Vol. 13 Issue 2
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
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
4 5
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
6 7
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/
8 9
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
10 11
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
12 13
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
on the executive board, and her many lasting contributions will not be
forgotten.
Senior
Shoutouts
Anu
Majoring in Global Health and Computational Biology with a minor in
Women, Gender and Sexuality Studies, Anu has been a passionate and
active member of Frontiers since her freshman year and an Editor-in-Chief
for the last 3 years. From women’s health to public policy issues, she
demonstrates her devotion to keep WashU informed as a journalist. With
her attention to detail and strong writing background, Anu was an Editorin-Chief
that was loved by many. Her enthusiasm, care for others, and her
legacy as an Editor-in-Chief will continue on.
Contributors
Avni Joshi
Vidushri Mehrotra
Yumi
As a graduating senior, majoring in Biology and minoring in German, Yumi
has been a writer since Fall of 2017 and a web editor for Frontiers since
Fall of 2018. Because of her, Frontiers has a beautiful website that we
can be proud of. While juggling her studies in addition to maintaining and
updating frontiersmag.wustl.edu, her passion for Frontiers never ceases.
Yumi’s organization, resilience, and continued support for this organization
is something we will continue to be grateful for.
Illustrator
Writer
Thank you so much, Seniors, for all you’ve done for the
Frontiers family and for us as individuals. You will be
greatly missed, but we know that all of you will be amazing
wherever you go. Best of luck with your future endeavors!
36 37
LIKE WHAT YOU SEE?
Join Frontiers!
WRITERS AND EDITORS
eic.frontiersmag@gmail.com
ILLUSTRATORS
design.frontiersmag@gmail.com
EXEC BOARD
frontiersmag@gmail.com