Vol. 13 Issue 2

frontiersmag

FRONTIERS

Washington University Review of Health

IN THIS ISSUE

Create Circles: Lessons Learned about

Elderly Care and Social Engagement

The Metaphorical Virus

Bac to Basics

Volume 13

Spring 2020 Issue 2


Washington University Review of Health Spring 2020

Writers

Harry Arndt

Courtney Chan

Ryan Chang

Angela Chen

Ayda Oktem

Ben Lieberman

Madhav Subramanian

Rehan Mehta

Rachel Ulbrich

CONTENTS

Alyssa Yang

Editors

4

Letter to the Reader

Executive Board

Daniel Berkovich Ryan Chang

Akshay Govindan Anhthi Luong

Sophia Xiao

Illustrators

Jennifer Broza Angela Chen

Parveen Dhanoa Lily Xu

Eguenia Yoh Yu Xin Zheng

Photographer

R ehan

Choudhury

Lily Xu

Keshav Kailash

Daniel Berkovich

Anu Balasubramanian

Anhthi Luong

Soyi Sarkar

Isaac Mordukhovich

Alyssa Hyman

Jennifer Broza

Casey Connelly

Senior Executive Director

Executive Director

Executive Director

Senior Editor-In-Chief

Co-Editor-In-Chief

Co-Editor-In-Chief

Director of Operations

Director of Finances

Co-Director of Public Relations

Co-Director of Public Relations

Hannah Chung

Soyi Sarkar

Lucy Chen

Victoria Xu

Lucy Chen

Eugenia Yoh

Victoria Xu

Shubhanjali Minhas

Ayda Oktem

Yumi Sasaki

Ryan Chang

Amaan Qazi

Co-Director of Design

Co-Director of Design

Co-Director of Design

Director of Outreach

Director of Outreach

Co-Web Editor

Co-Web Editor

Co-Web Editor

6

10

13

19

Breaking the Bubble: Bringing Neuroscience Education

to the St. Louis Community

Writers : Courtney Chan & Harry Arndt

Editor : Heather Chung

Create Circles: Lessons Learned about Elderly Care and

Social Engagement

Writer : Ryan Chang

Editor : Isaac Mordukhovich

The Metaphorical Virus

Writer : Angela Chen

Editor : Sophia Xiao

Don’t Lose Heart on Coffee

Writer : Ben Lieberman

Editor : Akshay Govindan

21

22

24

26

29

33

36

Illustration Feature

Cold Pancreatic Cancer? Not so much anymore!

Writer : Madhav Subramanian

Editor : Anhthi Luong

The State of Sex Ed in Missouri and How it Affects Teen

Pregnancy

Writer : Ayda Oktem

Editor : Soyi Sarkar

PCSK9 Inhibitors: A Novel Treatment for

High Cholesterol

Writer : Rehan Mehta

Editor : Soyi Sarkar

Rural Healthcare Disparity: A National Concern

Writer : Rachel Ulbrich

Editor : Daniel Berkovich

Back to the Basics

Writer : Alicia Yang

Editor : Daniel Berkovich

Senior Shoutouts

2 3



Washington University Review of Health Spring 2020

Dear Reader,

In the last several weeks the progression of the global coronavirus pandemic has left us

quite shocked, and some, distressed. We hope this message finds you healthy and well

during this uncertain time. As a student-led interdisciplinary health magazine, we have

begun to contemplate what our role might be in the face of this major public health crisis.

Frontiers has always been committed to relaying our love for science, medicine and healthcare

to a wide range of audiences. At our core, we are a group of passionate undergraduate

students working to publish reliable and compelling scientific information through journalistic

writing. Now more than ever, medical journalism holds relevancy at WashU and beyond.

Soyi Sarkar

SOYI is a junior from Short Hills,

New Jersey majoring in Neuroscience

and Mathematics. She

joined Frontiers to understand

the intersection of medicine and

journalism, specifically how we

can use medical journalism to

mitigate healthcare disparities.

Soyi loves to volunteer and give

back to the WashU and larger

STL communities, and is involved

in cancer research at the

med campus. In her free time,

she loves taking walks in Forest

park, and spending all her meal

points at Ibby’s.

Anhthi Luong

ANHTHI is a junior from St.

Louis, Missouri, majoring in

Neuroscience and minoring in

Healthcare Management. She

enjoys writing about science and

medicine, particularly topics

relating to research within the

medical community and controversial

medical issues. Other

than Frontiers, Anhthi is an

active hospital volunteer and is

a member of an anesthesiology

research lab.

Anu Balasubramanian

ANU is a senior from the Westford,

Massachusetts double

majoring in Global Health and

Computational Biology, and

minoring in WGSS. She joined

Frontiers because she loves

writing about science and

medicine, particularly topics

relating to women’s health.

Apart from Frontiers, she is

involved in Beat Therapy, sings,

does research at the med school,

and spends her spare time

catching up on sleep.

We are proud to present you with a diverse collection of articles engaging many aspects of

medicine including public health, biomedical research advances and reflections from clinical

settings. Our writers, editors and illustrators have continued to work tirelessly even under

dire circumstances. We hope our magazine has created a space for our members to establish

meaningful relationships between themselves, while publishing articles that allow

readers, like you, to immerse themselves in the text. We seek, above all, to create an environment

that cultivates honing creativity, engages investigative writing and open-mindedness

amongst all members.

Each article has been crafted by our passionate writers, critiqued with care by our attentive

editors, designed by our imaginative illustrators and published behind-the-scenes by our

dedicated executive members. We hope that some of these articles pique your curiosity and

represent the hard work and dedication to publish a magazine that enables us to spread

informative and scientific ideas.

If you would like to become a part of our Frontiers family, there is definitely a place for you!

Whether as a writer, an editor, an illustrator or a member of our Executive Board, we are

always excited to welcome new members. We would also love to hear any of your comments,

questions, suggestions, and/or concerns. Please contact us at eic.frontiersmag@

gmail.com or look at our website frontiersmag.wustl.edu for more information.

Please take a glimpse of what our accomplished members have put into this issue. We are

confident that it can shed a little light in our community and perhaps even beyond.

“In times of profound change, the learners inherit the earth, while the

learned find themselves beautifully equipped to deal with a world that

no longer exists.” - Eric Hoffer

Letter to the Reader

Happy reading,

Soyi Sarkar, Anhthi Luong and Anu Balasubramanian

EDITORS-IN-CHIEF

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Washington University Review of Health Spring 2020

Breaking the Bubble: Bringing Neuroscience

Education to the St. Louis Community

Writers: Courtney Chan & Harry Arndt | Editor: Heather Chung

| Photographer: Rehan Choudhury

Who wants to touch a

brain?”

I expected several girls to raise their

hands hesitantly and the others to

shy away. Contrary to my expectations,

nearly every girl in the room

raised her hand, their feet a pinch

too short for the lab stools in

Rebstock, hands already grabbing

for the goggles we loaned. Leading

a Sheep Brain Dissection through

Washington University’s neuroscience

club, Synapse, I passed around

forceps, paper towels and brain

anatomy worksheets to the eager

students.

As a collaboration between the

Washington University in St. Louis

(WUSTL) Institute for School

Partnerships (ISP) and the Synapse

Scholars program, the Sheep Brain

Dissection was one of the numerous

mentorship opportunities Synapse

provided to local elementary, middle

and high schools in the surrounding

St. Louis community. This Human

Brain Demo brought around thirty

female students from Hawthorn

Leadership School for Girls to

WUSTL’s campus. As we identified

parts of the brain and fielded

questions about anatomy, college

applications, and gadgets in the

Biology Lab, Synapse Scholars

provided an opportunity for

WUSTL students to connect with

younger students from the greater

community and encourage early

STEM and neuroscience education.

Over a decade ago, Synapse was

founded as an undergraduate club

affiliated with SIGN at the WU

School of Medicine. Nearly tripling

its size in the past decade, the club

aids WUSTL undergraduate students

in their current and future

neuroscience studies by organizing

monthly speaker events, physician

shadowing opportunities, research

panels and student mentorship

events. Moreover, students have the

opportunity to make a lasting

impact on the greater St. Louis

community by volunteering for

educational programs (i.e. Demo

Days, Synapse 101 and Synapse

Scholars) and sports rehabilitation

programs (i.e. dance, martial arts,

swim and open-gym). Students also

have the opportunity to volunteer

with local neuroscience outreach

events, such as the St. Louis Area

Brain Bee (SLABB) and events at the

St. Louis Science Museum.

“Elementary

school students in

particular have a

wonderful openness

to new ideas

if you can get them

to focus for a bit

and engage with

you.”

Working with the ISP, two years

ago, co-presidents Courtney Chan

(WUSTL ‘20) and Eric Song

(WUSTL ‘19) created a tracking

system to evaluate its community

impact, get feedback from local

teachers and improve Synapse’s

outreach. From 2018 to 2019,

Synapse 101, Demo Days and

Synapse Scholars served more than

680 local students, an effort involving

140 WUSTL student volunteers

hosting 78 visits combined. From

2019 to 2020, co-presidents Sid Rana

and Ankit Choudhury continued

collecting this data, with the

programs serving over 4,000 local

students including partnerships

with the St. Louis Science Center,

involving 147 WUSTL student

volunteers hosting 90 visits combined.

These programs not only give

WUSTL students the opportunity to

give back to their communities but

introduce younger students the

chance to ask college students

questions, learn about the brain and

explore a world of neuroscience and

STEM.

The Synapse Scholars program, the

newest of Synapse’s three educational

programs, was founded by

Sophie Zimbalist in Fall of 2017

(WUSTL ‘20). Serving approximately

120 students each year, Synapse

Scholars continues to grow. Reflecting

upon its starting moments,

Sophie recalls that she had “always

been interested in neuroscience and

the brain, so when [she] found out

that Synapse had an education

program that allowed [her] to

engage elementary students in the

community, [she] signed up immediately!”

While Sophie had been

involved in Synapse’s Demo Days

program in previous years, the two

existing educational programs,

Demo Days and Synapse 101, were

directed at elementary and middle

schools.

“The curriculum is

purposely left flexible

so that it provides

students

the time to engage

and explore based

on their own

questions and

interests.”

As a Demo Days volunteer, Sophie

reflects that “elementary school

students in particular have a

wonderful openness to new ideas if

you can get them to focus for a bit

and engage with you. I found that

they loved the activities and were in

awe when we brought in a human

brain that had been donated to us

from the medical school campus.”

Yet she wanted to know whether it

would be possible to sustain and

build upon this enthusiasm for more

than just an hour at an elementary

school level. This sparked her

creation of the Synapse Scholars

curriculum, which she created to

provide a neuroscience education at

a higher level to middle and high

school students. She spent the

summer of 2017 writing lesson

plans from scratch. At first, Scholars

started small, with several trial

visits in the Fall and Spring—by fall

of 2018, it expanded to six visits per

semester.

SLABB participants put their knowledge to the test in a neuroscience exam held

in Washington University’s Rebstock Lecture Hall.

Sophie explains, “[Scholars] works

with schools that have everything

from a basic Missouri State biology

curriculum to a full AP anatomy

and physiology lab classroom. I

wanted students from all backgrounds

and scientific levels to have

a better sense of how their brain

functioned but also how to keep it

healthy. The lesson plans vary in

topic from brain anatomy (with the

famous “real human brain”) to

mental health and even brain

imaging. The curriculum is purposely

left flexible so that it provides

students the time to engage and

explore based on their own questions

and interests.”

The St. Louis Area Brain Bee

(SLABB) has also grown tremendously

since its fruition in 2010 (St.

Louis Area Brain Bee). Founded as

a passion project for faculty advisor

Dr. Erik Herzog, the Brain Bee is an

academic competition in which high

school students’ understanding of

neuroscience is put to the test. The

test consists of a written and an oral

round with the top tester sent to

The National Brain Bee. (Lopez

2019) Turnout met record numbers

in 2019, bringing 58 students to

compete at WUSTL’s campus

(Lopez 2019).

Content on the exams are pulled

from a book called Brain Facts,

which is published by the Society

for Neuroscience. The book is

described as “a primer on the brain

and nervous system,” serving to

introduce students to the field and

perhaps catalyze a long-term

interest (Brain Facts). Synapse

volunteers assist every year to help

run the event, which has produced a

history of young winners. SLABB

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Washington University Review of Health Spring 2020

decade, Synapse hopes its reach and

attendance will continue to grow.

The greater recognition of the

competition by St. Louis high

schools and their students will serve

to not only expand students’

exposure to neuroscience, but also

the beneficial impacts of these

student groups.

SLABB participants engage in an interactive demo, learning about electrical impulses in their body.

has been particularly pushed by

Ankit Choudhury and Sid Rana,

current co-Presidents of Synapse.

This sentiment resonated seemingly

well with the students, as attendance

reached an all-time high

under Ankit and Sid’s guidance last

year.

“Through the Brain

Bee, we [are] able

to show them that

Neuroscience is

something fun and

interesting they

can study when

they get to

college”

“I was passionate about helping out

with the Brain Bee as it gave me an

opportunity to share my passion for

neuroscience with high school

students,” Ankit says. “Through the

Brain Bee, we [are] able to show

them that Neuroscience is something

fun and interesting they can

study when they get to college that

incorporates all the STEM subjects

they are currently learning about.

So, basically we are able to show

them a fun and interesting way to

stay involved with STEM post

high-school.”

While volunteering for SLABB is a

fun and fulfilling way for WUSTL

students to engage with their

community, the true significance of

the event is its effect on the young

competitors themselves. One

student at the 2020 Brain Bee flew

in from New York to compete.

Co-president, Ankit Choudhary

explains, “I feel like in high school,

students get exposed to the core

subjects of Biology, Chemistry,

Math, and Physics; but they miss

out on some of the more niche and

more interesting subjects like

neuroscience. I know when I was in

high school, I didn’t get any exposure

to neuroscience.”

The competition engages students’

passions for science by pushing

beyond what is necessarily available

in everyday high school life. While

SLABB brings awareness to students’

academic interests, it can also

foster students’ other needs as well.

High school student groups study

together in their preparations for

the competition, generating new

friendships and a sense of community

over their shared work. These

study groups can be instrumental in

students’ after-school lives, giving

them a place to study and the

means to find another meal. As

SLABB continues into its second

As a whole, Synapse seeks to

develop these connections between

greater St. Louis and the university’s

student body. As a current

Washington University alumna,

Sophie reflects, “Synapse played a

large role in my engagement in the

St. Louis community by providing a

number of educational programs as

well as community service opportunities

for me to participate in.

Synapse also provided a way for me

to engage with neuroscience at a

reasonably high level without

having a major in the department.”

For me, a senior and current

President Emeritus of Synapse, my

involvement in Synapse has been a

key experience that shaped my

college career. It provided me not

only with the opportunity to swim

with kids, attend engaging research

panels and shadow physicians, but

the unparalleled chance to see each

Hawthorn student put up her

ponytail, snap on her gloves and

light up when she touched a brain

in awe: a moment that I will

remember for years to come.

Washington University Synapse volunteers cheer on SLABB participants as the

SLABB 2020 winners are announced.

References

bee, but for neuroscience: WashU Brain Bee

set for Feb. 16. Retrieved from https://schoolpartnership.wustl.edu/2019/01/09/like-a-spelling-bee-but-for-neuroscience-washu-brain-beeset-for-feb-16/

Lopez, M. (2019, February 19). Record turnout

for WashU’s Brain Bee competition. Retrieved

from https://schoolpartnership.wustl.

edu/2019/02/19/record-turnout-for-washusbrain-bee-competition/

The Brain Facts Book. (n.d.). Retrieved from

https://www.brainfacts.org/the-brain-factsbook

The St. Louis Area Brain Bee. (n.d.). Retrieved

from https://sites.wustl.edu/slabb/

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Washington University Review of Health Spring 2020

Create Circles: Lessons Learned about

Elderly Care and Social Engagement

Writer: Ryan Chang | Editor: Isaac Mordukhovich | Illustrator: Victoria Xu

Note: The name of the woman described in this

article has been changed to protect her privacy.

And that’s the story of

how I met the President!”.

Martha concluded her story

with a flourish. I laughed, amazed at

Martha’s boundless imagination and

creativity in her storytelling.

Despite struggling with dementia

for several years, Martha never

failed to surprise me with her (often

made-up) stories and nuggets of

wisdom from throughout her life.

I visited Martha’s nursing home as a

volunteer for Create Circles, a

non-profit organization dedicated to

addressing common challenges

faced by older adult populations,

such as social isolation, negative

aging and cognitive decay. One of

Create Circles’ primary goals is

developing projects with the home’s

residents to promote a sense of

purpose. According to a 2018 study,

a purpose of life (PIL) “is conceptualized

as having goals, a sense of

direction, and a feeling that there is

meaning to present and past life.”

The study also found that having a

PIL is associated with positive

health outcomes like fewer chronic

conditions and reduced mortality.

Social isolation and negative stigma

are also prevalent problems among

older adults. The former has been

shown to increase risk for heart

disease, cognitive decline, obesity

and other health conditions, while

negative stigma surrounding aging

has been linked to increased rates of

physical and mental decline. The

prevalence and consequences of

these issues make addressing them

integral to Create Circles’ mission. I

had previously been unaware of

these unique problems affecting

older populations, but I became

fascinated with them and the

measures being taken to support

such individuals. I began volunteering

at a nursing home which

specializes in patients with various

forms of dementia during my first

semester of freshman year.

Negative stigma

surrounding aging

has been linked to

increased rates of

physical and mental

decline.

I began my first visit to the nursing

home with wracked nerves, nervous

that I was unprepared to engage

with a dementia patient – that I

would somehow mess up. Meeting

Martha assuaged some of these

initial worries, as she greeted me

warmly and welcomed me graciously

to the home. After we sat down

for our first discussion, I soon

noticed that Martha spoke in circles,

often repeating things she had said

a few minutes earlier and forgetting

my words just as quickly. Despite

my training, I initially struggled to

navigate the conversation, unsure of

how to reach through to Martha

when it seemed like nothing we

discussed stuck. The meeting began

to feel more and more disjointed,

with long periods of silence punctuating

short, awkward exchanges.

Fortunately, Martha’s daughter

visited the home soon after I

arrived, and her presence proved

invaluable in facilitating our

conversation. Even when Martha

struggled to remember facts like

how many children she had, her

daughter responded with warmth

and patience, gently reminding

Martha of her children and anything

else she would forget. What

struck me most was how the

daughter went with the flow of

Martha’s repetitive and false

statements, how confident and

animated Martha became as she

spoke with increasing excitement

and energy. As I began to imitate

this approach, I found myself

engaging with Martha more meaningfully,

even after her daughter left

early to attend to another commitment.

By the time my session with

Martha came to end, I felt more

confident in my ability to converse

with her and looked forward to my

next visit.

My second trip to the home got off

to a much smoother start as Martha

and I built on the rapport from the

previous visit, even though I had to

remind her a few times about the

last time we had met. Martha

launched into conversation and I

was enthralled in her story. My

mentor told me that Martha was

known for telling fantastic stories,

but I didn’t realize just how imagi-

native she could be. When she

wasn’t spinning tales about meeting

the President and traveling to

far-off exotic lands, Martha shared

insights and lessons from her

decades of living in St. Louis, telling

me about her favorite locales and

giving me advice about exploring

the city. This visit went by in a blur

and I realized that Martha’s penchant

for stories could make for a

perfect collaborative project.

Having learned so much from

Martha, I decided that sharing her

stories online would be a great way

to promote a PIL.

I wasn’t able to return to the home

for almost a month after this visit,

however, due to an increased

academic workload and continued

transition to college. When I finally

proposed my idea to Martha during

my third visit, she responded very

enthusiastically. We chatted animatedly

about different websites where

I could post her content as well as

potential stories to share. As we

talked, I noticed how Martha was

more engaged and animated than

during our previous visits. The

prospect of this storytelling project

had sparked a greater excitement in

her as she found a new goal to

apply her passion towards. I found

myself feeling just as invested in

the project as well and I left the

nursing home that day in high

spirits and eager to resume work

with Martha.

Near the end of the semester, I met

with the other Create Circles

volunteers for an additional training

session with two administrators

from the nursing home. The administrators

taught us more about the

history of the home as well as more

specifics on how to interact with

dementia patients. The meeting was

going well, and in one of my

conversations with an administrator,

I asked her, “By the way, how’s

Martha? I haven’t been back to the

home in a while.”

The administrator exchanged a look

with her partner, then carefully

said, “I’m sorry… but Martha passed

away a few weeks ago. She was

struggling with a lot of health

complications, and, well…”

Her words hit me like a truck,

stunning me into silence. The rest of

the day passed in a blur as my mind

replayed the conversations and

moments I had shared with Martha.

It surprised me how much I could

be affected by the death of someone

I had only spoken with three times.

As I thought about the exciting

project plans Martha and I had

made, I found myself grieving not

just Martha, but her lost opportunity

to share her wonderful voice

with the world.

As time passed, I learned to not

only to grieve, but to reflect fondly

on the times I spoke with Martha

and the personal lessons our work

imparted upon me. As an aspiring

physician, I came into college

focused on learning how to treat

people’s illnesses and promote

healthier, longer lives. Working

with Create Circles and speaking

with Martha helped me develop a

greater appreciation for how

focused engagement with the

elderly can prevent cognitive

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Washington University Review of Health Spring 2020

decline and encourage a more

positive, purposeful life. While I

continue my studies and path

towards medicine, I now understand

better than ever the value of care

beyond the clinic and the importance

of community engagement in

promoting positive physical and

mental health outcomes. With the

increased social distancing policies

implemented to combat the spread

of the recent COVID-19 outbreak, it

has become more important than

ever for people to engage with older

adults who have lost their support

systems, as increased socialization

is associated with lower rates of

depression, cognitive decline, and

physical disability. It has been

inspiring to see that, even amidst an

unprecedented global pandemic,

Create Circles is still training volunteers

to hold online visits with the

elderly and prevent the negative

effects of social isolation.

Although it hurts knowing I’ll never

speak with Martha again, I remain

inspired by her creativity and,

although I can never know for sure,

I like to think that speaking with

her and helping her develop her

project had a positive impact on her

life. My experience with Create

Circles helped me develop a deeper

appreciation for the unique challenges

faced by our aging population,

and how active engagement

can help combat the social isolation,

It surprised me

how much I could

be affected by the

death of someone

I had only spoken

with three times.

As I thought about

the exciting project

plans Martha and I

had made, I found

myself grieving not

just Martha, but

her lost opportunity

to share her

wonderful voice

with the world.

negative stigma, and loss of PIL

associated with aging. I will always

remember the joy Martha exuded

while sharing her fantastic stories,

and I intend to apply the lessons I

learned from Create Circles and

emulate Martha’s infectious energy

in all aspects of my life.

For those interested in getting

involved with Create Circles’ virtual

engagement, please visit https://www.

studentstoseniors.com/to learn more.

References

“About Us.” Create Circles. https://www.createcircles.org/about-us-1.

Musich, Shirley et al. “Purpose in Life and Positive

Health Outcomes Among Older Adults.”

Population health management vol. 21, no. 2,

2018, pp. 139-147. doi:10.1089/pop.2017.0063

“Social isolation, loneliness in older people

pose health risks.” National Institute on Aging,

U.S.

Writer: Angela Chen

Editor: Sophia Xiao

Illustrator: Angela Chen

Department of Health & Human Services, April

23, 2019.

https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks.

The Metaphorical

Golden, J., Conroy, R. M., & Lawlor, B. A. “Social

support network structure in older people:

Underlying dimensions and association with

psychological and physical health.”

Virus

Psychology, Health & Medicine,

vol. 14, no. 3, 2009, pp. 280–290.

doi:10.1080/13548500902730135

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Washington University Review of Health Spring 2020

Metaphor is a strong tool

in discourse. Linking

seemingly unrelated

concepts, it weaves a net of knowledge

that facilitates understanding

and sparks up insights at its nodes.

However, in a context that requires

objectivity, the net can lead us

astray. It distracts us from the

simplest facts and fogs our perception

and judgments. As early as the

medieval period, diseases have been

part of this network, and the

current COVID-19 pandemic is not

an exception. Related metaphors,

inconspicuous like the diseases

themselves, exert their power on

our minds and cause unwanted

influences.

In Illness as Metaphor (1978), Susan

Sontag analyses the metaphorical

meaning of diseases, especially

cancer and tuberculosis. As a

sufferer from cancer, Sontag is

clearly aware of the harm inflicted

by stereotypes and fantasies about

an illness. She argues, “illness is not

a metaphor, and that the most

truthful way of regarding illness –

and the healthiest way of being ill

– is one most purified of, most resistant

to, metaphoric thinking.”

(Sontag 5) She also acknowledges

the ubiquity and inevitability of

metaphors, which are the results of

humans’ abundant creativity and

imagination. But resistance to

metaphoric thinking is possible, and

the awareness of its existence is a

barricade. Sontag dedicated her

book to an “elucidation of those

metaphors” and thus, “a liberation

from them” (Sontag 4). Similarly,

this article is an attempt to unveil

the hidden metaphors about

contagions and examine the case of

SARS-CoV-2, the virus that is

devastating the globe and reshaping

the world.

Contagion as Metaphor

In the fourteenth century, the

bubonic plague, also known as the

black death, wiped out more than

one-third of the European population.

With little idea of how the

disease was transmitted, people in

the Middle Ages believed that the

plague represented divine wrath

and spread via “miasma” or “bad

air.” The religious connotations

directed the blame at the Jews and

foreigners, inciting rife persecution

and, the worst of all, religious

pogroms, in which communities

after communities were murdered

(Fowler 2019).

Even as the scientific explanation of

contagion emerged, its metaphorical

meaning had only become increasingly

complex and diverse, and the

sinister rhetoric of blaming minorities

and foreigners continues to

encroach upon logic and reasons.

As early as the sixteenth century,

physician-poet Girolamo Fracastoro

of Verona proposed that indirect

contact could cause infection via

“Fomes,” or “seeds of disease”

(Edward Worth Library). Between

then and the late nineteenth

century was a period of industrialism,

immigration and cultural

exchange. Intriguingly, cultures

share many similarities with

contagion. For example, like

contagions, cultures are communicated

(or spread) from person to

person unconsciously or consciously.

These similarities strengthened

the association between contagion

and cultures or people, especially

immigrants and minorities who

were regarded as “outsiders and

outcasts” (Pernick 2002). Serious

implications manifested in politics

and ethics, and, in turn, politically

and morally charged metaphors

have become ubiquitous in literary

and media narratives. Furthermore,

modern consumer culture breeds

“sensationalist rhetoric” and

“dramatic symbolism,” which

magnify the influence of metaphors

(Davis, 2002). For example, during

the Ebola outbreak in 2014, a

chyron of the CNN news read

“Ebola: ‘The ISIS of Biological

Agents?’”(Cole 2014). This unecessary

association with terrorism

certainly attracts attention, but it

sensualizes a disease and distracts

the public from understanding the

virus in a biological and factual

perspective. This is not a singular

phenomenon, and the problematic

linkage between terrorism and

pandemic continues to exist.

The malign stigma of disease and

the hostility toward minorities have

not disappeared as advanced

biological science took hold in

society after the nineteenth century.

Rather, inherent biases in knowledge

and theories reinforced the

stigma and justified hostility

(Buruma 2020). Unlike notorious

eugenics in the twentieth century,

connotations of contagion, just like

the virus, are more implicit and

unconscious, but they are just as

powerful. In the 1880s, the identification

of microorganisms as agents

of diseases led to a rise of military

metaphors (Sontag 65-66). For

example, bacteria are said to

“invade” or “infiltrate” (Sontag

65-66), and the body responds with

its own immunological defenses.

These choices of words evoke a

sense of aggressiveness and otherness.

The inherent characteristics of

contagions lay the foundation for

war-related metaphors in medical

and social discourse. The spread of a

contagion is often portrayed as an

invasion by a foreign enemy, and

this narrative fuels the declaration

of war against the disease and backs

up the aim of “identifying” and

“eradicating” it (Ferri 2018). The

metaphors also suggest a duality of

winning and losing, making people

susceptible to unrealistic optimism

and pessimism. Combined with the

close association between certain

people and the contagion, war

metaphors are very pernicious, as

they influence our opinions on the

sick and evoke verbal and physical

attacks on actual people.

The Case of COVID-19

Sontag (1978) argues in Illness as

Metaphor, “Any important disease

whose causality is murky, and for

which treatment is ineffectual, tends

to be awash in significance” (Sontag

58). Similar to tuberculosis and

cancer, SARS-CoV-2, the novel

coronavirus that arose in December

2019, also falls into this category.

Despite the rapid identification of

the virus and the wave of booming

research, many questions remain

unknown. Its ability to travel

through air and to launch an

infection is still debatable, and new

information such as its asymptomatic

transmission has just come to

light through ongoing research

(Yong 2020). The uncertainty

surrounding its infectious abilities

has caused divergent opinions

among experts, which has led to the

public receiving mixed signals and

different safety suggestions (Yong

2020). But the research effort in

“ILLNESS IS NOT A METAPHOR, AND

THAT THE MOST TRUTHFUL WAY

OF REGARDING ILLNESS – AND THE

HEALTHIEST WAY OF BEING ILL – IS

ONE MOST PURIFIED OF, MOST

RESISTANT TO, METAPHORIC

THINKING.”

developing an antidote has paid off:

63 days after the viral genome was

sequenced, Moderna developed an

experimental vaccine (Yong 2020).

However, as of April 16, it is still at

the Phase 1 trial, and subsequent

trials need to be carried out to

further evaluate its safety and

efficacy. Even if the vaccine proves

to be safe and effective, there are

challenges in manufacturing this

unconventional RNA vaccine (Yong

2020). Mysteriousness and danger of

this virus breed anxiety and fear in

the public, and such a disease is

prone to metaphorical interpretations

and their grave implications.

The most prominent influence is the

discrimination resulted from the

virus. Driven by fear, certain groups

of people and practices are highly

stigmatized and scapegoated (Ferri,

2018), such as people of Asian

descent and wearing masks in

current COVID-19 pandemic. In

France, one Vietnamese woman

reported that a car driver shouted to

her “Keep your virus, dirty Chinese!”

and sped away through a

puddle, splashing her (Rich 2020).

This is only a minor incident among

the countless verbal and physical

aggression inflicted on people with

Asian descent. Naming SARS-CoV-2

as the “Chinese Virus” in social

media and official settings is thus,

extremely dangerous and problematic.

It cements the conception that

Chinese people, and people with

East Asian appearances in general,

are inherently diseased, inciting

more conflict between individuals,

cultural groups and nations. It could

potentially harm international

collaboration, which is highly

critical in a pandemic.

Moreover, regarding the patients

(“the people”) as the representation

of the virus leads to underestimation

of the real gravity of the

situation. Especially at the early

14 15



Washington University Review of Health Spring 2020

stage of local transmission, confirmed

cases can be only the tip of

an iceberg. Even though they are

successfully contained, the virus

can go undetected. On February 27,

there were only 15 cases in the

United States.

On the same day, displaying a chart

indicating the United States preparedness

for a pandemic, President

Trump claimed, “we’re prepared like

we have never before…one day —it’s

like a miracle—it will disappear”

(The White House 2020).

Besides showing underestimation

and optimism, his commentary

represents a sense of exceptionalism

and superiority. But such a belief

will not automatically grant the

country immunity to an infectious

disease.

Science writer Ed Yong commented,“And

I do wonder if that propensity

to think of [the U.S.] as being

truly exceptional, that slight hubris,

left it more unprepared than it

needed to be” (Gross, 2020).

Narratives around the spread of

contagion are susceptible to war-related

diction and metaphors, and

COVID-19 is not an exception. In

the New York Times article, “Its

Coronavirus Cases Dwindling,

China Turns Focus Outward,” words

such as “blitz,” “diplomatic offensive,”

“battleground” and “combat”

paint the offering of medical

assistance to other countries as

highly aggressive and the pandemic

as conflict between nations and

ideologies (Myers and Robin 2020).

But in reality, the pandemic is a

global phenomenon, and SARS-

CoV-2 is a virulent natural agent

that is trying to survive and reproduce

but is dangerous to human

health. Similar portrayal, however,

undermines our sense of solidarity

as human beings. Moreover, war

metaphor also abets irrational and

ignorant behaviors. Defying

experts’ warnings to attend large

gatherings and downplaying

physiological vulnerabilities are

considered as “brave” actions, while

staying at home is an “ignoble

retreat.” A woman posted a video of

an evening gathering on St. Patrick’s

Day and chose the caption

“Downtown Nashville is undefeated.”

Similar metaphors of terrorism

exacerbate such ignorant bravado.

As an inadequate metaphor, terrorism

shares nothing in common with

COVID-19 except both evoking fear

and mistrust. The purpose of

terrorism is creating terror. Since

9/11, refusing to “live in fear” and

carrying on as normal have become

essential parts of “American

Resilience” (Loofbourow 2020).

However, the virus is not a manmade

threat, but a natural one. It is

not sentient and cares nothing

about the emotions of human hosts,

only their availability. Patriotic

bravery evoked by declaring a war

against this “invisible enemy” will

not help in a pandemic but feeds

into ignorance and irrationality.

COVID-19 is also highly politicized,

both domestically and internationally.

“…when it comes time to talk

about the pandemics… you gotta get

out of politics,” said President

Trump in the meeting on Feb. 27

(The White House 2020).

But he did not get out himself: he

expressed that Democrats were only

busying on impeachment and

exaggerating the severity of the

virus. Aided by media coverage, the

pandemic quickly took on political

overtones. Multiple surveys have

found a partisan divide in opinions

about the severity and response to

the pandemic. An ongoing analysis

of the partisan politics of COVID-19

reveals significant differences in

behaviors and attitudes between

self-identified Republicans and

Democrats. The latter are more

likely to wash hands more, avoid

gatherings and agree that there is

not enough testing (Pepinsky, 2020).

Partisanship not only influences

individual behaviors but also state

measures according to the affiliation

of the governor. A working research

by Adolph et al. (2020) found that

Republican governors were generally

less likely to execute strict

restrictions. Strict measures are

associated with certain political

beliefs and ideologies, making

people reluctant to take necessary

actions or follow safety instructions.

These ideas, thus, become as

dangerous as the virus itself.

Conclusion

In “Virus as Metaphor” (2020),

Buruma wrote, “Nationalism should

have no place in medical discourse.

And medical language should never

be applied to politics. Coronavirus

isn’t Chinese or foreign; it is global.”

The pandemic is a conflict between

humanity and nature, not a battle

between countries, cultures or

ideologies. In front of nature, we

share more than we differ. We have

all witnessed hubris and sluggishness,

experienced loneliness,

anxiety and grief. But we have also

seen devotion, creativity and love.

Crisis brings out the worst of us and

the best of us.

Just as Yong said in the interview,

“The periods of great social upheaval

carry with them great risk and

tragedy, but also great potential.”

(Gross 2020)

In his speech on European Conference

of Science Journalists, Oliver

Lehmann (2015) said, “The role of

journalists in this situation? A voice

of reason, not a scream of excitement.”

Media should be more aware of its

power and influence on the public

and deliver truthful information. On

Fresh Air (2020), Gross and Yong

used the word “take off” rather than

“originate” when mentioning China

and SARS-CoV-2. The surprising

subtlety of words shows the little

possibility of refraining from

“THE PERIODS

OF GREAT SOCIAL

UPHEAVAL CARRY

WITH THEM GREAT

RISK AND

TRAGEDY, BUT

ALSO GREAT

POTENTIAL.”

metaphoric thinking, but it also

demonstrates that resistance can be

achieved. For us, as the audience,

the ability to reflect and discern is

the only way we can manage the

spread of the metaphorical virus,

rather than letting it control us.

16 17



Washington University Review of Health Spring 2020

Don’t Lose Heart on Coffee

Writer: Ben Lieberman | Editor: Akshay Govindan | Illustrator: Eugenia Yoh

References

Adolph, C., Amano, K., Bang-Jensen, B.,

Fullman, N., & Wilkerson, J. (2020). Pandemic

Politics: Timing State-Level Social Distancing

Responses to COVID-19. APSA Preprints.

doi:10.33774/apsa-2020-sf0ps This content is

a preprint and has not been peer-reviewed.

Buruma, Ian. “Virus as Metaphor.” The New

Yorker, 28 Mar. 2020, https://www.nytimes.

com/2020/03/28/opinion/coronavirus-racism-covid.html.

Cole, T. (2014) “What Is It” in The New Yorker ,

7 October 2014 [online] http://www.newyorker.

com/books/page-turner/what-is-ebola (Accessed

14 April 2020)

Davis, C. J. (2002). Contagion as Metaphor.

American Literary History, 14(4), 828–836.

Retrieved from https://muse.jhu.edu/article/1987/summary

Ferri, Beth A. “Metaphors of Contagion and

the Autoimmune Body.” Feminist Formations,

vol. 30, no. 1, 2018, pp. 1–20., doi:10.1353/

ff.2018.0001.

Fowler, D. (2019). Who Was Blamed? • Black

Death Facts. Retrieved from https://blackdeathfacts.com/blame/

Gross, T. (Executive Producer). (2020, April,

1). Fighting COVID-19 Is Like ‘Whack-A-Mole,’

Says Writer Who Warned Of A Pandemic

[Audio podcast episode]. Fresh Air . NPR.

https://www.npr.org/sections/health-

shots/2020/04/01/825179922/fighting-covid-

19-is-like-whack-a-mole-says-writer-whowarned-of-pandemic

Infectious Diseases at Edward Worth Library.

Retrieved from https://infectiousdiseases.

edwardworthlibrary.ie/Theory-of-Contagion/

Myers, S. L., & Rubin, A. J. (2020, March 18). Its

Coronavirus Cases Dwindling, China Turns Focus

Outward. The New York Times. Retrieved

from https://www.nytimes.com/2020/03/18/

world/asia/coronavirus-china-aid.html

Loofbourow, L. (2020, March 17). Is This

American Resilience? Slate Magazine. Retrieved

from https://slate.com/news-and-politics/2020/03/coronavirus-crowds-dumb-notbrave.html

Lehmann, O. (2015, November 3). 15|11|03:

Infectious Diseases as Metaphor. Retrieved

April 15, 2020, from http://www.oliverlehmann.

at/2015/11/diseases-metaphor/

Pernick, M. S. (2002). Contagion and Culture

. American Literary History, 14(4), 858–865.

Retrieved from https://muse.jhu.edu/article/1991#FOOT14

Pepinsky, Tom. “The Partisan Politics

of COVID-19.” Tompepinsky.com, Word-

Press.com, 27 Mar. 2020, tompepinsky.

com/2020/03/27/the-partisan-politics-of-covid-19/.

Rich, M. (2020, January 30). As Coronavirus

Spreads, So Does Anti-Chinese Sentiment. The

New York Times. Retrieved from https://www.

nytimes.com/2020/01/30/world/asia/coronavirus-chinese-racism.html

Sontag, S. (1978). Illness as Metaphor. Farrar,

Straus, and Giroux.

The White House. (2020, February 27).

President Trump Attends a Meeting and Photo

Opportunity with Black Leaders [Video]. Youtube.

https://www.youtube.com/watch?v=Aas-

3YQKIFeY.

Yong, E. (2020a, March 25). How the Pandemic

Will End. The Atlantic. Retrieved from https://

www.theatlantic.com/health/archive/2020/03/

how-will-coronavirus-end/608719/

Yong, E. (2020b, April 1). Everyone Thinks

They’re Right About Masks. The Atlantic.

Retrieved from https://www.theatlantic.com/

health/archive/2020/04/coronavirus-pandemic-airborne-go-outside-masks/609235/

Many studies over the

years have tried to

answer that question.

One of the first large-scale studies

was the Honolulu Longitudinal

Heart Study. It examined many

factors in over 8000 Japanese men

residing in Hawaii from 1965 to

1968. Specifically, the study investigated

the association between cardiac

event outcomes and lifestyle

factors like smoking and drinking,

including an item for coffee. A 1986

study following up with the data

found that--although the effect size

was small-- there was a statistically

significant impact of higher coffee

consumption on total serum

cholesterol, both of which are

well-established risk factors of

coronary heart disease risk, especially

in men. These studies had to

use a model that took into account

the correlation between smoking

and coffee consumption. This effect

was not present for caffeinated tea

and cola, control sources of caffeine.

In 1991, a prospective cohort study

confirmed this finding, showing

that coffee can be a risk factor in

raising total cholesterol.The researchers

randomly split sixty-four

healthy volunteers into three

groups. One group drank six cups of

non-filtered coffee daily, one group

drank six cups of filtered coffee, and

one group did not drink any coffee.

Non-filtered coffee drinking was

positively correlated with higher

low-density lipoprotein (LDL)

levels. They concluded some

LDL-raising factor is responsible. In

1995, scientists identified a component

in coffee called diterpenes that

are a causative agent of higher

serum cholesterol. These can easily

be filtered out. So does

boiled-and-unfiltered coffee consumption

lead to high cholesterol?

Not necessarily. Many of these

studies were admittedly small

case-control studies and looked at

cholesterol without considering

other effects that also influence

coronary heart disease (CHD) risk

at the population level. A recent

2015 population study found lower

incidence of CHD events in those

who drank coffee than those who

didn’t. Specifically, the graph was a

U-shape, with a declining risk until

the greater than five cups per day

segment had a higher risk than

three to five cups per day segment.

Scientists today know there are

positive effects of moderate coffee

consumption on long-term CHD

risk, perhaps due to antioxidants or

other components or associated

lifestyle factors that go along with

moderate coffee consumption. This

means three to five cups a day is

ideal, with more or less consumption

leading to higher risk within

the population. A 2014 meta-analysis

confirmed a whopping 16

percent reduction in total mortality

in the population associated with

four cups per day, where four was

the ideal number.

Drinking coffee probably won’t

make up for other unhealthy habits.

But there is little reason to stop

moderate consumption as long as it

is filtered. Working from home can

be tough. Whether you’re a morning

person or all hours, hopefully

coffee can be a source of cardiovascular

health in a time of stress.

18 19



Washington University Review of Health Spring 2020

Illustration

Feature

References

Haskell-Ramsay, Crystal & Jackson, Philippa

& Forster, Joanne & Dodd, Fiona & Bowerbank,

Samantha & Kennedy, David. (2018). The Acute

Effects of Caffeinated Black Coffee on Cognition

and Mood in Healthy Young and Older

Adults. https://www.researchgate.net/publication/328034750_The_Acute_Effects_of_Caffeinated_Black_Coffee_on_Cognition_and_

Mood_in_Healthy_Young_and_Older_Adults

RHOADS GG. Hemoglobin A1c Reproducibility.

Ann Intern Med. 1980;92:574. doi: https://doi.

org/10.7326/0003-4819-92-4-574

CURB, J. D., REED, D. M., KAUTZ, J. A., & YANO,

K. (1986). COFFEE, CAFFEINE, AND SERUM

CHOLESTEROL IN JAPANESE MEN IN HAWAII.

American Journal of Epidemiology, 123(4),

648–655. https://doi.org/10.1093/oxfordjournals.aje.a114284

Vroon, T. F., Smelt, A. H., & Cohen, A. F. (1995).

A placebo-controlled parallel study of the effect

of two types of coffee oil on serum lipids

and transaminases: Identification of chemical

substances involved in the cholesterol-raising

effect of coffee. The American Journal of

Clinical Nutrition, 61(6), 1277–1283. https://

doi.org/10.1093/ajcn/61.6.1277

Choi, Y., Chang, Y., Ryu, S., Cho, J., Rampal,

S., Zhang, Y., Ahn, J., Lima, J. A. C., Shin, H.,

& Guallar, E. (2015). Coffee consumption

and coronary artery calcium in young and

middle-aged asymptomatic adults. Heart,

101(9), 686. https://doi.org/10.1136/heartjnl-2014-306663

Eugenia Yoh on Abortion Rights

Lily Xu on A Sociological View of COVID-19

Peters, S. A. E., Singhateh, Y., Mackay, D.,

Huxley, R. R., & Woodward, M. (2016). Total

cholesterol as a risk factor for coronary heart

disease and stroke in women compared with

men: A systematic review and meta-analysis.

Atherosclerosis, 248, 123–131. https://doi.

org/10.1016/j.atherosclerosis.2016.03.016

Urgert, R., & Katan, M. B. (1997). THE CHO-

LESTEROL-RAISING FACTOR FROM COFFEE

BEANS. Annual Review of Nutrition, 17(1),

305–324. https://doi.org/10.1146/annurev.

nutr.17.1.305

van Rooij, J., van der Stegen, G. H., Schoemaker,

R. C., Kroon, C., Burggraaf, J., Hollaar, L.,

Ding Ming, Bhupathiraju Shilpa N., Satija Ambika,

van Dam Rob M., & Hu Frank B. (2014).

Long-Term Coffee Consumption and Risk of

Cardiovascular Disease. Circulation, 129(6),

643–659. https://doi.org/10.1161/CIRCULA-

TIONAHA.113.005925

Crippa, A., Discacciati, A., Larsson, S. C., Wolk,

A., & Orsini, N. (2014). Coffee Consumption

and Mortality From All Causes, Cardiovascular

Disease, and Cancer: A Dose-Response Meta-Analysis.

American Journal of Epidemiology,

180(8), 763–775. https://doi.org/10.1093/aje/

kwu194

Parveen Dhanoa on Type I Diabetes

20 21



Washington University Review of Health Spring 2020

Cold Pancreatic Cancer? Not so much

anymore!

Writer: Madhav Subramanian | Editor: Anhthi Luong

The asymptomatic nature of

pancreatic cancer results

in a five-year survival

rate of 6 percent (Siegel et al.,

2014), the worst among cancers..

With extremely moderate advances

in the treatment for the disease, it is

projected that by 2030, pancreatic

cancer will be among the leading

causes of death for both men and

women (Rahib et al., 2014).

Over the past few years, immunotherapy

has provided substantial

relief to previously incurable

metastatic cancers. For example,

metastatic melanoma, which

previously had an average life

expectancy between six to 12

months, now has a three-year

survival rate that tops 50 percent in

some studies due to the implementation

of immune checkpoint

blockade as the standard of care

first-line treatment (Weiss et al.,

2019). While immunotherapy in the

form of immune checkpoint blockade,

and now vaccines and adoptive

T Cell transfer, has revolutionized

patient care for a number of

disorders, immunotherapy remains

largely ineffective against pancreatic

cancer (Brahmer et al., 2012;

Royal et al., 2010).

The ineffectiveness of immunotherapy

in pancreatic cancer can be

attributed to its “immune-cold”

nature. There are a number of

factors contributing to the ability of

pancreatic cancer to remain largely

unresponsive to immunotherapy.

The anti-tumor immune response is

highly dependent on antigenicity:

the ability of tumor cells to form

new and distinct proteins that our

immune system can recognize as

foreign, of the tumor. Unlike

melanoma and lung cancer, pancreatic

cancer has an extremely poor

antigenicity (Vogelstein et al., 2013).

However, it is well documented that

our immune system can recognize

pancreatic cancer cells suggesting

the presence of more complex

mechanisms through which pancreatic

cancer builds defenses against

our immune system.

Recognition of pancreatic cancer

cells by our immune system is

largely hindered by the presence of

a largely immunosuppressive tumor

microenvironment, which is

characterized by a dense stroma and

pro-tumoral immune and stromal

cells (Torphy et al., 2018; Young et

al., 2018). Tumor cells are surrounded

by fibrous tissue that contains

cancer-associated fibroblasts, blood

vessel endothelial cells and immunosuppressive

immune cells. The

stroma leaves anti-tumor lymphocytes

tumor-excluded or unable to

get in direct contact with tumor

cells and trapped by the dense

tissue surrounding the tumor cells

(Beatty et al., 2017). Importantly,

cells like alternatively activated

macrophages and regulatory T Cells

constitute the majority of infiltrated

immune cells in the tumor microenvironment.

The immunosuppressive

immune cells present in the stroma

help secrete factors that promote

the formation of the fibrous stroma,

promote the formation of new blood

vessels that tumors exploit to obtain

resources, enable the growth and

progression of tumors and, importantly,

dampen the immune response

against the tumor. The

density of the stroma also impairs

the flow of oxygen which results in

hypoxia and an acidic environment

that prevents the infiltration of

anti-tumor immune cells. The

physical and chemical barriers

posed by the tumor stroma ultimately

results in a “cold” immune

environment. With the clear

importance of the pancreatic cancer

stroma in protecting tumor cells

from our body’s defenses, one of the

biggest questions plaguing scientists

is whether we can deplete this

stroma to improve delivery of

therapeutics and facilitate the

infiltration of immune cells into the

tumor microenvironment.

A lot of research on ameliorating

pancreatic cancer outcomes is

conducted right here in Washington

University in St. Louis. Specifically,

Dr. David DeNardo in the Washington

University School of Medicine is

actively searching for ways to

mitigate the effects of the pancreatic

cancer stroma. DeNardo has

developed a track record in mounting

significant responses to immunotherapy

in mice models of

pancreatic cancer, which like

humans, historically do not respond

to immunotherapy. His lab accomplishes

this by targeting elements of

the pancreatic stroma to unleash

the immune response against

pancreatic cancer. Using innovative

strategies, DeNardo’s lab has

developed techniques to target

fibrosis around tumors, a highly

immunosuppressive cell immune

cell type known as myeloid derived

suppressor cells, tumor-associated

macrophages and dendritic cells.

One prominent therapeutic target

identified is the Focal Adhesion

Kinase (FAK). In their 2016 Nature

Medicine paper, they describe the

benefits in using FAK inhibitors in

combination with immunotherapy

for pancreatic cancer (Jiang et al.,

2016). The use of FAK inhibitors

resulted in significant reduction in

tumor size due to reduction in

fibrosis, reduction in infiltration of

immunosuppressive cells and

increased infiltration of anti-tumor

immune cells, particularly cytotoxic

T Cells. More importantly, the use

of FAK inhibitors rendered the

References

Beatty, G. L., Eghbali, S., & Kim, R. (2017). Deploying

Immunotherapy in Pancreatic Cancer:

Defining Mechanisms of Response and Resistance.

American Society of Clinical Oncology

Educational Book. American Society of Clinical

Oncology. Annual Meeting, 37, 267–278.

https://doi.org/10.1200/EDBK_175232

Brahmer, J. R., Tykodi, S. S., Chow, L. Q. M.,

Hwu, W.-J., Topalian, S. L., Hwu, P., Drake, C.

G., Camacho, L. H., Kauh, J., Odunsi, K., Pitot,

H. C., Hamid, O., Bhatia, S., Martins, R., Eaton,

K., Chen, S., Salay, T. M., Alaparthy, S., Grosso,

J. F., … Wigginton, J. M. (2012). Safety and

activity of anti-PD-L1 antibody in patients with

advanced cancer. The New England Journal

of Medicine, 366(26), 2455–2465. https://doi.

org/10.1056/NEJMoa1200694

Jiang, H., Hegde, S., Knolhoff, B. L., Zhu, Y.,

Herndon, J. M., Meyer, M. A., Nywening, T. M.,

Hawkins, W. G., Shapiro, I. M., Weaver, D. T.,

Pachter, J. A., Wang-Gillam, A., & DeNardo, D.

G. (2016). Targeting focal adhesion kinase

renders pancreatic cancers responsive to

checkpoint immunotherapy. Nature Medicine,

22(8), 851–860. https://doi.org/10.1038/

nm.4123

previously unresponsive pancreatic

cancer models responsive to

immunotherapy. This discovery has

manifested in a Phase 1 clinical trial

that is projected to be completed in

July 2020. DeNardo lab has identified

numerous targets, like FAK,

that can be exploited to target

components of the dense to render

pancreatic cancer responsive to

immunotherapy (Jiang et al., 2016;

Panni et al., 2019).

Innovative techniques to overcome

the barrier posed by the tumor

stroma are the future of pancreatic

cancer treatment. Such therapeutics

not only improve the efficacy of

Panni, R. Z., Herndon, J. M., Zuo, C., Hegde, S.,

Hogg, G. D., Knolhoff, B. L., Breden, M. A., Li,

X., Krisnawan, V. E., Khan, S. Q., Schwarz, J.

K., Rogers, B. E., Fields, R. C., Hawkins, W. G.,

Gupta, V., & DeNardo, D. G. (2019). Agonism

of CD11b reprograms innate immunity to

sensitize pancreatic cancer to immunotherapies.

Science Translational Medicine, 11(499).

https://doi.org/10.1126/scitranslmed.aau9240

Rahib, L., Smith, B. D., Aizenberg, R., Rosenzweig,

A. B., Fleshman, J. M., & Matrisian, L.

M. (2014). Projecting Cancer Incidence and

Deaths to 2030: The Unexpected Burden of

Thyroid, Liver, and Pancreas Cancers in the

United States. Cancer Research. https://doi.

org/10.1158/0008-5472.CAN-14-0155

Royal, R. E., Levy, C., Turner, K., Mathur, A.,

Hughes, M., Kammula, U. S., Sherry, R. M.,

Topalian, S. L., Yang, J. C., Lowy, I., & Rosenberg,

S. A. (2010). Phase 2 trial of single agent

Ipilimumab (anti-CTLA-4) for locally advanced

or metastatic pancreatic adenocarcinoma.

Journal of Immunotherapy (Hagerstown,

Md.: 1997), 33(8), 828–833. https://doi.

org/10.1097/CJI.0b013e3181eec14c

immunotherapy but can also help

minimize doses and improve

delivery of other therapeutic agents

like chemotherapy. Work done by

scientists like DeNardo are actively

helping improve outcomes for

pancreatic cancer patients by

turning the previously cold tumors

hot.

Siegel, R., Ma, J., Zou, Z., & Jemal, A. (2014).

Cancer statistics, 2014. CA: A Cancer Journal

for Clinicians, 64(1), 9–29. https://doi.

org/10.3322/caac.21208

Torphy, R. J., Zhu, Y., & Schulick, R. D. (2018).

Immunotherapy for pancreatic cancer: Barriers

and breakthroughs. Annals of Gastroenterological

Surgery, 2(4), 274–281. https://doi.

org/10.1002/ags3.12176

Vogelstein, B., Papadopoulos, N., Velculescu, V.

E., Zhou, S., Diaz, L. A., & Kinzler, K. W. (2013).

Cancer Genome Landscapes. Science (New

York, N.Y.), 339(6127), 1546–1558. https://doi.

org/10.1126/science.1235122

Weiss, S. A., Wolchok, J. D., & Sznol, M. (2019).

Immunotherapy of melanoma: Facts and

hopes. Clinical Cancer Research. https://doi.

org/10.1158/1078-0432.CCR-18-1550

Young, K., Hughes, D. J., Cunningham, D.,

& Starling, N. (2018). Immunotherapy and

pancreatic cancer: Unique challenges and

potential opportunities. Therapeutic Advances

in Medical Oncology, 10. https://doi.

org/10.1177/1758835918816281

22 23



Washington University Review of Health Spring 2020

The State of Sex Ed in Missouri and

How it Affects Teen Pregnancy

Writer: Ayda Oktem | Editor: Soyi Sarkar | Illustrator: Victoria Xu

In 2017, the Centers for

Disease Control (CDC)

determined that the national

average rate of teen pregnancy

(mothers aged 15-19) in the

United States is 18.8 of every

1,000 live births. Teen pregnancy

has affected high schools and

surrounding communities for

decades; however, Missouri’s rate,

at 22.5 per 1000 live births, is more

disappointing and concerning than

most states.

Some reasons that contribute to this

high rate of teen pregnancy are the

prevalence of “no condom culture”

and Missouri’s abstinence only

sexual education in public schools.

Both, in fact, have been shown to be

counterproductive to the ongoing

goal of reducing teen pregnancy

rates. Currently, Missouri legislation

only requires that public

schools provide sex education

relating to STDs, relationship

violence and “critical thinking”,

which includes concepts such as

giving the right decisions when it

comes to sexual health and the

dangers of sexting (“Stats of the

State of Missouri”). Unfortunately,

most schools fail to sufficiently

educate students on condom use,

contraceptives and abortion.

Missouri high schools also fall short

on educating students on non-heteronormative

relationships and

different gender identities.

In 2018, the United States spent

$100 million on funding abstinence-only-until-marriage

programs

(“A History”). These programs

do not give information

regarding contraception and

condom use, which are two powerful

ways to reduce the incidence of

teen pregnancy. According to

several studies, abstinence-only

education does not decrease teenage

pregnancy rates (Stanger-Hall 2011),

and does not cut down STI transmission

rates (Ott 2007) in high

school teenagers aged 15-19.

To address inadequate sexual

education, the CDC named 19

sexual health and wellness topics to

be incorporated into high school sex

ed curriculums across the nation a

couple years ago. These topics

include access and use of condoms,

effective communication and

consent, preventative sexual

healthcare and finding unbiased

information regarding sexual

health. Educating students from a

perspective other than abstinence

only enables them to make more

informed decisions and would

eventually reduce unwanted

pregnancy rates. Across the US,

different states teach these 19 points

differently; some of them pick and

choose between the points, and

some states, like Missouri, do not

fulfill the 19 point criteria in preparing

sex ed curricula.

Transitioning to a more comprehensive

sexual education curriculum in

Missouri will enable students to

make better informed decisions,

prevent the spread of STDs and alleviate

stigmas around sexual health,

ultimately reducing unwanted teen

pregnancy. By incorporating a

wider breadth of topics, like effective

contraception methods and

how to access them, consent and a

discussion about LGBTQ+ identities,

as well as others, teenagers

across the state would be able to

make more well informed decisions

about their sexual health.

These programs

do not give information

regarding

contraception and

condom use, which

are two powerful

ways to reduce

the incidence of

teen pregnancy.

References

but not stressing abstinence (Office

of Adolescent Health 2019). Furthermore,

according to the US National

Library of Medicine, there is a

relationship between increased

emphasis on abstinence and increasing

teen pregnancy rates (UN

Population Fund). Students use

contraceptives and use them

correctly when they possess the

knowledge necessary to make

informed and educated decisions.

A comrehensive sex ed is critical for

everyone, especially for teenagers

to learn more about their sexual

health and wellbeing in what are

known to be particularly formative

years. Changing Missouri’s abstinence

only curriculum to a comprehensive

sex education program

would be beneficial for the students’

well-being for Missouri and for the

United States.

Transitioning to a comprehensive

sexual education curriculum has

already produced extraordinary

results as seen in other states.

Massachusetts, for example, has the

lowest rate of teen pregnancy in the

US at 8.1 births/1000 females aged

15-19 (Mangel 2019). Unlike Missouri,

Massachusetts’ sex education

curriculum requires “sexual orientation,

gender identity, consent

choices, reproductive anatomy,

condom education, birth control

methods [and] STIs” while covering

Mangel, Linda. “Teen Pregnancy, Discrimination,

and the Dropout Rate.” ACLU of Washington,

July 19, 2017. https://www.aclu-wa.org/

blog/teen-pregnancy-discrimination-and-dropout-rate.

Office of Adolescent Health. “Trends in

Teen Pregnancy and Childbearing.” HHS. US

Department of Health and Human Services,

May 30, 2019. https://www.hhs.gov/ash/

oah/adolescent-development/reproductive-health-and-teen-pregnancy/teen-pregnancy-and-childbearing/trends/index.html.

Ott, Mary A., and John S. Santelli. “Abstinence

and Abstinence-Only Education.” Current Opinion

in Obstetrics & Gynecology 19, no. 5 (October

2007): 446–52. https://doi.org/10.1097/

GCO.0b013e3282efdc0b.

Stanger-Hall, Kathrin F., and David W. Hall.

“Abstinence-Only Education and Teen Pregnancy

Rates: Why We Need Comprehensive

Sex Education in the U.S.” PLoS ONE 6, no. 10

(October 14, 2011). https://doi.org/10.1371/

journal.pone.0024658.

“A History of Federal Funding For Abstinence-Only-Until-Marriage

Programs.” Sexuality

Information and Education Council of the

United States. SIECUS, August 2018. https://

siecus.org/wp-content/uploads/2018/08/A-

History-of-AOUM-Funding-Final-Draft.pdf.

“Stats of the State of Missouri.” Centers for

Disease Control and Prevention. Centers for

Disease Control and Prevention, April 11, 2018.

https://www.cdc.gov/nchs/pressroom/states/

missouri/missouri.htm.

24 25



Washington University Review of Health Spring 2020

PCSK9 Inhibitors: A Novel Treatment

for High Cholesterol

Writer: Rehan Mehta | Editor: Soyi Sarkar | Illustrator: Parveen Dhanoa

High cholesterol is one of

the most prevalent

health issues in the U.S.

and is a major risk factor for

heart disease, which is the

leading cause of death in this

country. According to the CDC,

about one-third of American adults

have high or borderline high levels

of cholesterol (BRFSS Prevalence &

Trends Data, 2015). Of the three

components of cholesterol— triglycerides,

high-density lipoproteins

and low-density lipoproteins—

high levels of low-density

lipoproteins (LDL) is known to

increase the risk of developing heart

problems. LDL cholesterol is known

as “bad” cholesterol since it can

build up in the walls of arteries,

causing them to become hard and

narrow. This reduces blood flow and

increases the risk of artery blockage,

which can cause a heart attack

or stroke. Current treatments for

high cholesterol, while generally

effective, can cause significant side

effects for many patients. The

development of a new therapeutic

agent, utilizing PCSK9 inhibitors,

has given high hopes to researchers

to address this major concern since

these inhibitors are able to significantly

reduce LDL levels and

potentially reduce the risk of heart

disease.

Currently, statins, a class of cholesterol-lowering

drugs, are prescribed

for people with high cholesterol.

These drugs have been around since

the 1980s and have proven to be

quite reliable and effective for most

people. Despite this, many patients

are unable to reach optimal LDL

cholesterol levels. One study of over

9950 patients with coronary heart

disease revealed that only 37

percent were able to achieve

optimal levels of LDL cholesterol

even though most of them were on

statin therapy (Karalis et al. 2012).

Some patients are unable to achieve

these treatment goals due to factors

that limit the effect of statins in the

body, such as type 2 diabetes, and

adverse effects such as muscle aches

and liver damage, which leads

patients to stop taking statin drugs.

Others, such as those with familial

hypercholesterolemia, a genetic

disorder resulting in high levels of

LDL cholesterol, are likewise unable

to achieve optimal levels of LDL

cholesterol even with high intensity

statin treatment (Chapman, Stock,

& Ginsberg 2015). Due to these

unmet needs, a new treatment is

needed to ensure that optimal LDL

cholesterol levels are attainable.

PCSK9 inhibitors are a new class of

drugs that allow patients to achieve

these optimal LDL levels. PCSK9 is

an enzyme in the liver that binds to

and degrades specific receptors on

the liver cells that are needed to

break down LDL. With less of these

receptors, LDL levels remain high.

PCSK9 inhibitors work by inactivating

the PCSK9 enzyme, resulting in

an increase in receptor availability

which increases capture and break

down of LDL (Do, Vogel, &

Schwartz 2013). There are multiple

approaches that are able to inhibit

the PCSK9 enzyme; however, the

most successful approach has used

monoclonal antibodies. Since the

antibodies in testing are fully

human monoclonal antibodies, the

likelihood that an immune response

occurs in response to the antibody

and the development of antibody

inhibitors is low (Do, Vogel, &

Schwartz 2013). This quality

improves the safety and effectiveness

of this treatment.

The results of several clinical trials

using PCSK9 inhibitors to lower

LDL cholesterol have shown

remarkable success and have

established these inhibitors as a

viable alternative to statins. One

recent phase 3 trial involving 27,564

patients with atherosclerosis, who

were not at optimal LDL cholesterol

levels and were receiving statin

therapy, revealed that the PCSK9

inhibitor reduced LDL cholesterol

levels by approximately 60 percent.

About 87 percent of the patients

were able to achieve optimal LDL

cholesterol levels. PCSK9 inhibitors

were also able to reduce the risk of

heart attack, stroke, and other heart

complications by 21 to 27 percent,

indicating that this therapeutic is

able to reduce the risk of cardiovascular

events. A two year follow-up

further revealed that optimal LDL

cholesterol levels were sustained

(Sabatine et al. 2017). Another

clinical trial evaluating PCSK9

inhibitors in 803 patients with

hypercholesterolemia revealed a

reduction in LDL cholesterol levels

by 52 percent in patients not

receiving statin therapy and 59

percent in patients who were (Roth

et al. 2016). Together, these results

Given the prevalence of high

cholesterol and heart disease, the

development of PCSK9 inhibitors as

a new form of cholesterol manageprovide

evidence of the effectiveness

of PCSK9 inhibitors, especially

in patients who do not respond well

to statins.

The results of these clinical trials

have enabled PCSK9 inhibitors to

gain approval by the FDA and be

available on the market. In 2015, the

FDA approved the first PCSK9

inhibitor alirocumab which was

followed by evolocumab later that

year. Since 2019, both of these drugs

have been approved to prevent

heart attack and stroke (Anderson,

Leigh Ann, ed. 2019). These treatments

would consist of a subcutaneous

injection that can be self-administered

once or twice a month.

Inclisiran, a new PCSK9 inhibitor

still pending approval, would only

need to be taken once or twice a

year (Ray et al. 2020). Statins, on the

other hand, must be taken daily.

Overall, alirocumab and evolocumab

are considered to be quite safe

with only minor side effects, of

which the most common are

redness, pain or itching near the

injection site (Sabatine et al. 2017).

Currently, one of the biggest

limitations to these inhibitors are

their high costs. While prices have

been reduced by 60 percent since

they have been released, they are

still relatively high and cost much

more than statins (Munjal 2019).

The low cost of statins makes it

unlikely that PCSK9 inhibitors will

become the standard of care

anytime soon,

ment is crucial in improving

cardiovascular health and outcomes.

PCSK9 inhibitors represent an

effective treatment addressing the

unmet needs of many patients in

the case where statins have shown

to be ineffective. With PCSK9

inhibitors as a viable alternative to

statins, more patients are able to

achieve optimal LDL cholesterol

levels and maintain their cardiovascular

health. Perhaps in the future,

given further price reductions, these

inhibitors will become the new

standard for lowering cholesterol.

While they might be limited to

certain at risk groups currently,

PCSK9 inhibitors provide a lot of

hope for improving cardiovascular

outcomes in future patient populations.

26 27



Washington University Review of Health Spring 2020

Rural Healthcare Disparity: A National Concern

Writer: Rachel Ulbrich | Editor: Daniel Berkovich | Illustrator: Jennifer Broza

References

Anderson, L.A. (Ed.). (2019). PCSK9 Inhibi

tors: A New Option in Cholesterol Treatment.

Drugs.Com. Retrieved April 22, 2020, from

https://www.drugs.com/slideshow/pcsk9-inhibitors-a-new-option-in-cholesterol-treatment-1166

Centers for Disease Control and Prevention, Division

of Population Health. BRFSS Prevalence

& Trends Data (2015). https://www.cdc.gov/

brfss/brfssprevalence/index.html

Chapman, M. J., Stock, J. K., & Ginsberg,

H. N. (2015). PCSK9 inhibitors and cardiovascular

disease: Heralding a new therapeutic

era. Current Opinion in Lipidology,

26(6), 511–520. https://doi.org/10.1097/

MOL.0000000000000239

Do, R. Q., Vogel, R. A., & Schwartz, G. G. (2013).

PCSK9 Inhibitors: Potential in Cardiovascular

Therapeutics. Current Cardiology Reports,

15(3), 345. https://doi.org/10.1007/s11886-

012-0345-z

Karalis, D. G., Victor, B., Ahedor, L., & Liu, L.

(2012). Use of Lipid-Lowering Medications

and the Likelihood of Achieving Optimal

LDL-Cholesterol Goals in Coronary Artery

Disease Patients. Cholesterol, 2012. https://

doi.org/10.1155/2012/861924

Munjal, R. (2019, May 27). Are PCSK9 inhibitors

about to take off? PharmaTimes. http://

www.pharmatimes.com/web_exclusives/are_

pcsk9_inhibitors_about_to_take_off_1289184

Ray, K. K., Wright, R. S., Kallend, D., Koenig, W.,

Leiter, L. A., Raal, F. J., Bisch, J. A., Richardson,

T., Jaros, M., Wijngaard, P. L. J., & Kastelein, J.

J. P. (2020). Two Phase 3 Trials of Inclisiran

in Patients with Elevated LDL Cholesterol.

New England Journal of Medicine, 382(16),

1507–1519. https://doi.org/10.1056/NEJ-

Moa1912387

Roth, E. M., Moriarty, P. M., Bergeron, J.,

Langslet, G., Manvelian, G., Zhao, J., Baccara-Dinet,

M. T., & Rader, D. J. (2016). A phase

III randomized trial evaluating alirocumab 300

mg every 4 weeks as monotherapy or add-on

to statin: ODYSSEY CHOICE I. Atherosclerosis,

254, 254–262. https://doi.org/10.1016/j.

atherosclerosis.2016.08.043

Sabatine, M. S., Giugliano, R. P., Keech, A. C.,

Honarpour, N., Wiviott, S. D., Murphy, S. A.,

Kuder, J. F., Wang, H., Liu, T., Wasserman, S. M.,

Sever, P. S., & Pedersen, T. R. (2017). Evolocumab

and Clinical Outcomes in Patients with

Cardiovascular Disease. New England Journal

of Medicine, 376(18), 1713–1722. https://doi.

org/10.1056/NEJMoa1615664

W

e don’t have time to

wait for the ambulance

to get here.

We’ll just take her ourselves.”

The nine-year-old, curled into a

fetal position on the table, didn’t

care which vehicle would be

transporting her to the nearest

trauma center. She just wanted the

pain in her abdomen to go away, so

she could go back to school and

keep learning cursive. She couldn’t

understand why her parents were

panicking; after all, they were

doctors. They’d seen plenty of

pediatric patients with stomach

pain before. However, the image

that hung on the x-ray viewer

behind her would have unsettled

most seasoned physicians: an

unidentifiable mass overtook her

abdominal cavity and compressed

the vital organs within. Every

second counted. In the frightened

parents’ minds, there wasn’t time to

wait for a pediatric helicopter to fly

over 200 miles when they could

drive their daughter themselves.

Their Chevy Suburban broke a few

speed limits that day, but what’s a

speeding ticket compared to the life

of your child? That little girl was

me, and the choice my parents faced

that day is only one example of the

many ways that the rural healthcare

crisis continues to affect people

across the country.

Sixty million Americans live in an

area classified as “rural”; this

comprises a little less than 20% of

the American population. Only nine

percent of American physicians

practice in rural communities

(Rosenblatt, 2000). In the last 10

years, many of these rural Americans

have faced the closure of local

hospitals, 119 in total (Kahn,

Morgan, 2019); at that rate, 25% of

all rural hospitals will close within

the decade (NRHA, 2020). These

closures are primarily due to

financial circumstances unique to

rural areas: diminishing populations

are too small to support the existence

of high-profit specialty

departments and are less likely to

have high-paying insurances, while

Medicare’s Disproportionate Share

Hospital (DSH) policy disadvantages

rural hospitals compared to

urban ones. For Beverly Rollings of

Sedalia, Missouri (population of

22,000), the rural location of her

co-owned architecture firm directly

impacts the kind of insurance

options she’s able to offer her

employees: “In Pettis county…, if

you purchase through the Affordable

Care Act, you have one option.”

The limited network of this insurance

option doesn’t include providers

in Kansas City, the nearest

metropolitan area. One such

employee and his wife, after

learning that their unborn child had

polycystic kidney disease, were

forced to consider moving their

entire family to either Kansas City

or St. Louis in order to have some

kind of insurance coverage for the

treatment. After the insurance

company assured them that an

exception could be made in their

case, the couple chose to have a

C-section in Kansas City. Their

child, Simon, only lived for 12 hours

after birth. Following his death,

they received a bill for $50,000 in

the mail, as their insurance had

refused to cover the costs of their

procedure after all. The harsh

realities of this situation may be

shocking to some, but to inhabitants

of rural areas, it’s only another

anecdote highlighting the deficits

within the rural healthcare system.

Of the hospitals that remain open,

47% spend more money on a

monthly basis than is brought in,

leaving the future existence of these

hospitals in jeopardy (Kahn and

Morgan 2019). Hospital closures

cripple local economies, lead to

disinvestment in the area and

negatively impact a community’s

ability to attract other healthcare

providers to the area. For citizens

that already face a significant

commute to reach a healthcare facility,

these closures further limit the

ability of rural Americans to access

both emergency and preventative

care. In emergent cases, waiting an

additional 20 minutes for EMS to

arrive might mean the difference

between life and death. For farmers,

ranchers and other rural workers,

driving to a healthcare provider

may mean taking off work, which

delays the treatment of conditions

that otherwise might have been

preventable. Driving long distances

both delays the treatment of these

conditions and disincentivizes

people from consulting specialists.

Hospital closings have only increased

the distance people must

travel to gain access to basic

medical care. Dr. Roy Elfrink, a

general surgeon who’s worked in

Marshall, Missouri (population of

13,000) for over 25 years, notes that

low socioeconomic status and rural

culture both play a role in these

disparities.

28 29



Washington University Review of Health Spring 2020

“Rural life is hard,” he notes. “Rural

people seem to be more accepting of

illness and death and take responsibility

for their less than ‘standard of

care’ healthcare decisions, often

leading to poorer outcomes.”

These circumstances manifest as

increased death rates in rural

communities due to “heart disease,

cancer, unintentional injury (including

vehicle accidents and opioid

overdoses), chronic lower respiratory

disease, and stroke” (Warshaw,

2017). Deaths due to modifiable

behaviors and a lack of preventative

care, like tobacco and drug use, and

cervical and colorectal cancer, are

also higher in rural areas (Warshaw,

2017). Needless to say, the limited

access to healthcare faced by rural

Americans leads to higher incidences

of preventable disease and poorer

outcomes.

The limited number of hospitals

means that rural Americans are

reliant on primary care physicians,

including family practice, OB/GYN,

and internal medicine physicians to

treat both chronic and acute

conditions. These providers must

often work outside of their scope of

practice to treat patients that cannot

afford to take time off to travel to

see specialists (Peterson, Fang,

2018).

Carol Platt, of Union, Missouri

(population of 12,000), notes that, in

urban areas, “your regular physician

passes you off to other doctors in

the city for special procedures, but

family physicians here do it all.”

The shortage of rural primary care

providers has been documented for

nearly 85 years (Kelley, 2020), and

shows little indication of reversing

anytime soon. According to Roger

Rosenblatt, co-investigator of the

Washington, Wyoming, Alaska,

Montana, and Idaho Rural Health

Research Center (Rosenblatt, 2000),

one of the major contributors to this

issue is the prioritization of specialization

in medical education.

Specialists tend to generate more

income than do primary-care

physicians, giving medical students

more incentive to specialize early in

their education. The more specialized

a physician becomes, the more

likely they are to be located in an

urban area, leaving rural Americans

with no choice but to drive to the

nearest metropolitan area for initial,

primary, and follow-up specialist

visits or forgo seeing a specialist at

all.

Given that rural healthcare disparities

affect a large portion of the

American population, systematic

changes are being studied and

implemented to varying degrees to

try to address this issue. Medical

education has the widest-reaching

effect on the physician population

as every practicing physician must

attend medical school, so many

efforts that focus on increasing the

number of rural physicians are

centered in that field. Federal

programs like the Area Health

Education Centers (AHECs),

Federally Qualified Health Centers

(FQHCs) and the National Health

Service Corps (NHSC) offer competitive

loan repayment options for

recent graduates who practice in

rural areas (Mareck, 2011). Similar

statewide programs exist, as do

medical school-specific initiatives.

For example, at the University of

Missouri School of Medicine, the

Bryant Scholars Pre-Admission

Program is part of a rural track

pipeline program that recruits

high-achieving students from rural

Missouri communities as undergraduates.

As a part of this program,

I was offered a place in the

School of Medicine and have been

given opportunities as an undergraduate

to learn how to best serve

rural communities and cope with

the unique challenges such communities

present. So far, the program

has been deemed successful: 61

percent of Bryant Scholars practice

in a rural location and 70 percent

stay in Missouri (Bryant Scholars

Pre-Admission Program, 2020).

Telemedicine is also an incredibly

promising practice that may

mitigate the effects of geographic

distribution of both patients and

healthcare providers. Telemedicine

refers to the practice of caring for

patients remotely via telecommunications

technology. The option to

meet with a specialist or primary

care provider via video conference

or another medium would drastically

improve healthcare accessibility.

Telemedicine appointments could

be substituted for initial and

follow-up appointments, and in

cases where a hospital is accessible

but the specialist is not, vitals and

other testing documentation could

be collected on-site and directly

transmitted to the healthcare

provider. The remote reading of

EEGs is one example of telemedicine

that is actively in practice in

some hospitals; dermatology

consults have also utilized this

technology. Despite their promising

future, current telemedicine efforts

are “uncoordinated, expensive,

inaccessible, and at times even

illegal” (Rosenblatt, 200). Initiatives

to reconcile these issues would

foremost involve resolving professional

licensure regulations so that

urban physicians are legally allowed

to remotely practice medicine

across state lines. In addition, a

unified infrastructure is absolutely

necessary to reduce operating costs

and allow patients to communicate

“your regular physician

passes you

off to other doctors

in the city for special

procedures, but

family physicians

here do it all.”

with multiple providers over the

same network (Gill, Dykes, Rudin,

Storm, McGrath, Bates, 2020). The

development of telemedical legislation

also offers an opportunity to

secure reasonable third-party rates

for telecommunication services

provided. The existence of a cohesive

telemedical option in rural

areas would likely serve to decrease

preventable deaths and increase the

utilization of medical services.

As harmful as the spread of

COVID-19 has been to healthcare

systems nationwide, it has served to

highlight the critical healthcare

disparities rural Americans already

face on a daily basis and the impact

of these disparities outside of rural

areas. For example, in Saline county,

Missouri, a lack of financial resources

and preparedness led to only two

boxes of N95 masks being stockpiled

at the healthcare department

in case of emergencies. While

COVID-19 was not active in the

town at the time, other rural areas

faced similar shortages while

combating the spread of the disease

in their community. If rural hospitals

were politically prioritized and

legislation passed to strengthen

their infrastructure, the nation as a

whole would have been better

prepared to combat community

transmission. In addition, the

financial impact of the COVID-19

crisis will affect rural hospitals and

healthcare providers for years to

come. Rural hospitals tend to

operate in the red in the best of

times, but the cancellation of

non-essential medical services and

the increasing costs of PPE means

that operating costs will become

unsustainable. When urban hospitals

run out of room for COVID-19

patients, rural hospitals will likely

be called upon to pick up the slack

and may serve as recovery centers if

they lack formidable critical care

departments.

As for my story, the immediate

action taken by my parents, other

local doctors and the physicians at

Children’s Mercy saved my life. I

was in a privileged position to be

surrounded by medical experts and

to have a rural hospital in my

hometown; other patients in rural

areas are not so lucky. Stories like

these, as well as the continued

spread of COVID-19, highlight the

need to invest in rural infrastructure

and consider policy changes to

address the primary-care disparity

present in these communities for

the good of both rural populations

and the rest of the country.

30 31



Washington University Review of Health Spring 2020

Back to the Basics

Writer: Alicia Yang | Editor: Daniel Berkovich | Illustrator: Lucy Chen

References

Bryant Scholars Pre-Admissions Program.

(2020). Retrieved from https://medicine.missouri.edu/education/admissions/bryant-scholars-pre-admissions-program

Gill, E., Dykes, P. C., Rudin, R. S., Storm, M.,

McGrath, K., & Bates, D. W. (2020). Technology-facilitated

care coordination in rural

areas: What is needed? International Journal

of Medical Informatics, 137. doi: https://doi.

org/10.1016/j.ijmedinf.2020.104102

Kahn, C., & Morgan, A. (2019, November 16).

Rural healthcare needs innovation, policy

changes to survive. Retrieved from https://

www.modernhealthcare.com/opinion-editorial/rural-healthcare-needs-innovation-policy-changes-survive

Kelley, T. (2020, January 14). Despite Decades

of Initiatives, Rural Physicians Grow Scarcer.

Retrieved from https://www.managedcaremag.

com/archives/2019/11/despite-decades-initiatives-rural-physicians-grow-scarcer

Mareck, D. G. (2011). Federal and State

Initiatives to Recruit Physicians to Rural Areas.

AMA Journal of Ethics, 13(5), 304–309. doi:

10.1001/virtualmentor.2011.13.5.pfor1-1105

Missouri Population 2020. (2020). Retrieved

from https://worldpopulationreview.com/

states/missouri-population/

NRHA. (2020). Retrieved from http://www.

ruralhealthweb.org/advocate/medicare-cutshurt-rural

Peterson, L. E., & Fang, B. (2018). Rural Family

Physicians Have a Broader Scope of Practice

than Urban Family Physicians. Rural & Underserved

Health Research Center Publications, 5,

1–5. Retrieved from https://uknowledge.uky.

edu/cgi/viewcontent.cgi?article=1004&context=ruhrc_reports

Rosenblatt, R. A. (2000). Physicians and rural

America. West J Med., 173(5), 348–351.

Retrieved from https://www.ncbi.nlm.nih.gov/

pmc/articles/PMC1071163/

Warshaw, R. (2017, October 31). Health Disparities

Affect Millions in Rural U.S. Communities.

Retrieved from https://www.aamc.org/news-insights/health-disparities-affect-millions-rural-us-communities

Tumor. Cancer. Surgery.

Disorder. Disease.

Treatment. Doctors have

the responsibility to tell their

patients “bad news” all the time.

The “news” is not some abstract

story that can be simply watched

out of boredom or skimmed over

with glazed eyes. The “news” is

about one’s future of living or

dying. Far more difficult to swallow

than prescribed pills is the fear of

dying and suffering. Doctors

possess special vocabulary reserved

for delivering “news” beyond

medical terms. “Best”, “try”, “everything”,

“understand”, “support”,

“sorry”. They aren’t big words, but

they somehow take on greater

importance in the context of a

fluorescent, sterile, Purell-scented

doctor’s office.

Doctors are the communicators of

truth about bodies and well-being.

Clear patient-directed communication

is a way to restore some

control in the midst of what could

be a dehumanizing and undignified

circumstance. A patient being

examined in a gown that exposes

their imperfect nakedness to the

whims and waits of the healthcare

system—it is an experience that

could be forever ingrained in

memory. Paul Kalanithi, a neurosurgery

resident at Stanford who

became a patient and passed away

before finishing his book, When

Breath Becomes Air, learned the

true role of a physician after he lost

the power of the role.

He learned “something not found in

Hippocrates, Maimonides, or Osler:

the physician’s duty is not to stave

off death or return patients to their

old lives, but to take into our arms a

patient and family whose lives have

disintegrated and work until they

can stand back up and face, and

make sense of, their own existence”

(Kalinithi 166).

Kalanithi eloquently characterizes

the patient-physician relationship.

It is inherently unbalanced. The

physician’s job is to enter into the

patient’s existence and personal life.

The physician is the safeguard of

sensitive, HIPAA-sheltered information.

Doctors communicate advice

on how to live better. They ask very

personal questions about our lives,

prescribe medications, write

directives and tell us what to eat

and how much to move. All of these

actions require clear and compassionate

communication.

Health literacy is the term given to

describe the ability to acquire and

make sense of information and

resources regarding health. A

displaced immigrant or refugee may

be familiar with different foods and

traditions; they may come from a

different culture with its set of

medical practices and beliefs; they

will almost definitely not speak the

same language or have the same

mannerisms as their providers in

the United States. In these situations,

health literacy is not just a

matter of knowledge and implementation

as language and culture

become major barriers to access.

The Center for Immigration Studies

gathered information regarding the

prevalence of foreign languages

spoken in the United States in 2018

(Zeigler & Camarota, 2019). The

representation of almost all languages

has steadily increased. The

most prevalent languages spoken in

the U.S. following English are

Spanish, Chinese and Tagalog.

While much energy is wasted on

debating whether or not healthcare

is a right, no energy is needed to

realize the fact that all people need

access to healthcare services. Title

VI of the Civil Rights Act of 1964

ensures that federal money given to

hospitals must not discriminate on

the basis of race, color or national

origin (“Title VI of the Civil Rights

Act of 1964”). This means that

healthcare providers that receive

federal funding must provide equal

access to healthcare for all of its

patients by providing professional

medical interpretation. Even with

policy protection, the reality for

non-native English speakers is

bleak. In order to receive federal

funds, hospitals must comply with

the law and “provide adequate

language services, but virtually

everyone agrees that too many

32 33



Washington University Review of Health Spring 2020

cases slip through the cracks”

(Eldred, 2018). There are many gaps

in communication and a lack of

enforcement, and medical professionals

are often unprepared.

Politics of healthcare aside, more

needs to be done to ensure that

patients from all backgrounds are

included, represented and advocated

for in the healthcare system. While

most hospitals have free translation

services for multilingual or non-native

English speaking patients, the

demand will continue to surpass the

available resources given the

upward trajectory of the prevalence

of other languages.

Jose Salinas Valdivia, a Hispanic

Studies Ph.D. candidate at Washington

University in St. Louis, volunteers

at Casa de Salud where he

serves as a qualified Spanish

medical interpreter to the mostly

uninsured patient population, most

of whom are immigrants or refugees.

Jose came to St. Louis for his

academic pursuits, and while he had

always been involved with culture-related

volunteer work at home

in Peru, medical interpreting was

not an activity he had sought out. It

started with curiosity and the desire

to do something meaningful.

Jose is one of many interpreters

who represent a variety of experiences.

Many older medical interpreters

immigrate to the United

States from places of war or persecution.

They come to the United

States with years of field experience

as engineers, physicians and

professors. But given the near

impossibility of validating their

degrees to match U.S. standards,

these individuals provide their

language skills in the humble

profession of medical interpreting

to serve people with the shared

experience of living in a foreign

country.

The effectiveness of medical interpreting

is contingent on the invisibility

of the interpreter. The medical

interpreter’s job is to be the twoway

street for the non-native

English-speaking patient and the

English-speaking physician. The

interpreter’s own voice has no place

in the medical office unless there

are cases of abuse or mismanagement.

Jose conveyed the challenge

of sitting behind the patient and

minimizing his presence even when

he notices something unfair. Jose

argues that the patient has the right

to know if the physician is racist,

for example. For Jose, medical

interpreting is volunteer work, but

it is a matter of life and death for

some patients.

In Medical Spanish class, an undergraduate

introductory course at

Washington University in St. Louis,

we practice medical interpretation

and we role play the doctor, the

patient and the interpreter. The only

correct positions for the medical

interpreter are to the side or behind

either the doctor or the patient.

Medical interpretation provides the

basics of healthcare for non-native

English speaking patients.

Medical interpreting is a self-effacing

profession, but as Jose shares,

“it’s so important to be able to help

the communication between the

patient and the doctor that otherwise

wouldn’t be there.”

While Jose has been interpreting at

Casa de Salud for only a little over

two years for a few hours every

other week, he already has gained

enough experience and exposure to

know that there is an overwhelming

need for and undeniable meaning to

his work. Medical interpreting is

rewarding. Success is measured on

the individual patient level.

Jose knows he has done a good job

when “a patient walks out of the

clinic feeling calmer and more

hopeful than when they walked in.”

As a medical interpreter, his job is

to be the bridge that allows the

patient to know that they are being

cared for and that they can have

hope. This volunteer work has

become one of Jose’s major focuses

during his time in St. Louis. He has

been working on a project proposal

to the Gephardt Institute to establish

a network to connect students

with medical interpreting positions.

Medical interpreting reminds us

that healthcare relies on much more

than what the white coat embodies.

Brittany Jones, a Community

Referral Coordinator with the St.

Louis Integrated Health Network,

understands the power of the white

coat. She strongly voices for greater

participation and integration of

social workers and community

health workers into healthcare,

especially for displaced and at-risk

patients. Physicians have a lot of

influence that can be leveraged for

good, but many times the burden is

too great. This is where the coordination

of care is crucial for the

follow-through and continuity of

healthcare access. Hospitals would

collapse without the support of

janitorial services, technicians,

social workers, administrative

workers, etc. We may see medical

interpreting as another non-essential

administrative role, but without

these dedicated professionals who

faithfully do their jobs behind the

scenes, the physician’s ability to

speak to patients would be utterly

broken. Patients would be left

stranded on a one-way street.

My conversation with Jose ended

with him telling me about his

favorite specialty to interpret:

physical therapy. The minor movements

and posture adjustments that

physical therapists impart to

patients with occupational pains

and chronic suffering can be

life-changing. Small changes that

will not make the patient wealthy

or give the patient a better job,

instead, these changes improve

quality of life little by little. Small

changes can make all the difference.

The less glorified roles in healthcare

are integral to the functioning of

the entire system and the delivery

of services.

Jose concludes, “it’s about going

back to the basics.”

References

Eldred, S. M. (2018, August 15). With Scarce

Access To Interpreters, Immigrants Struggle

To Understand Doctors’ Orders. Retrieved

from https://www.npr.org/sections/healthshots/2018/08/15/638913165/with-scarce-access-to-medical-interpreters-immigrant-patients-struggle-to-unders

Kalanithi, Paul. When Breath Becomes Air.

Random House, 2016.

Title VI of the Civil Rights Act of 1964. (n.d.).

Retrieved from http://www.justice.gov/crt/fcs/

TitleVI

Zeigler, K., & Camarota, S. A. (2019, October

29). 67.3 Million in the United States Spoke a

Foreign Language at Home in 2018. Retrieved

from https://cis.org/Report/673-Million-United-

States-Spoke-Foreign-Language-Home-2018

34 35



Washington University Review of Health Spring 2020

Lily

Exec

Graduating with degrees in Biomedical Engineering and Computational

Biology, Lily has been a member of the Frontiers community since the Fall

of 2017. Lily contributed to Frontiers as a writer, an illustrator, and a web

editor, and in the Fall of 2019, she embraced the role of executive director.

Truly a jack of all trades, Lily has empowered our organization to overcome

obstacles and flourish. Her expertise and versatility will be greatly missed

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Shoutouts

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Women, Gender and Sexuality Studies, Anu has been a passionate and

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legacy as an Editor-in-Chief will continue on.

Contributors

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Illustrator

Writer

Thank you so much, Seniors, for all you’ve done for the

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