Stanford Journal of Public Health Volume 3 Issue 1 Winter 2013

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Stanford Journal of Public HealthVolume 3 Issue 1 Winter 2013

InvestigationEmma Makoba

In the Midst of Social Stigmaand Violence: A Look at Attacksagainst Persons with Albinism inTanzania

PolicyEileen Mariano

Childhood Obesity:A Growing Epidemic

ExperienceChristina Wang

Hepatitis B Eradication:An Unsolved Challenge


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Stanford Journal

ofPublic Health

An Undergraduate Publication

Volume 3 Issue 1 Winter 2013

sjph.stanford.edu


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Volume 3 Issue 1 Winter 2013Stanford Journal of Public Health

Jessie Holtzman

Emma Makoba

Emily Cheng

Christina WangGianni Sun

Andrew Liao

Judith Shanika Pelpola

Christina Wang

Yifei Men

Eileen Mariano

Judith Shanika Pelpola

Lauren Nguyen

Madeleine KaneCaroline Zhang

Charlotte Greenbaum

Editor-in-Chief

Editor-in-ChiefInternet Marketing Manager

Campus Marketing Manager

Financial Manager

Layout Director

graphics

writers

Jean Guo

Jennifer Jenks

Liz Melton

policy

research review

experience investigation

over photo courtesy of Jessie Holtzman Logo courtesy of Kiran Malladi

with support from

The Bingham Fund for Student Innovation in Human BiologyASSU Publications Board

Haas Center for Public Service

letter from the editors:Jessie Holtzman and Emma Makoba editors-in-chief

HOLTZMAN

MAKOBA

Jessie is a Human Biology major with a concentration in the cellubasis of human disease, combining her passions for policy and the nural sciences. She hopes to use her biology background, along with hinterest in womens and childrens health, to develop effective polsolutions to growing local, national, and international health dispaties. Through theJournal, she looks forward to spreading awarenesspublic health topics and proposing new, innovative, interdisciplinways to address such dilemmas.

Emma is an Anthropology major with a concentration in MediAnthropology and a Human Biology minor. She will attend medischool at Mount Sinai School of Medicine in New York through tHumanities and Medicine Early Acceptance Program. She is intereed in exploring the important cultural considerations necessary to iprove patient and doctor interactions both in one-on-one clinical stings and in the implementation of broader public health initiative

We would like to extenda warm welcome to the Winter2012-2013 issue of the StanfordJournal of Public Health, a bian-nual undergraduate publicationthat seeks to connect the enthu-siastic, widely distributed publichealth community at Stanfordby encouraging scholarly dis-cussion of todays most perti-nent public health issues. As the

journal enters its third year, weare thrilled by the growing inter-est in the public health eld at auniversity that has traditionallylacked a unied forum throughwhich to address this topic. Wefeel that this journal fosters thespirit of Stanford University inits innovative, academic, and in-terdisciplinary efforts.

Since the Journals foundingin 2011, we have had the plea-sure of working with dedicatedfaculty and staff from all cor-ners of the campus, includingthe Stanford Ofce of Commu-nity Health, the Center for In-novation in Global Health, theProgram in Human Biology,the Haas Center for Public Ser-vice, Stanford Service in GlobalHealth, and the Sexual Health

Peer Resource Center. We wouldlike to acknowledge the gener-ous support of The BinghamFund for Student Innovation inHuman Biology and the ASSUPublications Board.

During a recent lecture, DeanLloyd Minor of the StanfordUniversity School of Medicineproposed three basic tenets of

innovation: combinatiolaboration, and chance.health is an interdisceld that combines ecomedicine, biology, andpolicy. It requires the cotion of experts across diary and departmental boies to provide a robust aof a given research quYet, Minor argued that, egether, we can only do s

until we open ourselvesunexpected. By drawmany different approapublic health, the Journato promote the unexpecencourage the spark of May you encounter newand perspectives as yothis latest issue.

Warmly,Jessie Holtzman 14Emma Makoba 14


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etters from the advisors

am delighted to see this academic years rst issue of the Stanford Journal of Public Health appearprint. As always, the Journal is dedicated both to providing an outlet for undergraduates to pub-

sh their research and perspectives on public health issues and to bringing important contemporarysues in public health to the wider undergraduate community. As the Journal continues to grow, itas now merged with Stanford Service in Global Health, and in doing so it has added a new Experi-nce section. Because many students wish to pursue professional and programmatic roles in publicealth as well as scholarly ones, this new section is dedicated to creating a forum for students to share

their own personal on-the-ground experiences. The Journal thanks you for yourongoing interest and support.

Grant Miller, PhD, MPP

Associate Professor of Medicine; Associate Professor, by courtesy, of Economics andof Health Research and Policy and CHP/PCOR Core Faculty Member

contents

Investigation

Public Health Interventions in the Midst of Social Stigma and Violence:A Look at Attacks against Persons with Albinism in Tanzania........................... ..................... ......

Emma Makoba

The Parkinsons Voice Initiative:Early Diagnosis for Parkinsons Disease through Speech Recognition....................................... Yifei Men

Policy

Childhood Obesity: A Growing Epidemic......................................................................................Eileen Mariano

Medi-Cal 2016: What Obamacare Means for California Patients..............................................Judith Shanika Pelpola

Experience

The Ethics of Striking: A Public Health Concern...........................................................................Jessie Holtzman

Hepatitis B Eradication: An Unsolved Challenge..........................................................................Christina Wang

Research Review

Polio Eradication in India: Lessons for Pakistan?........................................................................Ravi Patel

Infertility: A Plague Gone Unnoticed...............................................................................................

Nitya Rajeshuni

Can Schools Prevent the Next Pandemic:A Study of School-located Inuenza Vaccination in Metro Atlanta, Georgia.......................... ...... Julia Brownell

IVF Coverage: A Policy and Cost Conundrum............................................................................. Elizabeth Melton

Catherine A. Heaney, PhD, MPH

Associate Professor (Teaching)Stanford Prevention Research Center

Amy Lockwood

Deputy DirectorStanford University Center for Innovation in Global

Health


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Photo Courtesy of Emm

Theinvestigationsection of the SJPH presents and analyzes

pressing public health issues through the lens

of epidemiological, medical, and scienticperspectives.

In this issue, we investigate critical advances

in computational technology available to aid

in the diagnosis of chronic, degenerative

diseases like Parkinsons disease and explore

the background and consequences of attacks

against individuals with Albinism in Tanzinia.

Public Health Interventions in t

Midst of Social Stigma and Violen

A Look at Attacks against Persons with Albinism in Tanza

Emma Makoba

This is a photo of a higher security elementary school located in Bukoba, Tanzania where many children

nism from different parts of the region were moved to in order to ensure their safety.

In recent years, a disturb-ing phenomenon of the system-

atic killings of persons with al-

binism in certain parts of EastAfrica has been documented byboth academics and the globalmedia. The motivation behindthese attacks in parts of Tanza-nia involves a highly complexsystem of social tensions thathave erupted in violence againstchildren and adults who havethis genetic condition. Further-

more, the practice continuestoday because the limbs and

body parts of persons with albi-

nism can be sold at prices rang-ing from US $500-2000 on theblack market. In addition, thereis overt discrimination againstpersons with albinism due towidespread and persistent mis-understanding and misinforma-tion about albinism. This situa-tion serves as an important andtragic example of the need for

public health interventhelp improve and prot

lives of innocent but stigmand marginalized groupdividuals. More specicregions where persons wbinism have faced violenendure not only manyproblems resulting from ease itself such as vision ment and high susceptibskin cancer, but they alslife threatening injuries


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ult of attacks and often requirehysical therapy, rehabilitation,nd prosthetics if they sufferss of limbs. Yet, difculties re-ain to ensure that persons withbinism have access to the nec-sary health and rehabilitationrvices because of both a lack of

ealth infrastructure, as well ashe persistent and severe stigmand threats against them.

There is an unusually high

cidence of occultocutaneousbinism type II, the most severend the most common type ofbinism in Sub-Saharan Africa.he cause for this condition isrgely unknown. It is denedomedically as a genetic con-tion that causes the defective

roduction of melanin resultingthe lack of pigmentation in the

kin, hair, and eyes, vision prob-

lems, and a high susceptibilityto skin cancer.1 In Tanzania, itis estimated that the number ofpersons with albinism rangesbetween 8,000 and as many as170,000 individuals in a popula-tion of 45 million. If the higherend of the estimation is to be be-lieved, this would make the rateof albinism in Tanzania, approx-imately one in three thousandas opposed to one in twenty

thousand [in] Europe and NorthAmerica.2

The high concentration ofmurders and attacks on per-sons with albinism primarilyin northwestern regions of Tan-zania began in early 2007. Asmany as 54 individuals werekilled within two years; and todate, a total of 71 murders havebeen documented.2 Many more

persons with albinism were leftdisabled due to the attempteddismemberment of their bodies.It must be noted that the actualnumber of persons with albi-nism killed and attacked duringthis time span may never be ac-curately known and is likelymuch higher, due to the lack ofreporting and documentation inmany rural regions of the coun-try. The attacks took place pri-marily in a particular region ofnorthwestern Tanzania referredto as Sukumaland, in the areassurrounding the cities of Mwan-za and Shinyanga. Accordingto Deborah Fahy Brycesons ar-

ticle Miners Magic: ArtisanalMining, the Albino Fetish andMurder in Tanzania, the kill-ings of persons with albinismin this region, are said to traceback to myths perpetuated bywitchdoctors, referred to as wa-ganga in Swahili.3 The myth thatwas disseminated and perpetu-ated by the waganga is that thebody parts of persons with al-binism can be used to make apotion which when consumedor bathed in, will bring an indi-vidual wealth, luck and success.3However, many other mythssurround persons with albinism,such as the idea they are ghosts,sub-human, immortal, or thattheir condition is contagious.The physical symptoms of albi-

nism take on a social functionin that they set them apart fromothers within the populationthat do not share the physicalsymptoms of the genetic condi-tion. Furthermore, because oftheir susceptibility to skin can-cer, many persons with albinismavoid sunshine, and are thusseen as weak and sedentary ina social context that often de-

ctured is a young boy who was attacked and mutilated by individuals

eeking to sell his limbs on the black market for sizable cash rewards.

mands hard physical labor ineither the dominant mining in-dustry or the agricultural eldsin the area.

Albinism is not just a geneticdisease, but also a socially con-structed illness experience inwhich individuals aficted arehighly stigmatized, dehuman-ized, discriminated against, andhunted. The persons with al-binism do not only endure thephysical symptoms of a lack ofpigmentation, visual impair-ment, and increased risk of skincancer, but they also live in con-tinual fear for their lives becauseof socially constructed beliefs

that their body parts bring aboutgood luck. Furthermore, havinga child with albinism can causea family to fear for the childslife, seek out ways to keep thechild safe, ostracize, or kill thechild because the risk may betoo great or the family may seethe child as not human. Personswith albinism may be deprivedof education or job opportuni-ties because of the falsely heldbelief that their condition is con-tagious. Children may be forcedto stay home from school be-cause leaving the house wouldput them in jeopardy from peo-ple who could potentially attack

and dismember them.Once the complexitie

practice of murdering tacking persons with ain the Sukuma contextderstood, it becomes clextent to which personalbinism are victimized. turn, provides a better cocomprehend and addresdifculties that personalbinism face and how ahealth intervention to ithe lives of persons winism in this context muinto account the degree ttheir health needs are nebecause of social stigmat

To nd references for this article, please refer to the end of this section.

The Parkinsons Voice Initiative:Early Diagnosis for Parkinsons

Disease through Speech RecognitioYifei Men

Parkinsons disease is thesecond most common neuro-degenerative disease, affecting6.2 million people globally.4 Itis most prevalent in the elder-ly, though 5-10% of diagnosesreect early-onset Parkinsonsdisease. For some individuals,symptoms may begin as early asage 20.4 Early warning signs of

Parkinsons disease usually in-

volve impairment of movement,including uncontrollable shak-ing, rigidity, difculty walking,and unsteady gait. As the dis-ease progresses, cognitive andbehavioral complications mayarise, commonly leading to de-mentia.5

There are currently no curesfor Parkinsons disease, and the

exact mechanisms leading to theloss of brain cells observed inpatients are largely open to de-bate. Medications, surgery, andmulti-disciplinary treatment,however, are widely adoptedfor relief of disease symptoms.Drugs are especially effective indelaying degeneration of motorfunctions. For instance, the aver-age time between initial disease

onset and complete dependencyon care-givers increases from 8years without treatment to 15years with regular usage of a sin-gle drug, Levodopa.6 However,pharmacological interventionsmust be initiated in early stagesof disease in order to be e fcient,as motor symptoms progress ag-gressively in the early stages ifleft untreated, leading to irre-

versible disabilities.Effective treatment an

diagnosis for Parkinsonsare hindered by a lack ofable biomarkers and omeasures of disease psion. As there are no dialab tests available for sons disease, the currenstandard for diagnosison an in-clinic neurolog

and brain scans to rule ou

PVI: A new model for diagnosi

kinsons based on speech recog

and machine learning technolo

Photo Courtesy of Emma Makoba

Photo Courtesy of Parkinson


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0 Volume 3 Issue 1 Winter 2013Stanford Journal of Public Health

eurological causes of symp-oms.4 This process is extremelyostly and requires a high levelf expertise, placing stress onxisting medical infrastructure.

With improving life expectan-es in developing countries andn aging population in manyeveloped countries, early andccurate diagnosis of Parkin-ons disease will undoubtedlyose an increasing challenge forealthcare systems.

Researchers have proposednew model for diagnosis of

arkinsons based on speechecognition and machine learn-ng technologies. Introduced

y Dr. Max Little, Chairman ofarkinsons Voice Initiative, thispproach requires only a singleound recording of sustainedhonation (saying aaah) fromatients. Voice processing toolsubsequently analyze the soundecordings and compare themo a database of recordings ofarkinsons patients and non-arkinsons patients that serves a control. The algorithm de-eloped by this research team isble to detect specic variationsn sound vibrations linked to vo-al tremors, breathlessness, and

weakness. By detecting suchoice changes that are indicative

of neurological degeneration,the algorithm is able to generateaccurate diagnoses and predictdisease progression based on thepresence and severity of suchdegenerative symptoms.7

Although the project is stillin the early stages of develop-ment, preliminary results arepromising; the team claims a99% success rate in positive di-agnoses of Parkinsons disease.8Accuracy aside, the proposedmodality of diagnosis has sig-nicant benets over conven-tional analytical methods. Theresearch team has not publishedexact cost estimates, but the

method is predicted to be ultra-low-cost once it is marketedand fully operational. As theprocess of analysis is computer-ized, no medical professionalsor additional administration arerequired for analysis and naldiagnosis. This approach is thusvery attractive to areas with less-developed medical infrastruc-ture. Speech-based tests can alsobe easily scaled-up in responseto higher demands by increas-ing computational capacities.Since voice recordings can bereadily obtained and transferredusing existing telecommunica-tion systems, remote diagnosis

is also possible, increasing ac-cess to rural areas or regionswith poor healthcare programs.Remote testing also makes large-scale screening feasible in areaswithout the capacity to supporthigh numbers of clinical consul-tations.

Experts suggest that voice-based diagnosis will likely im-prove early intervention andmanagement of Parkinsons dis-ease. Scientists have long sug-gested that voice degenerationmay be one of the rst detectablesymptoms of Parkinsons dis-ease.10 Detection of voice chang-es in Parkinsons disease patients

would make it possible for ear-

lier intervention before the onsetof disabling physical symptoms.Treatments in the early stages ofthe disease are critical to delayfurther aggressive and irrevers-ible neurological degeneration.Voice changes may also serve asan easily assessable and objec-tive proxy to determine diseaseseverity and monitor early tra-jectories o f disease progression.Disease progression is routinelymonitored using the 176-pointUnied Parkinsons DiseaseRating Scale (UPDRS),9 in whichpatients are scored in categoriessuch as mood, behavior, mo-

tor skills, and ability to carryout daily tasks. However, thisassessment requires long inter-views and necessitates frequentclinical visits. Although speechtests will not be able to fully cap-ture the degree of physical andmental disability assayed bythe UPDRS, they may serve asa proxy to reduce the number ofclinical visits and become a low-cost alternative to the UPDRS inresource-scarce regions.

While the project holds greatpromise, it still faces many chal-lenges. Current studies make useof high-quality sound recordingscollected in laboratory settings.

Although the algorithm remainsrobust when laboratory-record-ed clips a re distorted articially,it is considerably more difcultto lter out ambient noises thatmay confound performance.8The Parkinsons Voice Initia-tive is currently pooling clips ofphonations sent in by volunteersaround the globe to build a moreextensive database and formu-late more precise algorithms fordiagnosis and prediction. The

initiative has already garneredmore than half of its target of10,000 recordings to date.7

The Parkinsons Voice Initia-tive is a promising new approachto facilitate effective early diag-nosis of Parkinsons disease. Thecost and capabilities of the initia-tive are particularly attractive toregions without a strong medi-

cal infrastructure or acwell-trained professionadevelopment of this inalso reects a greater moof data-driven medicineadvancements in computechnology are becominpensable in formulatintive diagnostic and manaprotocols in medical sett

1. Makulilo, Ernest Boniface. Ablino Killings in Tanzania: Witchcraft and Racism? M.A Thesis, Dep

Peace and Justice Studies, University of San Diego; 2010.

2. Kiprono, Samons Kimaiyo, ed. Quality of LIfe and People with Albinism in Tanzania: More than On

of Pigment. Scientic Reports; 2012: 1-6.

3. Bryceson, D.F, ed. Miners Magic: Artisanal Mining, the Albino Fetish and Murder in Tanzania. Th

of Modern African Studies; 2010 48(3): 354-382.

References for The Parkinsons Voice Initiative article

4. de Lau LM, Breteler MM. Epidemiology of Parkinsons disease. Lancet Neurol. June 2006; 5 (6): 525355. Jankovic J. Parkinsons disease: clinical features and diagnosis. J. Neurol. Neurosurg. Psychiatry. April 200

36876.

6. Raguthu L, Varanese S, Flancbaum L, Tayler E, Di Rocco A. Fava beans and Parkinsons disease: useful

supplement or useless risk?. Eur. J. Neurol. October 2009; 16 (10): e171

7. Parkinsons Voice Initiative - Science. Avail able at: http://parkinsonsvoice.org/science.php. Accessed November

8. A. Tsanas, M.A. Little, P.E. McSharry, J. Spielman, L.O. Ramig. Novel speech signal processing algorithms f

accuracy classication of Parkinsons disease. IEEE Transactions on Biomedical Engineering. 2012; 59(5):1264

9. Ramaker, Claudia; Marinus, Johan, Stiggelbout, Anne Margarethe, van Hilten, Bob Johannes. Systematic eval

rating scales for impairment and disability in Parkinsons disease. Movement Disorders. September 2002; 17 (5):

10. Hanson, DG, BR Gerratt, and PH Ward. Cinegraphic observations of laryngeal function in Parkinsons diseas

goscope. March 1984; 94 (3): 348-53.

The diagnosis of Parkinsons disease may soon be just a phone ca

Graphic Illustration byJudith Shanika Pelpola

Photo Courtesy of iStockP


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The policysection of theSJPH explores the intersection of public

health research and innovation and its

deployment in the real world. The section

approaches health topics at the forefront of

scientic debate by integrating legislative,

ethical, and economic perspectives.

In this issue, the Policy Section explores

regulation of public health issues at the

state and national levels, investigating

the consequences of the Affordable Care

Act on Medi-Cal patients and various

interventions to address the growing

childhood obesity epidemic.

Eileen Mariano

Childhood Obesity: A Growing Epidemic

Even though the HIV virustransferred from monkeys topeople in the 1920s, there wereeight million people living withthe disease by 1990. At that time,with no cures yet denitivelyproven and a steady climb inthe number of diagnoses, HIV/AIDS appears to be one of theworst epidemics to ever plaguethe United States.

However, at the turn ofthe 21st Century, yet anotherproblem has taken center stagein the battle for the future healthand wellbeing of Americans.Over the past few decades,healthcare professionals havegrown increasingly concernedwith childhood obesity, anepidemic now affecting anunprecedented proportion ofthe American population.

More than one third ofchildren and adolescents in theUnited States were overweightor obese in 2008, and thatnumber has not shown anysigns of decline.2 3 In fact, sincethe 1970s, the childhood obesityrate has tripled.4 As a result ofthis increase, it is estimated that

the generation currently in theirchildhood will be the rst inAmerican history to live shorterlives than their parents.5

Healthcare providers worryabout obesity because it isclosely associated with diabetes.Specically, Type II diabetes maylead to blindness, hypertension,an increased risk of heartproblems, and in extreme cases,

amputation of digits and limbs.For these reasons, obesity andobesity-related illnesses are theleading cause of death in theUnited States every year, and itis estimated to shorten lives byan average of twelve years.6

Further, the harm of childhoodobesity and diabetes transcendsthe physical symptoms alone.Those who suffer from obesityare also impacted by social

discrimination, to the pointwhere individuals have difcultynding jobs, participating inactivities, and even formingdesired relationships.7

At a national level, theobesity epidemic has becomea national security threatbecause up to one-quarter ofthe people trying to join themilitary are unqualied becauseof their weight.8 In addition, itis estimated that obesity-relatedcomplications cost the UnitedStates health care system $344billion dollars a year.9

What is already being doneto combat this growing, harmfultrend? Steps are being taken atboth the local and national levels.Locally, many propositions

and social movements havebeen enacted. According toChristopher Gardner, AssociateDirector of Nutrition Studiesat the Stanford PreventionResearch Center and AssociateProfessor of Medicine at StanfordUniversity there is room to beoptimistic. It is sometimes verydifcult to make a big change. Sowhat people have started to do is

play around with little cas part of the movemenI think its working, Gexplained.

A few examples of thchanges that Gardnerto include efforts fromYork Citys Mayor Bloowho started an initiatiprohibited the purchase using food stamps in Newand Measure N in Ca

the rst proposed soin the country to appeaballot.11 In addition, Mimplemented Double UBucks, an initiative thabonus token rewardspeople buy fruits and vegfrom farmers markets12, Santa Clara County Towhich states a toy cansold along with a fast foounless the meal meets fat, salt, and sugar guidelines. Unfortunatelyspecic restrictions and ascope, the ban only four restaurants. Howreceived national attentwas later implemented Francisco and proposedstate of Kansas.

Nationally, the administration has madeefforts to curtail the epIn January of 2012, PrObama announced thwould add $3.2 billion tobillion school lunch prThe extra support woused to add more frugreen vegetables to breand lunches and redu


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onald Barr is a physician and an Associate Professor of Sociology and Human biology at Stanfordniversity. He researches a wide variety of topics, one of which is the social and economic factors

ontributing to health disparities, and specically to obesity.

hristopher Gardner is the Director of Nutrition Studies at the Stanford Prevention Research Center andn Associate Professor of Medicine at Stanford University. He received his PhD from the University ofalifornia and now researches dietary intervention and the way that food increases disease risk factorsnd body weight.

mount of salt and fat. Obamasubsidies also provide theunding for whole grains, low-t milk, and the technology toonitor the amount of calorictake per lunch per student.13

Michelle Obama has also playedsignicant role in the effort

reduce childhood obesity,aiming that she is going to

ontinue to do everything thathe] can to focus [her] energy toeep this issue at the forefront ofhe discussion in this society.14pecically, she established herets Move! initiative, whichncourages nutritional foods,creased physical activity, and

healthy start for children.he campaign has launchedumerous movements, whichclude paying restaurant

hefs to move to schools,warding subsidies to schoolshat start a vegetable garden,nd initiating a summer foodrogram that allows children

eat healthfully year-round.he First Ladys initiatives havencouraged healthier eating ande inuencing student lifestylesl over the country.15

But the question remains,e the current local and

ational level efforts enoughstop an epidemic? Donald

Barr, Physician and AssociateProfessor of Sociology andHuman Biology at StanfordUniversity, does not think so. Hepointed out, if you think its aproblem now, its about to be aneven bigger one, which is whylocal, state, and national levelgovernment need to increasetheir efforts, given the severityof the epidemic.

To put the anti-childhoodobesity efforts into perspective,in 2008, the federal governmentcommitted to spending $48

billion over the next ve yearson HIV/AIDS prevention andtreatment efforts. This aid willaffect the 1.2 million people livingwith HIV in the US.16 There are,comparatively, 9 million obesechildren. Despite the currentlocal and national efforts toreduce childhood obesity, thoseinitiatives are not sufcient.Preventing the expansion of thisepidemic is a crucial step towarda healthy future for Americans.

o view the references for this article, please refer to page 43

Medi-Cal 2016:What Obamacare Means

for California PatientsJudith Shanika Pelpola

Medicaid, better known asMedi-Cal in California, will cov-er a greatly increased number ofpatients by 2016 as a result of theAffordable Care Act (ACA). Pop-ularly known as Obamacare,this recent healthcare reformhas sparked numerous discus-sions regarding its effect on thealready overstretched Medicaid

and Medicare systems. Califor-nia has decided to opt in to thenew program established by theACA, thus ensuring healthcarecoverage under Medi-Cal for allindividuals with an income be-low 133% of the federal povertyline. 1 According to the Washing-ton Post, California expects toenroll an additional half a mil-lion people in the program by2014, with that number increas-ing signicantly by 2020. 2

Medi-Cal, like other Medic-aid programs across the nation,was originally created for thoseeligible for welfare, specicallythe elderly, the disabled, andsingle parents with young chil-dren. It was set up as a programnot for all poor people but for

only certain categories of poorpeople, and it was originallytied to whether you got welfarechecks, Don Barr, a professor ofHuman Biology at Stanford, said.Once a state signed up for theprogram, it was required to sup-port every person in the abovecategories. Poor was dened indifferent ways for each of those

groups but if you were not inthose three groups, even if youwere extremely poor, you gotzero coverage, explained Barr.Thus many low-income individ-uals often go without healthcarecoverage unless their employersprovide it.

The federal government par-tially supports Medi-Cal, basing

contributions on the average percapita income in the state. Ac-cording to the US Department ofHealth and Human Services, thefederal government pays 50%of Medi-Cal costs as of 2012. 3California covers the remaining50%, a nancial burden that hasstrained the budget and made itdifcult to expand Medi-Cal toother low-income individuals.This affects many other states,though lower-income states re-ceive up to a 75% subsidy ofcosts from the federal govern-ment.

By setting an income levelof 133% of the federal povertyline, the ACA makes healthcarecoverage available for most low-income people below the speci-

ed income level. Currently, theeligible income level in Califor-nia is around 60% of the federalpoverty line, as calculated usingMedi-Cal monthly income re-quirements divided by the pov-erty line (see 2012 HHS PovertyGuidelines). 4 The AffordableCare Act has said, lets get awayfrom this idea of this being only

for certain categories opeople; lets make it for apeople, claimed Barr.

In raising the minimcome level, the ACA alsnates shares of cost foMedi-Cal and other locome patients. The shareprogram applies to thosthe minimum income lev

still qualify as low incoming these patients nresponsible for a share medical expenses. Howemeans that even those what 61% of the federal pline were forced to pay of cost, which is appliedMedi-Cal payment covermaining cost of care. 5 WACA, any individual orhold earning up to 133%federal poverty line, cu$15,130 per year for a fatwo or $1260 a month, longer have to pay hecosts. According to theFamily Foundations suof the ACA, even thosethis line will receive suto help purchase coverag

private sector.One concern with re

the ACA is the increasethat the program will inculike California will contcover the cost of patientthe original program, wfederal government wilall incoming patients for few years. By 2020, sta

Graphic Illustration byJudith Shanika Pelpola


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onald Barr is a physician and an Associate Professor of Sociology and Human biology at Stanfordniversity. He researches a wide variety of topics, one of which is the social and economic factors

ontributing to health disparities, and specically to obesity.

Compilation of Patient Protection and Affordable Care Act. Available at: http://housedocs.house.gov/energycommerce/

pacacon.pdf.

Kliff, Sarah. Obamacares Medicaid Expansion Already Covering a Half-Million Americans. Washington Post. Avail -

ble at: http://www.washingtonpost.com/blogs/wonkblog/wp/

012/07/03/obamacares-medicaid-expansion-already-covering-a-half-million-americans/. Accessed November 30, 2012.

Department of Health and Human Services. Federal Financial Participation in State Assistance Expenditures. Avail-

ble at: http://aspe.hhs.gov/health/fmap12.shtml. Accessed November 30, 2012.

Department of Health and Human Services. 2012 HHS Poverty Guidelines. Available at: http://aspe.hhs.gov/

overty/12poverty.shtml. Accessed November 30, 2012.

California Healthcare Foundation. Share of Cost Medi-Cal. Available at: http://www.chcf.org/

/media/MEDIA%20LIBRARY%20Files/PDF/S/PDF%20ShareOfCostMediCal2010.pdf. Accessed November 30, 2012.

Kaiser Family Foundation. Summary of Coverage Provisions in the Patient Protection and Affordable Care Act. Avail-ble at: http://www.kff.org/healthreform/upload/8023-R.pdf. Accessed November 30, 2012.

Milken Institute. Medicaid Expansion May Cripple Californias Burdened Health System. Available at: http://www.

ilkeninstitute.org/newsroom/newsroom.taf?function=

urrencyodeas&blogID=523. Accessed November 30, 2012.

Lowerey, Annie and Robert Pear. Doctor Shortage Likley to Worsen with Health Law. New York Times. Available at:

tp://www.nytimes.com/2012/07/29/health/policy/too-few-doctors-in-many-us-communities.html?_r=2&. Accessed on

ovember 30, 2012.

over 10% of the cost of the newatients, while the federal gov-rnment covers the remaining0%. 7 In the long run, the ACAexpected to reduce the federal

ecit in part by reducing costsncurred by county hospitalsnd clinics, which provide un-ompensated care for those whoo not qualify for Medi-Cal. Ac-ording to the Milken Institute,alifornia hospitals provided12 billion in uncompensatedare in 2009.8 Uncompensatedare is supported only in part byayments from the federal gov-rnment. In making previouslyninsured, low-income patients

igible for Medi-Cal, the ACAnsures that many hospitals andoctors that provide such ser-ices will be compensated. All

of a sudden the hospitals andthe doctors have a source of pay-ment for these people, clariesBarr.

However, a shortage of doc-tors and care facilities is expectedin places like the Veterans Hos-pital in Palo Alto, which acceptMedi-Cal as payment. Accord-ing to Barr, this continues tobe a very serious problem sinceMedi-Cal pays doctors less than70% of what Medi-Care pays,and Medi-Care pays about 80%of what the private market pays.That means its less than half ofthe usual charges, so lots of doc-tors just say were not going to

take Medi-Cal. This puts strainon community clinics to whichMedi-Cal patients turn. Ac-cording to the New York Times,

the Inland Empire of SouthernCalifornia has only half of thenumber of recommended pri-mary care physicians for itspopulation. 10 This is a commonconcern across California coun-ties. While the ACA provides forroughly 15,000 new doctors incommunity clinics nationwide,anxiety still remains regardingthe number of primary care doc-tors for newly eligible patients.According to Barr, the questionremains regarding the shortageof primary care doctors for newMedi-Cal and Medicaid patientsacross the country. Thats theissue that is unclearThere are

things in the Affordable CareAct to expand community clinicdelivery systems and well see ifthats going to be adequate.

The experiencesection of the SJPH presents public

health challenges that students have

encountered personally, highlighting the

relevance of such issues to student life ona day-to-day basis.

In this issue, our articles explore a range

of interests sparked by our writers

experiences, from local to international,

including the ethics of Spanish healthcare

workers striking and the benets of

lobbying legislators to achieve awareness

and prevention goals with respect to

hepatitis B.


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The Ethics of Striking:

A Public Health Concernessie Holtzman

In late November, morehan 75,000 healthcare profes-onals gathered in Puerta delol, in the heart of Madrid, hold-g signs that read health care

uts kill and public health: notr sale.1 Amidst new austerityeasures, these employees wereriking to protest a set of cutsarticularly worrisome to theublic health community. With

he Spanish economy in crisis,he conservative government ofresident Rajoy announced thatpain needed to cut 10 billionuros of health and educationpending each year starting in012. Seven billion Euros worth

these cuts are taken from theealthcare budget.2 Spaniards,nd specically members of theealthcare sector, have reactedrongly to this reduction, sincetargets a key element of the

rized welfare state that de-eloped in the 1970s transitionom dictatorship to democ-cy. While these workers have

ood intentions and many validoncerns, their strike hurts theatient population rather thanrgeting the government violat-

g their rights. Instead of strik-g, doctors and nurses shouldke up more productive waysdemonstrating dissatisfactionavoid punishing the patient

opulation for government aus-rity decisions.

With the current state ofisis, the Spanish governmentust make cuts to its extensive

healthcare budget in an attemptto revive the oundering econo-my. Starting in 2000, Spain be-came an increasingly popularcountry for immigration due tothe generous benets providedto immigrants. Immigrationcame with benets, helping tomaintain the population as thecountrys growth rate fell to1.1 children per couple. It camewith costs as well, though. The

country became a frequent desti-nation for healthcare tourism,with residents of other Europe-an Union countries traveling toSpain for its superior healthcareprocedures at low costs. As ofAugust 2012, the government nolonger provides free healthcareservices to undocumented im-migrants, and healthcare tour-ists must reside within Spainfor more than three months be-fore receiving free healthcareservices.3 Now, the system onlyprovides healthcare to foreign-ers in cases of grave illnessor accident, pregnancy andbirth-related care, and to thoseyounger than 18. These changesdiscourage non-tax-paying resi-dents from using the healthcare

system, a worthwhile policy toprevent unfair exploitation oftax-paying citizens.

However, further broad cutsto the rest of Spanish societycome at a time when Spanishunemployment has climbed todangerously high levels. Span-iards are paying an increasinglylarge percentage of their health-

care costs directly, while theirsalaries are dropping to histori-cally low levels. Retired citizensnow contribute a 10 percentcopayment toward the costs ofmedicine, while non-retiredcitizens pay between 40 and 60percent copayments, scaled toincome level. Citizens now payfor wheelchairs, crutches, andsplints, as well as non-urgenttransport to hospitals.3

The most controversial ele-ment of the recent changes toSpanish public health nancingis the Fiscal and AdministrativeMeasures Law, implemented onJanuary 1, 2013. This legislationaims to privatize six major hos-pitals in Madrid, as well as 27non-urgent health clinics. In ad-dition, the measure adds a oneEuro xed supplemental chargeto the cost of each prescriptionmedication. These proposedchanges sparked heated debate,with left-wing deputy AntonioCarmona saying, Privatizinghealthcare isnt efciency; itsbusiness. This isnt law; it is ascandal.4 Doctors and nurseswent on strike for ve weeks be-fore the passage of the law, lead-

ing to the cancelation of morethan 40,000 patient visits anda 1.74 billion Euro loss in 2012from work stoppages. Althoughexperts agree that the Spanishpublic health system needs re-form, healthcare workers fear theconsequences of these changes.

Spanish doctors and nursessee these changes as threatening

their practices and patients. Thehealthcare sector claims that itprotested not due to a threat toworking conditions or privi-leges, but rather for the right ofeveryone to have access to qual-ity healthcare. Doctors fear thatthe changes jeopardize the deli-cate balance of healthcare ex-penditure, quality, and benetin favor of a better business ar-rangement. They point to claimsby government administratorsthat hospital expenditures percapita will decrease from 600Euros to approximately 450 Eu-ros.3 Where the measure calls forcuts in treatments with lower

proven efcacy, doctors fear thateliminating procedures to savemoney could reduce quality ofcare and ease of access.

Yet, the extended striking ofdoctors and nurses, la mareablanca, raises questions aboutthe obligation of health profes-sionals to provide quality health-care. This essential service sectorhas a right to negotiate for ac-ceptable working terms, but pa-tients also have a right to expectuninterrupted access to care.The strikes effect of stopping

all non-urgent care challengesthe patient-physician contract,which requires that physiciansact responsibility and providecontinuing care to patients. Doc-tors have a fundamental obliga-tion to treat their patients to thefullest extent possible, so alter-native methods of manifestingdissatisfaction toward the gov-ernment would be preferable.However, effective non-strikingoptions require fundamentaltrust between the two parties,which is currently absent inSpain. Historically, Spaniards donot trust the government due tothe high levels of corruption and

nepotism that lead to concernsabout the motives behind gov-ernment decisions. Neverthe-less, given the ethically dubiousnature of healthcare profession-als striking, the government andthe unions must put aside theirdifferences to achieve a feasiblelevel of budgetary cuts in thistime of dire economic crisis.

The associated doctors ofone of the healthcare unions is-sued a statement saying, Weneed the patients to know thatwe do this for them, because

we know the depravitysystems of incentives in healthcare. It is a questiosponsibility. 4 The doctoto act out of care for prather than interest in thcompensation. Indeed, bing, union workers acceand decreased salaries, infor calling attention to whsee as unfairly imposed ameasures. While some may agree with the doctsupport the strikes, thouhealth care strikes harmtient population, with tcelation of thousands ofdures. Striking on behal

patient population surelya public statement aboutsatisfaction of physicianurses, but it also jeopthe goal of the public heatem to ensure the condiwhich people can be heHealthcare workers aretial to society, and as sucunion rights cannot be iUltimately, a doctors rstrike cannot, and shouldentirely eliminated. Neless, this does not meanstrike is the best option.

1. Thousands protest austerity measures in Spain. RT [online]. December 18, 2012. Available at: http:/

news/spain-union-protest-mass-228. Accessed December 28, 2012.

2. Day, Paul. Spain seeks health care cuts as crisis deepens. Reuters [online]. April 18, 2012. Availabl

http://www.reuters.com/article/2012/04/18/us-spain-health-idUSBRE83H0LX20120418. Accessed Dec

2012.3. Los recortes sanitarios, uno a uno. El Mundo [online]. April 25, 2012. Available at: http://www.elm

elmundo/2012/04/24/espana/1335249973.html. Accessed December 14, 2012.

4. Sevillano, Elena. El bastion de la marea blanca. El Pais [online]. November 10, 2012. Available a

ccaa.elpais.com/ccaa/2012/11/10/madrid/1352585971_ 718417.html. Accessed December 12, 2012.

5. The Future of the Publics Health in the 21st Century. Institute of Medicine of the National Academi

vember, 2002.


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Hepatitis B Eradication:An Unsolved Challenge

hristina Wang

I grew up in China withoutnowing that one in ten peopleround me suffered fromepatitis B. It wasnt until Iame to college that I learnedhat hepatitis B is and that thisisease is in fact ten times morerevalent that AIDS, and 100mes more infectious.1

My childhood ignorance is astament to the evasive nature

f this virus to communityublic health efforts. Hepatitis

mostly affects Asian Paciclanders, a demographic thatnly comprises six percent of thenited States population. In a

ountry that frequently focusesn public health efforts that willfect populations that comprise

a greater proportion of society,hepatitis B does not constitutea signicant enough threat tomotivate sizeable involvementby the public health community.In addition, a vaccination forhepatitis B exists and has beenwidely implemented. Theurgency of addressing hepatitisB lessened beginning in 1992,when all newborns began to bevaccinated against this virus.Thus, for young, American-bornindividuals, hepatitis B no longerposes an immediate threat.However, in port cities includingSan Francisco and New YorkCity, immigrants from highlyaficted countries are constantlyarriving, warranting continued

focus on this topic. Additionally,the asymptomatic nature ofhepatitis B leads to continuingconcern, as patients do not knowthey are infected until they arealready signicantly ill.

As a member of Team HBV,an intercollegiate organizationthat seeks to eradicate hepatitisB in nearby communities, Ihave experienced all of thesebarriers to hepatitis B awarenessefforts, rst-hand. The goal ofthe organization is to educateStanfords campus membersthrough events like the ScreeningInitiative Program. The premiseis simple: visit Vaden HealthCenter, provide documentationto show that hepatitis B

screening was performed, andreceive a reward. Analysis ofthe results of 80 test subjects leftthe organization both optimisticand perplexed. None of the 80students who had been screenedfor hepatitis B tested positive.Clearly, Team HBV was nottargeting the right audience, asthe majority of the test subjectswere Stanford undergraduates,born on or after 1992 and whohad been vaccinated.

Though on campus screeningproved to be a rather ineffectivemeasure to reduce hepatitis Bprevalence, the organization stillwanted to increase on-campusawareness of the disease and itsprevalence in a tangible manner.Thus, Team HBV organized aHepatitis B Awareness Week,during which yers illustratinghepatitis B facts and a scheduledelineating a weeks worthof educational events weredistributed across campus,attached to balloons in orderto call attention to the event.Yet all of these efforts provedto be largely ineffectual. Somestudents may now be cognizantof the existence of hepatitis Band the organizations effortsdramatically increased theoccurrence of on-campusscreening, but the overall effectswere strictly limited to theStanford campus.

Despite the narrowimprovements on the Stanfordcampus, other eradicationefforts worldwide have shownsignicantly more promise. Iwas fortunate enough to havethe opportunity to organize

World Hepatitis Day in thesummer of 2012. The WorldHepatitis Alliance challengedviral hepatitis organizationsacross the world to participatein a Guinness World RecordsChallenge of having the mostpeople performing see no evil,hear no evil, speak no evilactions in numerous venuesaround the world, over a 24-hour period. A total of 50 TeamHBV high school and collegestudents came out to the CrissyField location in San Franciscoon July 28th, 2012.

The worldwide event wasfeatured in articles in the WorldJournal and the Tsingtao News,the two largest circulatingnewspapers among the Chinese-American population in SanFrancisco. The publicity that thisevent received shed light on amore effective method throughwhich to target the populationat risk: reaching out to thelocal media. Not only were weable to communicate directlyto the highest risk populationin the Bay Area, but we werealso communicating to them intheir language, through mediasources that they trusted.

A second event that provedeffective was a service trip thataddressed the subject of hepatitisB in San Francisco. One of thetrip days highlighted advocacy

efforts by splitting the groupin half and rallying legislativeofces to raise awareness ofhepatitis B. While the groupmembers were initially skepticalof the potential impact of thistype of advocacy work, the

majority of students cafeeling that the represenof elected ofcials hadand understood the mthat they were sWhile state budgets wconstraining factor, thetold the students thawould do their best to afor hepatitis B screeningfuture. Most interestinglyof the representatives rthat they had not hehepatitis B prior to the stvisit, which raises the quif these elected ofcials hheard of this critical publiissue before, how can wetheir constituents to beof the disease? The expof Team HBV highligefcacy of discussing keyhealth issues with legofces. In particular, Feinsteins ofce notethey greatly enjoy studenbecause student constitunot paid for the messagthey deliver, but rather dof sheer interest and conc

Team HBV has apprtheir goal of the eradicahepatitis B through a of methods, several ofoffer fresher and amore effective methodon-campus education. the latter remains an imtactic, the battle with hep

will require use of a wideof broadly targeted aveeducate a greater percenresidents in the UnitedThe sooner that awareraised, the sooner hepwill be eradicated.

1.Liu, J. and Fan, D. Hepatitis B in China. The Lancet. 2007; 369 (9573): 15821583.GraphicIllustrationbyJudithSha

nikaPelpola


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Theresearch section of the SJPHinvites the members of the Stanford community

to share their essays, perspectives, and research

with a broader audience interested in public

health.

In this issue, we present a highly varied collection

of research from the undergraduate community

that addresses national and international topics.

Our authors have explored topics relating to

the effectiveness of school-located inuenza

vaccination programs, a cost and policy analysis

of in vitro fertilization, a comparative policy

analysis of polio eradication methods used in

Pakistan and India, and techniques to reduce the

psychological and economic burdens on infertile

women in America.

It has been claimed that,apart from the atomic bomb,Americas greatest fear was po-lio in post-World War II Ameri-ca. However, this American fearwas conquered in 1956, whenDr. Jonas Salk developed therst polio vaccine. Salks poliovaccine has been highly effec-tive, and today, it has led to theeradication of endemic polio inall but three countries world-wide: Afghanistan, Nigeria, andPakistan. Although separatecountries today, Pakistan andIndia were both carved out in

Polio Eradication in India:Lessons for Pakistan?

Ravi Patel

Ayurvedic or traditional medicine shop. Karachi, Pakistan. December 2011.

1947 from a single territory thenknown as British India. As a re-sult of this common heritage, thetwo countries face similar social,political, and, most importantly,developmental challenges to-day. Along with similar histori-cal and social contexts, both In-dia and Pakistan share similarper child cost of vaccination, an-other factor placing Pakistanspolio crisis in context of Indiaspast experiences (Figure 1). Spe-cically, this paper analyzes thecase of polio eradication in In-dia, and in tandem identies po-tential lessons for Pakistan in itsquest to eradicate polio.

Today, polio can bein four main areas in PFATA (Federally AdmiTribal Areas), Khybetunkhwa and Baluchistanthe border with Afghaniwell as in parts of Sindh 2). These locations also to experience the greaterity vulnerabilities fromIslamic groups such as trik-i-Taliban Pakistan. Tsecurity conditions in thees enable polio to thrive bof difculties in sustainibust public health infrastrThe vulnerability of poliers in Pakistan was be

Photo Courtesy of


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ated by a series of coordinatedttacks in Khyber-Pakhtunkhwand Karachi by Taliban associ-ted militants in December 2012nd January 2013. In total, 16ealth workers were killed, in-uding 12 women, and the U.N.ecided to temporarily suspends operations against polio in theountry. Women health workersre essential in Pakistans battlegainst polio since women in theonservative Pakistani culture,nlike men, can get access tohildren and other women in theousehold.

The four regions in Pakistanome to polio are tribal in na-ure, and have large, migratingopulations, making vaccineistribution difcult to orga-ize. The Taliban and other fun-amentalist Islamic groups haveso banned polio health work-

rs from delivering care in cer-ain parts of the county wherehey exert inuence claiming

that these workers are Americanspies. This misconception wasreinforced with a fake polio vac-cination campaign in Abottabadcarried out by Dr. Shakil Afridiunder CIA supervision to obtainDNA conrming Osama BinLadens presence.

Coupled with this continu-ing suspicion, many in Pakistanbelieve that the polio vaccine isa Western rouse to sterilize Mus-lim. A similar distrust exists inNigeria, where some religiousleaders have called for boycot-ting polio vaccination becausethey believe it causes sterilityin girls, spreads HIV and can-

cer. Resistance ultimately led toseveral northern Nigerian statesboycotting the polio vaccine forabout 10 months during 2004.7

The fallout of Nigerias strug-gles with immunization in 2004not only led to polio spreadingto previously polio-free areasin Nigeria, but to also spread toeight polio-free countries sur-rounding Nigeria. Beyond theseexisting issues, Pakistan facespoor public health infrastructureand possesses a critical shortagein human resources. Expertshave argued that Pakistan facesa massive funding shortfall forpolio eradication. So far, Paki-stans government has so faronly been allocated half of whatwas budgeted for 2012-13 by the

Global Polio Eradication Initia-

tive (a public-private partner-ship led by organizations suchas the WHO and the U.S. Centersfor Disease Control and Preven-tion to eradicate polio). Clearly,Pakistan faces immense politicalobstacles as it seeks to eliminatepolio.

India, Pakistans neigh-bor to the west, has also faced

a long battle against polio. Asrecently as 2009, India had thehighest number of polio casesin the world.2 Like Pakistan, In-dia faces rampant poverty, highbirthrates, large populations,and remotely located commu-nities. Along the same lines, In-dia has weak public healthcareinfrastructure, reected in itspoor track record of deliveringmedical care. For example, In-dia was ranked 112th of 191 bythe WHO in terms of its abilityto deliver adequate healthcare toits citizens. Despite these chal-lenges, India has implementedmeasures that such that Janu-

ary 2010 marks the last reportedcase of polio. Political commit-ment was the primary changethat made India successful inits ght against polio. With po-litical backing from the rulingCongress Party, the Indian gov-ernment apportioned signicantresources to polio eradicationcampaign. By 2013, India willhave invested nearly $2 billionto combat polio. As a result ofthis political support nearly 170

gure 1: Operations costs per Child

r SIAs (Supplementary Immuniza-

on Activities)18

million Indian children are im-munized through two nationalpolio vaccination campaignseach year. Furthermore, Indiawas effective with targetingnomadic populations by usingbetter mapping technologies inconjunction with the aid of localcommunity workers. Not onlydid these workers better un-derstand nomadic populations,but they also were able to gainthe trust of people they served.Indias robust surveillance andimmunization network was cru-cial to polio eradication opera-tions as well.4 To date, India has33,700 reporting sites, managed

with the assistance of 2.5 millionvaccinators.11 The infrastruc-ture established by Indias poliocampaign has encouraged addi-tional immunization campaigns.Because of these customized po-litical measures, India has beenable to defeat polio, a threat thathas dominated the land for hun-dreds of years.

While it is difcult to gaugewhether Pakistan will success-fully embrace the polio eradica-tion policies exercised in India, itis obvious that failed strategiesin Pakistan will require inter-vention. Polio conditions in In-dia vastly improved subsequentto employing techniques usedin neighboring Bangladesh (alsocarved out from colonial British

India like India and Pakistan aswell). Bangladesh eradicatedendemic polio in 2000. India,in particular, was able to adoptsome lessons from Bangladesh(also carved out of British Indialike India and Pakistan), whicheradicated endemic polio in2000. In the case of Bangladesh,the campaign against polio wasparticularly successful because

it was able to build a robust in-frastructure monitoring polio. InBangladesh, more than 90% ofcases of acute accid paralysis,a clinical symptom of polio, areinvestigated within 48 hours ofnotication. Based on these les-sons, India was able to improveits polio surveillance networkand this move was one of thekey factors that help it win itsown battle with polio.

A simple cut and paste ofIndias public health set up maynot by itself eliminate polio inPakistan. These lessons, nev-ertheless, do highlight crucialchanges that would serve as astarting point for Pakistan to be

more effective against pPakistan, there is politicport against polio at the levels of government. Fople, Pakistani President AZardari announced at tGeneral Assembly in Sep2012 that he and his govewould work to make Ppolio free. This elitecal support has not yet down to the local and prlevel. From my informversations with local PPPstan Peoples Party, thepolitical party) workers Sindh, the persistence ocan be attributed to thecoordination on polio e

Figure 2: Map of Polio

Hotspots in Pakistan, 201019

Children playing after receiving the polio vaccine in Sukkur, Pakis

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on efforts between the districtshemselves. Even with wide-pread political backing, failing

coordinate the battle againstolio and provide vaccine ac-ess to nomadic communitiesas caused polio to continue toague the people of Pakistan.btaining greater political sup-ort at the local levels might alsoad to an improved security en-ronment for health workers

ecause obtaining support fromhese local leaders lessen resis-nce from local communities.

Pakistan could develop a robustsurveillance and immunizationnetwork akin to that of India.Adopting Indias approach willbring Pakistan one step closerto eliminating polio, and poten-tially other preventable diseases,from its own land.

Collaborating with Indiaon polio eradication would re-duce, if not eliminate, the polioburden from the country, serv-ing as a bridge in an otherwisefrosty bilateral relationship.Furthermore, cooperation on

the polio issue between the twocountries could be a conduit forfurther collaboration on othercritical public health issues suchas HIV/AIDS or tuberculosis.Perhaps, greater cooperationin public health could have im-plications for other regional de-velopment issues such as theprospect of building more crossborder trade. By applying les-sons from Indias experiencesdefeating polio, Pakistan cansave more lives from experienc-ing the effects of this disease.

The Polio Crusade American Experience. Public Broadcasting Service. 2009

John, Jacob and Vipin Vashishtha. Path to Polio Eradication in India: A Major Milestone Indian Pediatrics. Vol-

ume 49, Number 2 (2012), 95-98.Muhammad, Peer. Security Situation a risk to anti-Polio effort: WHO. The Express Tribune. 2012. Available at:

http://tribune.com.pk/story/419545/security-situation-a-risk-to-anti-polio-effort-who/ Accessed Dec 1, 2012

The War on Pakistans Aid Workers. The New York Times. 2013.Available at: http://www.nytimes.com/2013/01/05/

opinion/the-war-on-pakistans-aid-workers.html Accessed Jan 10, 2013.

Walsh, Declan and Donald McNeil Jr. Female Vaccination Workers, Essential in Pakistan, Become Prey. The New

York Times. 2012. Available at: http://www.nytimes.com/2012/12/21/world/asia/un-halts-vaccine-work-in-pakistan-

after-more-killings.html?pagewanted=all. Accessed Jan 10, 2013

Walsh, Declan. Taliban Block Vaccinations in Pakistan. The New York Times. 2012. Available at: http://www.ny-

times.com/2012/06/19/world/asia/taliban-block-vaccinations-in-pakistan.html Accessed Dec 1, 2012

Tohid, Owais. Move to Get Bin Laden Hurt Polio Push. The Wall Street Journal. 2011. http://online.wsj.com/ar-

ticle/SB10001424052970204190504577038781784474056.html Accessed Dec 1, 2012

Personal Conversations with local Pakistani Political Leaders in December 2011.

Jegede AS (2007) What Led to the Nigerian Boycott of the Polio Vaccination Campaign? PLoS Med 4(3): e73.

doi:10.1371/journal.pmed.004007

0. Polio boycott is unforgivable. British Broadcasting Corporation. 2004. Available at: http://news.bbc.co.uk/2/hi/

africa/3488806.stm

. Winsten, Jay and Emily Serazin. Victory Against Polio is Within Reach. The Wall Street Journal. 2012. Available at:

http://online.wsj.com/article/SB10000872396390444025204577546562570306028.html Accessed Dec 1, 2012

. World Health Report 2000. World Health Organization.

. UN Health agency marks WPD with renewed efforts to eradicat e the disease. Available at: http://www.un.org/apps/

news/story.asp?NewsID=43366&Cr=polio&Cr1=#.UIzLBMXA8kk Accessed Dec 1, 2012

4. Building on Indias Success on Polio. The Wall Street Journal. 2012. Available at: http://b logs.wsj.com/indiareal-

time/2012/10/24/building-on-indias-success-on-polio/ Accessed Dec 1, 2012. Schaffer, Teresita. Polio Eradication in India: Getting to the Verge of Victory and Beyond? Center for Strategic and

International Studies. 2012.

6. USAID/Bangladesh. Polio: On the Brink of Eradication. Available at: www1.usaid.gov/bd/les/polio.doc. Accessed

Dec 1, 2012

7. Zardaris Pledge to Polio. Dawn. 2012.Available at: http://dawn.com/2012/09/28/govt-taking-polio-eradication-cam-

paign-seriously-zardari/ Accessed Dec 1, 2012

8. Financial Resource Requirements 2012-2013. Global Polio Eradication Initiative. World Health Organization.

9. Available at: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx Accessed Dec 1, 2012.

In an era of ongoing policychange and evolution, womenshealth is just one more hot-but-ton issue to add to the laundrylist of contentious policy battles.In recent years, the debate hasbecome particularly intense,involving heated discussionsbetween various demograph-ics, ranging from men versuswomen to Republicans versusDemocrats to old versus youngto even women versus women.However, the issues present inthe media every daytopics likeabortion and contraceptionareonly part of the story. In theshadow of such discussions,other equally important issuesin womens health have beenmasked. When is the last time amajor national debate took placeregarding funding for researchon infertility or health care cov-erage for its treatment? Has anysuch large-scale debate ever oc-curred in the rst place? Whatabout the ramications that of-ten come with inability to start afamily? Is it likely that currentlegislatures will fund treatmentof the depression and cases ofmental illness associated with

Infertility:

A Plague Gone UnnoticedNearly 6 million women and their partners in the US suffer frominfertility. Most think it is just another medical problem, but thetruth is, the suffering of these victims goes far beyond the biology tothe psyche, leaving deep lasting scars. Little has been done to rec-tify this problem at the policy level. But through an active, multi-disciplinary effort, a fresh current of change might just be possible.

Nitya Rajeshuniinfertility when most do noteven fund the treatment itself?

Infertilitymillions ofwomen across the nation todaystruggle with this condition;yet, despite the prevalence ofthis plague and the sufferingit brings, their plight has goneseverely unnoticed, maskedby the ever- present discussionon abortion and contraception.However, one must wonder, ifsociety is so concerned regard-ing policy covering not only theprevention of birth but of con-ception, shouldnt the creationof life receive equal attention?Infertility is a major problem inthe US, proving not only chal-lenging but extremely expen-sive and psychologically detri-mental, particularly to women.Despite these negative implica-tions, very little policy on the

subject has been proposed todate. However, that is not to saythat national or state legislationwould have very little impact onthe issue. Rather, the proposalof such legislation could havemuch to offer, if constructed ina multifaceted and interdisci-plinary manner. Through suchan approach, combining both

federal and state effortsto psychological servicaffordability of treatmencertainly be increased asimproved. Of course, onask, how might we achieAlthough there is mucto be done, an excellent pstart would be throughproposals such as the bill I have constructed alined in this paper.


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Nearly 6 million women and

heir partners in the US are in-

rtile, accounting for approxi-ate 10-15% of the entire re-

roductive population.7 Whilebout 40% of infertility cases cane attributed to male-related fac-rs and 40% to female-relatedctors, 20% are attributed tocombination of the two, ren-

ering exact diagnosis oftenfcult.7 Furthermore, evena particular partner has beenentied as the source, diagno-s can prove equally if not more

hallenging,7 despite the varietymedical treatments available.

Approximately 25% of allouples in the US have troubleonceiving.7 Typically, 10-15%an eventually succeed using ba-c methods, such as regimented

xual intercourse, discontinua-

on of birth control, and chang- in lifestyle, diet, and nutrition.

While 80% of those who beginith the basics succeed, the re-aining 20% typically move onfertility drugs, hormonal ther-

py, and nally assisted concep-on (intrauterine insemination,-vitro-fertilization (IVF) andtracytoplasmic sperm injec-

tion (ICSI)), posing a dishearten-ing 20% success rate.7

While these treatments offerpotential medical solutions tothe problem of infertility, issuesof mental health have increas-ingly garnered more attentiondue to the lack of efforts andfunds in this area. A promis-ing, albeit inadequate, amountof research has been conducted,indicating that the mental healthof women facing infertility is in-deed a very real problem. How-ever, the ndings have hardlybeen applied. According to theDepartment of Health and Hu-man Services 2010,4 the seven

leading mental health issuesfaced by infertile women are 1)anxiety 2) depression 3) anger 4)marital problems 5) sexual dys-function 6) social isolation and 7)low self-esteem. Statistics haveshown that amongst infertilecouples, women often displayhigher distress than men, al-though when infertility is attrib-uted to the male factor, the re -sponses in males and females arethe same.2 Furthermore, 15-54%of infertile couples experiencedepression, much higher thanthe average percentage of fertilecouples experiencing depres-sion.2 8-28% of infertile couplesalso experience severe anxiety.2

To complicate matters further,couples with a previous history

of depression are susceptible toa two-fold increase in the like-lihood of experiencing depres-sion.2 This positive feedbackloop is perhaps the biggest chal-lenge women face; while pre-vious mental health issues canalter ones ability to deal withthe psychological stressors of in-fertility, the stressors associatedwith assisted conception often

exacerbate these very feelings ofexasperation and anxiety.2 OneHarvard Medical School studyhas even likened this phenome-non to the emotional distress ex-perienced by heart disease andcancer patients.8 Accordingly,knowing when to stop treatmentoften proves the most difcultdecision.8

Now, who exactly qualiesas infertile? According to na-tionally accepted criteria, wom-en under the age of 33 unable toconceive within a year are con-sidered infertile, as are womenover the age of 34 unable to con -ceive within six months. Over

the years, the number of wom-en seeking treatment has risen,due to later childbearing, bettertreatment options, and increas-ing awareness of the many ser-vices available.2 However, onecannot help but wonder why themental health implications as-sociated with infertility have notyet been adequately addressed?As is the case with many otherhealth conditions, medical di-agnosis is often prioritized overmental health, while researchfunding for basic science is ofteneasier to obtain than funding forpsychological postulations. Thiscoupled with the lack of under-standing and empathy for thecondition of women strugglingwith infertility has accordingly,

resulted in a dearth of infertilityrelated policy.That being said, some steps

towards rectifying this prob-lem have been taken. Currenttreatments for resulting mentalhealth conditions include cogni-tive behavioral group psycho-therapy, support groups, generalstress relieving techniques, andpotentially antidepressants. Ac-

cording to the New York Times,8

in the past two years, nearly halfof the 370 infertility centers ap-proved by the Society for As-sisted Reproductive Technology(SART) have incorporated suchservices. However, despite theslight progress that has beenmade, one cannot help but won-derwhy hasnt more been ac-complished? The answer to thisquestion is undoubtedly quitecomplex, however, a good placeto start is rst recognizing thatbalancing the interests of themany stakeholders involved isquite challenging. Althoughthe Obama Administration has

largely been preoccupied withthe push to address more con-troversial issues in womenshealth such as abortion, contra-ception, and health care cov-erage of these procedures, itspoint of view (or lack-thereof)is absolutely critical to inuenc-ing the policy-eld and affectingchange. The DHHS and its agen-cies are also integral, particular-ly in implementing such policychange. At the other end of thespectrum lies State Legislaturesand their constituents, runningthe gamut from health care pro-viders to private and public hos-pitals, to special interest groups,to national associations, and -nally, to individual voters, par-ticularly infertile women.

Balancing these variousinterests is undoubtedly dif-cult, reducing the likelihoodof passing infertility legislationdramatically. In fact, in the last10 years, Congress has complete-ly failed to pass infertility legis-lation on a national scale. Whatbills have even been proposed inthe rst place? Two major piecesof legislation in particular that

have repeatedly surfaced: 1) theFamily Building Act (2009, 2007,2005, 2003) requiring all healthcare plans to provide benets fortreatment of infertility and 2) theMedicare Infertility CoverageAct (2005, 2003) amending Medi-care to cover infertility treat-ments for individuals entitled byreason of disability. Other pro-posed bills have also discussedresearch on and coverage of can-cer-related infertility, a tax breakfor qualied infertility treatmentexpenses, and the creation of anInteragency Task Force. Howev-er, not a single one of these billshas ever reached the oors of

Congress. At the state-level, f-

teen states have now mandatedcoverage of infertility diagnosisand treatment,5 each outliningits own specic guidelines; how-ever, many of these plans arestill incomprehensive, with nonein particular addressing men-tal health.6 The 1998 SupremeCourt case Bragdon v. Abbottrst fueled this discussion cit-ing reproduction as a major lifeactivity warranting protectionunder the Americans with Dis-abilities Act.1 However, whilethis historic precedent precludedemployer discrimination on thebasis of infertility, it did not re-solve the question of coverage.3

Even more recent events suchas the Patient Protection and Af-

fordable Care Act (PPACA) donot directly address issues of in-fertility, although prevention ofunwanted pregnancies as wellas maintenance of healthy preg-nancies are well represented.9

The shortfalls in currentpolicy are numerous. While,no sustainable, active effort hasbeen made by national or stategovernment, policy directly

targeting the mental heaplications of infertility been proposed at all. Yestrengths are to be notpossibility of nancial has at least been broachethermore, the infrastrucalready in placeBragAbbott and the PPACA room for more expansivcial coverage; they need claried or amended. does one deal with such lem? One can either 1ate its effects or 2) eliminsource itself. Below, I halined and provided an eof a policy proposal tack

infertility challenge froends. Under each suhave provided in italics asummary of the requirlisted under each respectsection:

STATEMENT OF INAccess to psychological res must be made more a cand treatment more affothereby increasing accessthe possibility of pregnanthe reduction of psychstress.

TITLE I: Increased APsychological Services totate Coping

SUBTITLE A: The (Department of Health andServices) should work wit(Society for Assisted Repr

Technology) leadership toa mandate urging the rehalf of SART-approved incenters to incorporate cognhavioral therapy and strestion services by the end Services should be integracounseling on adoption anfree living.

Currently, approxhalf of the SART-appro

aving a child is a common dream

at many women share.

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rtility centers in the nationrovide psychological services

couples dealing with infertil-y to help cope with the stress

being unable to conceive.uch services would also targetelping patients deal with otherental and emotional health im-ications, including depression,

nxiety, suicidal thoughts, etc.he form of such services couldke a variety of forms, includ-g cognitive behavioral thera-

y, general stress reduction tech-ques, and counseling/therapy.

uch efforts should also be com-ned with counseling on the

ptions that are available to cou-

es 1 should) they be unable toford infertility treatment or 2)hould their infertility treatmentil. Such options include adop-on and child-free living. Thisubsection mandates that the re-aining half of SART-approvedfertility centers that do not al-ady provide such psychologi-

al services develop the relevantfrastructure and programs by

he end of 2014.SUBTITLE B: Any feder-

ly funded hospital currentlyroviding infertility diagnosisnd treatment must appropri-e some funding towards de-

eloping psychological servicesy the end of 2014. Each centerust submit a cost analysis and

roposed budget. Federal subsi-

es should then be provided aseemed necessary.While certain hospitals in

he nation are privately funded,any receive funds from thederal (national) government

varying levels and degrees.ccordingly, the federal govern-ent has an important say in

ow such funding is used andlocated. This subtitle mandates

that any hospital that receivedfederal funding must allocatesome portion of this funding to-wards developing psychologicalservices to help patients copewith the implications of infertil-ity. The forms of such servicesare outlined in the italicized de-scription of TITLE I, SUBTITLEA above. Because evaluation ofthe enforcement of such policy isintegral to successful implemen-tation, each federally fundedcenter must provide a projectedbudget for the programs theyplan to develop. If further fund-ing is needed, the federal gov-ernment may provide subsidies

as needed if deemed appropriatebased on proposed budgets sub-mitted by each center. This mustbe met by the end of 2014.

SUBTITLE C: DHHS shouldconsult with Director FrancisCollins of the NIH and DirectorThomas Insel of the National In-stitute of Mental Health (NIMH)on increasing the budget or ap-propriating a larger percentageto research on the psychologicaleffects of infertility and potentialfacilitators of coping.

SECTION I: The possibilityof developing relevant extramu-ral grant programs should bediscussed.

SECTION II: Research on thenancial burden of depression(assuming it go untreated) must

not be neglected.Interdisciplinary coopera-tion and collaboration are ab-solutely critical to tackling anendeavor as ambitious as ex-panding infertility treatment op-tions, care, research, and healthcare coverage. Thus, interagen-cy cooperation is crucial. Ac-cordingly, as per this subsection,DHHS leaderships make an ac-

tive effort to collaborate withleaders of the NIMH under theNIH. Although actionable col-laboration need not take placeimmediately, the purpose of thissubsection is to encourage thetwo organizations to immediate-ly begin discussions focused onthe possibility of expanding orreallocating funding providedto the NIMH extramural grantprogram (funding provided tonon-NIH afliated laboratoriesand institutes) for research oninfertility treatment and psycho-logical services.

TITLE II: Increased Accessto Infertility Treatments through

Affordable CostSUBTITLE A: DHHS mustmandate that the 35 states cur-rently offering no coverage of in-fertility diagnosis and treatmentmust develop plans addressingthis issue by January 1, 2014.

SECTION I: Because this isa contentious issue, the specicswill be left up to the states.

SECTION II: States should beencouraged to, at the very least,cover basic infertility diagnosisand treatment, including medi-cal counseling, supplements,basic medication, and hormonaltherapy.

SECTION III: These insur-ance plans should be preparedindependently of ACA State Ex-changes.

Currently, only 15 of 50 statesin the nation provide state-basedinsurance plans covering infer-tility treatment. This subsectionmandates that the remaining 35states develop state-based plansthat include coverage of infertil-ity treatment by the beginningof 2013. This plans would be de-veloped outside of the PPACA(an expansive national univer-

sal health care bill passed dur-ing the Obama Administration)and because federal mandateson state-based insurance plansis often a contentious issue, thespecics of these plans and thetype, form, and amount of cov-erage will be left up to the StateLegislatures. At the very least,states will be encouraged to pro-vide coverage of infertility diag-nosis and treatment.

SUBTITLE B: Amend theACA to include a category oninfertility under the EssentialHealth Benets by January 1,2014 and, should the amendmentfail, encourage State Exchanges

to address infertility and mentalhealth potentially under the Es-sential Health Benets package.

Currently, the recent univer-sal health care bill the PatientProtection and Affordable CareAct (PPACA) does not includeprovisions for coverage of in-fertility treatment, althoughcontraception and abortion areaddressed. Thus, this subtitlemandates that the EssentialHealth Benets section under the

PPACA be amended to includea section on infertility treatmentby the beginning of 2014. TheEssential Health Benets sectioncovers the essential services thatevery government health-careplan must include. However,should this amendment fail topass through the Congress, theState Exchanges established bythe PPACA should be encour-aged to incorporate coverage ofinfertility treatment and mentalhealth services in the plans theydevelop. State Exchanges are es-sentially the instrument throughwhich the PPACA will be ex-ecuted in each respective state.

SUBTITLE C: Push throughthe Family Act of 2011, amend-ing the Internal Revenue Codeto allow an income-based taxcredit for 50% of qualied infer-tility treatment expenses. Rein-troduce in the 113th Congress ifnecessary.

According to this subtitle,members of Congress shouldmake an active effort to pass theFamily Act of 2011, reintroduc-ing the bill as necessary, since all

bills that are not passedend of a Congressional are killed. This act the tax code so as to pr50% tax credit (reductionment) on expenses paid tthe cost of infertility trea

SUBTITLE D: Reinthe Family Building AMedical Infertility Cover

According to this smembers of Congress reintroduce the 1) Familying Act and 2) Medical InCoverage Act (discussedously in this paper). Threspectively require all care plans to provide

for infertility treatmenamend Medicare to covetility treatments for indientitled to this coveragetheir acquirement of a direlated to infertility.

TITLE III: Develop aagency Task Force to pawareness, research, intcy cooperation, preventiriculum, and multidiscpartnerships on infertilits mental health implica

COMMENTARY: this multi-pronged apthe problem of not onlyand cost of care but allevimental health challengebe addressed at a fedestate level. It is not nethat all provisions pass;

it is the hope that a balatween federal and state erations can be struck.

Of course, a bill assive as this must make usequate and available refrom interdisciplinary sowell. First and foremosagency and private-pubtor cooperation amongous parties including theInfertility can cause frustration for those who want to become parents.

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IH, State Legislatures, andART are key. Funding is alsoxtremely important. While theIH may be able to contributegnicantly to the research bud-et, the more difcult nancialsue lies at the state levelhowill states be able secure enough

apital to fund infertility cov-age through state-insuranceans? If they choose to tackle

his issue through the PPACA,ate Exchanges will be respon-ble for appropriating money aseeded, whereas if they choose

tackle it from the perspectivestate-mandated insurance

ans, collaboration between

ate Legislatures and healthare providers is critical. From arivate sector route, the engage-ent of SART and other nation-associations would be integral

convincing private centersintegrate more psychologi-

al services into their treatmentrograms, while bipartisan part-erships and discussion will betegral to passing federal legis-tion. Thus, lobbyist and advo-

acy groups should be engaged should community organiz-s and clinics.

Because coordinating thesearious interdisciplinary effortsould certainly prove difcult well as complicated, estab-

shing an appropriate timeliner the enforcement of different

tles and subtitles under a billcritical as well. For the billutlined above, an appropri-e timeline would include thellowing deadlines: 1) TITLESUBTITLES A and B must beet by the end of 2014 2) TITLE SUBTITLES A and B would

e subject to the January 1, 2014eadline imposed on State Ex-hanges by the ACA 3) TITLE III

establishing an Interagency TaskForce and TITLE I: SUBTITLE Ctargeting NIMH research shouldbe implemented immediately,allowing NIH to begin imple-menting the ndings of thesediscussions as early as FY 2013or FY 2014 and 4) TITLE II: SUB-TITLES C and D dealing withfederal legislations idealisticallyshould be addressed in the cur-rent 112th Congress and reintro-duced as needed.

Finally, evaluation of theenforcement of such a bill mustbe conducted as well to ensurethat progress is being made.Outcomes of the bill above, for

instance, could be monitoredand evaluated regularly by anInteragency Task Force, whichwould be required to prepare bi-annual reports of ongoing poli-cy advancements, incorporatingfeedback and progress reportssubmitted by involved agenciesas well as private parties onemonth prior. NIH could be incharge of evaluating researchprogress, conducting annual re-views of independent researchgrants, while the DHHS couldselect a nonpartisan NGO toconduct yearly reviews of bothTask Force behavior and policydevelopment. Data at all levelsshould be collected in the formof statistics, interviews, andprogress summaries.

Although both national andstate environments surround-ing the infertility debate areundoubtedly sticky, proposalssuch as the one outlined in thispaper offer not only potentialbut signicantly improved solu-tions to the neglected plagueof infertility and its medical, -nancial, emotional, and mentalimplications. Fortunately, the

research and vehicles for changeare already partially in place andthrough effective federal-stateand public-private collabora-tions, could blossom into a morenationally integrated networkbalancing various stakeholderinterests. As evidenced by theresearch and statistics in thispaper as well as the illustratedexample of potential policy solu-tions, interdisciplinary and inter-agency cooperation is absolutelycritical to the success of such anambitious endeavor, and if ex-ecuted properly, could have thepower to reverse the negativetrend of neglect and ignorance

that has surrounded the infer-

tility debate at both the popularand governmental levels. Thecondition of infertility must notbe neglected or ignored. Rather,we must embrace it and forgeahead, accepting that people ofall medical conditions deservea fair chance at having a shotat their dreams of better healthand improve

Stanford Journal of Public Health Volume 3 Issue 1 Winter 2013

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Transcript of Stanford Journal of Public Health Volume 3 Issue 1 Winter 2013