Stanford Journal of Public Health

Stanford Journal of Public Health
Volume 2 Issue 2 Spring 2012

Special Issue:
Prevention in
Public Health
Policy Practice nvestigation Research
The Ethics of Prevention and Treatment - 9
Stealth Prevention: PepsiCo Tackles Salt as NCD Prevention Strategy - 15
Too Complicated for Google Search: Palantir, Health, and Data Analysis - 21
Sleeper Cells: Latent Links Between Infection and Prostate Cancer - 26
Smoking in the Indigenous Australian Community - 35
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Stanford Journal
of
Public Health
An Undergraduate Publication
Volume 2, Issue 2, Spring 2012
sjph.stanford.edu
Mailyn Fidler
Daniel Bui
Emily Cheng
Ben Lauing
Lindsey Wilder
Aaron Chum
Jovel Queirolo
Kasey Kissick
Carey Phelps
Nairi Strauch
Helena Scutt
Perri Smith
Cristina Averhoff
Anna McConnell
Christina Wang
Eileen Mariano
McKenzie Wilson
Kasey Kissick
Katie Nelson
Helen Helfand
Emma Makoba
editor-in-chief
editor-in-chief
managing director
marketing director
campus marketing
marketing intern
layout director
layout
writers
Jessie Holtzman
Mary Bass
Jennifer Jenks
Jason Bishai
Lauren Platt
Storm Foley
policy
research review
practice
investigation
Cover photo from Wikimedia Commons Logo courtesy of Kiran Malladi
with support from
The Bingham Fund for Student Innovation in Human Biology
ASSU Publications Board
Haas Center for Public Service
Volume 2 Issue 2 Spring 2012 3
We welcome you to the
Spring 2012 issue of the
Stanford Journal of Public Health,
a biannual undergraduate
publication connecting the
passionate, diverse public
health community at Stanford.
In this issue, our staff focused
on the theme of Prevention
in Public Health. Prevention
has increasingly been at the
forefront of the public health
arena, offering population-
level solutions to important
health issues. Treatment
methods, alternatively, focus
on individual health. The
debate between prevention
and treatment raises important
questions about resource
allocation, an issue that will
dehne appioaches lo pulIic
health issues in years to come.
In an age where the holy
giaiIs of scienlihc ieseaich
largely exist in developing
complicated cures, this issue of
SJPH underlines the importance
of prevention as a valuable
tool in public health. Our staff
has selected a variety of topics
through which they analyze
the use, performance, and
value of preventative measures.
We hope that our articles will
excite our readers and serve
as a forum for discourse about
the use of prevention methods
in addressing public health
challenges.
We sincerely hope you
enjoy reading our third issue
of the Journal. We welcome
your thoughts and comments
about our work, the public
health community at Stanford,
or an issue you would like
to see us cover. Please dont
hesitate to reach out to us at
stanfordjournalofpublichealth@
gmail.com.
Warmly,
Daniel Bui 12
Mailyn Fidler 14
letter from the editors:
Mailyn Fidler and Daniel Bui editors-in-chief
BUI
FIDLER
Daniel Bui is a senior at Stanford University majoring in Human
Biology. His interests center around the application of innovative
point-of-care technologies in both preventative and treatment-ori-
ented ways to address public health issues.
Mailyn Fidler is a policy wonk with a scientifc bent, combining both
in her Stanford studies. Mailyn has interned at an AIDS NGO and
at the CDC twice and is excited to be involved in the creation of a
hub of engaged public health scholarship here at Stanford.
4 Stanford Journal of Public Health
letters from the advisors
The Spring issue of the Stanford Journal of Public Health is focused on prevention, a broad
theme and cornerstone of public health. To complement the spring issue, the Journal also spon-
sored a faculty panel discussion with students during the winter quarter, which included Eran
Bendavid, Bonny Maldonado, Tom Robinson, Scott Smith, and myself. The discussion spanned
a variety of important topics ranging across resource allocation between preventive and cura-
tive programs, cognitive biases that pose unique challenges in prevention, and ethics and ef-
fectiveness of prevention when unhealthy behaviors are highly valued. The Journal hopes that
you viII hnd lhis issues ailicIes engaging and lhal lhey encouiage you lo nake
your own contribution to a future issue.

Grant Miller, PhD, MPP
Assistant Professor of Medicine; Assistant Professor, by courtesy, of Economics
and of Health Research and Policy and CHP/PCOR Core Faculty Member

It might seem as though there is a tension between prevention and treatment as means for
inpioving gIolaI heaIlh. CeilainIy in lhe heId of HIV/AIDS ve heai lhe aigunenl lhal noie
funding is needed foi ARVs foi liealnenl oi foi R&D inlo a vaccine foi pievenlion. Hovevei,
lhe noie I ieecl on lhis lension, lhe noie I see lhe Iink lelveen lhe lvo. Ieihaps, ialhei lhan a
choice, its a spectrum where prevention can be seen as early treatment and treatment as preven-
tion of transmission for communicable disease. Certainly, both save and improve lives and are
critical elements of public health policy and practice. So, as in many things, its
not black and white, the distinction is subtle and nuanced, and we will all be bet-
ter off for understanding the full spectrum of responses.

Amy Lockwood
Deputy Director
Stanford University Center for Innovation in Global Health

Recently, at a faculty retreat of the Stanford Prevention Research Center (SPRC), Dr. Michaela
Kiernan suggested that we utilize the tagline Maximizing the Power of Prevention in order
to increase awareness of SPRCs mission. I think this tagline is also appropriate for this issue
of SJPH. Prevention saves lives and reduces suffering and disability. Yet, as a nation, the US
spends only a small fraction of its healthcare dollars on prevention. My hope is
that you will read the articles in this themed issue and become a standard bearer
for increasing the attention and resources provided to prevention efforts.

Catherine A. Heaney, PhD, MPH
Associate Professor (Teaching)
Stanford Prevention Research Center
contents
Policy
Healthcare Reform: The Debate Over the Patient Protection and Affordable Care Act........................................7
Christina Wang
The Ethics of Prevention and Treatment...............................................................................................................9
Helena Scutt
Born This Way: Preventive Medicine and the Genetic Information Nondiscrimination Act..................................11
Katie Riklin

Occupy Healthcare..............................................................................................................................................13
Anna McConnell

Opinion

Stealth Prevention: PepsiCo Tackles Salt as NCD Prevention Strategy..............................................................15
Eleanore Alexander, Derek Yach,George A Mensah, and Gregory L. Yep
Practice
Non-Communicable Diseases in Kenya: Balancing Priorities in Healthcare Funding and Initiatives..................19
McKenzie Wilson
The UV Tube: Technology and Preventing Waterborne Diseases.......................................................................21
Eileen Mariano
Too Complicated For Google Search: Palantirs Health Team Tackles Challenges with Data Analysis..............22
Mailyn Fidler

Gardasil versus GAVI: Challenges to Implementing HPV Vaccines in Developing Countries.............................24
Christina Averhoff
Investigation

Sleeper Cells: Latent Links Between Infection and Prostate Cancer..................................................................27
Kasey Kissick
The Obesity Plateau: Stigma, Statistics, and Success........................................................................................29
Perri Smith

Research Review
Correlates of Physical Education Participation in High School Students.............................................................32
Xinyue (Alice) Fang

Smoking in the Indigenous Australian Community..............................................................................................36
Elise Geithner

A Study of H1N1 Vaccination Trends in Illinois.....................................................................................................................41
Molly Fausone
The policy section of the
SJPH probes the intersection of public
health research and innovation and their
deployment in the real world. The section
approaches changing health issues
by integrating legislative, ethical, and
economic perspectives.

In this issue, the Policy Section explores
prevention in public health by investigating
healthcare reform, the ethics of prevention
and treatment in public health, and
legislation regarding access to genetic
information.
POLICY
Christina Wang
Healthcare Reform
The Debate Over the Patient
Protection and Affordable Care Act
On March 23, 2010, President
Obama signed the Patient Pro-
leclion and AffoidalIe Caie Acl
(ACA), his coineislone heaIlhcaie
iefoin liII. The ACA seeks lo
reduce the number of uninsured
individuals in the United States
while providing new protections
to individuals who already have
health insurance. This legislation
mandates that all individuals pur-
chase health insurance and ex-
pands Medicare eligibility to cover
approximately 30 million more
individuals.
Since ils passage, lhe ACA has
been extremely controversial.
Twenty-six states, along with nu-
merous organizations and individ-
uaIs, have hIed suils chaIIenging
the constitutionality of several of
the bills provisions. The Supreme
Court has agreed to hear challeng-
es brought against the bill. Oral
arguments will be heard in March
and the decision presented by late
June. Dr. Laurence Baker of the
Stanford Center for Health Policy
Research claims that the three
major points of contention are the
individual mandate, the sever-
ability of the individual mandate,
and the expansion of Medicaid
undei lhe ACA.
The individual mandate requires
that, by January 1, 2014, all US
citizens and legal non-residents
must obtain insurance. Likewise,
lhe ACA iequiies conpanies
employing 50 or more employees
to provide insurance to all work-
eis. The ACA fuilhei olIigales
unemployed or self-employed
individuals to utilize the insurance
exchange market. This market will
contain health insurance provider
data organized by state, allow-
ing individuals to compare health
insurance premiums side-by-side.
Individuals failing to meet the
level of minimum essential cover-
age would incur a penalty of $695
in 2016. Should a company fail
to meet the requirements, it will
have to face an annual $2000 per
employee penalty tax. Opponents
of lhe ACA queslion lhe conslilu-
tionality of the mandate, disputing
the federal governments right to
mandate an individual minimum
level of healthcare coverage.
In June 2012, the Supreme Court
may rule to uphold part, none, or
aII of lhe ACA, vhich liings inlo
question the severability of the
individual mandate. If the indi-
vidual mandate is ruled unconsti-
tutional, the Supreme Court will
decide whether the rest of the law
can be upheld despite severance
of the individual mandate. Op-
ponents of severability argue that
the provisions of the healthcare
reform legislation are intertwined
to such an extent that revoking one
mandate will nullify the entire act.
If the individual mandate is ruled
constitutional, the Supreme Court
hearing will proceed to address the
third contention: the expansion of
Medicaid.
The suils hIed againsl lhe ACA
also challenge the expansion of
Medicaid, which would be respon-
sible for nearly half of the laws
expected increase in nationwide
healthcare coverage. Paradoxically,
nany of lhe slales hghling nosl
adananlIy againsl lhe ACA aIso
have the highest rates of uninsured
residents, including Texas, where
27.6% of residents lack insurance
coverage.
1
States organize the
POLICY
current Medicaid program for the
disabled and poor, with the major-
ity of Medicaid programs funded
equally by state and federal funds.
Accoiding lo Di. }ay hallachaiya
of the Stanford Center for Health
IoIicy Reseaich, lhe ACA iequiies
that states expand Medicaid
eligibility to cover all individu-
als that earn an income of 133%
of the federal poverty line, rais-
ing concerns because healthcare
costs account for 18% of the US
GDP, the largest proportion com-
pared with other wealthy nations
GDPs.
2
Many states have already
expanded Medicaid programs in
the past few years in response to
increased federal matching funds.
As Di. hallachaiya fianes lhe
issue, lhe ACA nov iequiies lhal
each individual state increase its
Medicaid coverage, extending the
total covered population nation-
wide by about 30 million people.
The federal government will cover
all costs of the expanded Medicaid
program until year 2017, at which
point the states will gradually in-
crease their share of the burden by
up to 10 percent. Most uninsured
Aneiicans nov coveied undei lhe
bill, explains Dr. Bhattacharya, are
poor, self-employed, or part-time
workers for companies that do not
offer health insurance. The federal
government will provide subsidies
to individuals who cannot afford
to buy healthcare.
Dr. Bhattacharaya claims that
the plan will cost approximately
$1 trillion over a period of 10
years. Federal funding to subsidize
healthcare acquisition for individu-
als and support state funding for
the expansion of will largely rely
upon tax increases from high-in-
come taxpayers.
As Slanfoid Lav Iiofessoi
Greely discussed in his presenta-
lion on lhe ACA, lhe lhiee piinaiy
goals of healthcare are to provide
the best quality, access, and cost.
The ACA allenpls lo diaslicaIIy
increase the accessibility of health-
care, decreasing the number of the
uninsured by millions. Its implica-
tions for the cost and quality of
healthcare, however, remain to be
determined -- it will be exciting to
note how the presidential elections,
Supreme Court ruling, and state
government cooperation will im-
pact the dynamic of the healthcare
system in the United States.
Jay Bhattacharya is an associate professor of medicine and a CHP/PCOR core faculty member. His
research focuses on the constraints that vulnerable populations face in making decisions that affect
their health status, as well as the effects of government policies and programs designed to beneft
vulnerable populations. He received a BA in economics, an MD and a PhD from Stanford University.

Laurence Baker is chief of Health Services Research at Stanford University, a professor of health
research and policy, and a CHP/PCOR fellow. He is an economist interested in the organization and
economic performance of the US healthcare system. His research focuses on the effects of managed
care on the healthcare system. He received his BA from Calvin College, and his MA and PhD in eco-
nomics from Princeton University.
1. States Resisting the Affordable Care Act Have the Highest Percentages of Uninsured. Think Progress. Web. 01
April 2012. Available at: <http://thinkprogress.org/health/2012/03/06/436562/gallup-states-resisting-affordable-care-
act-have-highest-percentages-of-uninsured/?mobile=nc>. Accessed April 1, 2012.
2. Professor Henry Greely, Discussion & Presentation on Obamacare, March 2012 5:00p, Old Union 200.
POLICY
Public health programs
perpetually face the
dilemma of balancing
the allocation of limited
hnanciaI iesouices le-
tween prevention and
treatment. Present or
future? Short-term or
Iong-lein` AIlhough il
is easy to glorify preven-
tion, allocating resources
to people who dont yet
have a given disease over
current sufferers from
that disease can be hard
to justify.
If you can make the
investment and cover
everyone, prevention is
always a better invest-
ment and would likely
save the most people,
said Dr. Eran Bendavid,
a Reseaich Associale al
Cenlei foi HeaIlh IoIicy/
Primary Care and Out-
comes. However, it is
just not right to not treat
people when you have
treatment available. Its
just not right to deny
treatment to that popula-
tion.
HIV and naIaiia aie
two major diseases that
lack a vaccine and whose
prevention is largely
a matter of behavior
change. Examining the
efforts against these dis-
eases will provide insight
into factors that cause the
prevention and treatment
balance to vary, as well as
challenges of implemen-
tation, effective treatment
and prevention strategies,
and lhe signihcance of
cosl-lenehl anaIysis.
SeveiaI faclois inu-
ence prevention-treat-
ment equations: cost of
treatment, cost of preven-
tion, disease prevalence,
economic setting of
aficled aieas, and lhe
severity of the disease.
Much of it is about the
burden, as in the number
or percentage of people
affected, said Bendavid.
Political priorities also
play a huge role. Benda-
vid ciles lhe Soulh Afii-
can governments role
in lheii ievanped HIV
policy as an example of
this political effect.
Key points in this de-
bate are that prevention is
not always cheaper than
treatment and the costs
of prevention are chal-
lenging to measure. In
addition, evaluating the
success of a program is
one of the greatest chal-
lenges and can often be
unreliable.
Its hard to know
when youve prevented
something, said Benda-
vid. You dont get credit
for what hasnt happened
and you cant prevent
death; you can only delay
it. In fact, preventing one
disease can lead to more
expenses down the road.
Thus, in some cases,
preventive measures are
more expensive than
treatment.
Measures of preven-
tions effectiveness can be
challenging, as well. Dr.
Daivin Scoll Snilh, As-
sociale CIinicaI Adjuncl
Professor at the Stanford
School of Medicine,
points out, With pre-
vention, its hard to get
neasuiealIe lenehl and
therefore hard to know
its effectiveness. This
challenge in estimating
effectiveness applies to
national health policies as
well as research. When a
disease is being actively
controlled, its incidence is
low, and the importance
of prevention programs
is often forgotten in the
public sphere.
For example, Zanzi-
bar, an island state of
Tanzania, had a highly
successful malaria control
program in the 1960s, but
in 1968 it was forsaken
because malaria was
no longer considered a
health problem.
1
Conse-
quently, the disease re-
turned and, until recently,
malaria remained Zanzi-
bars number one public
health problem.
1

Zanzibar wiped out
malaria but is forced to
continue to spend money
on prevention efforts,
specihcaIIy vecloi con-
lioI, said Snilh. As a
major tourist destination,
thousands of potential
malaria-carrying people
ov in eveiy day. IeopIe
no longer have immunity
so an outbreak would be
The Ethics of Prevention and Treatment
Helena Scutt
HV-positive Sekayi and her HV-free son Tapiwa, Zimbabwe. HV
is an ongoing battleground between prevention and treatment.
EITHNE BRENNAN | Creative Commons
POLICY
devastating.
Since 2003, Zanzibars
government has reduced
parasite prevalence to
below one percent. This
effort has involved use of
artemisinin-based combi-
nation therapies, indoor
residual spraying pro-
grams, and insecticide-
treated nets.
1
Zanzibar
must continue to allocate
adequate funds to the
prevention effort despite
signihcanlIy ieduced in-
cidence levels of malaria
and correspondingly de-
creased treatment costs.
In contrast to malarias
prevention-dominated
efforts, most funding for
HIV in lhe pasl decade
has actually gone to treat-
ment, stated Bendavid.
HIV has seen enoinous
success in prevention, but
with the rise of antiretro-
viiaI lheiapy (ART) and
the lowering of its cost,
the pendulum has swung
toward treatment. With
an infectious disease like
HIV, if you lieal il in one
person, you prevent it
in someone else. There-
fore, treatment becomes
prevention, leading to
therapies known as pre-
ventative treatments.
You dont necessarily
have to pick one or the
other, said Dr. Yvonne
Maldonado, Chief of
the Division of Pediatric
Infectious Diseases at the
Stanford School of Medi-
cine. For example, pre-
venting mother-to-child
transmission (PMTCT) of
HIV is a neige of pieven-
tion and treatment.
For virtually all dis-
eases, prevention must
invariably be linked
to early diagnosis and
treatment. In developed
counliies, HIV lesling foi
pregnant women is man-
datory, just like testing
for Hepatitis B, syphilis,
and rubella, said Maldo-
nado. Even if tested at
the time of delivery and
labor you can still reduce
HIV liansnission iisk
by 90-98%. Its a major
investment because the
cost of caring for babies
vilh HIV is high. Molh-
er-to-child transmission
is prevented by giving
antiretroviral drugs to
the mother before child-
birth and small doses to
the newborn for a short
period after birth.
However, a promising
plan is nothing without
effective implementation.
AIlhough ieseaich and
trials can improve our
biomedical methods, the
behavioral side of pre-
vention is much harder to
quantify and control. In
the case of PMTCT, we
have lhe scienlihc an-
swers. The tricky part is
all in the implementation
and maximizing cost-
effectiveness, explained
Maldonado. To maxi-
mize the effectiveness
of prevention you have
to build new programs
around existing ones,
such as integrate PMTCT
into family planning.
In designing the bal-
ance of prevention and
treatment, the sustain-
ability of the program
and the structure of the
existing public health
system must be consid-
eied. A pievenlion-lased
strategy that cannot be
upheld in the long-term
is not effective.
AIlhough liealnenl
has received the most
attention, prevention
remains a vital compo-
nenl in conlioIIing HIV.
Countries in sub-Saharan
Afiica have Iaunched
HIV-pievenlion can-
paigns discouraging con-
currency, or having two
or more sexual partners.
Estimating $12003800
as the lifetime medical
cost of treatment for an
HIV-infecled individuaI
in Afiica, endavid used
disease modeling to show
that an anti-concurrency
campaign costing about
$0.25 per person annual-
ly would need a program
effectiveness of less than
5% in any of the study
countries to be cost-
saving.
2
Understanding
the cost-effectiveness of
prevention campaigns
is key to justifying any
spending on prevention
over treatment.
As lhe exanpIes of na-
Iaiia and HIV shov, lhe
balance between preven-
tion and treatment must
be customized to both the
disease and the targeted
area. These efforts must
take advantage of pre-
ventative treatment if
possible and use surveil-
lance to evaluate prog-
ress. Most importantly,
the approach must inte-
grate its efforts into the
publics consciousness
and harness the power
of behavior changeit
must capture the hearts
and minds of the affected
population.
US Army medical researchers in Kenya on World Malaria Day 2010.
US ARMY AFRICA | Creative Commons
POLICY
1. Africa Fighting Malaria. Keeping Malaria Out of Zanzibar. March 2008. Available at: http://www.fghtingmalaria.org/
pdfs/AFM_Zanzibar_March08.pdf. Accessed March 4, 2012.
Dr. Darvin Scott Smith is Chief of Infectious Disease & Geographic Medicine at Kaiser Permanente.
He currently teaches HUMBIO 153: Parasites and Pestilence: Infectious Public Health Challenges.

Dr. Eran Bendavid is the Assistant Professor of Medicine in the Division of General Medical Disci-
plines and Center for Health Policy/Primary Care and Outcomes Research Associate. He models
diseases and studies the relationship between health policies and their outcomes, particularly HV in
Africa.

Dr. Yvonne Maldonado is a Professor of Pediatrics and Health Research and Policy and Chief of the
Division of Pediatric Infectious Diseases at the Stanford School of Medicine. Much of her research
has been focused on the prevention of perinatal HIV transmission. She is also a Berger-Raynolds
Distinguished Fellow and Attending Physician at the Lucile Packard Childrens Hospital.
2. Enns E.A., Brandeau M.L., Igeme T.K., and Bendavid E. Assessing effectiveness and cost-effectiveness of concur-
rency reduction for HIV prevention. Int J STD AIDS. October 2011;22(10):558-567.
Born This Way
Preventive Medicine and the Genetic
Information Nondiscrimination Act
Katie Riklin
Earlier this month, I joined the
ranks of more than a hundred
thousand people who have had
their genotype sequenced by
23andMe. 23andMe is a leading
personal genetics company that
aims to help people understand
their genetic information through
DNA anaIysis and inleiaclive
online tools. Many users view
this service as a novel way to gain
insight into their health and ances-
liy. AddilionaIIy, ovei 75 of useis
give permission for their genetic
information to be used in research.
Genetic testing is not entirely new,
but 23andMe demonstrates the
success of a direct-to-consumer
(DTC) market fueled by a new
willingness to volunteer our ge-
netic information. Consumers have
seemingly overcome their previous
reluctance towards genetic testing
and fear of sharing their genetic
information.
DTC companies are cropping
up all over the map; one particu-
larly close to home is Counsyl, a
Stanford startup that sells tests
to couples to discern whether
they are at risk of having children
with a range of inherited genetic
diseases incIuding cyslic hliosis,
Tay Sachs, and sickle cell disease.
Over 100 fertility clinics around the
country already offer this test and
some insurers have begun to cover
the cost. Tests offered by compa-
nies like Counsyl and 23andMe
offer huge promise in the realm
of preventative medicine. Despite
advances in genetics, ethical con-
troversy still exists. For instance,
understanding genetic predispo-
sitions may help make healthier
lifestyle choices, but pre-pregnancy
genetic testing may allow couples
to avoid bearing children with
genetic diseases, a controversial
aiena. Anolhei concein is piivacy.
Genetic information in the right
hands has the potential to prevent
disease and save lives; however,
in the wrong hands, it could easily
lead to discrimination and invasion
of privacy.
The Genetic Information Non-
disciininalion Acl (CINA) of
2008 directly addresses this issue
of piivacy. Accoiding lo Saia L.
Tobin, a Senior Research Scholar
at Stanfords Center for Biomedi-
cal Ethics, the issue at hand be-
foie lhe inpIenenlalion of CINA
was that people were born with
certain genetic signatures and that
was being used against them.
The inlenl of CINA vas lo end
this injustice, and after 13 years of
debate in Congress, the bill passed
the Senate unanimously and the
House by a vote of 414 to 1. It was
signed into law on May 21, 2008,
arguably [paving] the way for
people to take full advantage of the
promise of personalized medicine
without fear of discrimination.
1

CINA piolecls Aneiicans fion
POLICY
discrimination relating to informa-
tion derived from genetic tests. It
forbids insurance companies from
basing coverage or pricing on
genetic information and prohibits
employers from making employ-
ment decisions based on a persons
genetic code. In addition, the law
prevents insurers and employers
from requesting or demanding a
genetic test.
Beyond assuaging the worries
of lhe geneiaI popuIalion, CINA
will allow innovation in disease
prevention and bioinformatics to
continue relatively unabated. The
decade since the completion of
the Human Genome Project has
shown an unprecedented rate of
such innovation, with the newest
chip technology allowing analysis
of over 2 million single nucleo-
tide polymorphisms at once. In a
press release last year, 23andMe
cofoundei Anne Wojkicki slaled
that their database has created
an entirely new model for con-
ducting research, which [they]
leIieve couId signihcanlIy inpacl
lhe speed of scienlihc discovei-
ies going forward.
2
In addition,
the possibility of personalized
medicine shows much promise.
This realm of medicine would
have little viability without the
pioleclions CINA affoids iegaid-
ing genetic information security.
This protection is important in
improving health outcomes, as
research indicates that people may
be more likely to follow treatment
or prevention guidelines that are
based on genetic information.
3
This
phenomenon, broadly known as
genetic exclusivity, shows that ge-
netic information has the potential
to improve healthcare effectiveness
and specihcaIIy inciease adheience
to preventive medicine.
3
Genetic information could
become one of the most valuable
modern tools for treating and
preventing disease. Increasingly af-
fordable genetic testing will allow
increases in knowledge regarding
genetic susceptibility to certain dis-
eases and use of this information
to facilitate better health outcomes.
This realm of science will only
progress if personal information
is protected adequately. Thus far,
CINA has ensuied lhis pioleclion.
However, in the coming years,
personal rights and ethics must
ienain paianounl in scienlihc
endeavors.
Sara Tobin received a BS in Zoology and a Ph.D in Developmental Biology, both from the University
of Washington in Seattle. She is currently a Senior Research Scholar at the Center for Biomedical
Ethics and Stanford University.
1. National Human Genome Research Institute Web site. Available at: http://www.genome.gov/24519851. Accessed
February 28, 2012.
2. 23andMe. Press release regarding company database and new research paradigms. Available at: ://www.23andme.
com/about/press/23andme_database_100000k_users/. Accessed February 28, 2012.
3. Dr. Joshua Knowles, Genetic Factors and Cardiovascular Disease, 22nd February 2012, Stanford University.
A partial karyotype of the human genome. The human genome contains 23 chromosome pairs and over three billion base pairs.
Wikimedia Commons | with permission
POLICY
From Tahrir to San
Francisco, individuals,
families, and entire com-
munities are protesting
for basic human rights.
People are not only upset
aloul lhe hnanciaI secloi
and the bank bailouts
they are tired of living
in a society where social
services are not provided
to those that need them
the most. Individuals
from all over the country
have come together to
Occupy Healthcare. The
global movement has
taken root.
Occupy groups and
other local community
organizations are de-
manding changes in the
way we provide afford-
able and accessible health
services. The conversa-
tion surrounding health
policy and reform is
occurring on both state
and national levels. Most
liberals and leftists are
asking not if, but when
universal healthcare is
going to emerge. Many
arguments in favor of
universal care stem from
research on the positive
effects of preventative
care, as the 50 million
Aneiicans vilhoul insui-
ance cannot afford cost-
saving preventative care.
Those opposed to univer-
sal healthcare, however,
argue that the cause of
the US healthcare mess
is governmental interfer-
ence.
1
For these people,
the solution is not more
governmental control but
rather the removal of all
government regulation.
In an effort to solve
this problem, the Occupy
movement and a group
of health professionals
in Occupy Healthcare
have been supporting
state initiatives such as
Californias SB 810. The
California Senate Bill is
a Medicaie-Ioi-AII
style single-payer plan
that combines public
hnancing vilh piivale
healthcare delivery in
which individuals will
have complete freedom
to choose their healthcare
piovideis. AII CaIifoinia
residents would be eli-
gible for the program, re-
gardless of employment
slalus oi incone. Addi-
tionally, the emphasis on
primary and preventative
care is estimated to save
Californians approxi-
mately $3.4 billion.
2

Donald Barr, associ-
ate professor at Stanford
University, comments
that the failure of our
current healthcare system
is revealed in dispari-
ties of death rates. In an
article in Health Affairs,
researchers Steven H.
Woolf and Paula Brave-
man reveal that if ev-
eryone experienced the
mortality rates of college
graduates, approximately
50 percent of all male
deaths and 40 percent of
all female deaths at ages
2564 would be avoided.
3

Moreover, income and
iace signihcanlIy affecl
these statisticseven at
age 25, the poorest blacks,
whites, and Hispanics
have lower life expectan-
cies than those of their
noie afuenl counlei-
pails. Reecling on lhis
study, Barr concludes, If
you are in a lower tier of
society as a young adult
in your 20s, you have a
difhcuIl palh ahead of
you. The more unequal
things are, the harder it is
to overcome.
4

The lack of support for
SB 810 may be a con-
sequence of the plans
exclusion of optional
supplements. Optional
supplements would
allow a resident to pay
more to receive addi-
tional coverage, such as
specialty services or el-
derly care. This one level,
or single-payer, system
fundamentally chal-
Ienges Aneiican ideaIs.
4

Everyone would have the
same access to healthcare,
so lhe Aneiican ideaI of
working hard and mak-
ing money wouldnt give
anyone an advantage. It
may be possible to devel-
op a single-pay program
that covers the essentials
for all citizens and also
cultivates a market that
offers additional insur-
ance for those who can
afford it. In fact, we see
this today in our Medi-
care system, but only
those over age 65 qualify.
If bills like SB 810 includ-
ed optional supplements,
they could expand this
Medicare dual model
to cover all citizens.
Looking towards the na-
tional level, Barr predicts
that 2014 will give rise to
interesting interactions
between previously exist-
Creative Commons | with permission
Occupy Healthcare
Anna McConnell
POLICY
ing state initiatives and
the new implementation
of lhe AffoidalIe Caie
Acl. AIlhough lhe nalion-
al plan remains a multi-
payer system, Barr has
hope that the differences
in federal and state fund-
ing will push the country
towards a Medicare for
all.
4

The push for universal
plans like SB 810 has
come out of the failings
of other models such as
consumer-directed insur-
ance, which has gained
popularity since 2003.
This model contains fac-
tors that may contribute
to growing disparities
in health. In consumer-
directed plans, health
insurers give consumers
a preset fund of money
they can use to cover
health costs, but after this
amount, consumers must
pay any expenses. Any
unused balance in the
account will rollover
at the end of the year to
increase future balances.
5

The incentive structure of
these accounts can lead
to delayed and avoided
care.
6
Ultimately, people
opt out of doctors visits
and regular preventative
care in order to avoid us-
ing the allotted spending
account. Those who are
the most concerned with
saving the account are
also the poorest and often
face the greatest health
consequences.
Barr has collaborated
with other Stanford
professors to publish
a series of opinion es-
says that were published
in the Boston Review
under the title Occupy
the Future.
7
AIlhough
the work represents an
academic approach to the
discussion on the Occupy
movement, it is an impor-
tant one. By presenting
the facts and research
that reveal the depth of
these health disparities,
students and workers can
be educated and inspired
to push for a better sys-
len. AIlhough lhe CaIi-
fornia Senate did not pass
SB 810 in January, its sup-
port represents the efforts
of a local movement and
the ability for individuals
and small communities to
hghl foi change.
1. Universal Healthcare: No Sick Joke (BusinessWeek) Web site. Available at: http://www.businessweek.com/debat-
eroom/archives/2007/06/universal_healt.html. Accessed March 1, 2012.
Donald Barr is a professor in the Human Biology program at Stanford University. His interests include
reform of premedical education, minority student attrition from the pre-medical curriculum, expanding
access to healthcare for California's low-income population, social and economic factors contributing
to health disparities, and measuring primary care quality.
2. SB 810 Fact Sheet. Mark Leno Web site. Available at: http://sd03.senate.ca.gov/sb810/fact-sheet. Accessed on
February 10, 2012.
3. Woolf S, Braveman P. Where Health Disparities Begin: The Role Of Social And Economic Determinants. Health Af-
fairs. October 2011;10:1852-1859.
4. Personal Interview with Don Barr on February 13, 2012.
5. The Impact of Consumer-Driven Health Plans on Healthcare Costs: A Closer Look at Plans with Health Reimburse-
ment Accounts. Available at http://www.actuary.org/pdf/health/cdhp_jan04.pdf. Accessed February 15, 2012.
6. Committee on Child Health Financing. High-Deductible Health Plans and the New Risks of Consumer-Driven Health
Insurance Products. Pediatrics [online]. 2007;3:622-626. Accessed February 15, 2012.
7. Inequality and Health in America (Boston Review) Web site. Available at: http://www.bostonreview.net/BR36.6/don-
ald_barr_occupy_movement_future.php. Accessed February17, 2012.
OPINION
Salt Reduction is a
Global Need
The importance of re-
ducing salt intake gained
international prominence
in 2011 during the UN
High Level Meeting on
Non-Communicable Dis-
eases (HLM). Excess salt
intake is strongly linked
to increased blood pres-
sure, and raised blood
pressure is a cause of
cardiovascular disease,
one of the four NCDs
(in addition to diabetes,
cancer, and chronic lung
disease) highlighted at
the HLM. NCDs caused
63% of global deaths in
2008 and are projected to
increase 15% from 2010
to 2020.
1
Salt reduction
was listed by the Lan-
cet as a best buy for
NCD prevention, second
only to tobacco control.
2

Governments have called
upon the food industry to
reduce salt use in order to
lower sodium consump-
tion. Due to high preva-
lence of excessive salt
intake, the food sources
providing salt in the diet
need to be investigated
to appropriately inform
poIicy. The INTLRSALT
study highlighted the
range of sodium intake
fion 18.4 ng/day in
male Yanomamo Indians
of iaziI lo 5,957 ng/
day in males in Tianjin,
China.
3
Mean sodium
intake in the US is 3,266
ng/day.
4
The WHO has
recommended lowering
sodium intake to less
lhan 2,OOOng/day as a
cost-effective method to
reduce blood pressure.
5

Sources of Sodium in
the Diet
Processed foods provide
the majority of sodium
in the diet in Europe and
the US, while sodium
often comes from sauces
and salt added at the ta-
lIe in Asian and Afiican
countries.
6
The lop hve
food categories contrib-
ute over 25% of sodium
intake in US adults and
include breads, cold
cuts, pizza, poultry and
soups.
4
Recent data from
Soulh Afiica shovs lhal
bread contributes more
than 50% of sodium
intake in some popula-
tion groups.
7
Soy sauce
contributes 20% of so-
dium intake in Japan, and
76% of sodium intake in
China is from salt added
during home cooking or
at the table.
3
Global Data Needs
Data for food sources
of sodium intake are not
available for most coun-
tries; currently, packaged
food sales data offers
the closest comprehen-
sive data to investigate
leading dietary sources
of sodium intake on a
gIolaI scaIe. Accoiding
to Euromonitor data, the
top packaged food manu-
facturers in a country are
often local small and me-
dium enterprises (SMEs)
rather than large multina-
tionals (MNCs).
8
MNCs
ranking in the top ten of-
ten account for less than
10% of national packaged
food sales in develop-
ing countries. This does
not include the informal
sector (non-taxed sales).
It is estimated that 2.5
billion people eat foods
purchased through the
informal sector daily, so
the importance of under-
standing the contribution
of the informal sector,
Eleanore Alexander,
1
Derek Yach,
1
George A. Mensah,
2
Gregory L. Yep
3

1. Global Health and Agriculture Policy, PepsiCo, nc., Purchase, NY, USA.
2. Global Nutrition, Global Research and Development, PepsiCo, nc., Purchase, NY, USA.
3. Long Term Research, Global Research and Development, PepsiCo, nc., Purchase, NY, USA.
Stealth Prevention
PepsiCo Tackles Salt
as NCD Prevention Strategy
OPINION
in addition to SMEs and
MNCs, to dietary sodium
intake in countries is
imperative.
9
Elements Needed for
Successful Sodium
Reduction
High income countries
including the UK,
Japan and Finland have
achieved success in
reducing sodium intake
through public health
education campaigns,
industry reduction
of salt in packaged
foods, and product
labeling legislation;
these interventions
achieved success due to
collaboration between
government, NGOs,
consumers, the media,
and industry.
10
New
York City is leading
the US National Salt
Reduction Initiative
(NSRI) with the goal of
ieducing Aneiicans
salt intake by 20% over
hve yeais ly pailneiing
with packaged food
companies and
restaurants to reduce
sodium levels in
products.
11
High income
countries tackling salt
reduction have several
attributes that support
success: strong regulatory
capacity, majority of
food sales through the
formal sector, public
knowledge of the
health risks of sodium
intake, and strong
states with enforcement
capabilities.
10
Low and
middle-income countries
likely do not have
the same regulatory
capacity and consumer
knowledge.
PepsiCo Actions to
Reduce Sodium
Reducing sodium intake
will require consumer
demand for reduced
sodium products in
addition to action from
governments, the media,
and industry. PepsiCo
has pledged to reduce
sodium by 25% in key
global food brands in key
markets by 2015 (with a
2006 baseline), and has
successfully reduced
sodium in products
in many countries
without compromising
product taste.
12
Much
of this reduction is
stealth and not directly
communicated to
the public to prevent
consumers from rejecting
the product based
on preconceptions of
poor taste. In the U.K.,
WaIkeis has signihcanlIy
reduced sodium in its
products since 2005. In
2011, Frito-Lay in the
U.S. reduced sodium by
nearly 25%, on average,
acioss ils enliie avoied
potato chip portfolio. In
Canada, Quaker instant
oats products have been
reformulated with a
15% to 25% reduction in
salt. In Brazil, sodium
was reduced in one of
PepsiCo most popular
snacks, Fandangos, by
more than 30%. The
public health impact of
reducing sodium levels
in PepsiCo portfolio is
limited by the amount of
sodium PepsiCo products
contribute to the diet.
Reducing Sodium on a
Global Scale
Gradually reducing
sodium content, while
maintaining product
taste, is essential to shift
consumers to products
with lower sodium con-
tent. Large companies
vilh signihcanl R&D
resources and consumer
insight knowledge will
lenehl fion encouiaging
SMEs to simultaneously
reduce sodium content
in their products because
it provides a level pro-
cessed food landscape
where consumers op-
tions are all similarly
low in sodium. PepsiCo
plans to share salt re-
duction best practices
and consumer insights
with SMEs in selected
developing countries
to encourage SMEs to
reduce sodium in their
products. Through local
workshops and ongoing
engagement, PepsiCo
viII engage R&D scien-
tists, consumer insights
experts, and ingredient
vendors in discussions
related to effective salt
reduction in a competi-
tive market. The project
viII piIol in Soulh Afiica
in 2012, with more loca-
tions for country forums
announced throughout
the year. The pilots aim
to provide the resources
SMEs need to reduce so-
dium in locally produced
foods, and PepsiCo hopes
that the forums will lead
to continued and more
informed dialogue be-
tween the food industry,
government and NGOs
regarding collaboration
to reduce salt consump-
tion.

Derek Yach, third from left, at a chickpea program feld in Ethiopia. Yach's team is investing in small-
scale farmers around the world to improve access to nutrition.
ELEANORE ALEXANDER | with permission
OPINION
Conclusion
The scienlihc evidence
linking excess dietary
sodium intake and ad-
verse health outcomes
is compelling. Similarly,
lhe heaIlh lenehls of
dietary sodium reduc-
tion strategies are now
proven. Knowing these
two facts is, however,
not enough. We need
effective partnerships
between governmental
agencies, NGOs, the
public health community,
consumers, health advo-
cacy groups, the media,
and the food and bever-
age industry to enable
successful salt reduction
slialegies. Al IepsiCo,
we hope that the forums
we have started will lead
to continued, informed
dialogue between all
stakeholders regarding
collaboration to reduce
salt consumption.
Derek Yach is Senior Vice President of Global Health and Agriculture Policy at PepsiCo where he leads
engagement with major international groups and new African initiatives at the nexus of agriculture and
nutrition. Derek and his team are focused on long-term strategic thinking and practices, underpinning
the business on strong sustainable development principles. The team promotes innovative thinking to
identify risk and opportunity to the business and to build Pepsicos corporate reputation.
1. WHO. Global status report on noncommunicable diseases 2010. Available at: http://whqlibdoc.who.int/publica-
tions/2011/9789240686458_eng.pdf. Accessed March 22, 2012.
2. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P et al.. Priority actions for the non-communicable
disease crisis. The Lancet 2011; 377:1438-1447.
3. Brown IJ, Tzoulaki I, Candeias V, Elliott P Salt intakes around the world: implications for public health. Int J Epide-
miol 2009; 38: 791-813.
4. CDC. Vital signs: food categories contributing the most to sodium consumption United States, 2007-2008. Available
at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm61e0207a1.htm. Accessed March 21, 2012.
5. WHO. Diet, Nutrition and the Prevention of Chronic Diseases. 2003. Available at: http://www.who.int/hpr/NPH/docs/
who_fao_expert_report.pdf. Accessed March 21, 2012.
6. Anderson CAM, Appel LJ, Okuda N, Brown IJ, Chan Q, Zhao L, et al. Dietary sources of sodium in China, Japan,
United Kingdom, United States Women and Men Ages 40-59: The INTERMAP study. J Am Diet Assoc. 2010; 110:
736-45
7. Wentzel-Viljoen E, Laubscher R, Steyn R. The foods that contribute to South Africans high salt intake. Submitted.
8. Alexander E, Yach D, Mensah GA. Major multinational food and beverage companies and informal sector contribu-
tions to global food consumption: implications for nutrition policy. Global Health 2011;7:26.
9. FAO. School kids and street food. 2007. Available at: http://www.fao.org/ag/magazine/0702sp1.htm. Accessed
March 21, 2012.
10. Yach D. Nutritional change is not a simple answer to non-communicable diseases. BMJ 2011; 343: d5097.
11. NYC DOH. Cutting Salt, Improving Health. 2011. Available at: http://www.nyc.gov/html/doh/html/cardio/cardio-salt-
initiative.shtml. Accessed March 21, 2012.
12. PepsiCo. Human Sustainability. Available at: http://www.pepsico.com/Purpose/Human-Sustainability.html.
Accessed March 21, 2012.
The practice section of the SJPH
centers on the implementation of public health
initiatives on the ground, initiatives that are the
culmination of research questions and policy
decisions.

In this issue, the articles explore approaches
to prevention in public health through different
technologies. The articles examine water
sanitation technologies, computer science
techniques, new approaches to non-communicable
diseases, and vaccine implementation as
prevention strategies.
PRACTICE
Non-Communicable Diseases in Kenya
Balancing Priorities in Healthcare
Funding and Initiatives
McKenzie Wilson
Development, as we
often understand it,
implies increased health,
wealth, and improved
governance. However,
there is a side of health
development that often
goes neglected in aid
programs and ministry of
health programs in low-
income countries. Indeed,
as the general health of
a population improves,
and epidemic diseases
fade from the public
mind, further challenges
surface. This so-called
epidemiological
transition happens when
developing countries
move out of a period
of epidemic shocks,
high mortality, and low
life expectancy from
infectious diseases to a
period of stable levels of
chronic disease. In this
phase, life expectancy
is higher, there are
few or no epidemics,
and most people die
of preventable long-
term illnesses like heart
disease. Many Afiican
countries are hurtling
towards this phase
without the appropriate
infrastructure to confront
it.
With the largest GDP
in Eastern and Central
Afiica, Kenya is cIassihed
as a developing,
eneiging Afiican nalion.
With forty-seven percent
below the poverty
line, Kenya hardly
seems an emerging
nation by Western
standards.
1
However,
recent national health
trends indicate that
Kenya is approaching
a transition into a
developed population
health structure, with a
corresponding shift in
their national disease
burdens where non-
communicable diseases
(NCDs), or lifestyle
diseases, are on the rise.
Kenyas 2.8% annual
population growth
rate has contributed
to the tripling of its
population over the last
four decades.
2
Fertility
rates are beginning to
decline due to economic
pressures, which will
begin to increase the
overall age structure of
the population.
3
These
increases are offset by
high infant mortality of
52 per 1000 and a low
life-expectancy at birth
of 59--20 years less than
the United States.
3
This
expectancy represents a
20% increase from 1969,
when the average life
expectancy at birth for
a Kenyan stood at just
50 years. This increase
has contributed to the
rise of chronic lifestyle
diseases.
3
Kenyans are
living long enough to
develop NCDs related
to cardiovascular and
metabolic health. NCDs
now account for majority
of hospital admissions
and are responsible for
22% of national deaths.
4
It
is important to establish
multi-sectorial practices
that will address NCDs
and minimize their
negative effects on
human capital and the
economy.
With two million
Kenyans infected with
HIV, lhe uigency of lhe
HIV/AIDs epidenic is
juslihed and difhcuIl lo
ignore, but the increasing
incidence of NCDs is
equal cause for concern.
NCDs will contribute
to over 60% of the
total national deaths
by 2030.
5
Accoiding lo
James Munene, head
of Kenyatta National
Hospitals Cardiac
Unit, risk reduction
efforts are not working
-- we dont see efforts to
ensure proper nutrition,
exercise [or the reduction
of tobacco use and the
harmful use of alcohol]
-- the things that could
prevent many of these
NCDs.
6
Risk reduction
efforts have been
hindered by the lack of
an ofhciaI NCD posilion
and policy statement.
Despite the establishment
of an NCD division of
the Ministry of Health
in 2001, the resource
allocation to NCDs
remains low, and foreign
aid initiatives prioritize
infeclious diseases. And
yet, these health concerns
are not entirely mutually
exclusive.
Accoiding lo a 2O11
observational study
conducled vilh HIV
patients in Western
Kenya, there is a
high prevalence
of hypertension
and oveiveighl/
olesily anong HIV+
patients, and the
caie of HIV+ palienls
in sul-Sahaian Afiica
should also include
lolh idenlihcalion
and management of
associated cardiovascular
risk factors.
7
In
particular, the study
found a positive
correlation between low
CD4 counts and incident
cardiovascular risks and
a particularly high rate
of hypertension among
young peopIe vilh HIV.
7

The researchers speculate
that increased rates of
associated cardiovascular
risk factors in younger
HIV-posilive individuaIs
are caused by metabolic
disturbances related to
HIV infeclion and Anli-
Retroviral Treatment
regimens.
7
Such hndings
have tremendous
implications for the
Government of Kenyas
future health policy and
practice.
Implementation of
culturally appropriate
and effective NCD risk
reduction strategies is
difhcuIl, hovevei, and
successful risk reduction
strategies from the
PRACTICE
West cannot simply be
transposed to Kenya.
Accoiding lo Ceoige
Gachie, cofounder of the
Mathare Roots Youth
Cioup, Afiica is veiy
different from the West
because most families
here dont have as many
options with food, so if
people get sick here [it]
will because they are
lacking a proper diet.
only a small percentage
of people can afford to
eat junk and sweet food.
It is impossible to dictate
the diets of people with
limited resources and
similarly not practical
to implement Western-
inspired anti-junk food
campaigns. If Kenyans
lack the resources to
eat proper nutrients,
preventing chronic
conditions will require
an initial infrastructural
investment in nutrition
and population health.
In Kenya, where many
families cannot provide
consistent food at home,
school is the primary
source of nutrition for
many children. However,
many Kenyan schools
feed maize to students
as their main source of
nutrition, which alone
cannol piovide sufhcienl
nutrition. Gachie says if
the government chooses
to focus on nutrition
as a risk reduction
strategy, its money
would be best spent
improving school food
piogians. AddilionaIIy,
Gachie suggested the
government should
encourage more farming
activities and support
farmers in bringing their
products to markets
to make it easier for
the increasingly urban
population to have a
healthy, affordable diet.
Gachie also emphasizes
the need for more local
health centers because
people suffer without
knowing what the
problem is, and by the
time they want to visit
the hospital in most
cases its too late. These
health centers could be
pieexisling HIV/AIDS
clinics or established
in local schools to
avoid expenditures on
additional infrastructure.
In Kenya, NCDs
present an equal
challenge to the high-
piohIe HIV epidenic
and infectious disease
problems. Instead of
competing for funding,
donors and health
ofhciaIs shouId le
aware of the correlation
lelveen HIV/AIDS and
chronic diseases and
prioritize prevention and
treatment of both. While
many national health
systems resources and
infrastructure are already
stretched to the limit, the
ongoing epidemiological
transition must be taken
into account. For the sake
of those already suffering
from chronic disease in
Kenya, the sooner, the
better.
One of Roots volunteers speaks to Mathare schoolchildren about
sexuality in society and healthy sexual habits and behaviors.
A Roots volunteer gives a leadership workshop talk as part of
Roots community health workshop.
GEORGE GACHIE | with permission GEORGE GACHIE | with permission
1. Kenya Country Brief. IMF. Accessed 26 February 2012.
George Gachie co-founded Mathare Roots Youth Group. Raised by a single mother, Gachie still received his college de-
gree. Gachie started the Roots youth group to provide Mathare kids with after school sports and public health programs.
2 Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health Survey 2008-09.
Calverton, Maryland: KNBS and ICF Macro. 28.
3 Shreffer, Karina M., and F. Nii-Amoo Dodoo. "The Role of Intergenerational Transfers, Land, and Education in Fertility
Transition in Rural Kenya: The Case of Nyeri District." Population and Environment 30.3 (2009): 75-92.
4 Kimono, Francis. Decision-making for NCDs in Kenya.
5 The NCD Alliance. First Kenya National Forum on NCDs concludes with the Naivasha Call for Action. Available at: http://
www.ncdalliance.org/node/3499. Accessed February 28, 2012.
6 IRIN News. Kenya: NCDs and HIV Fight for Limited Resources. Available at: http://www.irinnews.org/Report/93766/
KENYA-NCDs-and-HIV-fght-for-limited-resources. Accessed February 28, 2012.
7 Bloomfeld GS, Hogan JW, Keter A, Sang E, Carter EJ, et al. Hypertension and Obesity as Cardiovascular Risk Factors
among HIV Seropositive Patients in Western Kenya. [online]. 2011; 6 (7). Available from PLoS ONE.
PRACTICE
The UV Tube
Technology and Preventing
Waterborne Diseases
Eileen Mariano
Many developing countries are
plagued by waterborne diseases,
scourges that developed countries
left behind decades ago. Illnesses
caused by drinking unsafe water
kill millions of people annually,
primarily affecting communities
in Asia and Afiica
1
. For the most
part, such diseases stem from
consuming water that has been
contaminated by animal or human
feces. Though the range of illnesses
is diverse, they have one thing in
common: they are all preventable.
In fact, most of the people suffer-
ing from these diseases would be
healthy if they had access to safe
drinking water. These disparities
have led to a recent, worldwide
push to create effective, inexpen-
sive, and ieaIislic valei puiihca-
tion technologies. The Blum Center
for Developing Economies at the
University of California, Berkeley
is one of the many organizations
contributing to those initiatives.
Through different projects like
their Ultraviolet Tube Disinfec-
lion (UV Tule), lhe cenlei sliives
to reduce the number of people
suffering from preventable wa-
terborne diseases.
2
Humans need
clean water to accomplish their
daily washing, bathing, cooking,
and drinking. Yet, worldwide, ap-
proximately 1.1 billion people do
not have access to safe drinking
water, and as many as 2.4 billion
people do not have access to water
clean enough to properly bathe.
Because of this astonishing lack of
access to safe water, it is estimated
that more than two million deaths
result from waterborne diseases
annually, with illness affecting an
even larger number of people.
3

AIlhough nany diseases vouId le
prevented by appropriate sanita-
tion and access to safe water, there
are six particularly harmful bacte-
rial and viral infections that scien-
tists hope to prevent. The harmful
bacteria include Campylobacter spp.,
enteroaggregative Escherichia coli,
Salmonella typhi, and Vibrio cholerae.
The viiuses incIude Hepalilis A
and rotavirus. Once animal feces
contaminate water, human inges-
tion causes the bacteria to lodge
themselves in the lower intestine,
causing severe diarrhea, dysen-
tery, fever, and extreme dehydra-
tion.
4,5,6,7
Viiuses aIso liaveI in
animal feces but target the liver
and small intestines.
Though the bacterial and viral
diseases can usually be treated,
providing access to proper treat-
nenls can le difhcuIl in lhe Iov-
resource settings where they are
rampant. Thus, it is advantageous
to prevent the diseases before they
infect people, a task that can be
done by increasing the number of
communities that have access to
safe drinking water. For their part,
the Blum Center has created four
effective technologies as a part of
lheii Safe Walei & Sanilalion can-
paign. Particularly successful has
been their Ultraviolet Tube Disin-
feclion (UV Tule). The nan ie-
sponsible for the invention of these
technologies, as well as the famous
Daifui Slove, is Docloi Ashok
Gadgil, physician and professor.
He desciiles hov his UV puiihca-
tion invention works.
Il sends UV Iighl al vaveIenglh
of 240 nanometers into the unclean
valei. The DNA of lacleiia, oi of
the contaminants, is very sensitive.
When DNA inleiacls vilh lhal
specihc vaveIenglh, lhe covaIenlIy
bonded nucleotides are disrupted,
preventing the organism from be-
ing alIe lo iead lhe DNA anynoie.
This kills the organism. In other
words, sending light of a precise
wavelength at the contaminated
diinking valei deslioys any DNA
present. Without genetic coding in-
tact, all impurities in the water are
unable to survive and therefore do
not make the passage from water
to human intestines.
CadgiIs UV lule is inciedilIy
successfuI al lhoiough puiihca-
tion but works most effectively on
smaller amounts of water. For this
reason, the tubes are distributed
to individual families or shared
amongst a few households. In ad-
dition, the price is in an affordable
range for the recipients, and one
tube uses only 15-20 watts of elec-
tricity per day, making it a realistic
option for the impoverished com-
munities that use it.
9

However, the technology is not
Worldwide,
approximately 1.1
billion people do not
have access to safe
drinking water, and
as many as 2.4 billion
people do not have
access to water clean
enough to properly
bathe.
3

PRACTICE
peifecl. Accoiding lo Di. CadgiI,
improvements to the overall cost
need lo le nade. An affoidalIe
price for people in developing
countries to pay for clean water
is 4 cents per liter, the professor
explains. For these technolo-
gies, operational costs are only
1/5O
th
of a US cent per 10 liters.
However, once you add up the
cost of monitoring, maintenance,
salaries, and repeated testing, the
companies distributing the tube
have not yet found a way to easily
sustain themselves. This needs
to be worked out.In addition to
hguiing oul a vay lo ieduce lhe
cosl of nanufacluiing lhe UV lule,
the next step companies hope to
take is to increase the distribution
of lhese and olhei valei puiihca-
tion innovations. With help from
invenlions such as eikeIeys UV,
the number of people around the
world with access to safe drinking
valei is on lhe iise. As of Maich
6, 2012, the WHOs Millennium
Development Goal regarding safe
water access has been met: 89% of
the world now are using improved
water sources.
10
Hopefully the
number of people with preventable
waterborne diseases will soon be
on the decline as a result.
1. WHO: Waterborne Disease is Worlds Leading Killer. Website. Available at: http://www.voanews.com/english/
news/a-13-2005-03-17-voa34-67381152.html. Accessed February 13, 2012.
2. Gadgil, Ashok Ph.D., Director of the Environmental Energy Technologies Division of Lawrence Berkeley National
Laboratory and Professor of Civil and Environmental Engineering at UC Berkeley. Interviewed February 2, 2012.
3. Waterborne Diseases. Website. Available at: http://www.lenntech.com/library/diseases/diseases/waterborne-diseas-
es.htm. Accessed March 6, 2012.
4. Campylobacter Infections. Website. Available at: http://emedicine.medscape.com/article/213720-overview. Accessed
February 11, 2012.
5. Typhoid Fever. Website. Available at: http://www.cdc.gov/nczved/divisions/dfbmd/diseases/typhoid_fever/. Accessed
February 11, 2012.
6. Enteroaggregative Escherichia coli. Website. Available at: http://www.ncbi.nlm.nih.gov/pubmed/11871803. Accessed
February 11, 2012.
7. Vibrio Cholerae and Asiatic Cholera. Website. Available at: http://textbookofbacteriology.net/cholera.html. Accessed
February 11, 2012.
9. Ultraviolet Water Disinfection for Rural Communities. Website. Available at: http://blumcenter.berkeley.edu/global-
poverty-initiatives/safe-drinking-water-sanitation/UV-tube-disinfection. Accessed February 11, 2012.
10. Millennium Development Goal Drinking Water Target Met. WHO Media Centre.
Too Complicated For Google Search
Palantirs Health Team Tackles
Challenges with Data Analysis
Mailyn Fidler
This outbreak was dif-
ferent, it was clear. In
the summer of 2010, I
was an intern assisting
analysts in the Emer-
gency Operations Center
(EOC) at the Centers
for Disease Control and
Prevention (CDC). They
were on alert, monitor-
ing the progression of an
outbreak of Salmonella
Javiana in Indiana. This
infection causes particu-
larly nasty food poison-
ing and affects about a
million people annually.
1

More people were fall-
ing ill than had ever been
seen in Indiana from this
strain. The average case
age was much higher
than usual.
As case counls iose, lhe
analysts grew increas-
ingIy voiiied aloul hnd-
ing the source to stop the
outbreak. These analysts,
however, had the advan-
tage of an unusual group
of sidekicks. Next to
them sat the health team
from Palantir, a Silicon
VaIIey conpany speciaI-
izing in data analysis and
integration.
Lekan Wang is one of
those team members.
Wang, a Stanford gradu-
ate, joined Palantirs
health team during the
epidemic. Wangs team
includes a Stanford im-
munology PhD, a former
director of engineering
at a startup, and a medi-
cal student on leave from
Dartmouth.
PayPal executives
founded Palantir Tech-
nologies in the wake of
9/11 lo piovide soIulions
to some of the worlds
biggest challenges with
better data integration
and analysis. Palantir
has 500 employees in of-
hces acioss lhe gIole. The
health team, Wang said,
was created because we
saw problems [across our
healthcare system], and
there was a lot of data in-
volved, and we thought,
how can we use Palantir
to make it better?
Wangs team built a
PRACTICE
data analysis platform
for the CDCs Outbreak
Response and Prevention
Branch within the Divi-
sion of Foodborne, Water-
borne, and Environmen-
tal Disease. The platform
integrates huge amounts
of structured and un-
structured data used
during an outbreak. It
allows analysts to search
the data with different
hIleis, iecoid conneclions
between data, and to
track and share how they
develop their analysis.
If you need to visu-
alize your data, thats
assuming you already
have your data nicely
organized, Wang said.
In a large organization,
hundreds of databases
may be used, and this
organized data must
be integrated with less
formal data like that
LxceI hIe enaiIed lack
and forth for years,
Wang said.
The health team cus-
tomized the platform to
combine different types
of data. The data can
then be analyzed with
multiple searches and
hIleis. The pIalfoin
makes using the data
intuitive, meaning com-
plicated interactions with
databases are more ac-
cessible to analysts. The
platform also increases
lhe specihcily of a dala
search. The goal was to
create a system that had
the ability to give me
every location of a child-
care center that the wind
could have blown this
organism to, Wang said.
This problem is funda-
mentally different from
everyday searching and
gets a little complicated
for Google search.
The team had to ad-
dress concerns about data
sharing. Most health
info is highly sensitive.
We have to access this
data very quickly while
preserving security,
Wang said. The team
also wanted to allow ana-
lysts to share new data
and interpretations with
each other easily.
With spreadsheets,
it gets out of sync and
theres a lot of mess.
With the CDC, especially
with foodborne epidemi-
ology, you are interacting
with states, who prob-
ably have their own data
formats, Wang said. The
platform allows quick
sharing of new data with
the added feature of
sharing analysis you
can share a concept and
the path of how you got
there.
The platform helped
analysts pick apart
the details of the epi-
demic. The time and
location-based searches
of epidemiologic data
helped them separate the
Indiana epidemic from
the one in the south-
east. Combined with
liadilionaI heIdvoik, lhe
platform helped cluster
cases around a group of
restaurants. The tools in-
tegration of supply chain
information with epide-
miological data helped
determine the exact cause
of the outbreak lettuce
from a farm in Salinas
VaIIey, CaIifoinia.
These discoveries
are feasible outside of
Palantirs framework.
The platform, however,
makes these determina-
tions faster, saving time,
resources, and prob-
ably lives. Essentially,
Wang said, the system
is a platform that lets
you chase your thoughts
and quickly iterate on an
idea. The platform will
continue to integrate data
from the CDC over time,
providing an easy access
point to CDC institution-
al knowledge.
Palantir deployed the
platform for use during
the cholera outbreaks fol-
lowing the Haiti earth-
quake. The platform
helped integrate Twit-
ter posts and other data
sources to try to get the
early alert to where cases
were happening, Wang
said. Currently, the team
is turning its thoughts
towards the health insur-
ance realm and how to
process data to reduce
healthcare costs.
Overall, the team
approaches the intersec-
tion of public health and
computer science with an
inclusive attitude. Com-
puters are very good at
certain things, humans
are very good at certain
things, so combining
both of the best is where
we really get our value,
Wang said. In this case,
the platform combines
the vast memory of the
computer to calculate
possibilities with the in-
tuition of the analyst.
A slandaid oullieak
survey tool for use across
states, Wang said, is
The Palantir health team fghts off health problems with the power
of computing. The company is headquartered in Palo Alto.
LEKAN WANG | with permission
PRACTICE
probably next on the
teams development list
for the CDC. To conduct
surveys during the sal-
monella outbreak, EOC
staffers spent hours at the
phone banks, collecting
data the old-fashioned
way, by hand and on pa-
per. Palantirs platform,
with its lowered barrier
between data and ana-
lysts, would have been
a welcome addition to
those late nights.

1. Multistate Outbreaks of Salmonella Infections Associated with Raw Tomatoes Eaten in Restaurants. Available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5635a3.htm. Accessed February 26, 2012.
The map portion of the database shows the progression of the
outbreak and cumulative cases by state.
A comparison between Indiana cases and normal seasonal south-
eastern cases from the Palantir dashboard. Note the differing age
patterns and onset peaks.
Gardasil versus GAVI
Challenges to Implementing HPV
Vaccines in Developing Countries
Cervical cancer, caused by human
papillomavirus (HPV), is one of
few preventable cancers. In the
developed world, this cancer
is relatively easy to manage
with preventative surgery or
HIV vaccines such as CaidasiI.
However, in the developing world,
cervical cancer is a virulent threat
consistently ranking among the
leading causes of death in women.
1

HIV causes appioxinaleIy 275,OOO
deaths due to cervical cancer
each year, 88% of which occur in
developing countries.
2
If available
aiound lhe voiId, lhe HIV vaccine
could decrease rates of cervical
cancer by 70%.
2

The CIolaI AIIiance foi Vaccines
and Innunizalions (CAVI) vas
launched in early 2000 to support
the implementation of vaccination
programs to reduce child mortality
rates in 70 of the worlds poorest
countries.
3
CAVI galheis funds
from donors worldwide, and
decides which vaccines would
le lhe nosl efhcacious and cosl-
effective to introduce to these
counliies. RecenlIy, CAVI has
agieed lo fund lhe HIV vaccine.
This decision will likely protect
two million women in nine
countries from cervical cancer by
2015.
2
AIlhough CAVI has agieed
to fund this vaccine, impediments
to introduction of the vaccine
may still exist, says Dr. Lauri
Maikovilz, an expeil on HIV
and STIs at the Center for Disease
Control and Prevention (CDC).
4
CAVI nay covei lhe cosls foi
vaccines and some operational
costs, but the states are responsible
for delivering them in the most
effeclive and efhcienl vay.
Introduction of vaccine requires
capacity for storage, transport, and
personnel, which might be lacking
in the country, adds Markowitz,
further complicating the launch
of the vaccine program. Due to
infrastructure and capacity issues,
nany CAVI counliies nay deIay
the introduction of this vaccine.
Public health experts have
expressed concerns about the
Cristina Averhoff
Lekan Wang, MS&E '09 and Computer Science (Biocomputation) '11, works at Palantir Technologies and enjoys the free
T-shirts they give him.
PRACTICE
inpIenenlalion of HIV vaccine
piogians in CAVI counliies,
particularly regarding the
introduction and delivery of the
vaccine to preadolescent girls.
Unfortunately, countries have
little experience with routine
vaccination in the target age group,
pre-adolescents, and the required
three doses makes delivery even
noie difhcuIl.
5
An inleinalionaI
non-piohl, lhe Iiogian foi
Appiopiiale TechnoIogy in Healh
(IATH), iecenlIy pulIished
a paper claiming they have
acheivedachieved high rates of
coveiage fion lhe HIV vaccine
in low and middle income
countries.
5,6
This organization
worked with the governments
of India, Ieiu, and Vielnan lo
research and gather evidence to
determine how best to introduce
HIV inlo lhese counliies.
5,6
Their
study involved 7289 families, each
with a daughter in school who
was eligible to receive the vaccine.
This study found that school-
based implementation of the
vaccine resulted in high coverage
for these girls. Reasons for lapses
in coverage varied depending on
the country. Ultimately, lack of
awareness of the program and the
concern of the experimental nature
of the study were major factors
in the parents decisions to not
vaccinate their daughters.
5,6

Many CAVI counliies, hovevei,
have large rural populations in
ienole aieas lhal aie difhcuIl
to access, and even programs
initiated in schools and health
facilities will not reach many
young vonen. Accoiding lo
USAID, 25 of giiIs in deveIoping
countries do not attend school;
these millions of girls would
be neglected by a school-based
vaccination program.
67
Markowitz
remarked that alternative
programs for these regions are
being considered. Some have
suggested additional vaccination
programs for the isolated group of
girls within the target age group.
AddilionaI huidIes incIude
developing programs for a new
target age group and coordination
issues within government health
departments. Most routine
innunizalion syslens in CAVI
countries are geared toward
vaccinating children under the
age of hve. Ioi HIV, lhe WHO
has started to formulate unique
policies and program guidance
for the introduction of adolsecent
HIV vaccinalions. Inlioducing a
routine immunization program
for preadolescent girls requires
innovation, novel methods, and
numerous studies to determine the
efhcacy and feasiliIily of vaiious
models to have maximal coverage
for this unusual target age range.
Successful introduction of
HIV vaccine viII aIso iequiie
communication and collaboration
among many different groups
within the Ministry of Health,
a term used in many countries
to describe the national health
department. Unlike other
innunizalions, HIV iequiies
a major collaborative effort
among immunization programs,
cancer prevention programs, and
programs that address sexually
transmitted infections. In order
to have feasible policies for
introduction, these stakeholders
must cooperate, says Markowitz,
an additional hurdle to introducing
lhe vaccine in CAVI counliies.
AIlhough CAVI has agieed lo
fund lhe HIV vaccine as a iouline
vaccinalion, CAVI counliies aie
far from realizing a practical,
effeclive HIV innunizalion
program. Not only do many of
the countries lack resources and
capacity for introduction, but
implementing a vaccine geared
towards young women also
generates new infrastructural and
cultural challenges. Unlike routine
innunizalion piogians, lhe HIV
vaccination scheme has a unique
set of obstacles to overcome:
the additional infrastructure
required to administer the vaccine
to a novel and often neglected
target population, and the
need for increased government
coordination. In spite of these
challenges, some low resource
countries have already introduced
lhe HIV vaccine, vhich nay uige
olhei CAVI counliies lo oveicone
barriers and launch successful
programs of their own.
Dr. Lauri Markowitz MD is the Team Lead for Epidemiology Research in the Division of STD Prevention, Na-
tional Center for HV, Viral Hepatitis, STD and TB Prevention (NCHHSTP), Centers for Disease Control and
Prevention (CDC).
1. Womens Health. World Health Organization. Available at: http://www.who.int/mediacentre/factsheets/fs334/en/index.html. Accessed
April 1, 2012.
2. GAVI Takes First Steps to Introduce Vaccines against Cervical Cancer and Rubella. Global Alliance for Vaccines and Immunizations.
Available at: http://www.gavialliance.org/library/news/press-releases/2011/gavi-takes-frst-steps-to-introduce-vaccines-against-cervi-
cal-cancer-and-rubella/. Accessed March 4, 2012.
3. GAVI Alliance. Available at: http://www.gavialliance.org/. Accessed March 12, 2012.
4. Winkler, JL. Determinants of Human Papillomavirus Vaccine Acceptability in Latin America and the Caribbean. Vaccine
2008;26(11):73-79.
5. LaMontagne, DS. Human papillomavirus vaccine delivery strategies that achieved high coverage in low- and middle-income coun-
tries. Bulletin of the World Health Organization. 2011;89:821-830B.
6. USAID Offce of Gender Equality & Women's Empowerment: Gender Statistics. US Agency for International Development. Available
at: http://www.usaid.gov/our_work/crosscutting_programs/wid/wid_stats.html.
The investigation
section of the SJPH presents and analyzes
pressing public health issues through
the lens of epidemiological, medical, and
scientifc perspectives.
In this issue, we investigate prevention
in public health by examining the latest
research on effectively countering obesity
and prostate cancer.
INVESTIGATION
Sleeper Cells
Latent Links Between
Infection and Prostate Cancer
Kasey Kissick
Prostate cancer is a common diag-
nosis. In fact, it is the most com-
mon non-cutaneous malignancy
diagnosed and the second leading
cause of cancer death in men in the
United States.
1
Due to increasing
life expectancies, this late-onset
cancer has seen a marked increase
in incidence over the last few
decades. Despite its widespread
and growing prevalence, little is
understood about the actual causes
of prostate cancer. The only known
risk factors are family history,
age, and iace. AIlhough Afiican
Aneiicans have lhe highesl iales
of prostate cancer, the reason for
this prevalence is unknown.
1
Even
more perplexing is the fact that
lhal nen Iiving in Asia aie nuch
less likely to develop prostate can-
cer than those in the US or Western
Luiope. Hovevei, vhen Asian
men move to western countries,
their risk increases.
2
These results
indicate that prostate cancer risk
is not simply the result of genetics
and aging. Like many other can-
cers, environmental factors may be
involved. Current prostate cancer
research is investigating the role
of dietary factors, chemical agents,
cigarette smoke, and infectious
agents like bacteria and viruses.
Most would be surprised to
learn that a number of cancers
have infectious origin, but the
Aneiican Cancei Sociely iepoils
that 20% of all cancers are trig-
gered by infections. To name a few
pairs: Hepatitis B virus and liver
cancer, human papillomavirus
(HIV) and ceivicaI cancei, schislo-
somes and bladder cancer, and the
ulcer-causing bacteria, Helicobacter
pylori, and stomach cancer. Some
microbes induce carcinogenesis by
directly targeting and damaging
DNA, Iike HIV does vilh ceivi-
cal cancer. Others, like H. pylori in
stomach cancer, trigger a chronic
inannaloiy innune iesponse,
vhich danages DNA ovei line.
3
In
many cases, discovering the infec-
tious agents involved in cancers
can le difhcuIl lecause lhe cancei
develops years or even decades
after infection. Establishing these
links requires time-intensive,
large-scale epidemiological stud-
ies lo seIecl and conhin suspecled
infection candidates. H. pylori, for
instance, was linked to stomach ul-
cers in 1980, but it took 10 years, 12
studies, and a grand total of 1128
cases and 34O6 conlioIs lo conhin
that infection with the bacteria was
associated with an increased risk of
stomach cancer.
4
AIlhough il can lake nany yeais
lo conhin a suspecled ieIalion-
ship, uncovering a link between
an infectious agent and cancer is of
immense public health importance.
Idenlihcalion of lhe polenliaI cause
and effect facilitates preventive
measures and early treatment.
In lhe case of HIV and ceivicaI
cancer, the Gardasil vaccine is
estimated to protect against 70%
of cervical cancers.
5
Likewise, the
discovery that H. pylori increases
stomach cancer risk 6-fold could
be crucial to preventing stomach
cancer by screening for and treat-
ing ulcers early with antibiotics.
4

Similarly, schistosomes can be
screened and treated with a round
of anti-helminthic drugs to elimi-
nate the parasite before the onset
of bladder cancer. Knowing that
a certain virus or bacteria may
predict cancer later in life com-
pletely changes the picture; with
such knowledge, cancer prevention
becomes a very attainable goal. Dr.
Jonathan Simons, president and
CEO of the Prostate Cancer Foun-
dation explains, discovering the
pathogens that cause cancer has
been transformational in reducing
death and suffering and in generat-
ing entirely new prevention strate-
gies. The polenliaI lo signihcanlIy
INVESTIGATION
cut healthcare costs, save lives, and
alleviate suffering is what makes
this preventive research so worth-
while.
In the case of prostate cancer,
many signs suggest an infectious
agent may play a role in its patho-
genesis. Mirroring the relationship
between H. pylori and stomach
cancer, an infection causing chronic
inannalion nay, ovei line, Iead
to prostate cancer. Several bacteria,
viruses, and parasites have been
observed to infect the prostate
and geneiale an inannaloiy
response, and studies show that
ieguIai useis of anli-inannaloiy
agents such as aspirin report a re-
duced risk of developing prostate
cancer.
1
Current evidence suggests
lhal sone unidenlihed infeclion
occurs early in life and produces
chionic, asynplonalic inanna-
tion in the prostate, which after 20-
30 years, leads to prostate cancer.
1

Two microorganisms at the top of
suspect list include the protozoan
parasite, Trichomonas vaginalis,
and the notoriously widespread
and asymptomatic bacterial fam-
ily of Mycoplasma.
6,7
Both produce
chronic, largely unrecognized
infections. Interestingly, both infec-
lions aie noie pievaIenl in Afiican
Aneiicans, peihaps expIaining lhe
mystery of race as a risk factor.
6,7

Currently, no conclusive data
exists revealing a strong associa-
tion between a single microbe and
prostate cancer. The time lag and
symptomless nature of many
pioslale infeclions nake conhin-
ing the role of an infectious agent
a chaIIenge. AddilionaIIy, ieseaich
of the prostate is limited, and there
is still much uncertainty about
what constitutes the normal bacte-
iiaI oia of lhe pioslale. Wilh lhis
knowledge, it would be easier to
pinpoint the agents that might be
pioducing an inannaloiy, can-
cerous effect.
Solidifying the link between an
infectious agent and prostate can-
cer may not, however, be the sole
answer. There could be multiple
microbes involved or a number of
cofactors, such as dietary issues,
that could interact to create the
conditions necessary for prostate
cancer. Despite the challenges,
researchers remain optimistic.
Simons calls this search one of
the highest public health issues
of our era. Moving forward, he
believes the obvious suspects are
usually never responsible, and it
will require innovation and discov-
ery with new biotechnologies and
insights from innovative young
scientists to elucidate the microbe
or microbes that are respon-
sible. With modern diagnostic
technologies and growing interest
in research on cancer and infection,
a discovery may occur soon.
1. De Marzo AM, Platz EA, Sutcliffe S, Xu J, Gronberg H, Drake CG. et al. Infammation in prostate carcinogenesis. Nat Rev Cancer.
2007;7(4):256-69.
Jonathan Simons, president and CEO of the Prostate Cancer Foundation, is a recognized physician-scientist
and leader in prostate cancer research. Simons attended Johns Hopkins Medical School where he completed
a clinical fellowship in medical oncology and a post-doctoral fellowship in human cancer molecular genetics.
Macrophages attack a cancer cell by fusing with it and injecting toxins. This weakens the
cell and begins the process of cell death.
Wikimedia commons | with permission
2. Hsing AW, Tsao L, Devesa SS. International trends and patterns of prostate cancer incidence and mortality. Int J Cancer
2000;85(1):60-7.
3. Coussens LM, Werb Z. Infammation and cancer. Nature 2002;420(6917):860-7.
4. Helicobacter and Cancer Collaborative Group. Gastric cancer and Helicobacter pylori: a combined analysis of 12 case control studies
nested within prospective cohorts. Gut. 2001;49(3):347-53.
5. HPV Vaccines. National Cancer Institute. http://www.cancer.gov/cancertopics/factsheet/prevention/HPV-vaccine
6. Stark JR, Judson G, Alderete JF, Mundodi V, Kucknoor AS, Giovannucci EL, et al. Prospective study of Trichomonas vaginalis infec-
tion and prostate cancer incidence and mortality: Physicians Health Study. J Natl Cancer Inst. 2009;101(20):1406-11.
7. Barykova YA, Logunov DY, Shmarov MM, Vinarov AZ, Fiev DN, Vinarova NA, et al. Association of Mycoplasma hominis infection with
prostate cancer. Oncotarget 2011;2(4):289-97.
INVESTIGATION
American obesity rates have
sky-rocketed in the past two
decades. Accoiding lo lhe
Center for Disease Control and
Iievenlion, 33.8 of aII Aneiicans
are obese, while 17% of children
aged 2-19 are obese.
1
Physicians
and pulIic heaIlh ofhciaIs have
been concerned about this rapid
increase because obesity is often
a risk factor for many other
chronic diseases, including heart
disease and diabetes. Public
heaIlh ofhciaIs and goveinnenl
organizations have expended
considerable resources to establish
programs to tackle obesity,
especially among children.
Thanks to these efforts, the overall
prevalence of obesity in the United
States has stabilized in recent years
according to a January report by
the National Center for Health.
1

Further interventions are required
before we can count this plateau of
obesity prevalence a success rather
than a loss of momentum.
Most anti-obesity programs
focus on the positive adjustments
that individuals can make on
a daily basis in order to lead a
healthy lifestyle. For example,
in February 2010, Michelle
Obama launched the national
Lels Move! canpaign lo hghl
childhood obesity.
2
Lets Move!,
and other organizations such as
lhe NILs ILAY 6O, have laken a
positive approach to the epidemic
by encouraging children to get
outside and play games and
participate in activities as simple
as throwing a ball. In essence,
these programs convert time
spent on the couch to exercise.
Lets Move! also incorporates
a nutritional component that
provides information and support
for parents. For initiatives such
as these, the main objective is not
weight loss; the ultimate goal is
lifestyle changes that will allow
children to better pursue their
goals and dreams.
Other campaigns, such as
AlIanla, Ceoigias Sliong4Life
program have employed more
conlioveisiaI nelhods lo hghl
chiIdhood olesily. As a pail of
ChiIdiens HeaIlhcaie of AlIanla,
Strong4Life chooses to draw
attention to the negative effects of
obesity on a childs emotional and
physical health. The programs
advertisements, which feature
photos of obese children along
with messages such as Its hard
to be a little girl when youre not
and My fat may be funny to you,
but its killing me, have come
undei hie foi vhal is leing caIIed
fat shaminghumiliating and
degrading individuals because
they are fat.
3
Opponents of the
Strong4Life campaign believe
that it does more harm than good
because it reinforces stigmas about
weight. Furthermore, it raises
concerns about the prevalence of
disordered eating in the United
States. These concerns raise
questions about what message is
appiopiiale lo send lo Aneiicas
children about their weight
and body image. In addition,
are billboards and television
commercials the best forums to
present the issues? Individuals
and policy makers together must
strike a balance between the
potentially harmful emotional
effects of these advertisements
and the negative emotional and
physical consequences of obesity.
While these organizations and
campaigns have brought attention
to the prevalence of obesity
anong Aneiican chiIdien, sone
scholars question the leveling
off of the obesity rate. Dr. Lisa
Rosas, an instructor and researcher
at the Stanford Prevention
Research Center, cautions against
interpreting the National Center
The Obesity Plateau
Stigma, Statistics, and Success
Perri Smith
President Obama addresses a group of kids from "Let's Move!, Michelle Obama's
cornerstone obesity prevention campaign.
INVESTIGATION
for Health Statistics data at face
value.
I dont know that experts in
lhe heId aie ieaIIy ieady lo say
that weve plateaued, Dr. Rosas
said. When you start to look at
disparities you dont necessarily
see pIaleauing in aII iaciaI/elhnic
groups, and if you were to look
at education and income you
wouldnt see it in all those levels
either.
Furthermore, Dr. Rosas presents
another analysis of the plateau:
peihaps Aneiicans have sinpIy
reached the threshold for the
amount of people who can become
obese.
Moving forward, experts
believe policy changes and social
movements will play an important
role in further reducing the obesity
rates in both children and adults.
Dr. Gardner, a nutrition scientist at
the Stanford Prevention Research
Center, compared the anti-obesity
campaign to the anti-tobacco
movement of recent decades.
Policies that made it illegal to
snoke in hospilaIs, ofhces and
bars have been integral in reducing
the number of people who smoke,
and similar measures should be
enacted with obesity, Gardner
argues. San Francisco and Santa
Clara recently passed a toy ban
that prohibits the use of toys as an
incentive to purchase restaurant
meals that do not meet a certain
nuliilionaI slandaid. AIlhough
these actions have received some
backlash from parents and the
fast food industry, the enacting
governments consider these steps
necessary to prompt change in
other related areas.
Effective measures must be
taken in order to ensure that
obesity rates do not simply plateau
but also decline. Ultimately,
society, with help from individuals
and policies, must change the
way in which it views obesity
if we truly want to decrease its
prevalence. Programs such as
Lets Move! and Strong4Life
have taken the initial steps and
brought light to the epidemic, but
continued efforts are critical for
sustained results.
Social norms are going to have
to change, Dr. Gardner said.
Were going to have to make it
unacceptable to eat that way.
1. Prevalence of Obesity in the United States, 2009-2010. Available at http://www.cdc.gov/nchs/data/databriefs/db82.pdf.
Accessed January 26, 2012.
Dr. Christopher Gardner is an Associate Professor at the Stanford Prevention Research Center. He
earned his PhD in Nutrition Science from the University of California, Berkeley.
Dr. Lisa Rosas is an Instructor at the Stanford Prevention Research Center. She teaches the Obe-
sity in America course through the Human Biology Department.
2. Learn the Facts. Available at http://www.letsmove.gov/learn-facts/epidemic-childhood-obesity. Accessed January 26,
2012.
3. Strong4Life. Available at strong4life.com. Accessed January 26, 2012.
The research section of the SJPH
invites the members of the Stanford community
to share their essays, perspectives, and research
with a broader audience interested in public
health.
In this issue, we present a highly varied
collection of prevention-focused research from
the undergraduate community. Our authors
have explored topics relating to physical activity
in teenagers, the implications of smoking in
indigenous communities, and trends in vaccine
coverage in the United States.
RESEARCH
Introduction
The necessity of
physical activity in
21
st
cenluiy Aneiica is
undeniable. In adolescent
populations alone,
18% are categorized
as olese, a hguie lhal
has nearly quadrupled
since 1976-1980.
1
Lack
of physical activity, a
leading cause of obesity,
has ianihcalions in lolh
personal health
2
and
the national economy.
Regular physical activity,
on the other hand, has
been shown to increase
hlness, luiId heaIlhy
bones and muscle
strength, control blood
pressure, promote
psychological well-being,
and lower risk factors
for a variety of negative
health conditions.
2

In 2008, the US
Department of Health
and Human Services
reported that children
and adolescents should
participate in at least
60 minutes of physical
activity daily.
3
Currently,
this recommendation is
far from being met. In the
2009 Youth Risk Behavior
Survey (YRBS), it was
found that only 18.4
percent of 9th-12th grade
students were physically
active for at least 60
minutes on all seven
days preceding survey
administration.
4
For
adolescent populations,
school physical education
classes could serve a
crucial role in promoting
physical activity and
a healthy lifestyle.
5
In
fact, many national
organizations, including
the Center for Disease
Control, Healthy People
2O2O, lhe Aneiican
Heail Associalion,
and the National
Associalion foi Spoil
and Physical Education,
have championed daily
physical education in
schools.
6,7,8,9
In order
for groups at risk of
low physical activity to
le piopeiIy idenlihed
for intervention, it is
becoming increasingly
necessary to understand
the correlates of
physical education
participation and the
likelihood of physical
activity in the absence
of physical education.
Research in this area is
limited, however. While
studies have examined
the determinants
and demographics of
obesity and physical
activity,
10,11,12,13,14,15,16

studies on physical
education focus mainly
on temporal trends,
17

associations with health
and activity,
6,15,18,19
and
methods of teaching.
20

In order to address
gaps in the literature,
this paper studies
(1) demographic,
extracurricular, academic,
and personal attributes
associated with the level
of high school physical
education participation,
and (2) the physical
activity patterns of
students who do not take
physical education.
Methods
In order to examine the
factors associated with
differing levels of high
school physical education
(PE) participation, data
on physical education
and potential correlates
was acquired from the
2009 Youth Risk Behavior
Study (YRBS). First, PE
participation prevalence
rates were subset by
correlate and compared
to determine the groups
most lacking PE
participation. Then, the
sample without physical
education participation
was isolated for analysis
to determine which
correlate groups were
most at risk for lack of
daily physical activity.

Minutes of Active
PE per Week
Minutes of active PE
time per week was
chosen as a measure of
physical education.
Current national
Abstract
Amidst the United States' obesity epidemic and declining physical activity, physical education is being increas-
ingly championed as a strategy to increase physical activity in youth. In order to determine the factors associ-
ated with physical activity participation in high school students, minutes per week of active physical education
was compared among groups of varying extracurricular, academic, and personal attributes. Using data from
the 2009 Youth Risk Behavior study, relationships between active physical education time and gender, grade
level, grade (academic), weight, and desire to change weight were determined. Statistical analyses were per-
formed using t-tests. We found that females, 12th grade students, those who classifed themselves as "Very
Underweight, those who classifed themselves as "Very Overweight, those who wanted to lose weight, and
those who wanted to do nothing about their weight were most at risk for lack of active physical education par-
ticipation. With this knowledge, policy and intervention can be directed more specifcally at these groups.
Editors' note: Please see online version for supporing hgures.
Xinyue Alice Fang
Correlates of Physical Education
Participation in High School Students
RESEARCH
standards recommend
that high school students
spend 225 minutes per
week in physical
education, at least 50
percent of which
involving moderate to
vigorous physical
activity.
8
In order to
calculate minutes of
active PE per week,
students responses to the
questions In an average
week when you are in
school, on how many
days do you go to
physical education (PE)
classes? and During an
average physical
education (PE) class, how
many minutes do you
spend actually exercising
or playing sports? were
multiplied.

Graphical and
Statistical Analysis
To compare prevalence
within correlate groups,
minutes of active PE per
week was divided into
four categories to allow
comparison with the
national
recommendation: No PE,
up to 110 minutes, up to
225 minutes (meeting
national
recommendation), and
225+ ninules (exceeding
national
recommendation).
Prevalence graphs with
95 conhdence inleivaIs
were produced.
For students without
physical education,
similar graphs were
drawn with x-axis
categories as (1) active for
60 minutes per day in 0
days of the week, (2)
active for 60 minutes per
day in some days of the
week, and (3) active for
60 minutes per day in
seven days of the week.
The categories were again
chosen for ease of
comparison with the
national recommendation
of physical activity 60
minutes per day every
day of the week.
3

Hypothesis tests were
peifoined using STATA
9.1. Correlate groups
were analyzed with
t-tests to determine
whether differences
between groups were
signihcanl al lhe .O5
alpha-level.

Results

Physical education and
physical activity
Physical activity is
dehned ly lhe Youlh Risk
Behavior Survey as being
physically active for a
total of at least 60
minutes per day. Students
who had more days of
physical activity were
more likely to report
higher activity in PE.
Likewise, students with
higher amounts of
physical education
participation tended to
engage in more physical
activity. Compared to
students with 0 minutes
per week of active PE,
students who participate
in 225+ ninules of IL aie
active for 2.13 more days.

Gender
Females were less likely
to take physical
education classes, with
50.8% participating in
zero minutes of PE per
week. Males, on the other
hand, spent an average of
25.7 minutes more than
females in active PE each
week.
Females without PE
participation were also
less likely than their male
counterparts to engage in
physical activity in the
week. On average, males
were physically active for
.96 days more days in a
week than females.

Academics

45.4% of students with
noslIy As did nol spend
any time exercising or
playing sports in physical
education, a percentage
2.2% less than the
national average.
Students with mostly Bs
participated in physical
education for 11.5 less
minutes per week than
sludenls vilh As, and
students with Cs
participated for 14.6
minutes less.
The differences in
number of days
physically active between
non-PE students in
different grades were not
slalislicaIIy signihcanl.

Grade level

PE participation dropped
considerably from 9
th
to
12
th
grade. 10th graders
participated in PE for
24.2 minutes less, 11th
graders for 43.5 minutes
less, and 12th graders for
55.1 minutes less than
their 9
th
grade peers.The
differences in physical
activity between students
of different grade levels
who did not participate
in PE, however, are less
notable; though there is a
general trend of
decreasing physical
activity participation
with increasing grade,
the only statistically
signihcanl iesuIl is
between 9
th
graders and
12
th
, with 12th graders
participating in .18 less
days of PE than 9th
graders.

Weight
Students with differing
descriptions of personal
weight statuses also
diffeied signihcanlIy in
PE participation.
Compared to students
who were about the
right weight, those who
said they were very
underweight had 26.9
minutes less of PE time
per week, those who said
they were slightly
underweight
participated in 5.4
minutes less, those who
said they were slightly
overweight participated
in 14.1 minutes less, and
those who said they were
very overweight
participated in 16.9
minutes less.
Non-PE students with
different weight statuses
aIso diffeied signihcanlIy
in physical activity.
Compared to students of
normal weight,
students who claimed to
be very underweight
exercise for .87 less days;
students who were
slightly overweight
exercised for .44 less
days; and students who
were very overweight
RESEARCH
exercised for .56 less
days.

Desire for Weight Change
Students with differing
goals of weight change
also exhibited
signihcanlIy diffeiing
minutes of PE
participation a week.
SpecihcaIIy, conpaied lo
those who wanted to stay
the same weight, those
who wanted to lose
weight participated in 8.9
minutes less of physical
education, and those who
wanted to gain weight
participated in 14.8
minutes more of physical
education
Students who did not
participate in active PE
with different desires for
weight change also
diffeied signihcanlIy in
physical activity
participation. Compared
to students who wanted
to stay the same weight,
students who wanted to
lose weight were active
for .33 days less, students
who wanted to gain
weight were active for .39
days more, and students
who did not want to do
anything with their
weight were active for .31
days less.

Discussion
This study investigates,
foi lhe hisl line lo lhe
authors knowledge, the
relationship between the
above factors and
associated physical
education participation.
Though previous studies
have similarly analyzed
physical activity and
obesity, the
understanding of
physical education
correlates is limited. The
results of this study
readily allow active
intervention, since
physical education has
been shown to promote
physical activity.
15,18

From the national
sample, it was found that
64.8% of high school
students did not meet
national physical
education participation
recommendations; of
these students, 73.5% did
not participate in any
active physical education
(IL). These hndings aie
extremely disappointing;
despile leing idenlihed
as an area of national
concern since 1990, the
2009 YRBS data shows
that improvement is
minimal.
7,21
Even more concerning
results lie in the correlate
groups. For females,
50.8% participate in zero
minutes of active PE time
per week, and 38.9% of
non-PE students also
engage in no physical
activity. Similar groups
with high level of both (1)
lack of active PE and (2)
physical inactivity are
12th grade students,
lhose vho cIassihed
lhenseIves as Veiy
Underweight, those
vho cIassihed lhenseIves
as Veiy Oveiveighl,
those who wanted to lose
weight, and those who
wanted to do nothing
with their weight.
Physical education
classes may be a viable
way to allow these
groups of students to
increase their physical
activity participation.
Because of the lack of
both physical education
and other physical
activity, for these groups,
physical education
classes could be the
students only source of
physical activity,
magnifying the need for
specihc inleivenlion.
AIainingIy, allenlion is
not currently directed at
many of these groups
when it comes to physical
education promotion.
12th graders, for
example, have often
already met physical
education requirements.
However, 20.7% of all
12th grade students were
not physically active for
any day of the week.
Similarly, 32.2% of all
sludenls vho cIassihed
themselves as very
underweight did not
participate in any
physical activity in any
day of the week.
AIlhough lhese sludenls
were not overweight or
obese, their lack of
physical activity may
lead to health
complications later in life,
ones that impact both the
individual and the
publics medical care.
2
AIlhough 1Olh and 11lh
graders also showed lack
of active physical
education, the 10th and
11th graders who did not
take PE were, unlike the
groups in table 2, not
signihcanlIy diffeienl
from their counterparts in
other grades. Whereas
females who did not take
IL veie signihcanlIy Iess
likely than males who
did not take PE to engage
in physical activity, 9th,
10th, and 11th graders
who did not take PE were
nol signihcanlIy diffeienl
in their physical activity
participation, despite
how 9th, 10th, and 11th
giadeis have signihcanlIy
varying active PE
participation results. This
suggests that 9th, 10th,
and 11th graders are not
inherently different in
their physical education
and physical activity
participation; rather, their
PE participation is caused
independently, in this
case, likely by state and
school PE requirements.
18

It was also found that
students with lower
grades (Bs and Cs)
participate in less active
PE than students with
highei giades (As), a
result that complements
the Robert Wood Johnson
Ioundalions hndings
that children who are
physically active tend to
have better academic
performance.
16

Furthermore, there is no
signihcanl diffeience in
physical activity
participation among
students with no PE
participation. In light of
increasing focus on
standardized test scores,
these results are
signihcanl lecause lhey
show that active physical
education does not
hinder academic
achievement.
Despile lhe signihcance
of results, a variety of
limitations exist with this
study. First of all, the
nature of the YRBS, as a
voluntary school-based
survey, may have caused
RESEARCH
bias in the responses.
However, the sampling
frame and 3-stage cluster
survey design and
weighted responses
should have accounted
for potential
undercoverage and
overcoverage.
22
Lack of
indicators for states,
districts, and schools was
also a limitation of this
sludy, since specihc dala
points would have
allowed consideration of
state and local policy on
physical education
standards; in other
words, it would be
possible to detect
whether PE requirements
pIay a signihcanl ioIe in
active PE participation.
Future research could
examine other factors
potentially associated
with active physical
education participation,
such as TV and conpulei
use. Moreover,
association between PE
participation and
correlate variables
determined on a national
IeveI juslihes exaninalion
on a local level. States
and school districts ought
to perform similar
research to determine
how their results relate to
nalionaI hndings. Ioi
results that do not match
nalionaI hndings,
investigation should be
done on the differences in
policy or students that
caused the disparity.
Aflei idenlifying lhe
groups most at risk, these
groups could be
specihcaIIy laigeled foi
PE programs at a local
level to better match the
population at hand.
1. Ogden C, Caroll M. Prevalence of obesity among children and adolescents: United States, trends 19631965 through 20072008. Centers
for Disease Control and Prevention, Division of Health and Nutrition Examination Surveys. 2010.
Alice Fang is a freshman at Stanford from San Diego, California. After noticing that many of her peers
were not taking physical education classes in high school, she was inspired to investigate the groups
most at-risk for lack of physical activity. Alice is interested in the intersection of science and society and
is the founder of the Journal of Youths in Science (JOURNYS; www.journys.org), a science publication
that aims to promote peer-to-peer STEM education.
2. Keim NL, Blanton CA, Kretsch MJ. Americas obesity epidemic: measuring physical activity to promote an active lifestyle. J Am Diet Assoc.
2004;104:1398-1409.
3. Physical activity guidelines for Americans (ODPHP Publication No. U0036). US Department of Health and Human Services. 2008.
4. 2009 Youth Risk Behavior Survey. Centers for Disease Control and Prevention. Available at: www.cdc.gov/yrbss. Accessed 2011 Jan 19.
5. Trost, S. Active education: Physical education, physical activity, and academic performance. San Diego, CA: Active Living Research. 2009.
Available at: http://www.rwjf.org/fles/research/20090925alractiveeducation.pdf. Accessed January 2011.
6. Kahn LK, Sobush K, Keener D, et al. Recommended community strategies and measurements to prevent obesity in the United States
MMWR. National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity. 2009.
7. Healthy People 2020: the road ahead. US Department of Health and Human Services, Offce of Disease Prevention and Health Promotion.
2010. Accessed January 29, 2011.
8. Physical education in schools - both quality and quantity are important. American Cancer Society, American Diabetes Association, American
Heart Association. 2008. Available at: http://www.everydaychoices.org/.
9. Shape of the Nation Reston, VA. National Association for Sport and Physical Education & American Heart Association. 2010.
10. Levin S, Lowry R, Brown D, Dietz W. Physical activity and body mass index among us adolescents. Arch Pediatr Adolesc Med. 2003;157.
11. Adams J. Trends in physical activity and inactivity amongst us 14-18 year olds by gender, school grade and race, 1993-2003. BMC Public
Health. 2006;6:57.
12. Heath G, Pratt M, Warren C, Kann L. Physical activity patterns in American high school students. Arch Pediatr Adolesc Med. 1994;148.
13. Dowda M, Atnsworth B, Addy C, Sander R, Riner W. Environmental infuences, physical activity, and weight status in 8- to 16-year-olds.
Arch Pediatr Adolesc Med. 2001;155.
14. Caspersen C, Perfra M, Curran K. Changes in physical activity patterns in the united states, by sex and cross-sectional age. Medicine &
Science in Sports & Exercise. 1999;32:1601-1608.
15. Gordon-Larsen P, McMurray R, Popkin B. Determinants of adolescent physical activity and inactivity patterns. Pediatrics. 2000;105:6.
16. Trost S, Pate R, Sallis J, Freedson P, Taylor W. Age and gender differences in objectively measured physical activity in youth. Medicine &
Science in Sports & Exercise. 2002;02:350-354.
17. Lowry R, Brener N, Lee S. Participation in high school physical education - United States, 1991-2003. Centers for Disease Control and
Prevention Morbidity and Mortality Weekly Report. 2004;53:844-847.
18. Cawley J, Meyehoeffer C, Newhouse D. The impact of state physical education requirements on youth physical activity and overweight.
Health Economics. 2005;16.
19. Dowda M., Pate R., Saunders R, et al. Guidelines for school and community programs to promote lifelong physical activity among young
people. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. 1997;46(RR-6):1-36.
20. Burgeson CR, Wechsler H, Brener ND, Young JC, Spain CG. Physical education and activity: results from the School Health Policies and
Programs Study 2000. J Sch Health. 2001;71(7):279-293.
21. Healthy People 2010: Understanding and Improving Health, (2nd Edn). US Department of Health and Human Services, Offce of Disease
Prevention and Health Promotion. US Government Printing Offce: Washington DC. 2000.
22. Brener ND, et al. Methodology of the youth risk behavior surveillance system. Centers for Disease Control and Prevention Morbidity and
Mortality Weekly Report. 2004;53(RR-12):114.
RESEARCH
Hypothesis
My research investi-
gates the disparity in
respiratory health of In-
digenous versus non-In-
digenous AusliaIians. Il
explores the long cultural
hisloiy of snoking in Al-
original communities, the
history of displacement
and a lack of access to
health information, care,
and support for quitting
as possible explanations
for the disparity. Results
indicate that the most
important steps to ame-
liorating the health of
Indigenous AusliaIians
(IAs) aie undeislanding
the root causes of ad-
veise condilions, lhe IAs
perception of their health
and well-being, and the
individual differences
that shape the health of
an individual, a commu-
nity, and a population.
The best way to close
this gap is to develop a
culturally sensitive inter-
vention that is catered to
the unique needs of each
connunily of IAs. A suc-
cessful intervention will
target village elders, chil-
dren, and health work-
ers, each of whom play a
critical role in increasing
smoking cessation rates
of a community. It will
incorporate traditional
health practices of this
population, rather than
imposing a Western bio-
medical treatment model,
which could be alienating
and ineffective.

Introduction
Previous research has
shown that the most ro-
bust factor in uptake and
continuation of smoking
is social context. For dis-
advantaged groups such
as IAs, lhe chaIIenges
of unemployment, high
stress, and lack of access
to education and health-
care make individuals
more likely to smoke and
less likely to quit.
1
IAs
have also experienced
cultural fragmentation
and loss of identity,
contributing to their poor
mental health. This is cor-
related with high rates of
substance addiction.
Smoking must be ad-
dressed in the Indigenous
context as a collective
social practice as opposed
to an individual lifestyle
behavior.
1
In order for a
health intervention to be
successful, it must ad-
dress culture as a moti-
vating force behind pat-
terns of tobacco use and
obstacles of quitting, and
it must obtain communi-
ty buy-in and ownership
of the proposed behavior
changes. Because the is-
sue of indigenous health
is caused and maintained
by the complex interac-
tion of environmental
and genetic factors, there
is no simple solution.
In this paper, a survey
will be conducted of
current literature on the
snoking cuIluie of IAs
and lhe lenehls and Iini-
tations of current anti-
smoking interventions.
The data indicates that an
effective, culturally sensi-
tive solution involves
recognition of the com-
plex web of fundamental
causes of the issue, and
rigorous effort is required
on behalf of Indigenous
communities and outside
agencies.

Methods
Data for this project was
gathered from interviews
and observation at La
Perouse Medical Center
and Red Iein AloiiginaI
Health Services in Syd-
ney, AusliaIia, as veII as
bibliographic sources and
online videos.

Results

I. Origins of the
smoking problem
In the 1700s, Macassan
hsheinen fion Indonesia
hisl introduced tobacco
lo lhe IAs, vho incoipo-
rated the smoking pipes
into their ceremonies.
1

The ritual of passing
a tobacco pipe gained
popularity, and smoking
rituals were passed down
through generations
alongside oral traditions
of creation and coming-
of-age ceremonies. In
1788, when Europeans ar-
iived in AusliaIia, vhile
sellIeis paid AloiiginaI
laborers in tobacco,
and IAs legan lo use il
recreationally rather than
strictly ceremoniously.
1

Indigenous communities
saw their smoking rates
skyrocket, especially
because the activity was
seen as a family practice.
Furthermore, up until the
196Os, nany AloiiginaI
doctors viewed smoking
as an antidote to stress
and either smoked with
their patients or in their
presence.
2
Social pres-
sures, both implicit and
explicit from friends and
family who smoke, have
maintained the behavior
in communities to this
day.
1

Today, tobacco remains
rooted in the traditional
IA kinship syslen. Shai-
ing tobacco is a way of
giving and receiving
honors and strengthening
kinship lies. Alslaining
from smoking rituals may
be seen as a rejection of
the tribe and can lead to
isolation. Children who
grow up in a community
where individuals who
chose to quit smoking are
isolated often feel that
maintenance of smok-
ing behavior is the only
way to remain part of the
mob.

Smoking in the Indigenous
Australian Community
Elise Geithner
RESEARCH
II. The land-health
connection
You lose your land, you
lose your soul, you lose
your life. -Vic Simms
3
An Indigenous persons
relationship to the land is
ciuciaI foi his/hei con-
munal identity, individu-
al identity, and sense of
wellbeing. Without land,
an AloiiginaI peisons
sense of belonging and
purpose is diminished,
and this could lead to
substance use, including
smoking. Dispossession
by white settlers has
resulted in unstable
family and community
environments, negatively
impacting mental health.
IAs aie hospilaIized foi
mental and behavioral
disorders at twice the rate
of their non-Indigenous
peers.
4
As pail of lhe
Stolen Generation, many
adult survivors of child-
hood separation experi-
ence major psychological
issues.
5
Many IAs vho
feel stressed by unem-
ployment or from mental
illness in the aftermath of
forcible relocation by the
government have turned
to smoking as a short-
term antidote. Tobacco
increases alertness and
suppresses ones appe-
tite; these are cited by
Indigenous smokers as
juslihcalions foi snoking.
When asked why they
snoke, IAs in Nev Soulh
Whales responded, it
tastes good, makes me
look deadly, keeps me
awake, calms me down.
6

Cultural fragmentation
and associated identity
confusion are the result
of colonization around
the world. The history of
Indigenous and non-
Indigenous relations in
Noilh Aneiica and Nev
Zealand parallels that of
AusliaIia. In a conpaii-
son of the health discrep-
ancies between Indig-
enous and non-
Indigenous peoples in
Noilh Aneiica, Nev
ZeaIand, and AusliaIia,
the greatest disparity
between Indigenous and
non-Indigenous life
expeclancy is in Auslia-
lia; 56 years for males, 63
years for females.
7
The
AusliaIian uieau of
Statistics makes a conser-
vative estimate of a gap
of 9.7 and 11.5 years for
females and males,
iespecliveIy, lelveen IAs
and non-Indigenous
AusliaIians, vhiIe sone
have suggested a gap as
high as 20 years.
8,9

Of all Indigenous
AusliaIians and Toiies
Strait Islanders over the
age of 15, 47% are current
daily smokers.
10
Surpris-
ingly, 52% of pregnant
AloiiginaI vonen
smoke, compared with
17% of women in the
overall population.
10
IA
babies are twice as likely
as their non-Indigenous
counterparts to have low
birth weights, and there-
fore prematurely devel-
oped lungs, which are
more prone to develop-
ing infections and asth-
ma, when exposed to
tobacco smoke.
9
The
infant mortality rate for
IAs is 2.5 lines lhe lolaI
population rate.
9
By
giving up smoking,
moms will lower their
childrens respiratory
health risks.
The smoking trends in
lhe IA popuIalion aie
widely understood to be
contributing to poor
physical and psychoso-
cial health and longevity.
In 2OO6, lhe AusliaIian
Bureau of Statistics found
that 66% of children ages
0-14 lived in a house with
at least one regular
smoker.
10
Because they
grow up around family
members who smoke, it
is no surprise that chil-
dren and teenagers make
up the majority of all new
smokers. Through educa-
tion about household
smoking health risks, we
can reduce smoking-
induced morbidity and
mortality.

III. IA Reception to
Interventions
Despite numerous
government interven-
tions, Indigenous smok-
ing rates remain stable,
and these interventions
have received mixed
reviews from the Indig-
enous community. The
giaphic inages of TV ads
and panphIels Ied Vic
My tree model for understanding the causes of smoking in the Aboriginal community.
RESEARCH
Simms age 65 of the
Bidjigal tribe to quit; I
would have never known
about my severe heart
conditions, if it werent
for the governments
anti-smoking campaigns
which describe the
hoiiihc consequences of
smoking. Greg Ingram,
lhe AMS Red Iein nenlaI
health director, believes
that government inter-
venlions nake lhe IA
community dependent
on the government,
rather than encouraging
autonomy (16 November
2011). Ingram discussed
the negative impact of
historical displacement
and segregation on
AloiiginaI peopIes sociaI
and emotional wellbeing.
Over time, Red Fern has
seen an increase in educa-
tion levels, but current
government policy is
making things go
backwards.
Future anti-smoking
campaigns should pro-
mote the positive aspects
of quitting, rather than
over-emphasize the
negative consequences of
smoking. Psychology
research has shown that
framing conditions
positively rather than
negatively helps the brain
integrate information
more effectively. Diabetes
AusliaIia NSW used lhis
technique in their pam-
phlets section titled
Why quitting smoking
is good for you and your
mob. By appealing to
the pathos of their audi-
ence, the organization
was able to deliver
scienlihc infoinalion in
an accessible, rather than
overly technical or
alienating way.
Other challenges in the
IA connunily aie lhe
widespread notions of
egalitarianism and
general resistance to
Western interference.
People who quit can be
deiided ly olhei Aloiigi-
nes as trying to be like
grubs or white fella.
11

In cIose-knil AloiiginaI
communities, leveling
procedures such as
group pressure, shaming,
and gossip, reinforce the
group psyche, impeding
individuals quitting
effoils. Anolhei chaIIenge
to treating adults with
smoking addictions is the
ideal of personal autono-
my and an associated
antipathy to being told
what to do
11
. Western
health interventions often
conicl vilh liadilionaI
Indigenous health beliefs
such as the idea that
premature death and
sudden illness is the
result of a supernatural
cause, even if an indi-
vidual was a heavy user
of alcohol or drugs.
11

The IA connunily is
generating their own
response to the smoking
issue. In lhe pasl hve
years, there has been an
explosion in the number
of anti-smoking videos
on YouTube, which are
caleied specihcaIIy lo
IAs. Ioi exanpIe, Kick
the Habit2012 was made
ly IA schooIgiiIs singing
in their native language
about taking responsibil-
ity for ones own health
and quitting.

IV. Contemporary IA
Morbidity and Mortality
Many IAs aie conpIa-
cent about tobacco
because it is such a
widespread problem.
Future health efforts
must increase awareness
of tobacco as a health
priority, one that need
not be separate from
efforts to ameliorate
alcohol abuse, domestic
violence, and poverty.
13

Traditionally, the govern-
ment health organiza-
tions have addressed one
of these issues at a time,
but holistic approaches
may actually be more
effective. One key to ame-
liorating poor health is
offering and ensuring
access to high quality
seivices. In lhe pasl, IAs
have not had easy access
to adequate healthcare.
Lnsuiing lhal IAs have
equitable access to health
professionals is an issue
of social justice. Through
cooperation between
government, non-govern-
ment agencies, and
community leaders,
AusliaIia has lhe polen-
tial to improve the health
of its Indigenous popula-
tion.
Il vas difhcuIl lo
compare the success of
current interventions
against each other,
because they measured
different outcomes: %
increase in individuals
quitting, % increase in
conhdence of heaIlh
workers to offer cessation
advice, % decrease in
individuals smoking.
However, the effective-
ness of several interven-
tions could be graphically
compared, revealing that
the chemical options
(Nicotine Replacement
Therapy, Buproprion, and
VaienicIine) yieIded lhe
most dramatic quitting
iesuIls. These hndings
should not be taken to
advocate widespread use
of NRT, but rather to help
individuals gain an
understanding of its
effectiveness in some
cases. The best way to
tackle the smoking
problem in its entirety is
through community
partnerships with health
organizations.

Discussion

I. Comparing Existing
Interventions
There are many ap-
proaches that seek to
close the gap in smoking
non-Indigenous Auslia-
lians, and there has yet to
be a widely successful
intervention. It is unlikely
lhal a one size hls aII
approach will work,
given the varying needs
of each Indigenous
community. Things
dont change overnight
because the government
says, lets stop smoking.
Its a mindset change and
a societal change, says
Dr. Tom Calma, an elder
from the Kungarakan and
Iwaidja tribal groups,
whose traditional lands
are in the Northern
Territory.
14
From a
public health perspective,
the best solution is for
RESEARCH
people not to start smok-
ing cigarettes smoking
prevention, explains
Lupton, a sociologist of
health and illness.
15

Whether an intervention
falls into the prevention
or the treatment category,
it must address smoking
at two levels: the habit
and the addiction.
15

Interventions range from
public health education
campaigns (I Quit
ecause 2O11) lo specihc
training of community
health workers (Smoke-
Check 2009) and distribu-
tion of pharmaceutical
aids. There has also been
health education for
children and teens,
family-centered interven-
tions, quitting support
groups, and national
media campaigns (Na-
tional Tobacco Campaign
1997-piesenl). Anolhei
angle is implementing
legal controls on tobacco
advertising, packaging,
laxalion, and piicing. A
holistic solution is need-
ed for this problem.

II. Using the Addiction
Treatment Model
Another way to address
the use of alcohol, tobac-
co, and other drugs in
Indigenous populations
is culture as a form of
healing.
11
This idea has
spread from native
Canadians and Aneiican
Indians lo AusliaIia
through cultural diffu-
sion. It is now accepted
that treatment and
rehabilitation for native
peoples should be cultur-
ally appropriate and
may even involve going
back to the roots of the
culture.
11
Nalive Aneii-
cans and Canadians have
been incorporating
traditional and spiritual
practices into addiction
treatment programs and
some say embracing
their culture assists them
in achieving sobriety.
11

Many Indigenous
peoples feel that cultural
wholeness can serve as a
preventative, or even
curing agent in drug and
alcohol abuse, and this
method can be applied to
smoking cessation pro-
grams.
11
The rationale for
the use of tradition in
addictions intervention
rests upon the Indig-
enous interpretation of
the etiology of drug and
alcohol abuse their
status as a colonized and
dispossessed popula-
tion.
11
Prior to the arrival
of white settlers, the
traditional smoking
ceremony was designed
to cleanse and protect
the strength of the spir-
it.
16
This is seen as
separate from the con-
temporary use of tobacco,
in the form of cigarettes
laden with over 4,000
chemicals.
17
However,
there is also evidence for
substance abuse in
AloiiginaI connunilies
whose social organiza-
tion remains relatively
intact, and who have
retained intimate contact
with their land.
11
Thus,
there is no perfect for-
mula for causation of the
issue, but we can look at
correlations, risk factors,
and protective factors.
III. Suggestions for
Further Research
Social scientists should
continue investigating
hov lo inpiove IA
health. It is important to
assemble a board of
representatives from each
AloiiginaI connunily,
or tap into existing
NalionaI AloiiginaI
Health organizations, so
that anti-smoking materi-
als can be translated into
Indigenous languages.
Funding for the proposed
programs is a crucial
component to success. Its
important to further
invesligale lhe iuiaI/
urban trends of smoking
and health, to see if these
evolve over time. Cur-
rently, health status is
voise in iuiaI AloiiginaI
communities than in
urban ones. However, as
AloiiginaI peopIe aie
displaced from their
lands, or move into cities
seeking jobs and better
opportunities, will they
face new health challeng-
es, or will they be able to
take advantage of better
access to healthcare? Will
they experience declines
in mental health because
they are leaving their
traditional lands and
losing their connection
with their cultural his-
loiy` WiII lenehls of cily
life, including education
and employment oppor-
tunities, outweigh these
potential risks? The
aliIily of lhe scienlihc
and public health com-
munities to cooperate
vilh IAs viII lecone a
crucial piece in tackling
the disproportionately
high rates of smoking in
that population.

Conclusion
Combating the smoking
piolIen in IA connuni-
ties will require contin-
ued dedication of health
organizations and Indig-
enous community lead-
ers. Health workers
cannot undo the damage
of colonization to the
iools of AloiiginaI
AusliaIians, lul lhey can
move forward towards
improving health out-
comes. Hopefully, one
day, the community will
work to close the gap
non-Indigenous peoples
in AusliaIia and aiound
the world.
Example of Indigenous health promotion materials at Sydney
health centers.
GEITHNER
RESEARCH
1. Johnston, Vanessa, and David P. Thomas. Smoking Behaviours in a Remote Australian Indigenous Community: The
Infuence of Family and Other Factors." Social Science and Medicine 67 (2008): 1708-716. ScienceDirect. Web. 23
Sept. 2011. <http://www.sciencedirect.com/science/article/pii/S0277953608004644>.
2. Casey, Bill. Australian Studies. University of Queensland. 21-26 Nov. 2011. Lectures.
3. Simms, Vic. The Indigenous Communities of La Perouse and Red Fern. Sydney, Australia. 15, 16 Nov. 2011. Lecture.
4. Hunter, Ernest. Disadvantage and Discontent: A Review of Issues Relevant to the Mental Health of Rural and Remote
Indigenous Australians. Australian Journal of Rural Health 15 (2007): 88-93. The Centre for Rural and Remote Mental
Health, Cairns, Queensland, Australia, Feb. 2007. Web. 9 Nov. 2011. <http://espace.uq.edu.au/view/UQ:135692>.
5. Corporal, Stephen. Indigenous Health. Personal interview. 25 Nov. 2011.
6. SMOKERS: Its Deadly to Know. North Sydney, NSW: NSW Department of Health: Tobacco and Health Branch, 2005.
Print.
7. Bramley, Dale, Paul Hebert, Rod Jackson, and Mark Chassin. "Indigenous Disparities in Disease-specifc Mortality, a
Cross-country Comparison: New Zealand, Australia, Canada, and the United States. The New Zealand Medical
Journal 117.1207 (2004): 1-16. New Zealand Medical Journal. 17 Dec. 2004. Web. 27 Nov. 2011. <www.nzma.org.nz/
journal/117-1207/1215/>.
8. DEMOGRAPHIC, SOCIAL AND ECONOMIC CHARACTERISTICS: LIFE EXPECTANCY. Australian Bureau of Sta-
tistics. 16 Feb. 2011. Web. 25 Nov. 2011. <http://www.abs.gov.au/AUSSTATS/abs@.nsf/lookup/4704.0Chapter218O
ct+2010>.
9. Ring, Ian T., and Ngaire Brown. Indigenous Health: Chronically Inadequate Responses to Damning Statistics. Medi-
cal Journal of Australia 177 (2002): 629-31. Medical Journal of Australia. Web. 23 Sept. 2011. <http://www.mja.com.au/
public/issues/177_11_021202/rin10435_fm.html>.
10. Ivers, Rowena. Australia Government Institute of Health and Welfare. Institute of Family Studies. Anti-tobacco Pro-
grams for Aboriginal and Torres Strait Islander People. Resource Sheet Number 4 ed. Closing the Gap Clearinghouse,
Jan. 2011. Web. 21 Oct. 2011. <www.aihw.gov.au/closingthegap/documents/resource_sheets/ctgc-rs04.pdf>.
11. Brady, Maggie. Culture in Treatment, Culture as Treatment. A Critical Appraisal of Developments in Addictions
Programs for Indigenous North Americans and Australians. Social Science and Medicine 41.11 (1995): 1487-496.
PubMed. US National Library of Medicine. Web. 27 Nov. 2011. <http://www.ncbi.nlm.nih.gov/pubmed/8607039>.
12. Kick the Habit.mov. Yirrkala Homelands School. Online video advertisement. YouTube. 22 June 2010. Web. 3 Dec.
2011. <http://www.youtube.com/watch?v=yiE6-Nmu2q8&feature=related>.
13. Interventions Targeting Aboriginal Peoples and Torres Straits Islanders. Tobacco in Australia. Web. 20 Oct. 2011.
<www.tobaccoinaustralia.org/chapter-8-aptsi/8-10-interventions-targeting-aboriginal-peoples-an>.
14. Smoking and Pregnancy Program. Rural Health Education Foundation. Australian Government Department of
Health and Aging, 22 Apr. 2008. Web. 20 Oct. 2011. <www.rhef.com.au/program-1/?program_id=39&group_id=5>.
15. Lupton, Gillian M., and Jakob M. Najman. Sociology of Health and Illness: Australian Readings. Macmillan Education
AU, 1995. Print.
16. Smoking and Diabetes (fact sheet). NSW: Diabetes Australia-NSW. Print.
17. Cigarettes Are Full of Poisons. Quit Because You Can. 2007. Web. 3 Dec. 2011. <http://quitbecauseyoucan.org.au/
browse.asp?ContainerID=1832>.
Elise Geithner is a junior majoring in Human Biology. She was born in Tokyo and grew up in DC and
NY. She dreams of being a pediatric and adolescent psychiatrist when she grows up. Shes particularly
interested in the mental health issues of adolescent girls and is on a lifelong mission to destigmatize
mental illness, therapy, and bike helmet wearing. n her free time, she enjoys babysitting, cooking,
hiking, surfng, running, doing art projects, and teaching yoga to kids and adults.
RESEARCH
A Study of H1N1
Vaccination Trends in Illinois
Molly Fausone
Introduction
2010-2011 was the
hisl u season lhal lhe
CDC recommended all
people 6 months and
oIdei ieceive lhe u
vaccine. Despite having
one of the highest H1N1
infection rates of any
state in 2009,
2
Illinois had
the 9
th
lowest 2010-2011
H1N1 vaccination rate in
the nation and the lowest
rate in its region,
vaccinating 39.8% (3.7%)
of its residents. State
coverage throughout the
U.S. ranged from 36.5-
55.6% with a national
average of 43% (0.4%).
This paper investigates
H1N1 vaccination rates
in 2010-2011, factors that
inuence vaccinalion
rates, and possible targets
for improved vaccination
coverage in Illinois.
Lessons learned in
Illinois may prove to be
applicable to other
states.
3

Methods
Data included in this
paper were gathered
from previously
published sources.
Vaccine exenplion iales
were published by the
Center for Disease
Control and Prevention
(CDC) in Morbidity and
Mortality Weekly Report
(MMWR).
5,11,13,15
Rankings
and percentiles for
exemption rates were
calculated for this paper.
Medicaid reimbursement
rates by state and their
statistical association
with vaccination of poor
children were published
in the Journal of the
American Academy of
Pediatrics. Discordant
examples were observed
independently.

Results

Access to Vaccines
The hisl ieseaich ain
was to determine if
Illinois residents had
limited access to vaccines.
Despite having one of the
lowest vaccination rates
in the nation in 2010-
2011, Illinois had
signihcanlIy noie ig
Box vaccination
locations, retail chains
stores that offer vaccines,
than most other states.
AInosl haIf of aII ielaiI
clinics in 2009 were in 5
states, Illinois being one
of lhe hve. Theie veie 64
retail clinics in Illinois in
2009, 7% of all retail
cIinics nalionvide. Aloul
24.3% of residents lived
within 5 minute driving
distance of a retail clinic,
and 57.7% lived within 10
minutes. In fact, 35% of
Abstract

n the 2010-2011 H1N1 fu season, llinois had the 9th lowest vaccination rate in the nation and the lowest rate
in its region. Low H1N1 vaccination rates in llinois put residents, especially the young, the old, and the sick,
at serious risk of infection. This paper investigates the causes of the unexpectedly low H1N1 vaccination rates
in Illinois in 2010-2011 and proposes possible targets for improved vaccination coverage. Using statistical and
comparative analysis of previously published data from the Annals of nternal Medicine,1 access to vaccines
for particular populations, cost barriers, and vaccine exemptions were explored as possible explanations. Re-
sults show that although llinois had low vaccination rates, the state actually had more non-medical vaccination
location options than most other states. Because vaccination rates were furthest behind the national average
for African-Americans and people that identify as " Other, interventions targeted at these groups should fo-
cus on raising awareness for vaccination locations and understanding factors that determine where they go to
receive vaccines.

Cost is a concern for many unvaccinated residents in llinois but not signifcantly more so than in the rest of
the US. The percent of uninsured residents in llinois is not signifcantly higher than the national average and
is signifcantly lower than the number of unvaccinated residents. Raising llinois' Medicaid reimbursement
may improve vaccination rates, as Medicaid reimbursement is associated with low vaccination rates for poor
children. However, this intervention would not change rates for other groups within the population. llinois also
has high rates of vaccine exemptions compared to other states, signifying an anti-vaccine sentiment in llinois.
Survey results and low vaccination rates despite access and affordability suggest undervaluing the effects of
vaccinations may be a reason people do not get vaccinated. Education by providers and public health cam-
paigns should be investigated as an important next step.
RESEARCH
Chicago residents lived
within 5 minute driving
distance of a retail clinic,
and 80% lived within 10
minutes.
A nap of schooI
vaccination rates in
Illinois published by the
Chicago Tribune indicates
which particular schools
(public and private) have
below a 90% vaccination
rate for at least one
mandated childhood
vaccine, and which
schools have below a 90%
vaccination rate for all
hve vaccines.
4
The high
majority of schools in
both those categories are
in Chicago. A seaich of
Walgreens in Chicago
shows that Big Box
locations exist
throughout the city at
locations within walking
distance to these schools.
This data suggests that
most adults and children
are located near a
vaccination center but are
still not seeking medical
care. These low
vaccination rates may
therefore be due to a
societal preference of
getting vaccinated at
certain centers over
others. Indeed, previous
research has found that
populations vulnerable to
poor medical care,
including minorities, the
poor, sick, elderly, and
uninsured, are more
likely to get vaccinated at
medical settings than at
non-medical settings,
such as workplaces,
stores (including Big Box
locations), schools, senior
homes, and community
or recreation centers.
5

Therefore, encouraging
particular populations to
become open to getting
vaccinated at nonmedical
centers, which may be
more local to them, can
help improve vaccination
rates.
Disparities in H1N1
vaccination rates also
exist among racial and
ethnic groups in Illinois.
Vaccinalion iales of
Hispanics in Illinois were
4.3% above the national
average. However,
vaccination rates of
whites were 1.6% below
the national average,
Afiican-Aneiicans 5.8
below, and people self-
reported as Other 14%
below.
3
Future efforts to
increase vaccination rates
in Illinois may want to
focus on improving rates
for particular races or
ethnicities.
It should also be noted
that in some parts of
Illinois there is
signihcanlIy Iess access lo
Big Box vaccination
locations and there are
obstacles that exist even
at easily accessible
locations. Some clinics
offer vaccines everyday,
some only on certain
days, and some by
appointment only. Most
locations also require
minimal paperwork.
However, these obstacles
aie nol noie signihcanl
in Illinois than in the rest
of the nation, and if
anything, retail clinics
offer more opportunities
for people in Illinois to
get vaccinated than
people in other states.
However, consumer
awareness of retail clinics
is low, and ads for
phainacies/cIinics aie
usually within the stores.
6

This may indicate that
awareness of vaccine
availability is a greater
challenge than access.

Cost
I next attempted to
investigate cost as a
potential barrier to
vaccination for residents
of Illinois. In 2010, 15% of
Illinois residents were
uninsured, as compared
with 16% nationwide.
AIlhough IL had lhe
ninth lowest vaccination
rate, 23 states had higher
uninsured populations,
and the four states that
also had uninsured
populations of 15%
7
had
higher state vaccination
rates. For this 15% of the
population, cost may be a
serious barrier to
receiving vaccines.
However, nearly 60% of
Illinois residents were not
vaccinated in 2010-2011, a
much larger portion of
the population than was
uninsured.
The u vaccine al lhe
hve nosl connon ig
Box vaccination locations
costs between $25 and
$3O. AInosl aII ielaiI
clinics accept insurance.
With Medicare and
Medicaid u shols aie
free, and most insurance
plans cover at least part
of lhe cosl of a u shol.
8

States with higher
rates for vaccinations
have been shown to have
higher vaccination rates
of pooi chiIdien, dehned
here as children living at
less than 100% of the
federal poverty level.
9
In
2007, Illinois had the 37
th

highest Medicaid
reimbursement rate.
10

One study found a strong
association between
vaccination rates and
rates in three consecutive
u seasons.
11
It is
important to note there is
variability in the
association between
and vaccination rates of
poor children. For
example, in 2007, the
three states with the
lowest reimbursement
rates had the 10
th
, 11
th
26
th,

highest vaccination rates,
and the state with the
highest reimbursement
had the 20
th
highest
vaccination rate.
12
Not
surprisingly, providers
who were reimbursed
through capitated
payments, instead of fee-
forservice, were less
sensitive to
reimbursement rates.
10

However, It is possible
that raising the Medicaid
reimbursement would
increase vaccination rates
for Medicaid eligible
children in Illinois. This
increase, however, would
not affect rates in other
populations.
12

The fact that increasing
provider reimbursement
increases vaccination
rates suggests provider
incentives have a
signihcanl inpacl on
rates of vaccination. This
demonstration of
piovidei inuence
reveals a need to evaluate
cost for providers as well
as cost for patients.
Levels of vaccination
coverage on par with the
RESEARCH
national average,
coverage of the H1N1
vaccine by Medicaid and
Medicare, and acceptance
of insurance at Big Box
locations suggest cost is
nol a signihcanl laiiiei
for the majority of the
unvaccinated residents of
Illinois in 2010-2011.

Vaccine Exemptions
Overall sentiment
toward vaccination in
Illinois compared to other
states was also examined.
Vaccine exenplion iales
are a potential source of
general feelings about
vaccines in each state.
Illinois allows its
residents to apply for
religious or medical
exemptions to mandatory
childhood vaccines, but
not philosophic
exemptions. Exemptions
are needed only to
decline mandatory
childhood vaccines,
which do not include the
u vaccine.
MMWR data collected
on kindergarteners across
the United States
indicated that
nationwide, medical
exemptions in 2009-2010
ranged from 0 to 1.7%.
ReIigious/phiIosophicaI
exemptions range from 0
to 5.7%. Total exemptions
ranged from 0 to 6.2%.
11

In Illinois the medical
exemption rate was 0.9%,
the religious exemption
rate 3.4%, and the total
exemption rate 4.3%.
Illinois did not allow
philosophic exemptions
but it did have the 9
th

highest rate of
phiIosophic/ieIigious
exemptions and the 6
th

highest rates of medical
and total exemptions.
11

A polenliaI hypolhesis
is that states that do not
allow philosophical
exemptions would have
higher rates of medical
exemptions due to
increased pressure to
provide potentially
illegitimate medical
exemptions. In contrast,
results indicate that states
with high rates of
medical exemptions also
have the highest rates of
philosophical and
religious exemptions, and
therefore high rates of
total exemption. It is not
clear if high demand for
exemptions creates
pressure for legislation
allowing philosophic and
religious exemptions, or
if people in states with all
three exemptions take
advantage of their
increased opportunities
to become exempt.

Discussion
Research shows that Big
Box vaccination locations
are more numerous in
Illinois than in most other
states implying a lack of
vaccination locations is
likely not the cause of
low vaccination rates in
Illinois. Similarly, cost
does not present a
signihcanl laiiiei foi
most residents of Illinois,
and the uninsured
population very close to
the national average,
suggesting the size of the
uninsured population
does not explain low
rates of vaccination for
the state. Furthermore,
higher rates of vaccine
exemptions in Illinois
than in other states may
indicate an anti-vaccine
sentiment among the
residents of Illinois.
In IIIinois, Afiican-
Aneiicans and peopIe
that identify as Other
are farthest behind
the average national
vaccination rate. Surveys
show minorities are more
likely to get vaccinated
at medical settings. If
this is due to lack of
knowledge about non-
medical vaccination
locations, then
increasing awareness
of these opportunities
may help increase the
vaccination rates in the
segments of the Illinois
population that are most
underserved.
Increasing geographic
and hnanciaI access lo
vaccines in Illinois will
have very little affect
on vaccination rates if
residents do not believe
vaccines are useful or
inpoilanl. A 1996 sludy
published in MMWR
investigated self-reported
reasons for not receiving
lhe u vaccine anong
Medicaie lenehciaiies.
Researchers found that
less than 5% of people
surveyed said it was
because they were unable
to get to a location to get
vaccinated. The top three
reasons in numerical
order were: didnt know
the vaccine was needed,
couId cause inuenza,
and could cause
side-effects. Because
Medicaie coveis lhe u
shot this study indicates
that lack of knowledge
about the vaccine may
be a more important
deterrent of vaccination
than lack of access or
ability to pay.
13

A 2OO1 nela-anaIysis
of 20 studies showed
that mailing high-risk
patients an educational
packet about the
inuenza vaccine
doubled the vaccination
rate. The patients cited
the education packet
and their health care
providers as their main
motivators for getting the
vaccine.
14
The importance
of healthcare providers as
advocates for vaccination
cannot be understated.
For people who do not
have or regularly visit
a health care provider
broader public health
campaigns, or school and
workplace intervention
would be other ways to
effectively disseminate
information about
vaccinations.
Data on access to
vaccination locations
and ability to pay for
residents of Illinois
suggests that its residents
may value vaccines
less than residents of
other states or are less
educated about the
subject. Even if vaccines
can be received nearby
for a low cost, people
will not spend time or
money to get vaccinated
if they dont believe it is
effective and important.
The cause of low H1N1
Illinois in 2010-2011 is
still undetermined, but
the conclusions made
above give potential
targets for interventions
and questions for future
research.
RESEARCH
1. Rudavsky, R. Pollack, C. Mehrotra, A. The geographic distribution, ownership, prices, and scope of practice at retail
clinics. Annals of Internal Medicine 2009;151: 315-320.
Molly Fausone is a senior at Stanford University. She will graduate in June of 2012 with a Bachelors
in Human Biology and a concentration in Infectious Disease and Public Health. While interning for the
Northwestern University Department of Preventative Medicine she researched vaccination rates in
llinois, and worked on a public health project to increase HPV vaccination rates in Chicago-area high
schools. Outside of school Molly enjoys watching sports and spending time with family and friends.
2. Us Lab-Varifed Swine Flu Infections. Flu Count. Available at: http://www.fucount.org/.
3. CDC - Seasonal Infuenza (Flu) - 2010-11 State and Regional Vaccination Coverage. Centers for Disease Control and
Prevention. Available at: http://www.cdc.gov/fu/professionals/vaccination/reporti1011/reportII/.
4. Tsouderos, T. 2010-2011 School Immunization Data -- Chicago Tribune. Chicago Tribune 2011 Illinois School Report
Cards. Available at: http://schools.chicagotribune.com/immunization/.
5. Kennedy, E. Santibanez, T. Bryan, L. Wortley, P. Euler, G. Singleton, J. Bridges C. and Weinbaum, C. Place of Infu-
enza Vaccination Among Adults United States, 2010-11 Infuenza Season. Morbidity and Mortality Weekly Report
2011;60(23):781-785.
6. Deloitte. Retail Clinics: Updates and Implications. Deloitte Center for Health Solutions. 2009. Available at: http://www.
ccaclinics.org/images/stories/downloads/research/deloitte_us_chs_retailclinics_111209.pdf.
7. Health Insurance Coverage of the Total Population, states (2009-2010), US (2010). The Henry J. Kaiser Family Foun-
dation. Available at: http://www.statehealthfacts.org/comparetable.jsp?ind=125&cat=3&sub=39&yr=252&typ=2&rgn
hl=15.
8. Overview Immunizations. Centers for Medicare & Medicaid Services. Available at: https://www.cms.gov/Immuniza-
tions/.
9. Kids Medicaid-Covered Flu Shots Put Docs at a Loss: Study - US News and World Report. Health News Articles - US
News Health. Available at: http://health.usnews.com/health-news/managing-your-healthcare/infectious-diseases/ar-
ticles/2010/10/18/kids-medicaid-covered-fu-shots-put-docs-at-a-loss-study.
10. Yoo, B.K. et. al. Association Between Medicaid Reimbursement and Child Infuenza Vaccination Rates. American
Academy of Pediatrics. 2010; 126(5): e998-e1010. Available at: http://pediatrics.aappublications.org/content/126/5/
e998.full.pdf+html.
11. Stokeley, S. Stanwyck, C. Avey, B. and Greby, S. Vaccine Coverage Among Children in Kindergarten- United States
2009-2010 School Year. Morbidity and Mortality Weekly Report 2011;60(21): 700-704.
12. Trapp, D. Amednews: Medicaid Vaccination Rates Tied to Flu Shot Pay Levels :: Nov. 22, 2010 ... American Medical
News. American Medical Association - Physicians, Medical Students & Patients (AMA). Available at: http://www.ama-
assn.org/amednews/2010/11/22/gvsc1122.htm.
13. Drociuk, D. Reasons Reported by Medicare Benefciaries for Not Receiving Infuenza and Pneumococcal Vaccina-
tions - United States, 1996. Morbidity and Mortality Weekly Report. 1999;48(39): 556-890.
14. Van Amburg, J. Waite, N. Hobson, E. Migden, H. Improved Infuenza Vaccination Rates in a Rural Poplation as a
Result of Pharmaist Managed Immunization Campaign. The Journal of Human Pharmacology and Drug Therapy.
2001;21(9): 1115-1122.
15. Furlow, C. Gonzalez-Feliciano, A. Bryan, L. Euler, G. Ding H. Singleton J. Interim Results: State-specifc Infuenza
Vaccination Coverage- United States, August 2010-February 2011. Morbidity and Mortality Weekly Report 2011;60(22):
737-743
Areas for Future
Research
Anti-vaccine groups
and anti-vaccine
sentiment vary within
and among states, and
these trends should be
investigated as possible
instigators of low
vaccination turnout.
Future work should
also focus on analyzing
relation to socioeconomic
status and residence in
urban vs. rural locations.
Differences in promotion
of vaccination by
health care providers
in Illinois also have
not been studied. If
geographical and
cultural differences in
provider promotion exist,
then identifying these
patterns will be of great
utility in determining
which providers and
communities to target
in spending on vaccine
access, promotion, and
education in the future.
sjph.stanford.edu

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