for the Food and Agriculture Organization, a subset of the United Nations. Nabarro’s work has been more focused on the environmental aspect of health than general public health, but this could potentially bring an underrepresented perspective to the position of Director-General.6, 7

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An important part of the discussion is whom top media outlets have predicted as favorites to obtain the position. The media’s perspective is invaluable in this process, though not infallible. Dr. Flavia Bustreo of Italy was initially an overwhelming favorite due to her previous WHO experience, but she did not make it to the top three, which shows that perhaps the media’s views are not always the most didactic. Moreover, Ghebreyesus, of Ethiopia, offers two unique perspectives that have been often overlooked: a Director-General of the WHO has never been from Africa, nor lacked a medical doctorate degree. Some have said that the time is ripe to have a Director-General from Africa, seeing as he or she would be most accustomed to dealing with several of the most pressing disease outbreaks, many of which occur in Africa. However, the past eight Director-Generals, including Dr. Chan, were all medical doctors, and some argue that it is not possible to empathize with patients without having the experience of treating one’s own patients.7 In further analysis of the candidates, it is necessary to speak to how the three remaining candidates differ not only in background, but also in their current propositions and aims for leading the World Health Organization, arguably the most important aspect of this election. Dr. Nishtar’s focus is on human-health-climate interactions and countries achieving the Sustainable Development Goals, because weak infrastructure is a prominent obstacle to achieving universal health care and equitable health policy. His background in the Ebola crisis has informed Ghebreyesus’s priorities. He argues that improving response time to disease outbreaks is of the utmost importance but also seeks to determine a balance between international, national, and local health reforms and care. Lastly, Dr. Nabarro aims to further develop the International Health Regulations and the Sustainable Development Goals. He would also like to create a personalized system of health care and requests the help of all members of society to achieve this goal; after all, in his opinion, health care should be focused on the people.8

Top: A pedestrian bridge connects the old patient care building to the new research and education building at St. Michael’s Hospital in Toronto, Canada. Bottom: An unsanitary Nepalese delivery room demonstrates the current declining status of universal health

A great deal of analysis is required to choose between the final three candidates for Director-General, as, at this stage, all candidates are equally qualified. The Assembly must now base their decision on “soft” qualities, like the candidates’ personalities and who has the proper temperament and attitude to revive the WHO, in addition to their policy focuses. These sorts of elections can make or break an organization such as this, which is why this decision is of the utmost importance. As of now, the future of the WHO is extremely uncertain. What will become of the budget? Will their lack of financial donations eventually shut down the WHO? How will

Trump’s administration impact the international status of health? We’ll just have to wait until May 31st to find out. www

Matthew Pettus is a freshman in Saybrook College. He is a prospective Cognitive Science major. He can be contacted at matthew.pettus@yale. edu.

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HEALTH POLICY Flickr

White Male Suicide: The Exception to Privelege

n recent years, the American government and the public have given increasing amounts of attention to mental health issues and awareness on college campuses and amongst adolescents. College students and adolescents do represent two vulnerable populations, but neither constitute the subgroup with the highest suicide rate in America.1 Instead, middle-aged white men, who have historically maintained a place of privilege in the United States, are also at the highest risk for death by suicide. A 2001 study of members five U.S. ethnic groups and both sexes, white males were found to have the highest suicide rate relative to prevalence of depression over the course of one year.4 This trend continued to 2015, when another study found that the crude suicide rate for white non-hispanic males aged 40 to 65 was 37 per 100,000 people, more than twice the rate of suicide in the general American population.2 Neither study, however, attempted to define a causal relationship between gender, race, and suicide. It is tempting to suggest that the elevated rate of suicide among middle-aged white men exists simply because they have a higher prevalence of mental illness, such

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By Laura Michael as depression. However data show that women, not men, have a higher incidence and prevalence of depression.3 While suicide has long been linked to depression, high rates of suicide are not the definitive product of high rates of depression. This is because not every case of depression will result in suicide or even suicidal thoughts. Many hypotheses could explain this phenomenon. Jason Houle, PhD, articulated the complexity of suicide in a report published in Sociological Perspectives, saying: “we often think of suicide as an individual

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Part of the explanation for why white male suicide rates are so high is that on a broad level, men of all races and ethnicities are more likely to die by suicide than women.1 In 2015, the age adjusted suicide rate in white men was almost four times as high as in white women.2 Yet, women attempt suicide at a greater rate than men–––the difference is the mortality rate of each gender’s suicide attempts, which is significantly higher among men than women.6 One of the simplest reasons this paradox exists is that men are more likely to use methods

..middle-aged white men, who have historically maintained a place of privilege in the United States, are also at the highest risk for death by suicide.

act, but the social and physical environment is really an important determinant of suicide.”5

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of high lethality such as guns and hanging whereas women are more likely to attempt suicide by methods that can be reversed

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The increasing rates of death by suicide amongst white men, therefore, may indicate broader societal problems such as declining levels of social connectedness, weakened communal institutions, and fracturing along cultural, geographic, and educational lines.

such as drug overdoses and poisoning.6 Although more than 60% of the people in the United states who are killed by guns die by suicide, the high prevalence of suicide among middle class white males is more than a gun control issue.7 It is next to impossible to regulate the materials needed for other equally methods lethal such as hanging.7 The difference in the lethality in methods of attempted suicide in men and women may explain the gender disparity in suicide

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rate, but the motivation behind white male suicide attempts is more difficult to discern. One theory that could explain the increased rate of suicide amongst white males is “cultural script theory,” which posits that social expectations can influence the path of a person’s life, sort of like a script they unconsciously follow. The idea of cultural scripts can be used to explain many different societal trends; within the study of suicide it can be used to explain how societies in which men more frequently die by suicide have cultures that view fatal suicide as

a dignified and masculine, while attempted suicide or non-fatal self-harm are seen as weak and feminine.3 According to the cultural script theory, this behavior ultimately creates a vicious cycle in which “cultural expectations about gender and suicidal behavior function as scripts; individuals refer to these scripts as a model for their suicidal behavior, and to make sense of others’ suicidal behavior.”3 The cultural script theory provides a sociological explanation for the difference in suicide methodology and fatality between genders not only in the United States, but also in other English speaking Western countries such as Canada, New Zealand, and the United Kingdom. Aside from the gender gap, there is still a question of why middle-aged white men in particular make up such a large percentage of the deaths by suicide in the United States. The sociological and cultural and explanations for high suicide rates among older white men require further investigation. A 1977 study found that “there is rea-

Jez Arnold

The states of Colorado, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Wyoming a region which has come to be known as the “suicide belt” since sociologist Matt Wray noticed the trend in the early 2000s.

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son to believe that the mechanisms for unleashing suicidal thoughts are no different in blacks and whites.”8 In other words, the same characteristics lead to an increased likelihood of suicide in black men as did in white men. To explain the persistent gap between white and black male suicide in the United States, the study sought to investigate whether these characteristics occurred more frequently in white men than in black men. In an analysis of the general population, it found that white men were more likely to be unmarried, to know someone who had committed suicide, to feel that suicide was sometimes justified, and to lack pride in becoming older. While this study demonstrated a potential association between these attitudes and race, it was not able to conclusively determine the variables that accounted for the high risk of suicide in older white men because it lacked a fully representative sample. Few studies have attempted to identify specific risk factors for suicide specifically in white middle aged men, but some have investigated them in areas that happen to have large populations of middle aged white men. Specifically, the states of Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, and Wyoming constitute an area that has come to be known as the “suicide belt” after sociologist Matt Wray noticed the region’s alarming trend in the early 2000s. This “suicide belt” is disproportionately populated by middle-aged and aging white men, who are often socially isolated, unemployed, and have access to guns. Although there are many suicides in these states outside of the middle aged white male population, the large concentration of white men in these areas enables data from the suicide belt to provide a useful indication of the risk factors that lead to high rates of white male suicide fatalities. For example, a study published in 2013 found that residential instability plays a large role in the suicide belt’s elevated suicide rates.5 The high rate of suicide deaths in older white men is likely a result of a mix of many risk factors that, when combined, can be fatal. More research is necessary to identify the significance of various risk factors, enabling public health officials to create more precise projects for suicide prevention. In the meantime, our health institutions must take broader steps to prevent suicide. The most commonly noted concept in research about suicide in middle-aged white males is that many of the subjects have a feeling of separation from society. The increasing rates of death by suicide amongst mid-

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Gender gap: although women are more likely to attempt suicide, men are more likely to die by suicide. In 2015 white men in the United States had an age adjusted suicide rate of 23.6 per 100,000 whereas white women in the United States had an age adjusted rate of 6.92 per 100,000.

dle-aged white men, therefore, may indicate broader societal problems such as declining levels of social connectedness, weakened communal institutions, and fracturing along class, cultural, geographic, and educational lines.9 White men accounted for 7 out of 10 suicides in 2015.1 This is in part because they make up such a large portion of the American population, but also because the rate of suicide among middle-aged white men is so elevated. They are a subset of the American population that deserves more attention when it comes to suicide prevention, not only for their sake but for America’s: suicide costs the U.S. $44 billion annually in medical fees and the loss of productive workers.1 As treatments and prevention initiatives improve for biology-based diseases such as cancer and stroke, deaths by more psychology and sociology-based suicides (and the associated problems of overdose and addiction) climb to the top of mortality lists, particularly in developed countries. Policy makers currently struggle to justify spending on anti-suicide measures because it is difficult to determine and target the complex set of risk factors for suicide - it can be immensely difficult to quantitatively evaluate the success of preventative initiatives. Even the studies cited in this paper are observational rather than experimental, so while they are useful in theorizing about factors that are associated with elevated in

middle-aged white males, they cannot conclude direct causation. However, as difficult as understanding suicide may be, it is a critically important pursuit. While research is being done to identify more specific risk factors for suicide and methods for combatting them, we must rely on initiatives to broadly counter the societal environments that contribute to high suicide rates. Programs to target high-risk subsets of the population, like white middle aged men, must be viewed as necessary and life-saving public health measures. No matter your age, gender identity, race, or ethnicity, suicide is never the solution. There is never shame in getting help. If you or someone you know needs help, please contact the resources below: National Suicide Prevention Lifeline: 1-800-273-8255 Yale Walden Peer Counseling: (203)-432-8255 www

Laura Michael is a freshman in Pierson College. Laura is a prospective Applied Mathematics major. Contact her at laura.michael@yale.edu.

Flickr

DISEASE EPIDEMIOLOGY

By Sarah Spaulding

Drug-Resistant Tuberculosis T

hroughout much of known human history and prehistory, tuberculosis (TB) has surged and receded along a time scale that challenges much of the accepted scientific understanding of typical epidemic cycles of infectious diseases. Written records of TB appear in Greek literature dating as far back as 460 BCE, with Hippocrates’ description of “phthisis” as the most widespread, almost always fatal, disease at the time.1 Since Benjamin Marten’s 1720 conjecture that TB might be spread by “minute living creatures,”2 the medical community has come a long way in its understanding and treatment of the disease. Today, we know that TB is caused by Mycobacterium tuberculosis, a bacterium that is spread from person to person through airborne transmission. The most common symptoms are weakness, weight loss, fever, and night sweats. Although TB usually affects the lungs resulting in chest pain and coughing of blood, it can also affect other areas of the body, such as the brain, kidneys, and spine.3 Most importantly, it can be extremely fatal; over two-thirds of people ill with TB disease will die without proper treatment.4 Part of the difficulty in tackling TB stems from the sheer complexity of the disease. A person who is exposed to TB bacteria can

develop TB disease, as the bacteria multiply and destroy tissue in the body. Alternatively, exposure can lead to the development of latent TB infection, which does not present symptoms of TB disease, but can lead to the development of TB disease in the future.3 However, both types are treatable and curable, though they require differing levels of treatment severity. Depending on an individual’s risk factors for developing TB disease, which can include HIV, diabetes, malnutrition, and tobacco use, latent TB infection can be treated with a series of drugs over the course of several months that are designed to kill TB bacteria.5 Individuals with TB disease may be treated with a combination of the 10 currently FDA-approved anti-TB agents over the course of six to nine months.6 As of October 2016, TB is one of the top ten causes of death around the world, and over 95% of TB cases and deaths are in developing countries.7 Currently, approximately one-third of the world’s population has latent TB4, and TB remains a leading killer of HIV-positive individuals, accounting for thirty-five percent of HIV deaths in 2015.7 Additionally, TB treatment is a heavy financial burden on many nations, which disproportionately affects the the health and economies of developing nations more than developed nations. The BRICS nations (Brazil, Russia, India, China, and South Af-

rica), which comprise approximately half of the world’s TB cases, rely on domestic funding for the majority of their financial support. By contrast, 87% of TB financing in low-income nations and 60% in middle-income nations comes directly from international donor funding from organizations such as the Global Fund to Fight AIDS, TB, and Malaria.10 Even so, the $700 million TB received in monetary support from these sources in 2014 are far smaller than that of HIV and malaria, which received $5.4 billion and $1.7 billion respectively in the same year.10 Even more burdensome is the lack of massive reductions in global TB incidence rates needed to push forward TB eradication efforts. Although ending TB epidemic by 2030 is a high priority of the Sustainable Development Goals set forth by the UN, the annual decline in TB incidence would need to reach 4-5% to reach the 2020 milestone of the “End TB Strategy.” Since 2000, the rate of incidence has only fallen by 1.5% per year on average.7 Further complicating the issue is the rise of drug-resistant TB. In one of the earliest comprehensive studies of drug-resistant TB, conducted in 2006, several global health organizations including the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) found that 20% of Mycobacterium tuberculosis isolates were resistant to mul-

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tiple first-line anti-TB agents. Furthermore, the report found that extensively drug-resistant TB (XDR-TB) was identified in each of the 25 reference laboratories around the globe that contributed data to the study.8,9,10 Furthering the crisis in the rate of drug-resistant TB incidence, a major impediment to the reduction of this rate stems from the severe lack of access to adequate treatment for drug-resistant TB. According to the 2016 WHO Global TB Report, of the 580,000 individuals with MDR-TB who became eligible for treatment in 2015, only 20% were enrolled.10 Two main sectors of drug-resistant TB exist: multi drug resistant TB (MDR-TB) and extensively drug resistant TB (XDRTB). MDR-TB is caused by bacteria that do not respond to the two strongest first-line anti-TB drugs: isoniazid and rifampicin. However, MDR-TB can be cured through treatment with second-line drugs, which are typically less effective, more expensive, and toxic compared to first-line drugs. By contrast, bacteria that causes XDR-TB is unresponsive to even the most powerful second-line anti-TB drugs. As a result, individuals with drug-resistant TB face more difficult treatment options, which typically include a combination of chemotherapy and extremely potent drugs. Additionally, individuals treated for drug-resistant TB face more extensive treatment periods and drawn-out recoveries: typical MDRTB treatment periods are 20-26 months, and XDR-TB treatment takes 32 months for completion. This lays a heavy burden on individuals treated for drug-resistant TB. On top of the severe side effects of treatment (which can include depression, psychosis, hearing impairment, hepatitis, kidney impairment, loss of mobility, vision impairment, and seizures), 73% are hospitalized, 37% require home isolation, 27% must stop working due to the sickness. As a result, this productivity costs an average of $134,000 for MDR-TB patients and $184,000 for XDR-TB patients.11 Several avenues for the emergence and proliferation of drug-resistant TB have collectively contributed to the current crisis in rates of MDR-TB and XDR-TB emergence. Since the first antibiotic treatment of TB in 1943, random genetic changes have allowed for the development of drug resistance in certain strains of TB. This process is further accelerated by poor management of TB treatments on a single patient basis. Within individual cases of TB, there are two methods by which an individual can obtain drug-resistant TB. Inadequate TB treat-

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ment, due to a number of things including failure to maintain proper TB treatment regimes and improper or substandard prescription of anti-TB drugs, can result in acquired drug-resistant TB. Moreover, drug-resistant TB can be directly transmitted from one individual to another.12

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but it allows for tailored TB eradication efforts specific to each nation’s situation.10 For example, the most recent Global TB Report showed six nations, India, Indonesia, China, Nigeria, Pakistan, and South Africa, were responsible for 60% of 10.4 million new TB cases in 2015 worldwide. As a re-

The most essential elements in the fight against drug-resistant TB are expansion of preventative treatment, more comprehensive global TB data, increases in TB funding, and major advancements in clinical research.

Despite a collective worldwide effort to end TB, such as the 2035 WHO milestone which aims to reduce TB deaths by ninety-five percent and TB incidence by ninety-percent, many global programs neglect to adequately address the incidence and prevention of primary drug-resistant TB, if at all.7 Additionally, eradication efforts are further complicated by the recent emergence of a strain of totally drug-resistant TB (TDR- or XXDR-TB), which is resistant to all first-line and second-line anti-TB agents,13 as well as the current coepidemics of TB and HIV/AIDS in African countries, which were predicted to fuel each other to “crisis proportions” in a recent study.14 The most essential elements in the fight against drug-resistant TB are expansion of preventative treatment, more comprehensive global TB data, increases in TB funding, and major advancements in clinical research. In 2015, only 7% of HIV-positive individuals eligible for preventative TB treatment were started on a treatment course.10 These numbers leave the door wide open to major improvements in access to preventative TB measures. Similarly, one of the most essential elements in drug-resistant TB eradication efforts is drastically improved data on global TB rates. 2015 marked the first year that 10 countries, including Kenya, reported data for rates of TB preventative treatment given. Although this trend is promising, more than two-thirds of the countries with the highest rates of TB in HIV-positive individuals did not report any quantitative data concerning the disease.10 Until we can implement national “notification and vital registration systems” as outlined in the 2016 WHO Global TB Report, comprehensive data from each country through prevalence surveys will be invaluable; not only does it provide crucial information regarding the relative burden each nation faces,

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sult, the WHO has been able to give special attention to targeting the current state of TB prevalence in these nations when designing their future efforts in TB eradication. Lastly, substantial progress in TB-related clinical research is essential to the reduction of drug-resistant TB. Until the development of a universal TB vaccine that protects against all strains of TB, research efforts in drug susceptibility testing and the development of effective second-line drugs to treat MDRTB and XDR-TB will prove essential. Despite a challenging situation, current efforts to eliminate TB are promising. Since 1990, global TB mortality rates have fallen by 47%.15 Additionally, increasing efficacy in diagnosis and treatment of TB has saved over 49 million lives since 2000.10 Current TB research shows great potential for drastically shortening treatment times and minimizing debilitating side effects for individuals with drug-resistant TB.16 Although drug-resistant TB is an exceptionally complex issue in global health, as eradication efforts and advancements in medical research continue, we will be able to look forward to a TB-free future.

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Sarah Spaulding is a junior in Jonathan Edwards College double majoring in Environmental Engineering and Ecology & Evolutionary Biology. Contact her at sarah.spaulding@yale.edu.

Rini Sulaiman Center for International Forestry Research

FIELD WORK

INDONESIA:

Why International Agreeme Health Crisis of Palm Oil D 31

YALE GLOBAL HEALTH REVIEW

By Akielly Hu

ents Wonâ&#x20AC;&#x2122;t Solve the Deforestation VOLUME 4, NO.3

ast spring break, I had the opportunity to travel to Indonesia to learn about sustainable palm oil with a group from the Yale International Relations Association. As a naïve freshman, I remember asking the group leaders before we left, “What sorts of activism efforts might we do once we get back on campus? You know, to raise awareness about palm oil deforestation?” And while I still think that such educational efforts are important and effective, I realize now that pushing against an environmental catastrophe rooted in a deeply set system of economics, international politics, and modernization is a lot tougher than I thought it would be. Neither an awareness campaign, nor a United Nations treaty, nor a glossy campaign with crowd-pleasing slogans will solve the issue of palm oil deforestation and its environmental health effects. Instead, we must take a look at the local challenges that directly cause deforestation and consider the most realistic and effective interventions. Palm oil, derived from the red fruits of the oil palm plant, makes up the backbone of the global vegetable oil trade. These plants are extremely productive compared

to other oil plants: for up to 30 years, oil palm plants produce a yield of about 3.7 tons of palm oil per hectare – five times more than soy and four times more than sunflower.1 Because it is semisolid at room temperature, almost flavorless, and stable at high temperatures, palm oil is extremely versatile and used in almost everything: deodorant, chocolate, ice cream, toothpaste, and biodiesel, to name just a few examples. According to the World Wildlife Fund, about half of all processed goods in an average United States supermarket contain palm oil. Worldwide, palm oil constitutes more than 30% of total vegetable oil produced.1 The consumer demand for palm oil is unrelenting–and so are the production efforts of the suppliers. Over 85% of the world’s palm oil comes from Indonesia and Malaysia.1 In Indonesia, where the most palm oil production occurs, the palm oil industry employs over three million people.1 The most common (and cheapest) way to clear space for palm oil plantations is by burning down forests, including high-carbon forests and areas marked for conservation. To obtain even more arable land,

peatlands (wet, carbon-rich soils) are often drained of water, which raises the frequency and duration of forest fires, as formerly unburnable lands become dry and flammable.1 The amount of forested land destroyed continues to increase at alarming rates. From 2005 to 2014, palm oil land nearly doubled, reaching over 8.5 million hectares.2 An estimated 53% of palm oil exports from Indonesia are sourced from illegal deforestation (with legal deforestation making up another significant portion of exports).1 Palm oil deforestation in Indonesia destroys habitats for animals including endangered species such as orangutans and rhinos, eliminates native plant species, and harms the livelihoods of communities living in Indonesia’s forests. One of the most visible and harmful effects of deforestation is the large amount of smog over Indonesia, Malaysia, and other countries in the region, often referred to as the Southeast Asian haze. This phenomenon occurs every dry season at the height of forest fires. The haze continues to worsen as more forests and peatlands are destroyed, and the smog outbreak of 2015 was the most severe since 1997.3 Forest fires re-

Palm oil is extracted from the oil palm fruit.

Icaro Cookie Vieira Center for International Forestry Research

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lease harmful fine particulates such as PM 2.5, which can lead to premature disability and death in affected areas. Even long after fires, fine particulates persist, penetrating lung tissue, remaining in the atmosphere, infiltrating indoor air, and spreading to other countries and regions in Southeast Asia.1 Every year, approximately 110,000 premature deaths in Southeast Asia are attributed to particulate exposure from forest fires, and overall long-term risk for cardiovascular disease and respiratory disease among affected populations increases.1 Infants and children, elderly people, and other immune system compromised individuals are especially at risk for developing respiratory tract infections and cardiovascular problems.3 Those closest to the source of fires are the most adversely affected. In the 1997 haze outbreak, for example, over 90% of respondents in a health survey of Jambi City, Indonesia (a city located close to forest fires) reported respiratory problems.1 The high economic costs of these health issues pose another burden: one study stated that the 1997 haze episode cost $199 million in health expenditures.1 Palm oil deforestation devastates all these facets of society–– health, economy, environment––and more.

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About half of all processed goods in an average United States supermarket contain palm oil.

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With so much at stake, it’s no wonder the international community has responded. While in Indonesia, our group had lunch with three United States diplomats – two from USAID and one from the State Department. We were collectively impressed with their detailed knowledge of the Indonesian political climate and the issue of palm oil sustainability, but even more so with their candor when it came to the motivation behind their work in Indonesia. As one diplomat phrased it to us, advocating for palm oil policy change was not a conservationist or humanitarian cause; rather, reducing deforestation aligns with the United States’ security interests. Therefore, their role is to work with Indonesia to make this happen to achieve U.S. diplomatic goals. Hearing about how actively the United States seemed to be working with the Indonesian government to enact deforestation policy change was fascinating, and

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An Indonesian palm oil worker transporting bunches of oil palm fruits in a wheelbarrow.

also a bit alarming. We all wondered how much the United States worked to influence the Indonesian government to fit U.S. security interests compared to other countries. Like the United States, the United Nations has also strongly advocated for action to alleviate deforestation and its effects. The Indonesian Palm Oil Pledge (IPOP), signed at the United Nations Climate Summit in 2014, was an agreement to ban all deforestation and labor exploitation between Indonesia’s five largest palm oil producers (making up over 60% of Indonesia’s palm oil economy).4 Enacted just recently in 2014, IPOP officially dissolved this past July because (as stated on the IPOP website), “IPOP signatories have decided that recent groundbreaking policy developments in Indonesia have fulfilled the purpose of IPOP to help accelerate and promote this transformation toward sustainability and therefore its presence can be dissolved”.5 These “groundbreaking policy developments” include a moratorium on peatland development, the formation of a Peat Restoration Agency, and a moratorium on palm oil licenses announced by President Joko Widodo in April 2016.5 While many see the abandonment of IPOP as a failure in international conservation efforts, others celebrate its dissolution. Several government officials openly criticized the pledge for harming small farmers.6 Others questioned how effective the pledge would be at shifting consumer and smallholder (small farmers who work for large palm oil companies) practices towards no deforestation.7 Some, like Scott Poynton, founder of The Forest Trust, a non-profit that works with corporations to improve sustainability, believe that IPOP was simply “good PR” for the international community.8 Poynton argues that follow-

ing Nestle’s groundbreaking No Deforestation Responsible Sourcing Guidelines in 2010, large palm oil companies (including the signatories of IPOP) implemented their own no deforestation policies long before IPOP’s creation. Without IPOP, he believes companies are now able to innovate new ways of addressing obstacles to enforcing these policies “free from the distraction of trying to work out how to collaborate pre-competitively”.8 Though the effects of IPOP and its dissolution remain controversial, I personally lean towards Poynton’s perspective on the issue. During our trip, we met with about a dozen members of the IPOP secretariat who shed some much-needed light on this program. A common theme during our conversation was the need for further development. This includes development of IPOP’s exact mechanisms, assessment of IPOP’s effects, and clarification of IPOP’s mission to “collaborate with the government and all stakeholders to attain a sustainable palm oil sector”.9 They emphasized that because IPOP was so new (formed in 2014), they hadn’t yet developed an established method of enforcing sustainable policies, nor determined the effectiveness of IPOP. In fact, the challenges that the IPOP team brought up were the same ones the Ministry of Environment and Forestry told us they were currently dealing with: decentralized governance, opaque supplier chains, and contradicting concession maps. However, the one difference appeared to be that palm oil companies and the government seemed to already act on initiatives to address these problems, while IPOP appeared to still be figuring out their approach. Despite years of effort by the Ministry, these issues of local governance have proven quite difficult to overcome. The fall of

Rini Sulaiman Center for International Forestry Research Forest fires are mostly caused by human activity. Palangkaraya, Central Kalimantan, Indonesia, 2011.

the Suharto regime in the late 1990s led to decentralization of power to local officials who are often unaware of federal palm oil policies.10 A World Resources Institute study on the 2014 moratorium on deforestation stated: “only three out of eight [local officials] knew the areas protected by the official moratorium map within their district boundaries”.11 Our conversations with the Ministry of Environment and Forestry and the World Resources Institute echoed these same issues of decentralized governance of protected forests. Similarly, the Ministry frequently mentioned the lack of transparency in supply chains as a main hindrance in enforcing a ban on deforestation. The team at IPOP also seemed focused on this issue, noting that without being able to ensure that each smallholder in the chain of supply of oil palm followed sustainable practices, a commitment to no deforestation was meaningless. However, neither IPOP nor the Ministry seemed to have a direct solution to this issue. The Ministry of Environment and Forestry also stressed the challenge of contradicting concession maps between different government agencies. Maps of the Indonesian forest designate forested land, protect-

ed land, and land available as concessions for development. However, within the Indonesian government, it’s common for “the Ministry of Forestry, the Ministry of Development Planning, the provincial government, and the district head to all use different maps for the same geographic area”.11 As a result, the government gives out more land than intended as concessions and/ or might mistakenly allocate concessions to two or more different palm oil companies. To address this issue, the Indonesian government has set up an initiative called “One Map” to consolidate the thirteen different maps used by various government agencies.11 As we spoke more with government officials, local non-profits, and palm oil industry executives, it seemed clearer and clearer to me that efforts to address these challenges were well under way, even without the still developing internationally-led IPOP program. Before traveling to Indonesia and learning more about this issue, IPOP and other international campaigns seemed to me like a great way to address palm oil deforestation and its harmful health and economic effects. What better way to address a global environmental health issue than to collab-

orate as a global community? Yet the more we spoke to those involved in the palm oil industry and regulation, the more skeptical I became. These central obstacles to enforcing a commitment to no deforestation – decentralized governance, opaque supply chains, and contradicting concession maps – seem best resolved by the government agencies and private corporations that directly control these processes. Rather than advocating for more internationally led pledges, our most appropriate role as people outside Indonesia and other palm oil producing countries is to continue to demand for sustainably sourced palm oil. With better enforcement of sustainable practices, we will hopefully one day see less smog, fewer premature deaths, and improved health of both the environment and the people of Southeast Asia and the world. www

Akielly Hu is a sophomore in Berkeley College majoring in Global Affairs. Contact her at akielly.hu@yale.edu.

YALE GLOBAL HEALTH REVIEW

FIELD WORK

INDIA: Consider the ASHA:

A qualitative analysis of accredited social health activists’ experiences in Udaipur, India Partha Sarathi Sahana

hushi Baby is a wearable mHealth platform tracking maternal and child health to the last mile. Its mission is to reduce infant and maternal mortality due to vaccine-preventable disease. As explained in the Khushi Baby 2016 Annual Report, the Khushi Baby system comprises of a culturally tailored NFC necklace, which digitally stores immunization and health records for pregnant mothers and children. The necklace interfaces with a mobile app to update records, and serves as a social symbol of health that can be used to recruit more mothers to immunization camps and antenatal checkups. The data is synced to a dashboard for health officials to manage care delivery resources. Also, the necklace serves as a social symbol of health that can be used to recruit more mothers to immunization camps and antenatal check-ups. The dashboard sends dialect-specific voice reminders to the family’s cell phone in the local dialect to encourage MCH awareness.1 The Khushi Baby concept originated in the Yale University class, “Appropriate Technology in the Developing World.” This class focuses on different global-scale

VOLUME 4, NO.3

By Sara Locke

problems. Students were assigned the task of developing vaccine-related innovations that could help prevent the 1.5 million deaths that result each year from vaccine-preventable diseases. While other teams focused on vaccine storage and delivery, Khushi Baby addressed the huge organizational difficulties faced by clinicians and parents as they document a child’s vaccination record. In many rural areas where public immunization rates are extremely low, methods for tracking vaccination history rely on outdated paper forms. Health workers are burdened by this inefficient system. Khushi Baby aims to streamline the data collection process. In the summer of 2016, I joined Khushi Baby as a Field Research Intern at their Headquarters, in Udaipur, Rajasthan. I am grateful to the Global Health Scholars program for enabling this work. While in Udaipur, I had the opportunity to gain hands on experience with designing and implementing a research study. With the help of Farhana Jamal and Pawan Singh, two members of the Khushi Baby team, we conducted a qualitative study focusing on rural community health workers’

experiences. I conducted the data analysis upon returning to Yale in HLTH 490: Global Health Research Colloquium with the guidance of Professor Elizabeth H. Bradley, PhD. What follows is an abbreviated version of the research paper produced in this class. The objective of the Indian Government’s National Rural Health Mission (NRHM) is to strengthen the healthcare delivery system in rural India, with a focus on the needs of vulnerable, village populations. In 2005, the NRHM established a new cadre of community health workers called Accredited Social Health Activists (ASHAs).2 ASHAs act as village-level, grassroots workers who link the community to the public health care system by addressing both supply and demand-side issues. ASHAs have three roles: (1) to create awareness on health and its determinants; (2) to mobilize the community towards local health planning; and (3) to increase utilization of the existing health services.3 ASHAs represent the cornerstone of NRHM’s strategy to address the millennium development goals on health related indicators in India.4

Since its implementation in 2005, the ASHA program has been evaluated in numerous studies. The 2011 assessment from the National Health Systems Resource Centre emphasized that while the ASHA program is now operating at scale and serves an integral role in the public health system, the ASHA’s functionality and effectiveness can still be improved.5 A further study found that the ASHA program increased immunization rates from 12-17%, but only in Indian states that give a focus to the program.6 Additional studies examined incentives, recruitment, roles and responsibilities, supervision, and training for ASHAs throughout India. The research emphasizes a need for stronger ASHA supervision and support, with clearly defined roles and responsibilities for all frontline health workers.2,3,7,8 Despite the usefulness of these findings, only one study of those reviewed report on the ASHA’s own views of their roles.9 This specific study involved 25 interviews and 5 focus groups with ASHAs, health professionals and community members as well as over 100 hours of non-participant observation at public health centers. The research investigated contextual features of the ASHA program that are hindering the ASHAs’ capacity to improve health outcomes and act as cultural mediators and agents of social change. The study found the ASHAs’ payment remuneration system was inadequate, and that the hierarchical structure within the public health system “limited opportunities for meaningful communication across levels of status, seniority and income”.9 The study concluded that progressive policy on community health worker programs must be backed up by more concrete institutional support designed to enable ASHAs to fulfill their roles. Therefore, despite numerous studies of the ASHA program, first-person accounts of the ASHAs’ experiences, including their views on the challenges they face in performing their various roles, remain largely unexplored. In particular, there is a lack of knowledge regarding the ASHA-patient relationship. With this in mind, the objective of the study is to understand how the ASHAs experience their work, including their perspectives on the challenges they must overcome to execute their duties. A specific focus of the study was to investigate the challenges the ASHAs face in the provision of immunizations and antenatal care for women and children. In the study, qualitative methods were used to capture the voice of the ASHA and to gain a holistic understanding of their role as the primary liaison between rural healthcare providers and the communities they serve. Given the

central role ASHAs are intended to play in India’s health system, a deeper understanding of their experiences can help Indian policymakers gain a more comprehensive and valid view of the healthcare delivery system. To understand the ASHA’s experience, we conducted a qualitative study with a group of ASHAs working in Udaipur, a city in the western Indian state of Rajasthan. Udaipur is relatively under-researched compared with other regions in India. Qualitative methods are particularly useful for providing in-depth, nuanced understandings of individuals’ experiences and perspectives within local contexts.10 Using purposeful sampling to recruit ASHAs, researchers held interviews in situ in the rural villages throughout the region surrounding Udaipur to ensure the sample was reflective of diverse parts of the state.

camps. This trust stemmed from regular, face to face contact: As we know them and do regular field visits, so they trust us and come here. (ASHA 8) Two other ASHAs explained that this regular visitation meant they could reinforce the importance of attending vaccination camps or receiving antenatal care. Those who do not understand, we visit them repeatedly and explain them again and again. (ASHA 11) Best way is to do home visit again and again. If we will sit with them and will explain and motivate them, then they will understand that if we are coming to them again and again, then there must be something good for the health of their child, that’s why we are coming here. (ASHA 1)

The final sample size was determined by theoretical saturation regarding questions about the ASHA role and challenges they faced in executing this role. Theoretical saturation was reached when participants were giving very similar answers to the questions. Data saturation was achieved upon completion of 11 participant interviews

Another participant described these visits as useful because they allowed the ASHA access to her patient’s family. The mother does not make health care decisions alone. Instead, the ASHA emphasized how health care is family decision. For example, one ASHA explained that to convince a mother to attend a vaccination camp, she also had to convince the patient’s family:

Data analysis was performed using factor analysis and constant comparative analysis. The data analysis generated a set of four key concepts, which represent the common view of the interviewed ASHAs that relate to the enablers that facilitate an ASHA’s ability to fulfill her role as a health care provider. The respective barriers to these enablers were also explored. We selected verbatim quotations to illustrate the recurrent concepts. The findings, reported below, are presented using the four factors as sub-headings.

Yes, door to door visit and explaining the parents. Visiting them at home is the best way. We have to talk to the family members also because if she is ready and the family members object that where she is going and like that, then she won’t come. So we have to explain them also. (ASHA 7)

CONCEPT 1: House to house visits All of the ASHAs described home visits as central to their work and important for their impact on clients and families, particularly for ensuring mothers attended vaccination camps or received antenatal care. ASHAs house-to-house visits are effective for a variety of reasons: crucially, the ability to develop a personal relationship of trust with their patients, and the ability to involve the family. ASHAs claimed that house-house visits form a relationship of trust between an ASHA and her patients. One ASHA explained that the patients’ trust in her is what motivated them to attend vaccination

Despite the importance of home visits, practical challenges were described as limiting ASHAs’ ability to conduct these visits. A barrier to an ASHA’s ability to conduct her house-house visits was limited time. When we asked one ASHA if there is anything else she would like to discuss, she explained her frustration at having to sit at the vaccination camp (the Aanganwadi centre) when she could be making house-to-house visits. In this case, the ASHA felt she was wasting her time, because her work was in “the field,” in the homes of her patients: As we sit most of the time at Aanganwadi centre, so we get less time to do household works. We have to manage our children also. Sometime we have to sit unnecessarily at the centre, because we do not have work daily. If we will spend more time in field, then we can be more in contact with the women. If you could help us, then we want that we should not have bonding to sit at the centre even if there is no work here. Our reimbursement is also so low. We are just

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given Rs. 1600/- and asked to sit at the Aanganwadi for the whole time. So, when will we go to the field and when we will do home visit and gather information. (ASHA 4) Lack of adequate transportation presented challenges for implementing home visits by the ASHA, and visits to the vaccination camps by mothers. Although forms of transport are available, this does not mean the transport is available when actually needed. One ASHA narrated a story of a patient who was unable to give birth at a hospital, because the ambulance was too slow. In this case, the ASHA was unable to fulfill her role, due to the inadequate infrastructure: We had 3 home deliveries here at our place after April. In the latest case, when I called 108 ambulance, I got the reply that it’s not working. Then the patient herself called the ambulance, they said that it’s coming from some other place, but by the time it arrived, delivery happened. (ASHA 9)

“

en are reluctant to give birth in the hospital, preferring to remain at home, in perceived safety: Some women are afraid of vaccination. Those who regularly take vaccines, they go to the hospital for delivery. But those who don’t take the vaccines, they avoid going to the hospital. She remains afraid. (ASHA 11) CONCEPT 3: Mothers’ availability ASHAs stated that their ability to provide health care largely depended on patients’ availability. Numerous ASHAs specified that mothers are often unavailable due to work, or because they are too busy caring for other children. Mothers do not feel they have the time to attend a vaccination camp or receive antenatal care, especially given that they must go more than once. Moreover, mothers are not available when an ASHA makes her house calls. As a result, the ASHA faces difficulty in accessing her patients, and spending crucial face-to-face time with them:

Khushi Baby’s mission is to reduce infant and maternal mortality due to vaccine preventable disease.

Closely related to this, another ASHA explained how rough, rocky rural terrain is a serious physical barrier. As aforementioned, all ASHAs included in this study travelled by foot. Yet the homes they are required to visit are often far away, in remote locations. The ASHAs struggle to reach their patients, and likewise, the patients are unable to trek to the vaccination center: Another problem is distance. As houses are located on hills in the village, so it takes time to reach at the center. Some women got busy in work, so they can’t come. (ASHA 5) C O N C E P T 2: Education Numerous ASHAs perceived that they play an important role as teachers. ASHAs educate patients about disease. They clarify why vaccinations, and healthcare in general, are important. Moreover, they explain why vaccinations might result in fever, and reassure mothers that this reaction is normal, and not to be feared. By doing so, ASHAs motivate their patients to receive the necessary vaccinations or antenatal care: Yes, they ask us that our children gets fever after vaccination, then we tell them that when immunization is done for the first time, the child gets fever, but it is for the protection from diseases. We tell them about the diseases. (ASHA 10)

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When asked to discuss the difficulties they face in motivating patients to attend vaccination camps or antenatal care, the ASHAs acknowledged that their patients are initially fearful of vaccinations. ASHAs explained that their patients do not understand the fever that often follows an injection, and therefore do not want vaccinations. There is a stigma surrounding vaccinations, which deters patients from seeking care from the ASHA. This fear was often cited as “illiteracy” by the ASHAs. While “literate” women know that vaccinations are effective, “illiterate” women require the assistance of the ASHA:

There are many women who get the vaccination done, but still some women don’t take vaccination, as they are afraid of fever and other things. So we motivate them that this fever is good for you, as it’s bringing out the illness (ASHA 6)

”

If the mother would be literate, she will bring the child on her own. She will contact us herself, that I want my child to be vaccinated, what should I do. And those who are illiterate, we have to go and explain them and inform them about the vaccines. Literate women are already intelligent. They know that if it’s not done here, then they have to go to Udaipur. For illiterate women, we face problem. We have to tell them because they do not know. (ASHA 1) If they do not come, we have to visit them again and again. Those who are intelligent, they come and those who are not intelligent, we have to go and call them again and again. Those who understands, they come on their own. But tribal and village people do not understand… because they are not literate. We have to visit them again and again. (ASHA 5) Moreover, when patients fear the vaccines, they are likely fearful of healthcare providers and healthcare more generally. An ASHA explained how her patients who dislike vaccinations are similarly anxious about hospitals. By consequence, the wom-

If they have some work at home or if their family member refuses and complains about problems like wasting of time and asks why they go repetitively etc., then the lady doesn’t come. For instance, today I called a lady over phone and then I visited her home also to inform, but she has not arrived yet. Her husband is saying that she will not come, she is getting treatment from some other hospital, so we don’t have time to come here and to go there. And he said that we have some guests also at our home, so she will not come. (ASHA 7) Village women give more attention on their work and not on their body. They remain engaged in farming works or take care of the children and could not care about themselves. (ASHA 3) CONCEPT 4: Inconsistent access to medical record information ASHAs reported that they require adequate medical records about their patients in order to fulfill their roles as health care providers. The NRHM established the use of immunization (MAMTA) cards to record the immunization status of patients in rural areas, carried by the patients themselves. ASHAs explained that they need this documentation to give correct vaccinations. However, some mothers forget to bring their cards, or do not have one. In such instances, while some ASHAs keep personal records of their patients, others will

not give treatment to the patient. Therefore, an enabler for ASHAs is to have adequate health records for their patients. They face a decision of whether or not they can give a vaccination without such records. One ASHA explained that she will give treatment to patients she recognizes, regardless of whether or not the patient brings the MAMTA card. This ASHA keeps her own records about her patients, which she refers to. ASHAs are knowledgeable about the health status of their patients, reinforcing the importance of the house-tohouse visits. This ASHA also will refuse to treat patients she does not recognize. Such a decision could have long-term impact for the patients seeking care: If she forgets [the MAMTA card] than either we tell her to bring the card or as we also do entry in our registers, so we check it in our record and get her vaccinated accordingly. But if she is an outsider, we return her because we don’t have their records and we don’t know which vaccine is to be given and which is not to be given. If she is from our area, then we know which vaccine is to be given and which not. (ASHA 6) One ASHA did not keep a personal record of her patients, and depended on MAMTA cards. When a patient did not have her card, even if the ASHA recognized the person, the ASHA refused to give any vaccination at all. This decision was rooted in the desire to deliver appropriate medical service. Yet, without an effective record-keeping system in place, patients are the ones who ultimately face the consequences: She will not be vaccinated, because it gives the record of all the check-up’s and vaccinations done. A seal is also put for HIV positive or negative on the card. If the woman is HIV positive, then her treatment can be started soon accordingly, so that the child doesn’t get HIV... We refuse. (ASHA 4) Another ASHA reported that she was able to give a vaccination based upon the child’s age and record the entry later. The purpose of a medical record is to hold up to date, correct information. However, if an ASHA is “doing entry later,” in retrospect, there are some concerns about the accuracy of the information recorded: Even if they forget to bring the card, we vaccinate them as they have come from far places. Entry can be done later, but it’s important that they came to the camp.

Table of ASHA Characteristics.

We know because we vaccinate them every month. On the basis of child’s age, we get to know. (ASHA 1) DISCUSSION We found the ASHAs play a critical role as a link between the community and the public health care system. Understanding the factors that shape these workers’ experiences is essential for the improvement of the health care delivery. Previous research has focused on the need for strong institutional support for the ASHA program as a whole, prioritizing the need for a better payment scheme, and improving communication between ASHAs and higher tiers of the health care delivery system. Results from our qualitative study provide insights about the ASHAs’ own perspective on the challenges they must overcome to execute their duties as health care providers. Therefore, the presented research explores from a different perspective and in detail why institutional support is necessary for the ASHA program. The study offers a novel understanding of the experiences of the ASHAs, with particular consideration on the ASHA-patient relationship, and how this relationship might be strengthened.

A predominant idea weaving through the four concepts discussed is the importance patients trusting the ASHA. ASHAs endorse house-to-house visits as a central component of their work because this was the “best way” to establish a bond with their patients and an understanding of their patients’ family situation. Additionally, ASHA’s required the trust of their patients to overcome the stigma surrounding healthcare practices, particularly in the issues patients have with antenatal care and vaccination. The main barrier to creating a relationship of trust was the inability to have faceto-face contact. This was a consequence of the ASHAs’ inability to visit the homes of her patients, either because she was required to sit at the vaccination camp for a certain number of hours or because transport was difficult. It was also a consequence of the patients themselves being unavailable, due to work or other family commitments. Facilitating ASHA’s ability to create a relationship of trust can markedly influence their impact. An ASHA’s household visit is a mechanism that results in a strong

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discussion with them and hear their perspective. In a future study, focus group discussions could also be used to facilitate easier conversation. CONCLUSION

Nick Cunard UK Department for International Development Rekha Rewat, an ASHA in Madhya Pradesh, India.

relationship between the ASHA and her patients. Given the importance of these visits, investigating the relative value of the required hours ASHAs must spend at vaccination camps should be a topic of future research. It is possible that with less time required at the camps, ASHAs might gain better access to patients in their homes. Additionally, with better access to patients’ homes, ASHAs might be more likely to enlist the assistance of patients’ families in healthcare decisions. This could strengthen the relationship with their patient, and lead to better health outcomes. Given that transportation was also cited as a barrier to household visits, this study has illuminated the need for either improved methods of transportation, or more health centers at accessible locations. From the perspective of the ASHA, inadequate transport limited their ability to fulfill their roles. Policy makers should prioritize infrastructure spending tailored toward ambulance availability in rural areas. ASHAs felt their role as teachers constituted an important factor in fostering trusting relationships with their patients. ASHAs acknowledged the “illiteracy” of their patients as an obstacle. Future research should analyze the most effective methods of education in these communities. Educational materials must be readily available for an ASHA to continue to de-stigmatize health care practices.

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It was found that ASHAs lack a uniform medical reporting procedure. Respondents reported that MAMTA cards are not always used. This hinders an ASHA’s ability to deliver appropriate health care services to her patients. A reliable system would ensure all patients who attend vaccination camps are accounted for and receive the appropriate medication. Future research should examine more effective methods of record keeping in rural areas. LIMITATIONS These findings should be understood in light of three main limitations. First, the sample size of 11 participants was determined by theoretical saturation -- there may be additional ASHA experiences that were not mentioned by the interviewed participants. This points to the need for a more extensive study with more participants. Second, the interviews lasted approximately 30 minutes. To achieve a more nuanced understanding of the ASHAs experiences, the discussion guide might be revised to allow for more questions and a longer conversation. Third, the researchers’ presence during interviews (although unavoidable) may have affected the participants’ responses. Some ASHAs initially thought the research team consisted of members of the Indian government, with the purpose of evaluating their performance. It required some persuasion to convince the ASHAs that we were only there to have a

The four concepts identified by this study are key considerations for the development of the ASHA program. The study highlights the importance of adequate institutional support for the ASHAs and also reaffirms the significance of trusting relationships between the ASHAs and their patients. The added value of the study is that it is based upon the perspectives of the ASHAs themselves and what they perceive as bridges and barriers to fulfilling their roles as grassroots health advocates and community health workers. The ASHAs are remarkable women, and with the right support, have the potential to improve the health of the vulnerable village populations in rural India. ACKNOWLEDGMENTS Thank you to Farhana Jamal and Pawan Singh Bhadauriya for their consideration of the ASHA. Thanks also go to the ASHAs who gave their valuable time for interviews. The Yale Global Health Field Experience & Seed Funding Awards funded this research. www

Sara Locke is a senior in Branford College majoring in History of Science, Medicine & Public Health. Contact her at sara.locke@yale.edu.

GLOBAL HEALTH TODAY

LATIN AMERICA:

Zika as Catalyst for Reproductive Rights Reform By Gracie Jin

-year-old Ianka Barbosa cradles her baby daughter, Sophia, in her parents’ tiny brick house in northeast Brazil. She was 7 months pregnant when she learned that Sophia had microcephaly, the incurable condition causing atypically small heads, severe birth defects, and intellectual disability, which doctors blamed on the Zika virus. Before Sophia was even born, her father had left. “I think, for him, it was my fault the baby has microcephaly,” Barbosa said to journalists from New York Magazine. “When I most needed his help, he left me.”¹

cially in an environment where sexual violence is so common”.⁵ The Zika epidemic is unveiling tragic failings of reproductive health policies in Latin America. Due to the poor quality of sex education, lack of access to contraception, and high prevalence of rape, many women in Latin America have little control over their reproductive lives.

Barbosa is not alone. On February 1, 2016, the World Health Organization officially declared Zika a public health emergency of international concern.² At the time, Zika transmission had already been reported in 23 countries, with 4,180 suspected cases of microcephaly in Brazil. In July 2016, 93.4 million people were at risk of Zika infection in Latin America and the Caribbean, 1.7 million of which were childbearing women.³

Hidden behind the staggering numbers and horrific photographs are stories of young mothers like Barbosa. Governments cannot wait for science to find a cure when Zika is crippling generations of mothers and children. To propose effective steps toward reproductive rights reform, Latin American health leaders must first examine maternal and child health as key to global development, then understand the factors exacerbating the problem: socioeconomic inequality and religious conservatism. Finally, governments must adopt culturally-sensitive policies around termination of pregnancy, education, and support services for women affected by Zika.

Since Zika currently has no vaccine or treatments beyond symptom alleviation, health officials have focused instead on prevention campaigns. In January 2016, many Latin American health ministers advised that women postpone pregnancy for six months to two years due to the Zika outbreak.⁴ However, these recommendations placed the whole burden of disease on women, blindly ignoring the controversial fact that 56% of pregnancies in the region are unintended. Zeid Ra’ad Al Hussein, UN Commissioner for Human Rights, explained the gender-biased response: “the advice of some governments to women to delay getting pregnant ignores the reality that many women and girls simply cannot exercise control over whether, when, or under what circumstances they become pregnant, espe-

Maternal and child health ranks near the top of global health priorities and indicates a country’s standard of living. Every year, more than half a million women—99% of whom live in developing countries—die in pregnancy and childbirth due to preventable reasons. In Latin America, high maternal mortality rates often affect the poor, rural, and indigenous. 55% of women in Nicaragua give birth at home, 65% are illiterate, and adolescents account for almost one-third of maternal deaths. Maternal-related health issues are the most common reason for public hospital admission in Nicaragua (29%), followed by pneumonia and diarrhea.⁶ These statistics place into context the lack of reproductive health knowledge, resources, and support in Latin America that render women powerless to fight

against the arrival of an epidemic as explosive as Zika. Latin America and the Caribbean are the most unequal regions in the world. The Zika epidemic reflects this egregious socioeconomic inequality. Zika is concentrated among poor, young, women of color from underdeveloped regions, who live in crowded neighborhoods exposed to mosquito breeding grounds, and who have the least access to reproductive health care. In addition to poor sanitation and substandard housing, the irregular water supply forces families to store water at home and spread the mosquito vector.⁷ In Managua, the capital city of Nicaragua, most of the over 150 informal settlements lack water service. The World Health Organization recognizes that “the burden of Zika falls on the poor”.⁸ Policies that neglect reproductive rights increase gender inequality by placing overwhelming financial burden on women. These strains begin with detection and diagnosis: “to identify if you have had Zika, the cost in private labs is close to 1000 reals (just over $250),” explains Brazilian activist and former Global Fund for Women board chair Jacqueline Pitanguy; “the majority of women cannot afford it.”⁴ In addition to costs incurred during pregnancy, women in many Latin American cultures are responsible for child care. The New York Times reports accounts of many mothers of infants with Zika-related disabilities who have been abandoned by their partners. In the impoverished Campina Grande, ground zero of the Zika epidemic, psychologist Jacqueline Loureiro works at a specialized microcephaly clinic to help mothers cope with stress and trauma. Only 10 out of the 41 women she counsels receive adequate support from their partners.⁹ “At first many of the women say they have a partner, but as you get to

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know them better you realize the father is never around and the baby and mother have effectively been abandoned,” Loureiro said. After the Bishop of São Paulo stated that women should take the care of babies with microcephaly as their mission, these mothers faced extreme loneliness, social stigma, and the effects of being stripped of their financial autonomy due to abandonment.6 With no ability to generate an income and little public health assistance, for women who already face an intergenerational cycle of poverty, “their childbearing dreams turn into nightmares because of the Zika virus.”¹⁰ While inequality is a root cause of the Zika epidemic, some risk factors of infection that can be addressed more readily include poor sex education and a lack of access to reproductive health services. Among the 18 Zika-active countries, the estimated Contraception Prevalence Rate (CPR) in 2015 was as low as 37.8% (Haiti) or 44.8% (Guyana).3 This reproductive health knowledge gap is often linked to cultural and religious conservatism. The WHO estimates that 22% of women across Latin America want to delay or prevent pregnancy but do not have access to birth control, are misinformed, or are not educated about contraception due to strong conservative dogmatism. This lack of education has led to high rates of teenage pregnancy in Latin America: 38% of girls and women get pregnant before the age of 20.⁴ While the landmark decision of Roe v. Wade is often taken granted for in the United States, many countries affected by Zika have some of the strictest termination of pregnancy (TOP) laws on the planet. Abortion is allowed in Guatemala, Haiti, Honduras, Paraguay, Suriname, and Venezuela only to save a mother’s life, whereas in the Dominican Republic, El Salvador and Nicaragua, TOP is illegal in all situations.¹¹ Voluntary interruption of pregnancy faces constant threats of retrocession, as politicians debate stiffening laws to give jail terms of 4.5 years to women who abort fetuses with microcephaly. Why are abortion laws so strict, especially in Central America? Spanish and Portuguese colonial law, which followed Catholicism, left a blueprint for the post-independence 1810 Napoleonic codes in Latin America. Instead of equating abortion with homicide and a death sentence like under Canon Law, the civil codes in Latin America criminalized abortion with imprisonment.12 Few modern politicians would consider publicly supporting the legalization of abortion, in fear of losing support of their conser-

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worldabortionmap

Abortion laws in Latin America.

vative constituents and the Church. Nicaraguan President Daniel Ortega has strongly supported his country’s total ban on abortion. Strict abortion laws refused to budge even when the Zika epidemic struck. Recently, Pope Francis suggested that contraceptives may be used to prevent the spread of Zika virus despite the Catholic Church’s ban on most forms of birth control; in the same statement, he called abortion “an absolute evil” and a crime like “what the Mafia does”. These sentiments resonate deeply with the Brazilian people, who are 65% Catholic. According to a poll conducted in February 2016, 58% of Brazil’s population did not support the right to abortion for women infected with Zika.¹⁰ While abortion is morally and culturally controversial, the undeniable fact is that the current system criminalizes poor women. To access abortions, women either have to have enough funds to pay for illegal procedures or fly out of the country. Approximately 850,000 Brazilian women have illegal abortions annually, and about 200,000 were hospitalized in 2013 because of complications.6 In Latin America, the Guttmacher Institute estimates that the total number of abortions rose to 4.4 million, 95% of them in unsafe conditions. One doctor in El Salvador described a case where a woman put caustic soda inside her vagina. Instead of ending her pregnancy, she was so badly burned she had to have a caesarean.¹³ These horror stories highlight a desperate need for reform in reproductive health policies across Latin America. In Brazil, abortion is the fourth leading cause of maternal mortality, demonstrating that the current legis-

lation saves neither embryos nor mothers. In El Salvador, some women face up to 40 years in jail on abortion charges. These disproportionately include poor women, single mothers, and rape victims. Some were not aware of their pregnancy and miscarried; others suffered complications near the end of their pregnancy and could not seek help in time. One international effort to tackle this criminalization debacle, “Las 17”, demanded the release of seventeen women imprisoned due to their miscarriages. Since the campaign launched in April 2014, two women have been released. The other 15 are still in prison.11 Governments must take action as they wait for scientists to find a cure for Zika. First, realistically adapt abortion policies, taking into account the culture of each community. Simply changing the law is not enough, however, and schools must educate girls to increase knowledge about reproductive rights and access to contraceptives. Third, provide financial and social support for women whose livelihoods are threatened by Zika. Last and more broadly, incorporate human rights issues such as gender equality into the global health approach in order to better respond to future epidemics and allocate resources to where unmet need is highest. Firstly, women should have the right to make fully informed decisions about their pregnancies. The Office of the United Nations High Commissioner for Human Rights recommended an “urgent revision” of Brazil’s reproductive rights legislation so that all women, especially those in fear of carrying a fetus with microcephaly, may have the

right to choose whether to proceed with or interrupt the pregnancy, protecting their physical and emotional integrity without “moral condemnation and criminalization”.⁷ Just as abortion sparks controversy in the United States, climates around the legalization of abortion vary across Latin America. Monica Arango from the nonprofit Center for Reproductive Rights explains that while South America is making advances in women’s rights, Central America is a place where “it is dangerous to be a woman of reproductive age”. When Uruguay decriminalized abortion in 2012, it became only the second country to do so in Latin America, after Cuba.13 Universal legalization of abortion may be an unrealistic goal, but maximizing reproductive rights reform will require joint effort across all sectors including the government, the courts, and the nonprofit community. On August 24, 2016, the National Association of Public Defenders petitioned for Brazil’s Supreme Court to allow termination of pregnancy in the case of women under “great mental suffering” from contracting the Zika virus. Joaquim Neto, president of the association, qualifies that “abortion would only occur in very exceptional cases,” and that the mental suffering would have to be verified by psychologists. “Abortion is not the main goal of the petition, but it is impossible to talk about Zika without addressing abortion”.11

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In Brazil, abortion is the fourth leading cause of maternal mortality, demonstrating that the current legislation saves neither embryos nor mothers.

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While Neto gives voice to the silent and vulnerable in the sphere of public policy, nonprofit organizations have also stepped up. In countries where women have no universal access to safe abortions, the nonprofit Women on Web (WoW) provides online telemedicine to help terminate pregnancy including mifepristone and misoprostol. Since the Zika alert issued by the Pan American Health Organization, WoW received statistically significant increases of between 36% and 108% in re-

quests for abortion. From November 2015 to March 2016 in Brazil, the number of requests doubled as a total of 1,210 women requested abortions while only 581.7 requests were expected (P<0.001).14 This overwhelming flood of requests reveals not only the need for safe abortions for the 56% of women in Latin America who did not intend their pregnancies, but also the government’s unfulfilled responsibilities. Ignoring these cries for help will put the whole weight of a public health crisis on individual women, depriving them of their dignity and financial autonomy. While reproductive health policy change is crucial for sustainable reform, legislation is ineffective without implementation through awareness and education. The situation in Colombia serves as an example of this gap. Although Colombia has one of the loosest abortion laws in Latin America, which allows women to terminate their pregnancies under circumstances including rape, birth defects, or risks to the mother’s physical and mental health, the Global Fund for Women reports that legal abortions in Colombia remain extremely rare because women have difficulty accessing doctors who will perform abortions.⁴ Another gap in women’s health education was unveiled by a British Medical Journal study on the prevalence of sexually transmitted diseases, HIV, and cervical neoplasia, which involved 1,185 women who attended health clinics in Nicaragua. Almost one out of five women had an STI, and 1 out of 13 had a precancerous lesion of the cervix. While only 30.4% of the women visited the clinic for STI-related reasons, 77% reported symptoms after probing.15 These numbers show a gaping lack of knowledge in STI prevention, screening, and treatment in Nicaragua. The government must take responsibility to improve the current state of women’s health education. Key strategies to combat this lack of access include starting sex education in public middle schools and increasing wider community knowledge about family planning and contraceptives. While much research is underway to understand the Zika virus and develop treatments for Congenital Zika Syndrome, few studies have examined the impact of Zika on family planning. Understanding the causes of Zika-related neurological disorders will help women make informed decisions

Wikimedia Commons

Mother holding baby with microcephaly

about their pregnancies, but in the short term, initiatives to help women achieve their basic health needs are crucial. As a human right, comprehensive reproductive health information should be provided to all women. Education efforts to reach women affected by Zika, who are already vulnerable due to socioeconomic inequality, must be strengthened. In addition to incorporating sex ed into middle school health curricula, possible methods of education outreach include informational displays at community centers, pamphlets delivered to health clinics, posters at grocery stores, speakers at public spaces, and various events catering to specific cultures. Clinics should adopt programs that equip nurses and doctors with the skills to respond to Zika; schools could train students to be peer health educators; government agencies and nonprofits could organize sex education and vaccination campaigns at rural clinics and urban hospitals. Furthermore, several organizations currently work to advance reproductive rights and women’s health education in Zika-affected regions. The Institute for Bioethics in Brazil demands accessible and affordable contraception. The Catholics for the Right to Decide network aims to soften extremist religious rhetoric in Latin America through reproductive health education. The SOS Corpo Instituto Feminista para a Democracia, directed by Silvia Camurça, is leading a national movement for sexual and reproductive rights in Bra-

YALE GLOBAL HEALTH REVIEW

zil. These organizations coalesce to help women realize their rights, advocate for them, and connect to services for safe motherhood. The positive effects of education are well-established globally. Studies in Africa and Latin America show that women’s education lowers their risk of HIV and other sexually transmitted infections, increasing their comfort and ability to discuss HIV with a partner.16 These advances made by education can and should be replicated for Zika-related reproductive health issues. Policy and education emphasize prevention, but governmental response to the Zika epidemic must not neglect social and financial support for women who already gave birth to children with congenital Zika syndrome. First, public health clinics must offer mental health services in addition to Zika testing. The stresses of women who are pregnant, infected with Zika, and uncertain about their pregnancies can be emotionally traumatizing. To better understand the emotional toll Zika takes on women, researchers evaluated mothers at a public clinic in Sergipe, Brazil, between November 2015 to June 2016. They compared data on anxiety, depression, and quality of life between two groups: one of which was comprised of nine mothers whose infants have microcephaly, and the other 20 mothers who had healthy newborns. The results confirmed the researchers’ fears. ZIKV-related microcephaly is significantly associated with high levels of anxiety and low scores in the psychological domain of the WHO quality of life ques-

tionnaire (P = .006) for mothers 24 hours after childbirth.17 To combat anxiety and increase self-esteem in mothers of children with Zika congenital infection, multidisciplinary counseling and psychoeducational intervention programs should be implemented.

those most victimized by the epidemic, the voices of women must be heard. To address the root causes of maternal mortality, the Zika epidemic, or any other women’s health issue, governments must view gender as a social and economic determinant of health.

Second, financial support is crucial to preserving long-term autonomy of women and families impacted by Zika. The current system of social assistance in Brazil limits financial benefits for families with babies with microcephaly to three years, but public lawyer Neto counters that “the disability of these children is permanent”.18 Sadly, the women in need are already among the poorest and most vulnerable; 66% of the babies with Zika-related birth defects have been born in Brazil’s Northeast, one of the least developed regions. For these women, financial assistance should be coupled with education programs to help them become fiscally independent. Instead of leaving already marginalized women and children behind to suffer the worst repercussions of Zika, the state must lighten their burden through social and financial support.

Barbosa and her boyfriend got back together three months after Sophia was born. The psychologist for mothers at the microcephaly clinic had encouraged their reunion. Although Sophia is still too young for doctors to assess her neurological and physical delays, Barbosa worked hard to teach her to speak and was incredibly proud to hear Sophia say “Mama” for the first time. Although an X-ray in Barbosa’s apartment shows irreversible calcification in Sophia’s brain, her mother has not given up. Barbosa takes Sophia to physical therapy sessions twice a week at the hospital’s microcephaly unit, which also offers donated formula and diapers. Although Barbosa’s family has a hard time getting by, she decided to help other women in similar situations by organizing an online fundraiser called Amor Maior, “Bigger Love”, which brought in 40,000 reals (approximately $11,000) in its first year. Barbosa distributed 1,200 reals (about $345) to 25 mothers.¹

The Zika epidemic echoes a broader problem in the current global health system: a lack of focus on gender and other diverse human rights issues during emergency response. Making women-specific recommendations to avoid pregnancy, without considering the structural gender inequality that deprive women of control over their reproductive lives, is a grave mistake. To bridge this disconnect between international health officials and

On November 18, 2016, the WHO removed the status of Zika as a global health emergency. However, for the women whose babies are affected by Zika, the disease remains painfully close to home. Just as much remains unknown about the workings of the Zika virus, much uncertainty awaits Sophia’s future. “While Sophia is making progress, there are things she will never be able to do,” Barbosa laments, “we really don’t know what her future holds.” But instead of being hesitant like she used to, Barbosa says that she is “not afraid to ask for what [she] needs for [her] children.”¹ Barbosa’s story of abandonment and tragedy has transformed into a tale of empowerment and hope. For the millions of women affected by Zika in Latin America, reproductive health education and comprehensive support are key to helping them escape poverty, realize their rights, and live lives of dignity. This is not just a fight for public health, but also one for women’s rights and social justice.

www

Gracie Jin is a freshman in Berkeley College. She is interested in studying neuroscience, global affairs, and medical anthropology. Flickr Urban slums are often mosquito breeding grounds.

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She can be contacted at grace.jin@yale.edu.

GLOBAL HEALTH TODAY

Jason Argo

A Legacy of Imperialism: Health Disparities in the Pacific By Erica Kocher

he Pacific Islands, sometimes known as Oceania, include the regions of Melanesia, Micronesia, and Polynesia. These three regions encompass tens of thousands of islands, each of which has a distinct culture. Although Oceania covers approximately 15% of the Earth’s surface area and is home to millions of Pacific Islanders, the unique issues and health concerns its population faces are rarely discussed.1 As a result, the specific health concerns of Pacific Islanders, including the rising burden of non-communicable diseases (NCDs) and continued prevalence of communicable diseases, remain largely ignored and unaddressed, both within the context of the Pacific and among migrant communities around the world. It is particularly important to understand the health disparities among Pacific Islanders because the issues that exist today are, at least in part, the result of imperialist action by the United States and other Western powers. The Pacific Islands are known and discussed internationally today for two reasons: tourism and military battles and bases. The Pacific is often viewed as open and untouched—a beautiful, natural space for vacation and

fantasy. Tourism on islands like Hawai’i began after their seizure and annexation by Western powers like the United States to counter Japanese power in the region at the end of the 19th century.2 The annexation of Hawai’i began with the overthrow of the Hawaiian kingdom by white plantation owners backed by the U.S. military. This was the first in a process of events forcing Native Hawaiians out of their homes and traditional ways of life, replacing staple crops such as taro and sweet potatoes with sugar cane and constructing luxury resorts and military bases over sacred burial grounds.3,4 In other parts of the Pacific, imperial military control has had even more destructive results, as nuclear weapons testing poisoned native peoples and their homes for generations in the Marshall Islands and French Polynesia.5 In spite of and perhaps because of this legacy of Western involvement, Pacific Islanders are largely unknown to much of the world. This obscurity is fueled by the perceived isolation of the islands, which are often excluded from world maps. In addition, the Asian American and Pacific Islander (AAPI) label remains widely used within the U.S., despite having since been replaced on the census with Na-

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tive Hawaiian and Other Pacific Islander (NHOPI), which further obscures the distinct concerns of Pacific Islanders.6 Without data about these specific concerns and experiences, the health issues Pacific Islanders face cannot be widely understood or represented. The Pacific Islands face the double burden of growing non-communicable diseases and continued communicable diseases. In general, the burden of disease, which is a measure of the causes of ill health in a population, is broken down into three broad categories: Group 1, which includes communicable, maternal, neonatal, and nutritional diseases; Group 2, which includes most other non-communicable diseases; and Group 3, accidents and injuries. In 2015, NCDs represented the largest share of the burden of disease in Oceana, accounting for 58.4% of disability-adjusted life years (DALYs) and 68.4% of total deaths.7 In contrast, “Group 1” conditions caused 30.7% of DALYs and injuries accounted for only 10.9%.7 Throughout the Pacific, ischemic heart disease is the leading cause of deaths annually, followed by diabetes and cerebrovascular disease, all of which are NCDs.7 As a result of these conditions, 7075% of deaths in the Pacific are considered premature, occurring before the age of 60.8 Even these statistics specific to the Pacific, however, obscure disparities and differences between the countries and territories. For example, in the Federated States of Micronesia, NCDs account for 73.9% of DALYs, but NCDs make up only 54.06% of DALYs in Papua New Guinea.7 Similarly, while, in the Northern Mariana Islands, injuries make up 13.75% of DALYs, in Samoa, they account for 9.74%.7 Though each island has its own unique balance of health concerns, the growing burden of NCDs is relevant throughout the Pacific and is often not discussed. One of the foremost health concerns among Pacific Islanders is obesity and the associated NCDs. In American Samoa, 95% of the population is considered overweight or obese.9 Similarly, 57% of people in Tonga are obese, compared to 35.7% of Americans.10,11 The high BMI and dietary risk factors associated with obesity are the top two leading causes of NCD-related death and disability in Oceania.7 Ischemic heart disease and diabetes, for which obesity is a risk factor, are among the top three causes of deaths in the Pacific. In the case of diabetes, prevalence among adults aged 20-79 ranges from 6.33% in Papua New Guinea to 37.06% in the Marshall Islands, compared to 9.3% among Americans.12,13 Because diabetes is a major risk factor for renal failure, chronic kidney disease is the fourth leading cause of death in American Samoa, Micronesia, Fiji, Stefan Lins

A home in Majuro, an atoll in the Marshall Islands.

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Without data about these specific concerns and experiences, the health issues Pacific Islanders face are not widely understood or represented.

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and the Marshall Islands.7 Understanding these serious conditions and their causes is central to providing effective treatment to improve the health of Pacific Islanders. The factors contributing to the rising burden of disease in the Pacific include genetics, the nutritional transition associated with urbanization, changing access to foods, and the continued importance of cultural traditions. A study published in 2016 found that approximately 25% Samoans have a gene mutation that predisposes them to obesity, a potential genetic mechanism to explain the high prevalence of obesity and overweight in these populations.14 The introduction and rise of obesity as an epidemic in the Pacific, however, is also closely associated with Western contact and imperialism. Through the Westernization of many Pacific islands, traditional sustenance farming lifestyles were replaced with more sedentary ones that involved office work and a reliance on cars for transportation. This process shifted Pacific cultures from their traditional labor-intensive agricultural lifestyles towards increased consumption of processed foods and inactive leisure time, which contributed to the rise of obesity.15 The rise in consumption of processed foods was the result of increasing reliance on imported foods that arrived by cargo ship. A 2013 study found that in Guam, 59% of food products were produced in the United States, with only 6 out of 2105 products produced in Guam itself.16 Fiji and New Caledonia also imported the majority of their food products.16 Foods that can be transported by cargo ship are often processed, high in sodium, or packed in oil. These less nutritious foods, such as turkey tails and mutton flaps, have come to dominate local food culture as signs of status and are even considered delicacies in places like Samoa and Tonga. The Pacific Islands have become a dumping ground for these products that cannot be sold elsewhere due to restrictions on fatty foods in the West. The adoption of liberal trade policies by the Pacific Islands allows manufacturers in high income countries to offload their cheap, low quality, and otherwise unsellable cuts of meat on these low-income countries.17 These products often then take the place of traditional staple foods in ceremonial feasts and cuisine, further contributing to rising obesity.16,17 While traditional practices like ceremonial community feasts may play a role in the NCD epidemic, the root causes of obesity were in-

Likuliku Lagoon Resort

Likuliku Lagoon Resort, one of the many luxury resorts that have come to

troduced with Western contact. It is not the traditional culture, but the way in which Westernization has interacted with these traditional values, that has led to a rise in NCDs. A study comparing the rural and urban regions of Western Samoa found that the prevalence of NCDs was significantly lower in rural regions.18 In these regions, Samoans maintain a more traditional, active lifestyle, growing and consuming staple foods and working on plantations, while in urban Apia, people tend to work sedentary jobs and eat a diet more supplemented with the imported, processed foods.18 The study was published in 1981, making the statistics out of date today, but it reported a prevalence of diabetes three times higher in urban populations than in rural ones, suggesting that it was Western modernization, and not cultural values alone, that helped shape the rise of NCDs and obesity in the Pacific.18

relocated.5 Although Bikini Atoll was declared safe for inhabitants to return in 1968, the 23 nuclear tests conducted there had left the island poisoned with radiation and those who returned developed cancers and birth defects.5 A 2003 study in the Marshall Islands found a higher prevalence of thyroid cancer among both those exposed to the nuclear testing and those born after testing but who lived in affected area.19 Similar problems have been documented in French Polynesia, the site of French nuclear testing, as well as food poisoning resulting from the associated environmental destruction.20 Cancers make up only 6.05% of DALYs in the Marshall Islands, compared to 15.34% in the United States. However, imperial powers who conducted the testing are still denying responsibility, thereby preventing access to resources necessary to fully diagnose and address the problem.7

In addition to the obesity-related NCDs facing Pacific Islanders, cancer resulting from nuclear testing is also a significant issue that must be addressed. As of 1980, the United Nations estimated that more than 200 nuclear bombs had been detonated in the Pacific by British, French, and American scientists and military personnel.5 The United States tested its first atomic bombs in the Marshall Islands, including many at Bikini Atoll, because they were largely isolated and had a small enough population to be easily

While NCDs dominate the discussion of health in the Pacific Islands, Group 1 conditions remain important to address, especially in Pacific countries with lower GDP per capita. Although most discussion of nutrition in the Pacific focuses on obesity, iron deficiency anemia is the third largest Group 1 cause of DALYs for the region, demonstrating the dual burden of both under and over-nutrition.7 Infectious diseases are also a concern for the Pacific. Lower respiratory infections cause 8.27% of total DALYs in Papua New

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In other parts of the Pacific, imperial military control has had even more destructive results, with the testing of nuclear weapons poisoning native peoples and their homes for generations.

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Guinea, and are the leading Group 1 cause of DALYs throughout Oceania.7 While malaria is a concern primarily for Papua New Guinea, the Solomon Islands, and Vanuatu, tuberculosis is most pressing in Kiribati, the Solomon Islands, and Vanuatu and remains more prevalent than malaria in the rest of the Pacific.7 Finally, neonatal preterm birth and other birth complications represent 3.77% of total DALYs for the region.7 In the United States, these conditions represent 1.45% of total DALYs, which suggests that they are preventable with stronger health systems.7 As they undergo modernization, the Pacific Islands continue to face this double burden of communicable and non-communicable disease. Despite the need for addressing the rising burden of NCDs, it is also important to recognize that communicable diseases are still a concern and that these issues occur in different combinations in each community throughout the Pacific, and in diaspora. Understanding the health concerns facing Pacific Islanders is crucial to more adequately addressing them both in the Pacific and among immigrant communities. Migration to and from the United States, Australia, New Zealand, and throughout the Pacific is common.21 It is estimated that at least 16,000 Pacific Islanders leave home each year, often young migrants looking for better education or work and sending remittance back to their families.22 As of 2010, 1.2 million people in the United States self-identified as Native Hawaiian and Other Pacific Islander.23 New Zealand has the second-largest population, at nearly 300,000 Pacific Islanders, not including the indigenous Maori population.25 The health issues observed among populations in the Pacific are also found among these immigrant populations in diaspora. 33.13% of NHOPI report having hypertension, compared to 25.05% of white Americans, and 36.44% of NHOPI are obese, compared to 27.2% of

white Americans.10 Similarly in New Zealand, 67% of adults and 30% of children who identify as Pacific Islanders are obese, compared to 32% of adults and 11% of children in the broader New Zealand population.25,26 These statistics demonstrate the importance of understanding and addressing the health issues specific to Pacific Islander cultures and contexts, even outside the Islands themselves. Although there are millions of Pacific Islanders living within and outside of Oceania, their health concerns are largely unknown and under-studied. Similar to the obscuring effect that the â&#x20AC;&#x153;AAPIâ&#x20AC;? label has had in inappropriately grouping Pacific Islanders with dissimilar groups, the use of Native Hawaiians and Polynesians to represent the entire Pacific obscures the interests of people from Melanesia and Micronesia. While Pacific Islanders have many common interests and shared health concerns, they remain an amalgamation of thousands of unique peoples. To appropriately understand and address their unique concerns, increased awareness and study of the region is crucial. More data needs to be collected about the burden and causes of disease and disability within individual regions of the Pacific, instead of using only a few cultures, usually those of Polynesia, to represent the interests of all Pacific Islanders. Finally, it is crucial that these efforts involve Pacific Islanders in studying their own health issues, because they are best prepared to understand how best to intervene to the benefit of their own people.

www Erica Kocher is a junior in Silliman College majoring in Sociology. Contact her at erica.kocher@yale.edu.

Cherrie Mio Rhodes

An example of a Samoan diet, including palusami (made with taro leaves and coconut cream), bread fruit, lo mean, and fried meat.

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GLOBAL HEALTH TODAY

CHINA:

Overcoming Challenges to Hospice Care By Evaline Xie

ucius Annaeus Seneca, an ancient Roman statesman and Stoic philosopher once wrote in his essay “On the Shortness of Life” that “it takes the whole of life to learn how to live, and […] the whole of life to learn how to die.”1 As courageously as the Roman Stoics faced death, Seneca illustrates an undeniable fact: even after living a happy life and recognizing and coming to terms with the inevitable brevity of existence, the end of life is a difficult time. Dying, especially as the result of a culmination of a long and painful chronic illness, can be mysterious and unpredictable, lonely and often undignified. The process of dying takes not only an array of medical supplies to alleviate physical pain but also the comforts of companionship, spiritual guidance and emotional support. To support the elderly and terminally ill with this struggle, modern medicine has developed the concept of hospice, or end-of-life care, a model of health care provided for people who are ill, have a prognosis that is likely to worsen, and will most likely die from their illness.2 The idea of hospice care was developed only relatively recently with the opening of the first modern hospice center in 1967 in London by the physician Cicely Saunders. After joining the faculty of the Yale School of Nursing in 1965, Saunders helped inspire the opening of the first American hospice in Branford, Connecticut in 1974.3 Hospice care focuses on compassion, alleviating pain and suffering, and improving quality of life, and it usually involves a team of doctors, nurses, social workers, chaplains, counselors, and volunteers working together with patients. In other words, hospice represents not a particular place or institution but rather a philosophy of care centered around the patient and the patient’s choices. Consequently, it is usually available anywhere, in places as intimate as an individual’s private home or in nursing homes and hospitals. While hospice care has been available for nearly 50 years, it took time for the practice to gain acceptance in the United States. In some ways, it can feel like giving up on life, surrendering curative treatments in exchange for a death sentence. Although it has recently become more common in the United States, with 1.6 to 1.7 million patients receiving services from hospice in 2014,3 in other countries, such as China, hospice care is still largely unknown or untrusted. According to a study by Susan Enguidanos et al. in 2013 among Asian populations in the U.S., only 11.8% of Chinese-Americans aged 65 and older reported knowing someone who had received hospice care.

Even those who had heard of it lacked knowledge of what kinds of services hospice programs provided and other details such as eligibility and insurance coverage.4 A 2015 report by The Economist Intelligence Unit evaluated 80 countries on the quality of end-of-life care based on five categories: the palliative and healthcare environment, human resources, the affordability of care, the quality of care, and the level of community engagement. Among the 80 countries, China was ranked 71st on “Quality of Death,” with its affordability of end-of-life care ranking 65th and quality of end-of-life care ranking 69th.5 Overall, China has been reluctant to accept and develop hospice care as a healthcare specialty. The country’s first hospice and palliative care facility was not created until 1990, followed three years later by the inauguration of the Chinese Association for Hospice and Palliative Care in 1993 – the first real milestone in the history of Chinese palliative care.6 In 1994, the Ministry of Health listed hospice care in the Subject Directory of Diagnosis and Treatment in Medical Institutions for the first time, essentially establishing the field as its own specialty with independent diagnoses and treatments.7 Since then, 32 hospices and about 120 palliative care facilities have been created in private and public hospitals throughout China, with most clustered in the highly-populated cities of Shanghai, Beijing, and Chengdu.5 These facilities have been supported primarily by philanthropists such as Li Jiacheng, who developed a foundation to support the development of hospice units.6 Despite all these advances, however, hospice in China is still very much an emerging specialty. While services lag behind those of other countries, hospice care is needed in China more than ever. China’s population is not only the largest in the world, with about 1.37 billion people as of 2013, but also one of the most skewed demographically. Due to the one-child policy instated in the country for almost thirty years, the proportion of elderly people over sixty years of age is projected to rise to 30% of the entire population by 2050, while the elderly dependency ratio is projected to rise from the current 11% to 38%.8 In other words, there may be in the next thirty years a large portion of the Chinese population in need of significant amounts of daily care and a much smaller proportion of younger relatives able to provide it. What, then, has prevented the faster growth of China’s hospice services? A large obstacle currently facing its expansion

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Wikimedia

Photo: An ink painting from a Song Dynasty album leaf titledÂ Illustrations of the Classic of Filial Piety.Â Composed between 350 and 200 BC, the Classic of Filial Piety became a classic Confucian text, teaching its readers that filial piety in the home brings peace and harmony to not only the individual but to society as a

simply derives from a lack of standardization, regulation, and professionalism. Given how it draws from multiple disciplines, from medicine and nursing to philosophy, psychology, and the arts, hospice care programs require large numbers of well-trained, dedicated personnel from all areas in order to be successful. China’s hospice care currently suffers from shortages in both quantity and quality of healthcare professionals. These shortages can partially be explained by the Chinese government’s lack of support for hospice and palliative care. Currently, the national health security system does not generally provide any government subsidies for palliative care, making it difficult for individuals to fund their own care.5 For example, the treatment of cancer, one of the three primary causes of death in China,9 costs about 300,000 Yuan (50,000 USD), while the annual per capita income in China is about 7,000 USD.7 Even at Songtang Hospice in Beijing, one of the country’s earliest palliative care institutions providing care with relatively low costs (an average of 1,000-2,000 RMB, or $126-320 per month), patients struggle to afford their care.5 The most significant challenge to expanding China’s hospice care, however, is the general attitude towards hospice itself, which is rooted in traditional Confucian values that have pervaded Chinese culture for thousands of years. In traditional Chinese culture, the family not only serves a social unit but also embodies the values and ideology of Chinese society as a whole. Filial piety, a sense of duty, respect, obedi-

ence, and obligation towards one’s parents and elderly family members, represents the foundation of the family. The character xiao consists of two parts. Pictorially analogous to a compound word in English, the top half of the character is the character lao, meaning “old,” and the bottom half zi, or “son.” In a remarkably concise, simple way, the character expresses the idea that children support the elderly, a weighty responsibility on their shoulders. It also demonstrates the strict hierarchy of family structure, where older generations have significant power over younger generations, who must show obedience and respect to their elders. Simultaneously, death itself is taboo in Chinese culture. Chinese culture reinforces the idea that anything associated with death brings ill fortune. As a result, people strongly avoid discussing death openly, even in medical contexts, where family members of patients often believe that telling the patient an unfavorable prognosis will weaken his strength and spirits, only making his condition worse or even driving him closer to death. Instead, believing that they are fulfilling their responsibility for filial piety, family members tend to push for additional intensive treatment to continue the patient’s life, even in cases of terminal illness, claiming “where there is life, there is treatment.”7 Unsurprisingly then, much of the population holds distrust towards hospice and palliative care, interpreting hospice care as a surrender to death, with patients receiving care simply waiting to die. If a patient with

Pixabay

An elderly patient being cared for in a hospice care facility.

late-stage cancer is admitted into a hospital, for example, family members will often ask doctors to treat the illness at all costs, even if treatment at that point has become futile and may, in fact, only cause more physical and emotional suffering.6 The alternative, allowing the parent to die by removing life support or giving up on curative treatment, is viewed as disgraceful, a disregard for filial piety.10 Even the presence of a hospice or palliative care center is looked down upon. For example, Song Tang Hospice, the first palliative care facility in China, has changed locations seven times since its initial establishment in West Beijing in 1987 due to complaints from nearby residents who thought it was a hospital for the dying, bringing calamity to their lives.7

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People strongly avoid discussing death openly, even in medical contexts, where family members often believe that telling the patient an unfavorable prognosis will weaken his strength and spirits, only making his condition worse.

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How do these cultural differences impact medical care in practice? A 2004 survey of sixty different oncology clinicians in Chinese cities by Dr. Xin Wang and others may illustrate how an end-of-life care experience in a Chinese cancer treatment center may differ from one in the West. First, it is unlikely (only 43% of respondents) that a cancer patient in one of these urban hospitals would have access to a hospital-based hospice service, and it is even less likely (only 13% of respondents) that a home-hospice service would be available. 11By comparison, as of 2014, there were 4,000 hospice care agencies in the United States, and 67% of hospitals with fifty or more beds reported having palliative and hospice care teams.12 As far as managing symptoms, although most clinicians deem themselves to be highly competent in managing patient’s pain, only about 40% report using standard

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Peter Griffin

A large hospital in Xuzhou, one of the largest cities in China’s Jiangsu Province. According to a study in 2012 by researchers at Xuzhou Medical College, only 18.4% of com-

pain assessment scales in practice. Furthermore, most physicians judge themselves to be incapable of managing their patients’ depression and other psychological issues during the last six months of life. As for communication between clinicians and patients, although a majority of physicians believe that patients should know their cancer diagnosis and prognosis, including when terminal, 70% believe that most families do not actually want their patients to know the truth. As a result, clinicians in these Chinese cancer treatment facilities are mixed in their practice of disclosing terminal prognoses: two thirds report that they would tell the truth when patients requested it directly, and 10% would never tell the patients their terminal condition. The main reason they cite is that informing patients about the nature of their illness would cause depression – aligning with the cultural belief that talking about death brings ill-fortune, weakening a patient’s spirit and morale and thus worsening his condition. This is a common trend among Asian countries in general, in which phy-

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sicians are much more likely to withhold unpleasant prognoses from patients at the family’s request.11 This diverges greatly from the models of end-of-life care that are now most prevalent in Western countries such as the United States, which emphasize the patient’s autonomy and right make decisions about what is important to them at the end of life and how they wish to pursue treatment, if any. So how can hospice care in China move forward? Perhaps the most important obstacle to be solved is the lack of education and training, both among healthcare professionals providing hospice care and the general population receiving it. Doctors, nurses, and volunteers need standardized palliative and hospice care curricula in order to understand the in-depth medical knowledge needed for appropriate care and drug use, including knowledge on the benefits of hospice care, when to transition from curative treatments to hospice, and how to communicate these options informatively for patients. On the other hand,

while changing public opinion is challenging, public health education about the advantages of hospice care should be provided to patients and families. The philosophies behind filial piety and hospice are not entirely divergent and can be reconciled with enough physician sensitivity. Both are concerned first and foremost with the patient and his or her needs; providing comfort and compassion at the end of life can be framed as just as much a fulfillment of filial duty as curative treatments. As the ancient Roman philosopher and statesman Seneca said, it may take our whole lives to learn how to approach the end of life, so there is truly no time like the present to begin learning. www

Evaline Xie is a sophomore in Grace Hopper College studying Cognitive Science. She can be reached at evaline.xie@yale.edu.

HEALTH PERSPECTIVES

CRISPR/Cas9 and the Future of Global Health By Akhil Upneja

he discovery of CRISPR/Cas9 has revolutionized the field of genetic engineering in countless ways. From targeting genes conferring antibiotic resistance to creating disease models in animals, the technique offers scientists a fast, cheap, and accurate alternative to other gene-editing systems on the market. UC Berkeley and UC San Francisco, major universities at the forefront of the biotechnology movement, plan to invest $125 million over the next five years to create solutions to some of the worldâ&#x20AC;&#x2122;s most pressing problems, and CRISPR co-discoverer Jennifer Doudna, who received an honorary degree from Yale in 2016, has publicly stated that the technology can and will be used to promote global health in the agriculture and microbial worlds.1 In this piece, I will expand on how CRISPR is being used, and will continue to be used, in the fight against insect-borne diseases and the global food shortage.

International Rice Research Institute

To understand how the technique is being used, it is first important to understand how CRISPR works at a fundamental level. The system, which takes the form of a double-stranded circular piece of DNA called a plasmid, contains DNA sequences for dozens of elements. The two most important elements for this discussion are a destroyer protein called Cas9 and a 20-nucleotide guide RNA sequence that can be designed by scientists to target any gene in the genome. The guide RNA sequence attaches to Cas9 and acts as a homing signal that takes the protein to the specified location and destroys the gene of interest. CRISPR/Cas9 can be used not only for deletion but also for modification and insertion as well, and this mechanism is critically important for the applications discussed below. This technology is already having a profound impact on issues relating

to the global food crisis in three ways: decreasing flowering time, preventing disease, and increasing yield in drought conditions. First, scientists at the Cold Spring Harbor Laboratory have been experimenting with flowering times for domesticated tomatoes sold in supermarkets all across North America. They found that while domesticated tomatoes are not sensitive to the amount of daylight they get per day, their ancestors -- the wild equatorial species -- are particularly sensitive to the sunâ&#x20AC;&#x2122;s rays.2 The researchers were able to trace this back to SP5G, an anti-florigen gene that regulates flowering periods depending on the amount of daylight present. Expression of SP5G spiked in the equatorial tomatoes when they grew in greenhouses in the US, and domestic tomatoes also contained residual amounts of SP5G expression as well. The researchers decided to eliminate SP5G from the tomato genome in order to let the tomato plant

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flower, regardless of sunlight availability. Using CRISPR/Cas9, the SP5G gene was deleted, and the researchers found a rapid increase in flowering time, and thus an increasing yield rate, making the process of production much more efficient. 3 Increasing the productivity of each individual crop could potentially yield vast dividends for the world’s food supply. Second, crops resistant to diseases represent a new wave in holding crop yields steady. Powdery mildew is a disease that manifests itself as a white fungus on the surface of plant parts. 4 It is a ruthless killer that has developed resistance to many traditional fungicides, and thus it exemplifies exactly the type of variable that scientists are looking to eliminate with CRISPR. Before CRISPR/Cas9, it took years of selectively cross-breeding specific crops to pass down favorable genes. Furthermore, even if the technique is carried out properly, farmers also inevitably get unfavorable genes that are part of the genomes of the “favorable” plants, thus making this process inefficient and only partially successful. In 2014, scientists at the Chinese Academy of Sciences in Beijing identified three genes that were repressing the ability of wheat to protect itself from powdery mildew, and they used CRISPR/Cas9 to introduce loss-of-function mutations to each of these three genes. 4 Through their exper-

DataBase Center for Life Science

A depiction of the CRISPR/Cas9 gene editing system.

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iments, the bread wheat showed heritable resistance to powdery mildew, a huge breakthrough in the field of disease-resistant crops.4

As drought becomes an increasingly important issue, CRISPR/Cas9 modifications represent game Third, drought conditions are a changers in the huge crop killer. An analysis published in fight against Nature in 2016 showed that droughts have reduced crop yields by 10 percent over the presglobal food past 50 years. The authors warned that s i o n , drought conditions continue to get worse and these shortage. 5

with climate change, and that yields will continue to deteriorate as global temperatures rise.5 Maize in particular has been severely affected by drought. The UN’s Food and Agriculture Organization declared that maize production had declined in Malawi by 27 percent due to extreme heat and low rainfall.6 To combat this, scientists continued to search for ways to encourage plants to adapt to such extremities, and eventually developed that CRISPR could help regulate the natural ethylene response in maize, which regulates stress in drought conditions. A study published in 2016 found that in maize, a gene named ARGOS8 was a negative regulator of ethylene responses.7 It was hypothesized that by increasing expression of ARGOS8, crop yields in drought conditions could potentially increase. Scientists then utilized CRISPR to insert a promoter ahead of the ARGOS8 gene to increase ex-

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modified crops were tested for their yield against unchanged crops in both drought conditions and normal conditions. In overexpressing ARGOS8, the scientists found that maize production substantially increased in the changed crops with less water, and that with normal amounts of precipitation, yield remained unchanged.7 As drought becomes an increasingly important issue, CRISPR/Cas9 modifications represent revolutionary technological advancements in the fight against the global food shortage. Perhaps the most controversial application of CRISPR/Cas9 involves the use of gene drives -- a molecular mechanism that makes the transmission of a particular allele essentially 100 percent -- as a weapon against insect-borne diseases. Normally, genes have two copies in a genome, and the likelihood that any given copy is passed down to offspring is 50 percent. However, if present, a gene drive removes this sort of uncertainty. Scientists at the Wyss Institute engineered a gene drive utilizing CRISPR/ Cas9 that can be incorporated into fly genomes to ensure the specific, desired allele is passed down from generation to generation. Suppose that a fly carrying a blue coloring allele mates with one that carries a black coloring allele. Their offspring will subsequently have one copy of each allele. If we want the blue allele to be passed down, we would engineer two sequences into the germ-line cells of the fly: a sequence coding for Cas9 and another sequence coding for guide RNAs against the black allele. When the blue allele is then transcribed and translated, Cas9 and guide RNA are created with it. Cas9 subsequently attaches to the guide RNA and combs the genome to find the

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Were scientists to release an untested product, the environment would reap the consequences on evolution, not just in the experimental species, but also in non-contact species that rely on the experimental organisms for survival.

black allele. When the black allele is identified, Cas9 creates a break in the DNA. At this point, there are two mechanisms by which the cell can repair its DNA. The first is the non-homologous end-joining pathway, in which the DNA simply tries to stick the two ends back together. This is an error-prone pathway because a part of the DNA was cut out, so the DNA will not be the same when it is ligated back together. The second pathway is homologous recombination. In this pathway, the DNA searches for the analogous place where the DNA was cut on the complementary strand. In this case, that would be where the blue allele is. A copy of the allele, including the gene drive sequence, is then made and inserted in the cut strand. Thus, the fly now has two copies of the same allele with the gene drive in place, meaning that any fly that it mates with will become blue in the same way,

regardless of the allele pairing of the other parent.8 To explain how gene drives have been employed in the fight against malaria, it is important to first understand how malaria is spread in vulnerable populations. First, a parasite called Plasmodium falciparum enters mosquitoes in gametocyte form.9 Two gametes then fuse to create a zygote, which develops into an ookinete. These ookinetes travel to mosquito guts, where they make their home and mature into oocysts. These oocysts release sporozoites that invade the circulatory fluid of mosquitoes, settling in their salivary glands. When mosquitoes bite humans, they inject sporozoites into our bloodstream, and these sporozoites cause malaria in our bodies.9 Malaria continues to be a deadly killer – the WHO estimates that there were 212 million new cases of

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malaria in 2015 alone, causing 429,000 deaths worldwide.10 While prevention efforts by the WHO have reduced the disease burden by 20% over the past five years, drastic measures need to be taken, in sub-Saharan Africa and beyond, to stop the spread of this deadly disease.10 The understanding of how malaria is spread through humans led to a scientific breakthrough in 2015, when scientists from UC Irvine and UC San Diego were able to identify several antibodies that conferred malaria resistance onto mosquitoes. Publishing their results in Proceedings of the National Academy of Sciences, the paper identified IC3 and 2A10 as potential malaria stoppers.11 IC3 blocks an enzyme called chitinase 1, which is critical in oocyst formation. By blocking the spread of malaria at such an early stage, parasites are theoretically unable to ever

Wikimedia Commons An example of powdery mildew manifesting itself as a white fungus on pumpkin leaves.

YALE GLOBAL HEALTH REVIEW

Wikimedia Commons CRISPR-mediated gene drives in mosquite species represent a controversial application of the new technology (above: Anopheles albimanus).

get into the salivary glands of the mosquitoes, thus stopping malariaâ&#x20AC;&#x2122;s spread to humans. The other antibody, 2A10, is a later-stage inhibitor that stops sporozoites from successfully infecting cells, essentially acting as a second inhibitor in case IC3 does not work. In 2015, the same lab decided to add these the genes coding for these antibodies, with CRISPR-mediated gene drives attached, into the genome of Anopheles stephensi, an urban Indian mosquito species well-known for its ability to infect humans in the sub-continent with malaria. Within just a few generations, the genes were transferred successfully into over 99 percent of mosquitoes. In those tested mosquitoes that received the genes, no sporozoites were found in their salivary glands, an encouraging sign that the CRISPR-mediated gene-drive works and that this technique can work for other insect-borne diseases like West Nile virus and dengue fever.11 Still, controversies abound regarding whether or not these engineered mosquitoes should be released into the wild.

VOLUME 4, NO.3

The main ethical issue concerns the accuracy of experimental testing â&#x20AC;&#x201C; indeed, there is no accurate experimental method for testing how mosquitoes will behave in the wild.12 By releasing an untested product, scientists reap consequences, for better or for worse, on evolution in not just the experimental species, but also non-contact species.12 Additionally, there is the idea that evolution always finds a way. Indeed, studies have found that over time, mosquitoes will start favoring the non-homologous end-joining pathway that will confuse the gene drive system, simply stop mating with mosquitoes carrying the gene-drive, or develop an unknown resistance that computer models cannot identify.13 While evolution will always play out over the long-run, it is critically important that we continue attempting to innovate in order to at least delay the rapid onset of diseases killing millions of people each year. Regardless of the ethics behind gene drive, scientists must push forward with CRISPRâ&#x20AC;&#x2122;s answers to the food shortage

problems across the world. The World Bank estimates that the world needs to produce 50 percent more than our current output of food by 2050, while climate change cuts production by 25 percent in the same time period.14 CRISPR provides a simple, yet efficient mechanism for modifying specific genes of interest, and it remains the best available option for us to continue innovating in order to fulfill the most basic needs of our society today. www

Akhil Upneja is a senior in Morse College interested in the intersection of global health, health policy, and clinical medicine. Contact him at akhil.upneja@yale.edu.

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