Stanford Journal of Public Health

Volume 2 · Issue 1 · Winter 2012
Policy · Practice · Ìnvestigation · Research
Another Reason to Stop Smoking: California Cancer Research Act - 9
Disease Detectives: An Inside Look at the Epidemic Intelligence Service - 21
Disruptive Design: Biomedical Engineering and Public Health - 28
Health Care Among Mexican Undocumented Immigrants - 42
How Gendered
HIV Policies May
Be Too Narrow
Stanford Journal
Public Health
An Undergraduate Publication
Volume 2, Issue 1, Winter 2012
Mailyn Fidler
Daniel Bui
Emily Cheng
Ben Lauing
Lindsey Wilder
Aaron Chum
Jovel Queirolo
Laura Potter
Kasey Kissick
Carey Phelps
Nairi Strauch
Helena Scutt
Perri Smith
Cristina Averoff
Anna McConnell
Seanan Fong
Christina Wang
Eileen Mariano
McKenzie Wilson
Katie Nelson
Helen Helfand
Jean Guo
Emma Makoba
managing director
marketing director
campus marketing
marketing intern
layout director
Jessie Holtzman
Mary Bass
Jennifer Jenks
Jason Bishai
Lauren Platt
Storm Foley
research review
Cover photo courtesy of FACE AIDS 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 1 Winter 2012 3
We offer you our sincerest wel-
come to the Winter 2012 issue of
the Stanford Journal of Public Health,
a biannual undergraduate publica-
tion seeking to connect the highly
passionate, diverse public health
community at Stanford by foster-
ing scholarly discussion of press-
ing public health issues.
One of the most beautiful, yet
frustrating things about public
health is its complexity; under-
standing an ongoing health prob-
lem requires a multidisciplinary
approach that explores biological,
social, economic, and political per-
spectives that lie under the surface
of the problem. This issue furthers
our dedication to creating a forum
where different, yet interconnected
areas of the public health commu-
nity can come together.
The Journal was founded with
the purpose of creating a hub for
the widely dispersed public health
resources on campus. Since our
inaugural issue in Spring 2011, the
SJPH has had the pleasure of de-
veloping strong relationships with
local organizations in the health
community, including the Stanford
Ofhce of Connunily HeaIlh, lhe
Cenlei foi Innovalion in CIolaI
HeaIlh, lhe Iiogian in Hunan
ßioIogy, lhe Haas Cenlei foi IulIic
Seivice, Slanfoid Seivice in CIolaI
HeaIlh, lhe SexuaI HeaIlh Ieei
Resouice Cenlei, and nany olheis.
These connections will become key
to the ongoing development of the
Journal’s role in public health at
Stanford University.

Editorial Staff Background
As Co-Ldilois in Chief, ve
bring differing yet complemen-
tary perspectives in public health.
Daniel’s passion for medicine
stems from his fascination with the
vast potential for biotechnology to
revolutionize the way we address
the growing disparities in health
between the developed and devel-
oping voiId. He hopes lo uliIize
his engineering
background and
spirit to develop
devices to ensure
that the qual-
ity of available
medical care a patient can receive
is not dependent upon his or her
Mailyn is a policy wonk with a
scienlihc lenl and has deIved inlo
issues ranging from the intricacies
of gIolaI AIDS
policy, to the ef-
fects of climate
change on aid
distribution for
vector-borne dis-
ease, to national
seat belt policy.
Tvo slinls inleining al lhe Cenleis
foi Disease Iievenlion and ConlioI
gave her a window into how one
of the premier public health insti-
tutions approaches public health
threats on a national and global
IeveI. In fuluie, she hopes lo pai-
ticipate in shaping more effective
social and political responses to
public health problems.
Focus of Volume Two
As a Journal, we investigate
public health through four lenses:
policy, practice, investigation, and
ieseaich. In lhis issue, lhe IoIicy
section addresses how policymak-
ers approach public health issues
at the state, national, and local
IeveIs. The Iiaclice seclion Iooks
at on-the-ground health interven-
tions in different resource settings.
Invesligalion piesenls iecenl
research advances in children’s
health. The Research section
presents the most recent student
research from the Stanford com-
munity on public health.
New Developments
We are pleased to announce two
new developments at the Journal.
The Journal will be producing its
hisl lhened issue in lhe spiing
of 2012, focusing on the role and
application of prevention in public
health. Our staff will be convers-
ing with top prevention faculty
members in preparation for this is-
sue, and we will be searching cam-
pus for the best student research
on prevention-related topics. We
are also happy to announce the
hisl avaid foi ßesl Reseaich Sul-
mission to the Journal. Winners
will be selected from all research
submissions and announced at an
event in spring.
We sincerely hope you enjoy
reading our second volume of
the Journal. We welcome your
thoughts and comments about our
work, about the public health com-
munity at Stanford, or about an is-
sue you would like to see us cover.
IIease don´l hesilale lo ieach oul
to us at stanfordjournalofpubli-
Daniel Bui (2012)
Mailyn Fidler (2014)
letter from the editors:
Mailyn Fidler and Daniel Bui editors-in-chief
4 Stanford Journal of Public Health
letters from the advisors
As the Stanford Journal of Public Health grows, it is learning more about readers’ needs and interests. As
part of these efforts, the Journal has luiIl lies vilh sludenl gioups and oiganizalions on canpus (lhe Hu-
nan ßioIogy piogian, lhe Cenlei foi Innovalion in CIolaI HeaIlh, lhe Ofhce of Connunily HeaIlh al lhe
MedicaI SchooI, lhe SexuaI HeaIlh Ieei Resouice Cenlei, Slanfoid Seivice in CIolaI HeaIlh, and Sludenls
Taking on Ioveily). Il aIso sponsoied a pulIic evenl on food access inequilies vilh a
nenlei of IoIicyLink as pail of Slanfoid´s ¨Iood Week.¨ AII of lhese aclivilies aie uni-
hed in lheii focus on incieasing avaieness aloul lhe Journal and building ties within the
public health community on campus. The Journal is eager to hear from you about needs
you believe the Journal could meet or activities you would like to see it sponsor. And as
always, the door is open to students wishing to contribute to an upcoming issue.

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

The successful debut of the Stanford Journal of Public Health in May 2011 has led to the development of
seveiaI ofhciaI ieIalionships vilh facuIly and sludenls acioss lhe univeisily. Acling as a nexus foi pulIic
health related policy, research, and practical endeavors, the Journal is becoming an impor-
lanl iesouice foi lhose deepIy invoIved and leginning lo Ieain aloul lhese issues. Look-
ing forward, the publication seeks to develop stronger relationships with the community
through enhancing its online presence and participation in related events and program-
ning. Il´s an exciling line lo le pail of lhe effoil and I encouiage sludenls, facuIly and
staff to join us.

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

I viile lhese voids fion a peich in lhe deseil in Saudi Aialia, vheie I an visiling as pail of a deIegalion
fion lhe Slanfoid Iievenlion Reseaich Cenlei. Saudi Aialia is a counliy vheie 1 oul of eveiy 5 aduIls is
dialelic and 1 in 4 is hypeilensive. In a counliy vheie Aneiican fasl food is leconing incieasingIy popu-
lar and driving has replaced most walking, the medical community must turn to public health education
campaigns and other lifestyle change initiatives to prevent these chronic diseases. After an afternoon in
lhe deseil iiding caneIs, ny Slanfoid coIIeague Di. Randy Slaffoid ieninded ne of lhe IsIanic saying
¨Tiusl in AIIah, lul lelhei youi caneI hisl.¨ Lach peison nusl pailicipale in change effoils in oidei foi
them to be effective.
The Stanford Journal of Public Health (S}IH) has nade a good slail in incieasing avaie-
ness in lhe Slanfoid Connunily aloul inpoilanl pulIic heaIlh issues. I an pIeased lo
announce lhal S}IH viII devole ils spiing pulIicalion lo lhe issue of pievenlion in pulIic
heaIlh. I hope lhal you viII conlinue lo enjoy and Ieain fion S}IH as il expIoies lhe op-
poilunilies lhal pievenlion effoils piovide. And lhen I hope lhal you viII ¨lelhei youi
caneI¨ and pIay a ioIe in inpoilanl pievenlion effoils on lhe Slanfoid canpus.

Catherine A. Heaney, PhD, MPH
Associate Professor (Teaching)
Stanford Prevention Research Center
Another Reason to Stop Smoking: California Cancer Research Act.............................................................7
Christina Wang
Towards Sustainability: Transitioning to the US Global Health Initiative........................................................9
Anna McConnell
Outdated and Overlooked: BPA Regulation in US Chemical Safety Standards...........................................11
Eileen Mariano


Global Health Security: Broadening Our Thinking........................................................................................13
David L. Heymann & Matthew Dixon
No Time to Waste: Community Emergency Responder Programs in South Africa......................................18
McKenzie Wilson
Disease Detectives: An Inside Look at the Epidemic Intelligence Service...................................................19
Perri Smith
Slum Networking: Working to Improve Health Through Infrastructure.........................................................21
Cristina Averhoff
Access to Treatment for Congenital Heart Disease in Rural Gansu............................................................24
Seanan Fong
Disruptive Design: Biomedical Engineering and Public Health....................................................................26
Helena Scutt
The Littlest Index Case: How Pediatric Patients in San Francisco Helped Decode HIV/AIDS....................28
Nairi Strauch

Research Review
Transcending Global Frameworks: How Gendered HIV Policies May Be Too Narrow................................31
Emily Rains
The World’s Largest Smoking Ban: China’s Upcoming Smoking Ban and its Effect on Particulate Matter in
China’s Restaurants and Cafés....................................................................................................................36
Kyle Wong
Health Care Among Mexican Undocumented Immigrants: Barriers to Access and Utilization ...................40
Tim Dang
Unspoken Epidemics: Exploring Techniques for Understanding Female Pelvic Floor Dysfunction.............45
Liz Melton
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
regulation of public health issues at the
state, national, and international level, with
topics ranging from the domestic California
Cancer Research act, national legislation
on rules on chemical content limits, and
emerging foreign aid policies in developing
Volume 2 Issue 1 Winter 2012 7
Another Reason to Stop Smoking
California Cancer Research Act
Christina Wang
California ranks 32

among U.S. states in tax
on tobacco.
The state
eains a ¨D¨ giade fion
lhe Cenlei foi Disease
ConlioI foi funds aIIocal-
ed to tobacco control per
individuaI, and CaIifoi-
nia’s teen smoking rates
have stagnated despite
decreases nationwide.

The CaIifoinia Cancei
Reseaich Acl (CCRA),
set for the February 2012
statewide ballot, poses
a potential counter to
elevated smoking levels,
proposing to increase
tobacco tax from $0.87 to
$1.00 per pack of ciga-

The oljeclive of CCRA
is two-fold, according to
Di. Ceoige Iishei of lhe
Stanford Medical School.
First, it seeks to decrease
smoking among teenag-
ers, the largest contribu-
tors to smoking rates,
by raising the price of
lolacco. Thus, lhe CCRA
deters the nation’s youth
from beginning or con-
tinuing to smoke.

ond, the revenue gener-
aled fion CCRA viII le
directed towards cancer
research. Though this is
not the primary purpose,
CCRA laigels lolacco us-
ers as a potential source
of funding because the
mortality rate for lung
cancer is higher than that
of any other form of can-
cei, signihcanlIy incieas-
ing the state’s healthcare
costs, according to Fisher.
In addilion lo funding
research to treat cancer, a
Univeisily of CaIifoinia
sludy piojecls lhal CCRA
could preemptively save
CaIifoinia up lo $28.2
billion in healthcare costs
between 2012 and 2016
by decreasing smok-
ing related diseases and

Senaloi Don Ieiala
speaiheads lhe CCRA
campaign, with notable
support from Stanford
faculty, including Fisher
and Di. CiIleil Chu of
the Stanford Medical
SchooI, and NoleI Lauie-
ale IauI ßeig. Accoiding
to Fisher, raising the tax
on tobacco to one dollar
per pack is estimated to
lower teenage smoking
ly 5 lo 15 peicenl. ¨These
declines have been
shown in states such as
New York, where suc-
cessful after successful
tobacco tax-raising legis-
Ialion has leen passed.¨
Why target teenage
snoking` ¨Teenageis aie
the primary target for Big
Tolacco,¨ cIains Iishei.
¨HaidIy any aduIls legin
smoking – it’s mostly the
youth that start smoking,
become addicted, and be-
come lifetime consumers
–and Big Tobacco knows
CCRA faces signih-
cant opposition from
lolacco conpanies. Iasl
initiatives to increase the
lolacco lax in CaIifoinia
have either been aban-
doned prior to election
or have failed when
placed on the ballot due
lo ¨heavy canpaigning
fion ßig Tolacco,¨ cIains
Chu. In 2OO6, Iioposi-
tion 86 sought to increase
the tobacco tax to $2 per
pack but was rejected
in the general election,
receiving only 48 percent
of the vote (Fig. 1).
most recent attempt by
the state, Senate Bill 600,
soughl lo lax $1.5O pei
pack of cigarettes but was
ultimately abandoned
due to allegations from
tobacco companies that
tax revenue was being di-
rected to deep-pocketed
hospitals. The current bill
seeks to redirect funds to
cancer research organiza-
tions, public and private
alike. Reports from the
CaIifoinia Secielaiy of
State show that tobacco
companies have already
spent $2 million combat-
ing CCRA.

Fisher describes cancer
ieseaich as ¨undeifund-
ed in geneiaI.¨ Chioni-
caIIy dehcienl funds Iead
8 Stanford Journal of Public Health
to competition between
different cancer causes,
resulting in groundbreak-
ing advances in certain
areas and stagnancy in
others; breast cancer, for
example, receives consis-
tent funding, while other
cancers, such as lung,
colorectal, and pancreatic
cancers, have compara-
tively low funding per
death. Fisher further
claims that research-
ers must take the most
accurate and effective
approach towards cancer
ieseaich: ¨Whal ve aie
looking for right now
is the genetic code be-
tween each individual’s
cancer. We don’t want
a zip code – we don’t
want to treat all ‘lung
cancers’ with a blanket
treatment – because each
cancer is different. We
need to combine clinical
trials and basic research
to form a two-pronged
allack lovaids cancei.¨
Augmented funding
will allow for the explicit
study of relatively under-
funded cancers, increas-
ing polenliaI specihcily
and efhcacy of liealnenl.
Financial support from
lhe NalionaI Cancei Insli-
lule ¨decieas|edj due lo
lhe econonic iecession,¨
said Chu, incieasing lhe
potential importance of
CCRA funding lo ie-
search organizations.
Fisher estimates that
the ballot measure
will raise an estimated
$600 million for cancer
research and tobacco
prevention yearly, with
60% of the revenue al-
located directly to can-
cei ieseaich. He fuilhei
describes the process of
allocations of funds as
a grant committee com-
posed of academically
pioninenl hguies lhal
will review applications
for grants and funding,
primarily from research
universities. Submis-
sions will go through
a rigorous peer-review
process to ensure that the
funds are appropriated
to clinical trials and labs
that are engaging in the
most innovative research.
Additionally, 20% of the
revenue will be allocated
to tobacco prevention
and cessation programs,
15° lo faciIilies and
capital equipment for re-
search, 3% to anti-tobacco
law enforcement, and no
more than 2% to adminis-
Chu enphasizes,
however, that the largest
pulIic lenehl of CCRA
will come from its deter-
rence of smoking.
Fisher states that the
measure is not a punish-
ment of the population
lul ialhei a hnanciaI in-
centive to lead a healthier
Iife: ¨lhe day vhen ve
get $0 dollars from the
CaIifoinia Cancei Re-
search Act, if ever imple-
mented, will be when
we will get rid of 1/3 of
all our cancers – because
no one will be smoking
1. Fisher, G. Talk on Clini-
cal Trials. Published Nov
1, 2011. Accessed Nov
18, 2011. [Obtained from

Tobacco Tax Comparisons
Amount of Tax (per pack)

Percentage Revenue to Cancer Control

Cancer Research Annual Funding
2. Lightwood, J, Glantz,
SA. Predicted Effect of
California Tobacco Con-
trol Funding on Smoking
Prevalence, Cigarette
Consumption, and
Healthcare Costs, 2012-
2016. Published 2011.
Volume 2 Issue 1 Winter 2012 9
Towards Sustainability
Transitioning to the US
Global Health Initiative
Anna McConnell
A capacity to endure:
sustainability. The word
has been subtly rumbling
through the social sphere
for decades, recently hit-
ting the core of America’s
collective intelligence.
From the economic sus-
tainability of the housing
market to the engineer-
ing of sustainable energy
sources, Americans seem
to be shifting to a mind-
set that values future-
minded management
of resources. Often, this
mindset means attempts
to salvage old infrastruc-
ture are often abandoned
in favor of developing
new programs that offer
a sustainable future. The
attitudes of the U.S. gov-
ernment towards global
health are no exception.
In May of 2OO9, Iiesi-
dent Obama announced
lhe U.S. CIolaI HeaIlh
Inilialive, a conpie-
hensive plan that en-
conpasses ILIIAR, lhe
Iiesidenl´s Lneigency
IIan foi AIDS ReIief fion
the Bush administration.
ILIIAR vas enacled in
2003, when Bush pledged
$15 liIIion ovei a peiiod
of 5 yeais lo HIV pieven-
tion, treatment, and care,
focusing on 15 counliies
that were home to 80%
of all people requiring
These coun-
tries were Botswana,
Cole d´Ivoiie, Llhiopia,
Cuyana, Haili, Kenya,
Mozambique, Namibia,
Nigeria, Rwanda, South
Africa, Tanzania, Ugan-
da, Zanlia and Vielnan.

AIlhough ILIIAR has
provided anti-retroviral
treatment to millions of
individuals, substantial
criticism of the program
ienains. Lxpeils aigue
that the program falls
short in its emphasis on
lhe Aß pail of lhe ¨AßC¨
approach (Abstain, Be
failhfuI, use Condons).
IniliaIIy, lhe US Congiess
mandated that 33% of
prevention funds be ear-
marked for abstinence-
until-marriage programs.

The abstinence program,
an approach that has
largely failed to decrease
signihcanlIy liansnission
of HIV, piovoked sone lo
question the legitimacy
and effectiveness of U.S.
global health aid. The
33% earmarked mandate
has since been revoked.
Despite the abstinence
ciilique, ILIIAR uIli-
mately demonstrates a
focused appioach lo HIV
Stanford researcher in
health policy, Assistant
Iiofessoi of Medicine
Cianl MiIIei, iefeis lo
ILIIAR as a ¨veilicaI ap-
pioach¨ lo gIolaI heaIlh
aid. Simply put, the pro-
gram focuses on a single
issue in specihc Iocalions
with clear objectives.
CHI, on lhe olhei hand,
embodies a broader, hori-
zontal approach. With
unprecedented funding
of $63 liIIion, CHI nov
enconpasses ILIIAR
and plans to surpass it in
size and scale by focusing
on primary health care
for women and children,
strengthening health sys-
tems, and country owner-

Lian ßendavid of lhe
Slanfoid Cenlei foi CIol-
aI HeaIlh coIIaloiales
with Miller on research of
CHI. In lheii papei, ¨The
US CIolaI HeaIlh Inilia-
live: Infoining poIicy
vilh evidence,¨ lhey
claim that sustainabil-
ity and ownership were
not prioritized in Bush’s
approach to health as-
sislance. In conliasl, CHI
iepiesenls lhe ¨luiIding
|ofj a fuluie in vhich
local health care systems
are capable of providing
sustainable health care

But what exactly is a
sustainable health care
service, and how is its
Local families wait outside clinic for HIV/AIDS treatment.
10 Stanford Journal of Public Health
success neasuied` Iei-
haps the most obvious
ansvei is hnanciaI sus-
lainaliIily. If piogians
and policies can oper-
ate on their own after a
period of implementation
and foieign hnanciaI sup-
port, one might consider
them successful. While
CHI sliives lo deveIop h-
nancially sustainable pro-
grams, it also intends
to broaden the scope
of each issue. The com-
mitment to maternal-
child health involves
¨piogians incIuding
infectious disease, nutri-
tion, maternal and child
heaIlh, and safe valei,¨

acknowledging that these
issues are inherently
Building sustainable
approaches to health-
care means addressing
complex systems, adding
a Iayei of difhcuIly lo
implementing horizontal
approaches. Miller notes
his recent research on the
implementation of cook
stoves to improve domes-
tic health in Bangladesh
as an exanpIe. He has
found that a woman’s
acceptance of a stove is
strongly dependent upon
her husband’s opinion of
the stove. Thus, in order
to introduce a stove in
the house and improve
the health of a woman
and her family, one must
also deal with underlying
gendei issues. Inpiov-
ing health is not separate
from the culture, the
history, and daily lives of
the people involved, and,
ethically, it is unclear the
extent to which cultural
values may be altered
externally in the pursuit
of improved health.
These issues pose a
dilemma for those who
wish to implement more
comprehensive health
Ultimately, the transi-
lion lo CHI offeis an
unprecedented opportu-
nity for the U.S. to fun-
damentally change the
global approach to health
aid. Bendavid and Miller
viile lhal ¨lhe oppoi-
tunity to inform future
policy with experimental
evidence can make the
CHI a piIIai of aclion as
veII as Ieaining.¨
inpoilanlIy, CHI viII
reveal the successes and
failures of developing
sustainable care, while
exploring questions such
as whether the imple-
mentation of gender eq-
uity should be addressed
in the public health
arena. The broader ap-
proach to health aid will
allow the U.S. to consider
how it can help commu-
nities over generations
and create programs that
will be sustainable within
a unique cultural and
historical context.
1. Merson M, O’Malley J, Serwadda D, Apisuk C. The history and challenge of HIV prevention. The Lancet 2008; 372:
Reminder posted outside local elementary school in
Zambezi River, Zambia.
JESSIE HOLTZMAN | with permission
GHI will reveal the
successes and
failures of developing
sustainable care, while
exploring questions
such as whether the
implementation of
gender equity should
be addressed in the
public health arena.

2. PEPFAR Reauthorization Action Team (a project of Health Gap) Web site. Available at:
Accessed on November 1, 2011.
3. Bendavid E, Miller G. The US Global Health Initiative. JAMA 2011; 306 (18): 1951-2048.
4. USAID. Implementation of the Global Health Initiative: Consultation Document. Available at:
our_work/global_health/home/Publications/docs/ghi_consultation_document.pdf. Accessed November 1, 2011.
Volume 2 Issue 1 Winter 2012 11
Americans usually
encounter Bisphenol-A
(ßIA) counlIess lines
per day, in forms ranging
from plastic hardeners to
cIeaning agenls. IailicIes
of ßIA found in Tuppei-
ware, soda cans, water
bottles, cleaning deter-
gent, and receipts often
rub off and enter the
human body by ingestion
and skin contact. As a
result, an unprecedented
92° of Aneiicans, age 6
and older, show detect-
able traces of the com-
pound in their systems.

Although researchers
have shovn lhal ßIA
found in concentrations
as Iov as O.1 lo 9 pails
per billion can be harm-
fuI, ßIA ienains an
integral part of commer-
cial products. Researchers
have not yet established
a conciele Iink lo specihc
diseases, but the com-
pound mimics estrogen
and alters natural hor-
mone levels in both men
and women,
leading to
possible side effects such
as premature puberty,
obesity, and cancerous

The chemical’s safety,
hisl queslioned in 193O,
remains under scrutiny
by government organi-
zations and physicians.
The NalionaI Inslilule
of HeaIlh (NIH) iecenlIy
decIaied ils ¨concein foi
effecls |of ßIAj on lhe
brain, behavior, and pros-
lale gIand¨ vhen feluses,
infants, and children
are exposed to the com-

¨In lhe case of ßIA, ve
have numerous, well-
designed studies done by
independent, academic
scientists with no ties to
the chemical industry,
who have demonstrated
harmful effects through
in vitro and in vivo experi-
ments in multiple animal
species,¨ Univeisily of
CaIifoinia San Iiancisco
School of Medicine Dr.
Sarah Janssen warns.
¨ßIA exposuie shouId le
avoided for all people of
reproductive age, chil-
dien and infanls.¨
InleinalionaI govein-
ments have begun work
to diminish the presence
of ßIA, and olhei polen-
tially hazardous chemi-
cals, in commercially
available products. The
Luiopean Union passed
lhe Regislialion, LvaIua-
tion, Authorization, and
Resliiclion of ChenicaIs
(RLACH), vhich lecane
effective in 2007, mak-
ing Luiope lhe Ieadei of
the movement to update
its chemical regulations
lo ießecl ßIA. RLACH
supports the motto of
¨No dala~no naikel.¨
Il slipuIales lhal coipoia-
tions, instead of govern-
ment organizations, must
prove the safety of chemi-
cal compounds used,
reducing governmental
chemical testing and
expediting evaluation.

This shift of account-
ability from the govern-
ment to the producers
allows the government to
make decisions regarding
chemicals’ safety more
Menleis of Congiess
recently began focusing
on meeting the increased
chemical safety standards
sel ly Luiope. The Safe
ChenicaIs Acl of 2O11,
sponsored by Represen-
tative Bobby Rush and
Senaloi Iiank Laulen-
berg, attempts to update
the Toxic Substances
ConlioI Acl of 1976
(TSCA), vhich Di. }ans-
sen desciiles as a ¨leiii-
lIy ouldaled Iav.¨

HeaIlh LegisIalive
Assislanl Noia Con-
nois agiees lhal TSCA
is ¨giealIy ouldaled foi
modern manufactur-
ing.¨ Undei TSCA, lhe
LnviionnenlaI Iiolec-
lion Agency (LIA) is
not required to assess
chemicals already on the
naikel. If lhe nev Iegis-
lation passes, companies
would be obligated to
prove that their chemicals
Outdated and Overlooked
BPA Regulation in US
Chemical Safety Standards
Eileen Mariano
Soda cans containing BPA being shipped to consumers.
Image: Salvatore Vuono/
12 Stanford Journal of Public Health
neel specihed slandaids
of chemical safety before
beginning their use in
production. Moreover,
lhe LIA says lhal lhe
new criteria demand
a ¨high luiden of
proof to show that a
chenicaI is unsafe,¨
increasing the strin-
gency of chemical safety

Although an improve-
ment over current stan-
daids, lhe Safe ChenicaIs
Act of 2011 may contain
lvo najoi ßavs. Iiisl,
the testing process for
chemicals takes a consid-
erable amount of time.
If a ied ßag cones up
during the assessment
process, proving that the
chemical is dangerous
can lake as Iong as hfleen
yeais. Second, if lhe LIA
hnds polenliaI heaIlh
hazards associated with
a chemical already in pro-
duction, the compound
will be tested again but
not immediately taken
out of production.

The chemical remains
incorporated in pro-
duction, allowing for
potentially hazardous
¨This is lecause lhe
government can’t abrupt-
ly stop manufacturing for
certain companies entire-
Iy,¨ Connois expIains. ¨A
whole chunk of economic
workforce would have to
More pressingly, this
legislation will not im-
minently appear on the
laIIol. Due lo insufhcienl
congressional support,
the bill remains in the
Subcommittee on Super-
fund, Toxics, and Lnvi-
ionnenlaI HeaIlh unliI il
garners further interest.
The liII aIso faces signih-
cant challenges from the
chemical industry, which
hopes to avoid increased
stringency of regulation
by thwarting the prog-
ress of the measure.

Despite stalled prog-
iess, lhe Safe ChenicaIs
Act of 2011 inspires
improvement not only
iegaiding ßIA lul aIso
in the greater arena of
general chemical safety.
Connois expIains lhal
recent developments
in effective, economi-
caI aIleinalives foi ßIA
Ied CaIifoinia Coveinoi
Jerry Brown to sign a law
pievenling ßIA fion le-
ing produced or sold in
CaIifoinia´s laly lollIes
by the year 2013.
lunaleIy, Connois poinls
oul lhal ieseaicheis ¨jusl
haven’t found or released
any good iepIacenenls¨
foi ßIA use in iesin Iin-
ings for cans. Although
neans of iepIacing ßIA
entirely remain unclear,
recent promotion of safe
chemical compounds
through government
regulation and laboratory
research suggest a prom-
ising future.

1. Harvard Studies BPA: Can the FDA Ignore This? Website. Available at:
Doctor Sarah Janssen, MD, PhD, MPH is a doctor at the University California San Francisco School of Medi-
cine. She works with patients in the Urology Department. She is also a Staff Scientist in the Heath and En-
vironment Program of Natural Resources Defense Council (NRDC). At the NRDC, she strives to accomplish
more appropriate restrictions on toxic chemicals.

Nora Connors is the Health Legislative Assistant for California Senator Dianne Feinstein. She was born in Wis-
consin and attended Macalester College. She has extensively researched BPA and contacted large manufac-
turing companies, informing them of the Senator’s concerns regarding the presence of the compound in their
The National Institute
of Health (NIH)
recently declared its
“concern for effects
[of BPA] on the
brain, behavior, and
prostate gland” when
fetuses, infants, and
children are exposed
to the compound.

2. Environment California: Bisphenol A Overview. Website. Available at:
mental-health/stop-toxic-toys/bisphenol-a-overview. Accessed November 20, 2011.
3. Chemical Reform Bill Would Shift Burden of Proof to Industry. Website. Available at:
news/2010/04/15/chemical-reform-bill-would-shift-burden-of-proof-industry. Accessed October 30, 2011.
4. Christensen, Adam. Congressional Science Fellow for Senator Dianne Feinstein. Interviewed October 31, 2011.
5. Gov. Jerry Brown Signs Ban on Chemical BPA in Baby Bottles. Website. Available at
greenspace/2011/10/bpa-ban-signed-by-california-governor-jerry-brown.html. Accessed October 30, 2011.
Volume 2 Issue 1 Winter 2012 13
In an incieasingIy
interconnected world,
many dimensions of
global health have
become interwoven with
international affairs and
foieign poIicy. In 2OO5,
Senalois Richaid Lugai
and Barack Obama
slaled, ¨vhen ve lhink
of the major threats to
our national security, the
hisl lo cone lo nind aie
nuclear proliferation,
rogue states and global
terrorism. But another
kind of threat lurks
beyond our shores, one
from nature, not humans
- an avian ßu pandenic.¨
CIolaI heaIlh secuiily has
leen dehned as infeclious
disease events that
could cross international
borders, as Obama and
Lugai did. Hovevei,
true health security
transcends this concept.
Il has coIIeclive and
individual aspects and
encompasses protection
from infectious and non-
communicable disease
lhieals. IndividuaI
health security, which
requires personal access
to medicines, vaccines
and other health-related
products and services, is
of particular concern for
low- and middle-income

Collective Health
Security: Acute and
Chronic Public Health
Threats Transcending
The WoiId HeaIlh
Oiganizalion (WHO)
dehnilion of gIolaI
health security includes
¨acule pulIic heaIlh
events that endanger
the collective health
of populations living
across geographical
regions and international
loundaiies ... |vilh anj
impact on economic or
political stability, trade,
tourism, access to goods
and services and, if they
occur repeatedly, on
denogiaphic slaliIily.¨

The example of the
iecenl H1N1 (svine ßu)
pandemic demonstrates
the endangerment to
collective health and
the economic and
demographic impact
across borders that can
be caused by newly
emerged infectious
Infeclions al lhe
human-animal interface
such as H1N1 and Seveie
Acquired Respiratory
Syndrome (SARS)
have gained political
attention. Domestic pigs
harbouring multiple
sliains of inßuenza
virus provided effective
vessels for the evolution
of noveI H1N1 viius,
vheieas caplive Civel
cals in Chinese vel
markets are thought
to have harboured the
coronavirus that crossed
the species barrier to
humans, causing the
SARS outbreak.
ease with which livestock
move across the globe
also contributes to the
movement of infectious
diseases that were once
restricted to narrow
geographic ranges. Rift
VaIIey Ievei, a viiaI
infection of cattle and
other ruminant animals,
once onIy knovn in Lasl
Africa, emerged in the
Aialian IeninsuIa in lhe
early 2000s. A hypothesis
for its emergence is that
livestock transported
the virus across the
Red Sea while being
moved from sub-Saharan
Movement of
infectious diseases not
linked to animals is also
a vital consideration; the
introduction of Neisseria
meningitides by pilgrims
to Mecca resulted in
epidemic outbreaks
of meningococcal

IoIilics can piovide
an opportunity for
emergence or re-
emergence of infectious
diseases. Iiogiess
on the eradication of
polio reversed in 2003
when political leaders
in Northern Nigeria
suspended immunization
activities following
growing distrust from
parents who believed
the vaccines were
contaminated with anti-
fertility agents.
As a
result, polio re-emerged
in many parts of northern
Nigeria and spread to
more than 20 polio-free
The evolution and
spread of bacteria
resistant to antibiotics is
also a major emerging
infectious disease threat.
Staphylococcus aureus
bacteria (MRSA) and
bacteria (NDM-1) have
spread throughout the
voiId. Inconsislenl
use, over-use, and sub-
optimal doses have
accelerated the evolution
of antimicrobial
resistance to drugs.
These organisms
have evolved mainly in
hospital settings where
antibiotics are frequently
used and highlight the
importance and potential
international spread
of hospital-acquired
Global Health Security
Broadening Our Thinking
David L. Heymann
Matthew Dixon
14 Stanford Journal of Public Health
Diseases (NCDs)
conpiise a signihcanl
health burden in
both developed and
developing countries.
Chief anongsl lhe
NCDs aie heail disease,
cancer, chronic lung
disease and diabetes,
contributing most
signihcanlIy lo gIolaI
disability rates. While
they do not spread across
borders as infections
can, determinants of
such diseases, including
smoking, unhealthy
diets and alcohol
aluse, aie inßuenced
by international trade,
marketing and other
policies and practices in
sectors outside of health.
In Iov- and niddIe-
income countries where
NCDs have a heavy
impact on the working
age population, the
economic and social
consequences are
devaslaling. Chionic
diseases included in the
NCD specliun need lo
be considered alongside
emerging and endemic
infectious disease threats
to global health security.

Individual Health
Security: Issues of
Unlike industrialized
countries, where most
individuals have
relatively easy access
to health care, access in
developing countries is
unieIialIe. In 2OO6, lo
protest the inequitable
nature of global access
lo vaccines, Indonesia
vilhheId H5N1 (liid ßu)
inßuenza viius specinens
fion WoiId HeaIlh
Organization laboratories
that manufacture
vaccines. Indonesia
expressed concern
that pharmaceutical
conpanies lenehlled
economically from
vaccines manufactured
from virus provided by
Indonesia and soId il
at a price unaffordable
in Indonesia and olhei
developing countries.

When H1N1 inßuenza
(svine ßu) eneiged in
2OO9, nisliusl deepened
as it became clear that
industrialized countries
could easily buy all
available vaccine
stocks, leaving little for
developing countries
to purchase, even at the
same price.

SulsequenlIy, WHO
member states have
made efforts to ensure
more fair and equitable
shaiing of inßuenza
vaccines to foster
global health security.
Negotiations in 2011
iesuIled in lhe Iandenic
Inßuenza Iiepaiedness
Framework, which
provided initial, limited
steps towards improving
equitable vaccine access.

Several other initiatives
increase access to
medicines in developing
countries. For instance,
medicines for neglected
tropical diseases such
as leprosy, lymphatic
hIaiiasis and sIeeping
sickness are provided
through public-private
partnerships where
manufacturers provide
free medicines.
CIolaI Iund lo Iighl
AIDS, TuleicuIosis
and Malaria provides
countries with funding
for medicines to treat
these three infections; the
Affordable Medicines
Facility-Malaria (AMFM)
Saudi authorities urged pilgrims to take all possible precautions against the H1N1 fu.
OMAR CHATRIWALA | wikimedia commons
Volume 2 Issue 1 Winter 2012 15
works with private,
pulIic and NCO
providers to create price
reductions and buyer
subsidies through co-

Iiospecls foi lhe
sustainability of some
donor-led programmes
are in jeopardy, especially
in today’s economic
climate. New ways
to enhance access to
care for infections and
NCDs nusl le expIoied,
including overcoming
entry barriers for health-
related products like
weak regulatory agencies
and import tariffs within
developing countries.
Conpounding lhe
difhcuIlies in access lo
vaccines and medicines is
the maintenance of their
quaIily. WHO eslinales
that more than 30% of
medicines available in
Asia, Afiica and Lalin
America are counterfeit.

The InleinalionaI
MedicaI Iioducls Anli-
Counleifeiling Taskfoice,
was developed in 2006 to
combat these problems,
but the issue is far from
controlled. Sales on both
the open market and the
Inleinel signihcanlIy
complicate control efforts.
Access to medicines,
vaccines and basic
health services could
be compromised
during periods of
instability following
natural disasters or
civil strife, especially
in countries with
political problems. This
is especially true when
healthcare systems are
destroyed and external
support for rebuilding
infrastructure is often
Lpidenics of
Lassa Ievei occuiied in
displaced populations
in Sieiia Leone duiing
lhe 199Os foIIoving
conßicl, and a choIeia
epidemic followed the
2OO9 Haili eailhquake.

Counliies nusl le lellei
prepared to deal with
these situations, and
industrialized countries
must continue to support
them in this endeavour.

Global Efforts Towards
Global Health Security
International recogni-
tion and action towards
global health security is
particularly evident in
lhe ievised InleinalionaI
HeaIlh ReguIalions (IHR
2OO5), vhich piovide a
framework for an in-
ternational response to
trans-border infectious
disease lhieals. IHR 2OO5
seeks to strengthen na-
tional alert and response
by requiring that each of
lhe 193 WHO nenlei
states maintain core ca-
pacities in epidemiology
and public health.

Other efforts seek to
increase understanding
of health issues within
the foreign affairs com-
munity. The 2006 For-
eign IoIicy and CIolaI
HeaIlh Inilialive (IICHI)
focused on global health
security and called for
heaIlh lo le a 'dehning
lens’ for consideration of
foreign policy problems.

In 2OO7, lhe OsIo Minisle-
rial Declaration empha-
sized ensuring greater
access to medicines and
strengthening health
neasuies in conßicl and
crisis management. By
associating health issues
with security concerns,
the Declaration reaches
another sector of govern-
ment and supports health
governance efforts such
as lhe IHR 2OO5.
NCDs have ieceived
increased international
political attention. The
UN High-LeveI Meeling
on NCDs in Seplenlei
2011 is the most recent
iecognilion of NCDs as
threats to security and
economic prosperity. The
Iianevoik Convenlion
on Tolacco ConlioI, ne-
golialed ly WHO nen-
ber states, provided one
of lhe hisl nuIliIaleiaI,
binding agreements to
lackIe NCDs.
there are strong concerns
that weak implementa-
tion of this framework by
national governments,
and strong lobbying by
the tobacco industry may
severely weaken its im-
pacl. Iiioiilizing NCDs
and infectious diseases in
the international public
health and foreign policy
arenas will consolidate a
multidimensional ap-
proach to targeting health
security on a global scale.
Matthew Dixon is currently a research intern in the Centre on Global Health Security at Chatham House. He completed
an MSc in Control of Infectious Diseases at the London School of Hygiene & Tropical Medicine and a BSc in Microbiology
from Imperial College London. His current work focuses on zoonotic/ emerging infectious disease epidemiology, interven-
tion design and policy.
Professor David L. Heymann is Head of the Centre on Global Health Security at Chatham House, Professor of Infectious
Disease Epidemiology at the London School of Hygiene & Tropical Medicine, and Chairman of the UK Health Protection
Agency. He is a former Assistant Director-General for communicable diseases and health security at the World Health
Organization where he also served as head of the polo eradication programme and director of the programme on emerg-
ing diseases. Prior to working at WHO, Professor Heymann worked as a medical epidemiologist on assignment in sub-
Saharan Africa and Asia for US Centers for Disease Control and Prevention. He is a member of the United States Institute
of Medicine and a fellow of the UK Academy of Medical Sciences, and was awarded the CBE in 2009.

Acknowledgements: Katharina Reinhardt, a research intern in the Centre on Global Health Security at, Chatham House,
kindly assisted in the development and review of this article.
16 Stanford Journal of Public Health
1. WHO (2007) World Health Report: A safer future. Available from: . Last
accessed: Accessed 7 November 2011.
2. Webster RG (2004) Wet markets÷a continuing source of severe acute respiratory syndrome and infuenza?, The
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3. Shoemaker T, Boulianne C, Vincent MJ et al (2002) Genetic Analysis of Viruses Associated with Emergence of Rift
Valley Fever in Saudi Arabia and Yemen, 2000-01. Emerg Infect Dis. 8(12): 1415–1420
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106(423): 185-204.
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7. Global Health Watch (2008) Global Health Watch 2: An alternative world health report, London: Zed books. Available
online from: Last accessed: 7 November 2011.
8. Fidler, D. 2010. Negotiating Equitable Access to Infuenza Vaccines: Global Health Diplomacy and the Controversies
Surrounding Avian Infuenza H5N1 and Pandemic Infuenza H1N1. PloS Med 7(5).
9. Fidler, DP and Gostin LO. 2011. The WHO Pandemic infuenza preparedness framework: A Milestone in global gov-
ernance for health. JAMA, 306 (2), pp. 200-201.
10. Mrazek, MF and Mossialos E (2002). Stimulating pharmaceutical research and development for neglected diseases.
Health Policy, 64: 75-88.
11. Arrow K, Panosian C, Gelband H. (2004) Saving lives, buying time: economics of malaria drugs in an age of resis-
tance. Committee on the Economics of Antimalarial Drugs: Board on Global Health. National Academy of Sciences.
Washington D.C.
12. Adeyi O, Atun R. (2010) Universal access to malaria medicines: innovation in fnancing and delivery. The Lancet.
376: 1869-1871
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14. Chatham house (2009) Rethinking Global health. Report of a Chatham House Conference. http://www.chatham- (accessed 17/10/2011)
15. Macrae. J. (1995) Dilemmas of 'post'-confict transition: lessons from the health sector. London: Overseas Develop-
ment Institute . 36 pp.
16. Dowell SF, Tappero JW, Frieden TR. (2011) Public Health in Haiti — Challenges and Progress. N Engl J Med. 364:
17. WHO. Revision of the International Health Regulations, WHA 58.3 Available from
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18. Rodier G, Greenspan AL, Hughes JM, Heymann DL (2007) Global Public Health Security. Emerging Infectious Dis-
eases. 13(10): 1447-1452.
19. Arnorim C, Douste-Blazy P, Wirayuda H, et al (2007) Oslo Ministerial Declaration- Global Health: a pressing foreign
policy issue of our time. The Lancet. 369: 1373-78.
20. WHO. (2011) Booklet about the WHO FCTC. (Accessed 05/01/2012)
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
In this issue, our articles explore approaches
to health disparities in settings with differing
resource levels. We examine the strategies,
results, and limitations of three organizational
approaches to targeting health improvement:
the US CDC’s Epidemic Intelligence Service, a
community-based ambulance service in Africa,
and an innovatively-funded slum improvement
network in India.
18 Stanford Journal of Public Health
No Time to Waste
Community Emergency Responder
Programs in South Africa
McKenzie Wilson
“Once in a lifetime comes
often, so be prepared.”
-OId LngIish Iioveil
Thal ¨once in a Iifeline¨
is often the chance to
save a Iife. Il can le
anyvheie, al anyline~a
car accident, cardiac
aiiesl, a gunshol~lhese
scenarios are common
medical emergencies, all
of which are successfully
treated on a routine basis
in developed countries.
These response systems
assume the preparation,
training, and competence
of medical personnel, and
also their timely arrival
on lhe scene. Indeed, lhe
successful recognition
and treatment of medical
emergencies can hinge
upon a matter of seconds
in ambulance response
These assumptions
cannot be made in
parts of the world
without reliable access
to emergency response
resources. Stanford
alumnus and Fulbright
Scholar Jared Sun
idenlihed lhis need foi
a prepared response
system to medical
eneigencies in Cape
Town, South Africa.
Recognizing that the
best and most effective
life-saving technologies
are often at the hands of
community members,
Sun developed the
Emergency First Aid
Response System (EFAR)
in the township of
Manenberg, South Africa,
jusl oulside Cape Tovn,
in 2OO9. Inlended lo liain
community members
as eneigency hisl aid
iespondeis (LIARs), lhe
program was organized
¨as a nassive expansion
of a sinpIe hisl aid
training course started by
six Stanford University
students back in 2008...
to sustainably equip
Manenberg township
residents with the
emergency skills needed
to keep near-death
patients alive until higher
caie vas avaiIalIe.¨

Through March 2011,
LIAR, vilh lhe heIp of
lhe Univeisily of Cape
Town, Stellenbosch
University, and the
Lneigency Medicine
Society of South Africa,
had ceilihed ovei 7OO
community members
as LIARs.
LIARs aie assigned lo
different sections of the
community divided
inlo lIocks, dehned as
¨cIusleis of iesidences
in which residents are
somewhat familiar
vilh one anolhei,¨ and
stations, larger block
As ordinary
community members
who have chosen to
ieceive lasic hisl aid
liaining, LIARs aie
expected to provide
immediate basic care
in medical emergencies
unliI ceilihed nedicaI
personnel arrive.
The inconsistent and
unreliable response time
of ambulances and other
emergency services in the
Cape Tovn aiea nean
lhal an LIAR nighl
provide basic care for
a few minutes or even
a few hours. A lack of
consistent funding means
that particularly in slum
areas, ambulances or
other emergency services
may take hours to arrive
on the scene.
The LIAR syslen´s
strength and potential
lie in its sustainable
organization and set-up,
helping it to bypass some
of the funding concerns
that have plagued other
emergency response
systems. Still, Sun noted
that initial funding for
the project was easy to
come by compared to
the challenge of making
the organization self-
sufhcienl and conlinuous.
To attain sustained
outside funding, an
effort such as Sun’s must
necessarily convince a
funder of its long-term
In nany deveIoping
countries, until recently,
vertical programs guided
by global health policy
have concentrated on
maternal and child
health and the control of
communicable diseases
rather than the expedient
treatment of medical
emergencies such as
cardiac arrest, road
liafhc accidenls, and
seIf-inßicled injuiies,
all of which are chief
emergency department
complaints in developed
countries. Slowly,
governments have also
Regular EFAR training sessions prepare community mem-
bers in basic frst aid and CPR.
JARED SUN | with permission
Volume 2 Issue 1 Winter 2012 19
begun to acknowledge
the importance of
addressing these
problems that might
limit a country’s human
resources. Fortunately for
Sun, UCT´s head of lhe
emergency department is
also the government head
of emergency medicine,
¨so funds lo conlinue,
run, and maintain the
project came from his
depailnenl,¨ invoIving
lolh lhe UCT and Soulh
African government in
the sustainable funding
and running of the
LIAR piojecl. Indeed,
the interconnectedness
of the government and
academic programming
in South Africa have
neanl ¨lhe syslen has
leen ideaI,¨ fion Sun´s
perspective, especially
since his preferred funder
would be the government
lecause ¨lhal´s vheie
the money is, and their
involvement is a sign that
they are invested in its
SeIf-sufhciency has
always been a primary
concern for health
services projects, and
yet it often still remains
an elusive goal, with
funding, personnel
resources, and continued
suppoil oflen difhcuIl
to consistently come by,
especially in developing,
countries. According to
Sun, ¨a Iol of piojecls
make the mistake of
creating an intervention
that is parallel and
not connected with an
endeavor the government
is aIieady doing.¨ The
importance of asking
local recipients what
they want is often
overlooked, although
it is a critical factor in a
piojecl´s seIf-sufhciency
and continuity. Without
support at the local level,
hnanciaI lacking fion
the regional, national, or
international level is of
little importance.
Though there is
certainly no proven
recipe for success, local
support is also crucial for
a sustainable program.
AIlhough LIAR´s seivices
aie designed lo lenehl
locals, ultimately they are
the ones responsible for
maintaining it.
¨I lhink lhe
overarching philosophy
is to think globally
and IocaIIy,¨ said Sun.
¨We´ie enpoveiing
local organizations in
smaller regions to set
up lhe LIAR syslen foi
themselves, with the idea
that as many of these
systems spring up, it will
be rolled out across a
popuIalion.¨ LIAR hIIs
those once-in-a-lifetime
moments of emergencies
with knowledgeable care
from prepared citizens.
1. “Emergency First Aid
Responder System.”
[Executive Summary]. 3
March 2011.
Disease Detectives
An Inside Look at the Epidemic Intelligence Service
Perri Smith
In lhe nid-199Os, an
outbreak plagued the
ßay Aiea Hispanic
community. Numerous
individuals developed
fevers, chills, nausea, and
diarrhea, all symptoms
of Salmonella. At the
time, no one knew what
vas happening~vhal
was the source of the
illness? Why was the
outbreak only affecting
the Spanish-speaking
community? And most
importantly, whom do
you caII lo hguie il oul`
The Chosllusleis of
the infectious disease
voiId, lhe CDC´s
Lpidenic InleIIigence
Seivice (LIS) voiked
diligently to identify
the source of the
outbreak and stop the
disease. They conducted
interviews, collected
patient histories, and
determined possible
connections between
cases. This is the crucial
voik of lhe LIS: lhe hunl
for origins of outbreaks.
The LIS piogian
legan in 1951 in
response to threats
of biological warfare
duiing lhe Koiean Wai.
Run ly lhe Cenleis foi
Disease ConlioI and
Iievenlion (CDC), lhe
program is part of the
Connissioned Coips of
lhe Uniled Slales IulIic
HeaIlh Seivice.
¨Il´s an ain of lhe
military; there are
unifoins and ianks,¨
explains Dr. Bonnie
Maldonado, currently
a piofessoi of Iedialiic
Infeclious Diseases al
the Stanford School
of Medicine. Since
ils eslalIishnenl, LIS
ofhceis have voiked
on the front lines of
major health issues
including pandemic
ßu oullieaks, nenlaI
health issues following
natural disasters, and
occupational health.
Like puisuing a caieei
in lhe niIilaiy, lhe LIS
can be both exciting
and challenging. The
LIS piovides liaining
and real-life experiences
for health professionals
interested in practicing
epidemiology in the
heId, vhich can incIude
potentially dangerous
unknowns. The highly
selective program accepts
individuals who have
completed graduate level
degrees in health-related
heIds. Once accepled,
the participants are
placed in a variety of
speciaIlies, fion ¨Chionic
Disease Iievenlion
and Occupational
Safely and HeaIlh¨ lo
¨LnviionnenlaI HeaIlh
and Lneiging Zoonolic
Stanford alumnus and Fulbright scholar Jared Sun started EFAR in 2009.
20 Stanford Journal of Public Health
Infeclious Diseases.¨
The program is two
yeais Iong, and ofhceis
are stationed in one
geographic location for
the duration.
In lhe nid-199Os, Di.
Saia Cody vas lhe LIS
ofhcei assigned lo lhe
ßay Aiea. Cody used
hei Spanish ßuency
to connect with the
Hispanic connunily.
She learned about
Hispanic cuIluie lo
pinpoint the source of
the Salmonella outbreak,
which, in this case,
was cheese made with
iav niIk foi Hispanic
naikels. Today, Cody is
Depuly HeaIlh Ofhcei
and lhe ConnunicalIe
Disease ConlioI Ofhcei
foi lhe Sanla CIaia
Counly IulIic HeaIlh
Depailnenl. Hei LIS
experience proved
valuable to her career.
In addilion lo offeiing
heId expeiience,
lhe LIS piovides an
intimate community
and mentorship
opportunities. Both
Cody and MaIdonado
credit their time with the
LIS as an exliaoidinaiy
opportunity to gain
access lo lhe heId of
epidemiology. Although
Cody ieIales hei line
as a trainee to that of
a ¨voikei lee,¨ she
also boasts about the
advantages of this tireless
¨In exchange foi leing
a worker bee, you build
a lot of contacts, and
you´ie nelvoiking,¨
Cody expIains. ¨You gel
to see from the inside
how things really work...
You |gain knovIedgej
that you never learned
in the classroom, that
you just learned from life
experience. You have to
hguie oul vhal you vanl
and how you integrate
it and put it together to
ciack a piolIen.¨
By investing in
LIS ofhceis, lhe CDC
essentially invests in its
future. A majority of
cuiienl CDC physicians
were trained through
lhe LIS piogian, and
Maldonado estimates
lhal one lhiid of LIS
ofhceis go on lo voik
al lhe CDC, vhiIe lhe
other two thirds go into
practice or academia.
Hovevei, lhe
LIS nodeI has ils
disadvantages as well.
As a government agency,
the organization and
nanagenenl of lhe LIS
can lead to different
outcomes than in another
¨Theie´s aIvays
an agenda when
noney cones,¨ noles
MaIdonado. ¨Il´s liue foi
a private foundation or
industry. The thing that’s
a little bit different about
the way the government,
al Ieasl lhe CDC, agenda
is formed is there’s this
overarching theme of
health, and if possible
¨And vilhin lhal, il´s
such a broad area so that
different mandates can
come through. Some of
lhen nake il lo lhe CDC,
some of them don’t make
it; or some of them make
it in a different form
than they were originally
neanl lo le.¨
Indeed, ieguIalions
can evolve greatly
from the time they
leave Washington to
the time they arrive
al CDC headquaileis
and heId siles. Ioi
example, policymakers
may allocate money
towards obesity without
specihc guideIines foi
expenditure. Since the
obesity epidemic is so
lioadIy dehned, lhe
CDC can deleinine
how much money is
allotted to upstream
and downstream affects,
effectively altering policy
through interpretation.
Nonetheless, mandates
from Washington,
hovevei specihc oi
broad, are the ultimate
guidelines within which
lhe CDC, and in luin, lhe
LIS, nusl opeiale.
To further complicate
nalleis, lhe LIS piogian
and other government
organizations must
deal with congressional
oversight and the
rapid turnover of
eIecled ofhciaIs. In
the past, political
agendas have conßicled
with investigations.
Maldonado relates the
sloiy of an LIS ofhcei
conducting abortion
suiveiIIance in lhe 197Os
or 80s, a time during
which abortion was
particularly controversial.
The funding for his
surveillance slowly
dwindled until he
ultimately left the
piogian. The ofhcei
eventually established
his own organization
studying reproductive
health. As in this
situation, the political
orientation of an
administration can
affect the allocation of
money to controversial
This example
underscores the effect
that policymaking can
have downstream on
healthcare practices.
Despile lhe LIS ofhceis´
hard work on the
frontline of disease
outbreaks, they do
nol have hnaI say
in preventing and
addressing disease. Their
work informs policy, but
the ultimate decision
lies with policymakers,
which can have broad
economic and political
inpIicalions. In lhe
case of the Salmonella
oullieak in CaIifoinia,
ofhciaIs shul dovn
the cottage industry of
queso fiesco, lenehlling
the established dairy
indusliy. In a siniIai
outbreak in Washington
slale, ofhciaIs pieseived
this cultural tradition
by teaching safe cheese
The LIS opeiales in a
circular relationship with
policymakers: their work
is dictated by prevailing
policy and informs its
future creation.
Dr. Sara Cody earned her MD from the Yale University School of Medicine. She currently serves as the Community
Disease Control Offcer and Deputy Health Offcer in the Santa Clara Department of Public Health.
Dr. Bonnie Maldonado received her MD from the Stanford University School of Medicine. She currently works as a
professor in the Pediatrics department specializing in infectious disease at the Stanford University School of Medicine.
Volume 2 Issue 1 Winter 2012 21
Dr. Priti Parikh is a Research Associate at Imperial College
and runs the consultancy frm Development Vision 2o2o.
She has been working for ffteen years with her father,
Professor Himanshu Parikh, on Slum Networking, a project
in India to improve living conditions in urban slums. Slum
Networking provides infrastructure, such as water sanitation
and drainage, to slum dwellers by utilizing innovative
partnerships between residents, governments and NGOs,
and private enterprise. The project has resulted in drastic
health and life quality improvements. This project recently
won a prestigious award called Sustainable Urban Housing:
Collaborating for Liveable and Inclusive Cities, through
the Ashoka Changemakers, a program that began to bring
together the world’s social innovators.
Averhoff: Why was Slum Networking started?
Iaiikh: Iiofessoi Iaiikh pioneeied lhis piogian
in lhe 198O´s in lhe cily of Indoie lhiough DIID
(Depailnenl foi InleinalionaI DeveIopnenl, UK)
funding to provide infrastructure services, i.e. door to
door water sanitation and drainage to slum dwellers.
Il coveied aII lhe sIun sellIenenls in lhe cily, aloul
half a million people. We discovered that when we
provide infrastructure services, slum communities
invesl in inpioving housing. If peopIe have noney
to improve their housing, then why are organizations
subsidizing it? This was the starting point of this
approach. We have also been working on developing
business models in this domain, looking at models
less reliant on subsidies and aid, and investigating
funding partnerships with different stakeholders.
Averhoff: How does Slum Networking’s funding
mechanism work?
Iaiikh: LssenliaIIy, if ve lieal sIun dveIIeis as lhe
base of a pyramid potential market, then there is a
demand for services. By subsidizing the services, we
are not tapping effectively into that market. During
ny IhD, I conducled 5OO inleivievs in Indian sIuns.
My data shows that the communities provide about
lvenly lines lheii iniliaI inveslnenl |ovei a peiiod of
len yeaisj foi inpioving lhe housing slocks.
In one sellIenenl, lhe IocaI goveinnenl piovided
one third of the cost for the services. One-third was
provided by the slum community, and one-third by a
private company. The company agreed because they
had workers living in the slum community. They
recognized that the services would improve health,
which actually increased the productivity in their
Atcrncff. lna| is signijcancc cf |nc nanc ´S|un
Iaiikh: If you Iook al a Iol of Iov incone sellIenenls,
many of them seem to be located near water bodies.
In effecl, vhiIsl lhey seen lo le pockels in isoIalion,
in reality, they are connected by a water network.
Additionally, if you take the water drainage network
in the city, and provide services along that network,
the services are likely to be very cost- effective
because they follow the natural drainage path and
ieIale lo lhe lopogiaphy. If you hook up lhese seivices
to the nearby slums, you can provide a network of
services to the cities, which ultimately connects these
slum networks, as well.
Slum Networking
Working to Improve Health Through Infrastructure
Cristina Averhoff in conversation with Dr. Priti Parikh
A site before and after the program. Communities experi-
enced quality of life increases across the board.
PRITI PARIKH | with permission
22 Stanford Journal of Public Health
Averhoff: How does this program improve the health of
these communities?
Iaiikh: We did see heaIlh inpiovenenls. The 5OO
househoId inleivievs I nenlioned eaiIiei aie lhe
basis for this evidence. As a result of the new services,
there has been a reduction in infant mortality rate, a
reduction in illnesses, and a reduction in the monthly
spending on nedicine in lhe Indian sIuns.
We also analyzed the amount of working days lost
due to illness. That relates to the whole notion that
illnesses affect the cost of living, but also reduces your
capability to go out and earn more money. There was
also a reduction in working days lost due to illness as
a result of this program.
Averhoff: How do you explain the positive effects across the
board in terms of education, health, wealth, etc?
Iaiikh: This nodeI is shifling avay fion chaiily lo a
more business-like approach, where the argument is
that if you provide enabling services, the communities
shift aspirations, and improvements follow in quality
of life, which includes improvement of health,
education, income, housing stock, etc.
Averhoff: Once you have provided the services to the
community, how do you maintain the quality of these
Iaiikh: Wilhin lhe sIuns ve piovide seivices,
which are then connected to city systems, outside
the slum boundary. Because local governments
are also partners, we usually convinced them to
take on maintenance of the slum services near the
boundary. Within the slum, the residence association
or community group makes sure that things are
working, even though they do not have the technical
expeilise. In leins of lhe hnanciaI nodeI, in one
settlement, we persuaded the government to charge
a tax on the basis of property size, in this case, size
of the shack or slum house. The government will
charge this tax, and it gives some form of status for
the slum dwellers. Another piece is land ownership:
in some communities, the government offers a lease
of land because the land traditionally belongs to the
government or a private owner. By giving a lease of
land, there is some form of security for the residents,
knowing that they will not be evicted for the next few
years, and gives them an incentive to improve the
Averhoff: What are the plans for the future for this
Iaiikh: The pIan is lo exlend lhe voik inlo lhe iuiaI
areas. We have tried the models in urban contexts.
Hov can ve appIy lhe concepls in lhe iuiaI conlexl`
Also, municipal corporations in about 20 settlements
have made it a city program. There is a bit of work
to get the local government involved, local corporate
partners or charities on board, so there is quite a lot of
initial investment required. Therefore, we are trying
to develop business models that enable us to scale
more quickly.
Averhoff: In this holistic approach to health improvement,
what would you characterize as the central purpose of this
Iaiikh: This nodeI is shifling avay fion an aid-
driven approach. The argument is that if you provide
the enabling services, then the communities shift
aspirations, and you are able to then improve the
quaIily of Iife. Il is a shifl fion lhe Iack of lasic
needs to higher aspirations and quality of life, by
using business models rather than a charity-based
A site before and after the program. Infrastructure improve-
ments shifted the aspirations of the whole community.
PRITI PARIKH | with permission
The investigation
section of the SJPH presents and analyzes
pressing public health issues through the lens
of epidemiological, medical, and scientifc
In this issue, we aim to investigate current
concerns and challenges faced in the feld
of international children’s health. We look at
the health issues of congenital heart disease
in China, HIV/AIDS in Oakland, and global
childhood pneumonia by drawing upon expert
accounts, scientifc investigation, and
technological expertise.
24 Stanford Journal of Public Health
Access to Treatment for
Congenital Heart Disease
in Rural Gansu
Seanan Fong
The hisl lhing lhal
strikes you when you see
Ieng Ieng is lhe appai-
ent size of his cranium –
unlike healthy babies his
age, who are blessed with
lhick Iayeis of fal, Ieng
Ieng´s gaunl cheeks Iel
his cranium loom large
in comparison. At eleven
months old, he weighs
onIy eighl kiIogians~
half the weight expected
for his age.
¨He is sliII veaiing lhe
same shoes as when he
vas 5 nonlhs oId,¨ his
grandmother remarks.
And she is worried that
he hasn’t started crawl-
The two sit quietly by
the window of the quiet
hospilaI ioon~lhey
are anxiously awaiting
suigeiy. Ieng Ieng is
one of thousands born
every year with a con-
genital heart defect in
Cansu piovince, China,
and now, he is one of the
fev lo hnd liealnenl in
the province’s capital,
Lanzhou. His case~a
hopeful exception to the
iuIe~piovides a gIinpse
into the complex pub-
lic health challenge in
treating congenital heart
disease in iuiaI China.
The combination of a
prevalent disease with
high barriers to access
has produced a massive
challenge that is only be-
ginning to be addressed.
Caused ly diveise and
difhcuIl lo idenlify fac-
tors, including both ge-
netics and environment,
congenital heart defects
come in many forms and
IeveIs of seveiily. Ieng
Ieng has lvo of lhe nosl
connon foins~a hoIe
in the wall between his
heart’s two atriums, and
another hole between his
As a result of these
holes, his heart struggles
to provide the normal
lIood ßov lhal his lody
needs. Because his heart
works so hard, yet can
only deliver minimal
amounts of nutrients and
oxygen to the rest of his
body, his growth is stunt-
ed and his energy is low.
His Iegs feeI Iike lags of
water, swollen from the
inefhcienl punping of his
There are many more
Iike Ieng Ieng. In Cansu
piovince, vheie Ieng
Ieng Iives, as nany as
one in 125 chiIdien nay
be born with congenital
heart disease (.8%), ac-
coiding lo Cao ßingien
al Lanzhou Univeisily´s
Second HospilaI. Many
of these children die early
in life, so between ages 2
lo 19, Cao slales lhal ap-
proximately one in every
175 chiIdien suivives
with congenital heart dis-
ease (.57°). Thal Ieaves
thousands of children in
the province with heart
The incidence of the
disease alone is not itself
too remarkable, how-
ever. The .8% estimated
incidence in Cansu is
roughly even with the
incidence of congenital
heart disease in the U.S.
Moreover, well-estab-
lished open-heart surgi-
cal operations can treat
most forms of congenital
heart disease; if caught
in time, patients usu-
ally recover fully and
do not have any long-
lein heaIlh piolIens. In
Cansu´s capilaI, Lanzhou,
several medical facilities
have the infrastructure
Little Jiao’s mother discusses medical documents with a worker from Little Red Scarf in
the courtyard of their home.
FONG | with permission
Volume 2 Issue 1 Winter 2012 25
and expertise to carry out
these treatments, and in
fact, most patients with
a defect are diagnosed
soon after birth.
Nevertheless, treat-
ment for congenital heart
disease lags far behind
what the province de-
mands, forming the
crux of the public health
chaIIenge. In 2OO9, no
more than 2,000 children
received treatment in all
of Cansu piovince, ac-
coiding lo Cao. Ten yeais
ago the situation was
even worse: in 2000, no
more than 1,000 children
received treatment in all
of Cansu. Though lhe
province has begun to
be able to provide the
needed treatment due to
recent advances in city
hospilaIs, Cansu is sliII
far from meeting the
needs of all the children
in the province with the
disease. Civen lhal lieal-
ment exists, why are so
many children missing
the opportunity to lead
healthier, productive
lives? The problem lies
in access: the socioeco-
nomic barriers standing
between a sick child and
ready treatment are sim-
ply too high.
Among these barri-
ers are the geographic
separation of poor ru-
ral families from urban
centers equipped to do
surgery, lack of connec-
tions or knowledge of
how to get treatment,
and the infeasibility
of families taking time
away from work to bring
children to treatment.
The nosl signihcanl lai-
rier, however, is cost: the
primary reason that the
vast majority of children
fail to receive treatment is
that families simply can-
not afford surgery. Many
rural families do end up
in hospitals in the cities,
seeking medical treat-
ment for their children.
There, they may receive
stopgap measures, such
as emergency medication,
that temporarily ad-
dress some of the con-
sequences of congenital
heart disease. For lasting
treatment, however, most
chiIdien vilh signihcanl
defects will need open-
heart surgery.
For most families,
however, the cost of this
surgery is simply beyond
reach. With both par-
ents working away from
home, a family’s yearly
income might be 1,000 to
2,OOO yuan (~$15O-$3OO)
in total, according to con-
versations with villagers,
while open-heart surgery
to treat the most com-
mon defects usually cost
more than 20,000 yuan
(~$3,OOO)~len yeais´
worth of income. Before
surgery is performed,
families have to scrounge
up the money to make
a down payment to the
hospilaI hisl. This cones
from meager savings as
well as loans from rela-
tives, friends, neighbors,
and, as a last resort, the
bank. (Most families
have government-run
insurance coverage, but
insurance only covers
up to 30% of the cost of
surgery done in the city.
Moreover, families have
to come up with the ini-
tial cash down payment
themselves, and will only
be reimbursed up to a
year later.)
This is beyond the
means of most families,
who might keep on going
to the hospital to receive
stopgap measures for
emergencies, but stop
short of getting surgery.
Lighl oul of len chiIdien
vho cone lo Lanzhou lo
receive treatment for se-
vere defects will end up
going home without the
needed surgery, accord-
ing lo Cao. Many noie
do not receive any treat-
ment at all.
Things are slowly get-
ting better. Taking an ap-
proach from private char-
ity, one group called the
LillIe Red Scaif AIIiance
searches for and fully
funds surgery for eligible
children from poor rural
faniIies~in 2O1O aIone,
the group paid for 187
successful surgeries.
They also provide social
support for the families
of the children as they
navigate the medical
system, and when these
families return home, the
program enlists parents’
aid in creating a grass-
roots network that helps
spread access for fami-
lies in similar situations.
Approaches like these
have nade a signihcanl
dent in the public health
problem, but in the face
of growing inequity, they
are only one step toward
the systematic change
needed in equity and
access to healthcare for
these families.
Gao Bingren is the director of cardiothoracic surgery at the Second Hospital of Lanzhou University.
Seanan Fong has interned with Little Red Scarf.
Little Jiao, a Little Red Scarf surgery recipient, with her
family in rural Gansu.
FONG | with permission
26 Stanford Journal of Public Health
Disruptive Design
Biomedical Engineering
and Public Health
In theory, you should
have a choice: one res-
piialoi is hl foi hospilaI
use only and requires
expensive compressed
oxygen, while the other
is portable, uses ambient
air, and costs 1% of the
original. When you lack
reliable electricity and the
local hospital can barely
afford to stay open, you
would like to be able
to choose the one most
likely to save your child
from pneumonia.
The heIds of lio-
medical engineering and
public health can seem
opposite in their images.
One is considered high-
end and expensive, and
the other resourceful by
necessity, utilitarian, and
focused on accessibility.
The lvo heIds nay seen
to work at different ends
of the health spectrum,
but in fact there is poten-
tial for important innova-
tion at the intersection of
biomedical engineering
and public health.
Inspiie MedicaI, a lean
of four Stanford
students, is on a mission
¨lo ieduce infanl noilaI-
ity through affordable
critical-care technolo-
Andiev Chang,
Caiey Lee, IaneIa ßan-
dyopadhyay Iavkov, and
Kaien Lun veie in lhe
LnliepieneuiiaI Design
foi Lxliene AffoidaliIily
class when they began
developing their low-cost
liealhing assislanl, In-
spiie. Lasl spiing lieak,
the team paired with a
hospital in Dhaka, the
capital of Bangladesh,
with the ultimate goal of
reducing infant deaths
from pneumonia.
Chang is lhe CIini-
caI Diiecloi of Inspiie
Medical and a fourth
year student at Stanford
MedicaI SchooI. ¨One
of the things that really
surprised us was that
pneumonia kills more
children every year than
measles, malaria and
AIDS conlined,¨ Chang
said. In fact, pneumonia
is responsible for one
in hve chiId dealhs and
kills more children than
any other illness in every
region of the world.

¨Those dealhs can
be prevented by fairly
simple interventions from
a respiratory point of
viev,¨ Chang said. ¨The
tragic thing is that it’s
a lack of resources that
causes these children not
to make it. That’s where
the extreme affordability
cones in.¨
Ineunonia is an acule
lower respiratory infec-
lion vheie pus and ßuid
interfere with oxygen
absorption in the lungs,
naking il difhcuIl lo
Treatment with
antibiotics is the most
common approach due
to its relatively low cost.
Hovevei, Inspiie Medi-
cal is attempting to lower
the cost of intensive-care
technology to make it
an equal option to an-
tibiotics. By making
cost-effective technology,
Chang hopes lhal Inspiie
MedicaI viII cieale ¨a
paradigm shift; you can
have affordable and high
levels of fairly intensive
The hospital in Dhaka
wanted to improve the
existing ventilator for
pediatric pneumonia, so
the team spent some time
in big cities discussing
inpiovenenls. Hovevei,
after more investigation,
they honed in on rural
areas, where inconsistent
electricity access, the
Helena Scutt
The complete CPAP delivery mechanism.
INSPIRE MEDICAL | with permission
Volume 2 Issue 1 Winter 2012 27
unavailability of com-
pressed oxygen, and cost
prevent the use of devices
like the Dhaka hospital’s
¨So,¨ Chang said, ¨ve
thought, let’s create a de-
vice lhal voiks lheie.¨
With trial-and-error
and user feedback, they
did jusl lhal. Inspiie is
a bubble continuous
positive airway pressure
(CIAI) device lhal voiks
by using pressurized air
and/or oxygen to expand
patients’ lungs. Inspiie´s
pump draws in ambient
aii and hIleis, hunidihes,
and compresses it for the
patient at an adjustable
ßov iale lhal is safe foi
an infant. Slightly bigger
than a shoebox, it costs
$200 instead of $20,000,
can run off a car battery,
and it does not require
(but is fully compat-
ible with) compressed
oxygen. There is a beauty
in the simplicity of the
¨Theie´s a liend in
biomedical engineering
towards bigger, more
glamorous, and more
expensive,¨ Chang said.
¨In oui appioach, ve´ie
shooting for cheap and
Hovevei, lhe puisuil
of cheap and simpler is
not without its challeng-
es, nosl nolalIy, ¨hnd-
ing the right pressure
souice,¨ accoiding lo
Caiey Lee, Inspiie Medi-
cal’s chief technology
ofhcei. Iovei is scaice
foi nosl Inspiie useis,
but pushing a lot of air
through a small diameter
breathing tube demands
a Iol of povei. ¨Il look a
fair bit of experimenta-
lion lo hnd a piessuie
source that was power-
fuI, eneigy-efhcienl, and
Lxpeiinenlalion nusl
be practiced carefully,
lhough. ¨One lhing I
want to clarify is that
interventions and de-
vice development can be
surprisingly easy since
developing nations don’t
have the FDA equivalent
and ieguIalions,¨ Chang
said. Inspiie is voik-
ing hard to pass all US
regulations before they
ever strap the device onto
a baby in the developing
ßesides, ¨ve vouId
have been shocked and
rather suspicious if we’d
gotten it right on the
hisl liy,¨ Lee said. The
team found that in rural
Bangladesh, people were
surprisingly hesitant
to use wall power and
much more comfort-
able using car batteries
since ßuclualions in vaII
power often lead to burn
¨Suipiises Iike lhis aie
why we prioritize di-
rect interaction with the
usei so nuch,¨ Lee said.
¨Wilhoul lhese insighls,
our device would not be
vhal il is loday.¨
Inspiie is a fanlaslic
example of biomedical
engineering applied to
public health, particular-
ly with a cost-conscious
perspective. Biomedical
engineeis ¨spend a Iol of
money and development
time trying to come up
with heavy duty devices
for rare or complicated
condilions,¨ Chang said.
¨The piolIen is lhal ve
lose sight of the fact that
old problems need to be
lackIed in nev vays.¨
Innovalois nusl ievisil
some of these issues and
make solutions more
affordable and more ap-
propriate for settings that
offer different challenges.
¨This is caIIed disiuplive
design. Ultimately, smart
design can trump the
naluiaI oidei of lhings,¨
Chang said.
Hovevei, Lee adds
to this, ¨In ny opinion,
device creation is just the
beginning, and training
and follow-up is where
the real impact is made.
Otherwise, instead of
saving lives, your device
might just end up gather-
ing dusl in a coinei.¨
Biomedical engineer-
ing is one of the fastest
gioving heIds, so even if
just a small portion of the
industry’s energy is dedi-
cated to investigating
public health solutions,
many lives could be im-
pioved oi saved. Chang
speaks foi lhe Inspiie
Medical team in his hope
lhal ¨al lhe veiy Ieasl, ve
get people talking and
thinking about solutions
to pneumonia but also
how we can use innova-
tion to solve the develop-
ing voiId´s piolIens.¨
Please visit inspire- and the
Inspire Medical Facebook
page for more informa-
1. Inspire Medical: Welcome Web site. Available at: Accessed November 1, 2011.
2. Melinda Gates. World Pneumonia Day – Celebrating Interventions that Save Lives. Huff Post Impact. Available at: http://www.huff- Accessed November 14, 2011.
3. The United Nations Children’s Fund and the World Health Organization. Pneumonia: The Forgotten Killer of Children, 2006. Available
at: Accessed November 1, 2011.
4. Inspire Medical: Team Web Site. Available at: Accessed November 1, 2011.
28 Stanford Journal of Public Health
Nairi Strauch
The Littlest Index Case
How Pediatric Patients in San Francisco
Helped Decode HIV/AIDS
In 1981, HIV/AIDS
seemed to emerge from
nowhere, forcing physi-
cians to diagnose and
treat a disease they knew
veiy IillIe aloul. In lhe
Nev Yoik Cily and San
Francisco hotspots, cases
veie IaigeIy conhned lo
gay communities, and
transmission seemed
strictly sexual. The dis-
covery of a pediatric case
broadened the under-
standing of the disease
and opened the path for
major advancements in
hghling lhe disease.
Dr. Arthur Ammann,
then the director of pedi-
atric immunology at Uni-
versity of San Francisco
MedicaI Cenlei, idenlihed
a child with an immuno-
Iogic piohIe siniIai lo lhe
piohIes of infecled gay
men. This patient had
received multiple blood
transfusions, suggesting
that the infection could
be transmitted through
shared blood.
¨Il vas veiy conliovei-
siaI,¨ expIains Annann,
¨The lIood lank peopIe
were afraid that it would
keep people from donat-
ing lIood.¨ Indeed, Iivin
Memorial Blood Bank
of San Francisco down-
played the suspicion that
blood could be a source
of the infection and made
no changes to their sys-
Ammann, to solidify
his hypothesis, investi-
gated other blood re-
cipienls fion his hisl
palienl´s donoi. He iden-
lihed a lvo and a haIf
year old girl born in San
Francisco with a compli-
cated medical history and
who had been through
multiple foster families.
After a year of search-
ing, he located the pa-
tient’s pediatrician. The
patient had been admit-
led lo ChiIdien´s Hos-
pital Oakland and was
under the care of Dr. Ann
Ieliu. Ieliu had diag-
nosed her with the worst
chickenpox she had ever
seen, pneumonia, and en-
of the brain. Ammann
determined that she had
the characteristic severe
immune system prob-
Iens. ¨He didn´l expIain
what it was; it didn’t
have a nane lhen,¨ says
Ieliu. ¨ßul he lhoughl il
was related to the epi-
demic seen in gay men in
San Iiancisco.¨
Ammann continued
lhe hunl. He nexl found
a case whose mother
was a prostitute and
intravenous drug user.
The daughter contracted
HIV al liilh. This case
became recognized as the
hisl iecoided inslance of
mother-to-child transmis-
sion of HIV.
ßy 1985, lhe nedicaI
community had accepted
that the virus could
spread through blood
transfusions. Blood
banks began to screen
and restrict blood dona-
HenophiIiacs vho
had previously received
blood transfusions and
those who displayed
¨iisky lehaviois¨ veie
also excluded as donors.
Accoiding lo Ieliu, such
lehaviois incIuded IV
drug users and homo-
MeanvhiIe, Ieliu
and other pediatricians
al ChiIdien´s HospilaI
Reseaich Cenlei OakIand
(CHRCO) legan a pio-
gram to identify children
who had transfusions
before the blood restric-
lions. Theii ¨Tiansfusion
Look ßack Iiogian¨
The Castro, a San Franciso neighborhood, continues to be
a hub where LGBT activists are fghting to end stigmas as-
sociating HIV/AIDS with LGBT individuals.
STEVE PARKER | Wikimedia Commons
Volume 2 Issue 1 Winter 2012 29
reached out to families
of children who had
received transfusions at
CHRCO lelveen 1978
and 1985. They senl 3,OOO
letters, suggesting that
these patients get tested
foi HIV. 3OO faniIies ie-
sponded. 17 of these 300
patients were infected
with the virus.
In addilion, CHRCO
idenlihed 16 infecled
hemophiliacs and discov-
ered a growing number
of children who had
leen infecled vilh HIV
al liilh. In iesponse lo
these increasing numbers,
Ieliu slailed lhe Iedial-
iic HIV/AIDS piogian
al CHRO, vhich she
patterned after a clinic at
the University of Medi-
cal and Dental School
in Nev }eisey. ¨I venl
lheie, and I said, 'Shov
me everything you have.
Tell me how you take
care of these kids because
I have no idea vhal lo do
foi lhen.´¨
Ammann, determined
to improve care for pe-
dialiic cases, Iefl UCSI
lo voik al Cenenlech,
a research-based bio-
technology corporation
founded in 1976. ¨I vas
frustrated that things
were just moving too
slowly on the pediatric
side,¨ says Annann,
¨The chiIdien veie leing
Iefl oul.¨ He aIso legan
voik al lhe Iedialiic
AIDS Ioundalion vhose
efforts brought pediatric
HIV lo lhe allenlion of
lhe NalionaI Inslilule
of HeaIlh. The iesuIling
collaborative studies and
case comparisons across
the country helped iden-
tify the best drug treat-
nenls lo hghl HIV/AIDS
and address mother-to-
child transmission.
SpecihcaIIy, in 1994
the drug azidothymidine
(AZT) became available.

Without treatment, ap-
pioxinaleIy 25° of aII
babies born to infected
mothers would be infect-
ed at birth. AZT, if taken
during the last six weeks
of pregnancy, intrave-
nously during labor, and
by mouth to the baby six
weeks after birth, reduces
infeclion fion 25° lo
Lffoils lo pievenl
mother-to-child transmis-
sion iepiesenled lhe hisl
clinical efforts towards
pievenling HIV.
Ammann, however,
still noticed a problem.
¨Whal I sav Iagging
behind was the interna-
lionaI epidenic,¨ said
Annann. ¨We veie
quite successful in stop-
ping the transmission to
babies in the US, fewer
than 100 new cases. But
the number of new infec-
tions per year in develop-
ing countries was some-
vheie lelveen 5OO,OOO lo
700,000. So that’s why we
slailed CIolaI Slialegies
|foi HIV Iievenlion in
15 niIIion chiIdien
aie HIV/AIDS oiphans
in Africa.
According to
Ammann, this number
increases by 3 million
annually; consequently,
orphans have become
an economic burden on
African governments.
The same money used for
orphan aid could be used
to prevent the problem at
ils oiigin: HIV. Oiganiza-
lions Iike CIolaI Sliale-
gies work to reverse this
trend by raising money
to prevent the orphan
epidemic through the
aggressive treatment of
HIV-infecled nolheis.
Today in the United
Slales, Ieliu sees fev
new cases of pediatric
HIV lecause of IMTCT.
Ieliu´s cIinic cuiienlIy fo-
cuses on counseling and
care to teenagers who
conliacled HIV al liilh.
One of Ieliu´s pa-
tients is now sixteen and
describes how the disease
affects her young life.
¨HIV iequiies conslanl
ieguIalion,¨ she viiles. ¨I
have to go to the doctors
every three months and
along with those visits,
I have lo nake line foi
lIood shols. Nov I jusl
take 4 (pills) in the morn-
ing… The medication
has some side effects to
it, such as fat displace-
ment, which means that
my body does not look
as normal as other girls
which can be frustrating
as a leenagei.¨
This teenager is one
of millions of who copes
with the challenges of
pedialiic HIV/AIDS.
Nonetheless, with that
struggle, she also holds
the legacy of helping doc-
tors make the critical link
to blood transmission,
helping to complete the
cIinicaI picluie of HIV/
Dr. Arthur Ammann attended New Jersey Medical School and completed his residency at the University of
California San Francisco Medical Center and fellowships in immunology at the University of Wisconsin Medical
Center and University of Minnesota Medical Center. He is now the director of Global Strategies for HIV Preven-
Dr. Ann Petru attended the University of California San Francisco Medical School and completed her residency
and fellowship in infectious diseases at Children’s Hospital Oakland, where she is now the director of the infec-
tious diseases department.
1. AIDS Timeline. Avert.
2. Prevention of mother-to-child Transmission of HIV (PMTCT). Avert.
3. AIDS Orphans. Avert.
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 research from the
undergraduate community. Our authors
have explored topics relating to the role of
gender in HIV policy, the implications of a
smoking ban in China, trends in technology
in urogynocology, and access to health care
for undocumented immigrants.
Volume 2 Issue 1 Winter 2012 31
Transcending Global Frameworks
How Gendered HIV Policies
May Be Too Narrow
Emily Rains
The WoiId HeaIlh
Organization estimates
that 1 out of 14 Tanzani-
ans are infected with
About 60% of these
cases affect women, as is
the case in most sub-
Saharan African countries
in this region.
nearly 80% of transmis-
sion occurs via hetero-
sexual intercourse and
women have higher rates
of infection, evidence
suggests that the dynam-
ics of heterosexual inter-
course in Tanzania lead
to unequal rates of
The gov-
ernment attributes
several contextual factors
that drive the gender
disparate transmission,
especially male-initiated
behavior, economic
inequality between the
sexes, and extramarital

Lxisling ieseaich on
HIV and gendei in
sub-Saharan Africa
focuses on gender in-
equalities inherent in
patriarchal societies. This
sludy specihcaIIy Iooks al
organizations in Tanzania
because the country has
one of the highest inci-
dence iales of HIV in
sub-Saharan Africa, has
an enabling political
cIinale in vhich NCOs
can operate, and most
importantly, exhibits
general epidemiological
characteristics parallel to
olhei nalions in Lasl
Africa. Researchers
studying Tanzania, as
veII as Llhiopia, Kenya,
Uganda, and Botswana,
sliess lhal HIV pieven-
tion policy needs to go
beyond basic knowledge
distribution and must
tackle gender inequality,
mostly through reduction
of gender-based vio-

Hovevei, lheie aie
many aspects of gender
inequality other than
sexual violence that
exacerbate the gap in
HIV iales. Ioi exanpIe,
young men typically
engage in much riskier
sexual behavior but
perceive less risk than
men perceive their risk
level based on their own
actions, while women
perceive their risk level
based on their partner’s
actions, which implies
that the unequal power
dynamic between the
genders allows men to
dictate the level of risk
involved in the sexual
behaviors of themselves
and their partners.
Unfortunately, al-
though the literature
from both governmental
and nongovernmental
researchers almost al-
ways stresses the need to
address gender inequal-
ity when creating inter-
there is very
little information on how
lhis shouId le done. Veiy
fev NCOs focus on
education of heterosexual
men to alter traditional
gender roles, and of those
that do, most focus on
education to reduce
Previous research on incorporating gender into HIV prevention education policies in sub-Saharan Africa has
focused on reducing gender-based violence in the context of HIV. However, many deeply rooted inequalities
exist that exacerbate the disparity in prevalence rates between men and women in this region, and these cul-
tural barriers have not been addressed by previous campaigns. This paper uses qualitative document analysis
of various HIV prevention organizations working in Tanzania in order to ascertain how gender is incorporated
in prevention education. This paper argues that focusing on women-centered responses to the crisis is too
narrow. Expanding focus to engage majority groups such as heterosexual men may be a critical step towards
ensuring gender equality and fghting the further gender-disparate spread of HÌV in East Africa.
A wall painting that states "We are together in the fght
against AIDS.”
RAINS | with permission
32 Stanford Journal of Public Health
violence and do not
explicitly incorporate
HIV pievenlion sliale-
gies. Hovevei, lhe
existing programs to
mitigate domestic vio-
lence can be adapted for
HIV pievenlion. This has
been performed in other
places by organizations
such as Iionundo in
Brazil, where cultural
behaviors among Brazil-
ian men are very similar
to those of Tanzanian
men. These risky behav-
iors stem from common
cultural beliefs that men
should begin having sex
at a young age, should
always have multiple
partners, should remain
in control over their
partners, and that unsafe
sex is more enjoyable
than safe sex.
researchers showed that
beliefs about manhood
emerge as the strongest
predictor of engaging in
risky behavior, both
sexually and generally.
They also worked direct-
ly with men in an infor-
mal education program
to renegotiate perceptions
of manhood to include
more gender-equitable
ideologies. They found
that this program led
men not only to agree
with more gender-equita-
ble norms, but also to
engage in less risky
behavior, which leads to
a snaIIei chance of HIV
contraction for them-
selves and their partners.

Young men who partici-
pated in the program
veie signihcanlIy noie
likely to report more
equitable ideologies than
those at the control sites,
and this change was
sustained after a yearly
foIIov up. The Iionundo
study concluded that
educating men directly in
an informal program to
question traditional
gender norms can be an
inpoilanl HIV pieven-
tion strategy.

MIT´s Ioveily Aclion
Lal successfuIIy engaged
nen in a diffeienl HIV
prevention strategy.
Researchers evaluated
lhe efhciency of lhiee
piololypicaI HIV pieven-
tion programs in Africa
(one that trained school-
leacheis on AIDS, one
that encouraged student
debates on condoms, and
one that paid students to
stay in school longer) and
also one less common
program that showed a
video on the dangers of
intergenerational dating
in Africa. The study
concluded that while
young women did not
reduce their sexual
activity, young men
increased condom use

Targeting men as the
audience in HIV pieven-
tion programs has a lot of
potential but has not
been extensively ex-
plored. This study pro-
poses lo legin hIIing lhe
gaps in literature on how
gender should be incor-
poialed inlo HIV pieven-
tion by understanding
how different types of
organizations address
gender norms in their
HIV educalion.

Documents from the
following four categories
of agencies were used:
international governmen-
tal organizations, domes-
tic governmental organi-
zations, international
nongovernmental organi-
zations, and domestic
nongovernmental organi-
zations. One organization
was selected as an exam-
ple of each category
based on each organiza-
tion’s funding, reach (in
terms of the size of their
target audience), and
focus on HIV pievenlion.
The hnaI oiganizalions
selected were the United
Nalions Iiogianne on
Tanzania Connission foi
Ialion Seivices Inleina-
lionaI (ISI), and Suppoil
foi InleinalionaI Change
(SIC). AIlhough seIecling
one organization for each
category does not ensure
a representative study,
this sample provides
examples of the kind of
work done by different
types of organizations.
To analyze the selected
documents, this study
used an inductive meth-
od of research in which
second pass interpreta-
tive codes were devel-
oped from patterns of the
hisl pass desciiplive
codes. The hisl pass
descriptive codes looked
mainly at surface level
patterns of recurring
organizations’ goals,
target audiences, and
motivations. The second
pass interpretative codes
explored how the organi-
zations described their
interventions in order to
understand what they
considered as most
effeclive HIV pievenlion
policy. This analysis
extrapolated the organi-
zations’ values in formu-
lating gender-sensitive
HIV poIicies and vhon
lhey idenlihed as poIicy
inpIenenleis. IsoIaling
main target audiences
seeks to address contem-
porary theory on the
Children take a break from their HIV lessons in Tanzania.
RAINS | with permission
Volume 2 Issue 1 Winter 2012 33
importance of guarantee-
ing health as a human
right, particularly to

Analysis of documents
indicates that human
rights and empowerment
rhetoric is prevalent in
each of the documents.
Results also show that
nongovernmental docu-
ments are much more
precise in their stated
goals and strategies than
governmental documents
are, and nongovernmen-
tal documents provide
much more concrete
examples than govern-
mental documents on
ways to provide more
than basic knowledge
dispersal in order to
address root drivers of
the epidemic. This aligns
with recent theory on the
importance of the non-
goveinnenlaI, nonpiohl
sector in delivering
healthcare in developing
All of the organizations
incorporate human rights
jargon or appeals into
their documents, which
becomes most clear in the
governmental docu-
nenls. UNAIDS expIic-
itly targets marginalized
groups and emphasizes
the need to reach out to
vulnerable populations
because violence, eco-
nomic instability, and
inequality are the driving
forces that leave margin-
alized groups more
susceplilIe lo HIV/AIDS.
The documents illustrate
the importance of antidis-
crimination laws to
protect vulnerable popu-
lations and mention
many different strategies
for empowering these
minorities through
education of rights
avaieness. In facl, aI-
lhough 8O° of HIV
transmission in Tanzania
is via heterosexual rela-
lionships, lhe UNAIDS
docunenls focus HIV
prevention policy on
intravenous drug users as
often as they focus on
heterosexual men, and
men who have sex with
men more often than they
mention heterosexual
men. With regard to
gender, women are
cIeaiIy dehned as lhe
main vulnerable group,
and UNAIDS advocales
that responses be women
centered and also stresses
the need for women to
have access lo lhese HIV
prevention services in
order to exercise their
rights. Women and girls
are mentioned six times
as often as heterosexual
men and boys in the
All of the documents
are rife with human
rights language, although
it is expressed differently
in the governmental and
nongovernmental docu-
nenls. The UNAIDS
documents stress the
importance of improving
HIV pievenlion seivices
for marginalized groups
in order to protect their
iighls. SIC sliesses lhe
importance of equipping
people with the skills
they need in order to take
ownership over protect-
ing their right to health.
All of the documents
stress that women are
included in (if not the
majority of) these vulner-
able groups. Most docu-
ments focus on women as
the main group vulner-
alIe lo HIV, vhich given
lhal 3 oul of 4 HIV
positive young people in
sub-Saharan Africa are
women, makes sense.
Hovevei, ¨vuIneialIe¨
includes several other
categories including
homosexual men and
intravenous drug users.
For the purposes of this
study, this study is
mainly concerned with
women as the major
vulnerable group com-
pared to heterosexual
As theory on the role of
nongovernmental non-
piohls in pioviding
health services to poor
countries suggests, the
governmental documents
are much more rhetorical,
while the nongovern-
mental documents are
much more focused on
implementation of
programs. All of the
documents suggest
concrete policies to
inpIenenl in lhe hghl
againsl HIV, such as
increased access to
condoms and antiretrovi-
iaIs, fiee HIV lesling,
funding, promotion of
male circumcision etc.
They also all attempt to
address some of the root
driving forces of the issue
(the economic and social
contexts that perpetuate
gender and income
inequality and increase
risk amongst women and
those in poverty). While
all discuss the impor-
tance of empowering
marginalized groups in
order to mitigate the root
drivers of the epidemic,
the nongovernmental
organizations incorporate
more concrete solutions
on how to push further to
encourage transformative
agency in the recipients
of their programs. Trans-
formative agency is
dehned heie as enalIing
people to organize for
change. Therefore, to
more effectively mitigate
the effects of the epidem-
ic, education needs to
transcend knowledge and
move to transformative
knowledge. For example,
lolh ISI and SIC pio-
nole use of a specihc
brand of condom, Sala-
ma, to build consistency
and trust in a local brand.
This approach takes
knowledge about how to
use a condom a step
further for their audience
and begins to encourage
aclion. ISI nainIy ad-
dresses heterosexual
Since the 1990s, there has been a clear institutionalization of health as a human right and of the norm that nations should empower their citizens to be
agents of their own health. Similarly, there has been a global shift of focus on the importance of targeting vulnerable people, such as women, in efforts to
promote human rights. This global acceptance of health as fundamental human right is best explained by world society theory. World society theory ex-
plains that organizations are legitimacy-seeking institutions that strive to adhere to international norms, increasingly leading to isomorphic discourse. An
interesting caveat of this theory is that there is often an accidental nature to the construction of world models as nation-states follow respected organiza-
tions and these nation-states will often adopt norms that are not necessarily effcient in an attempt to adhere to the global norm.
34 Stanford Journal of Public Health
transmission (which is
more contextually rel-
evant for Tanzania than
anything else) and ac-
knowledges that barriers
between knowledge and
agency include sexual
violence and power
imbalance. The nongov-
ernmental documents
stress the importance of
both peer education for
knovIedge and iedehn-
ing cultural constructs in
order to facilitate female

Clobal norms on hu-
man rights and empow-
erment permeate
throughout all of the
organizations’ docu-
nenls. In addilion,
nongovernmental organi-
zations are more contex-
luaIIy specihc and al-
tempt to foster
environments that enable
change of cultural norms.
The analysis argues that
organizations ascribe a
worldview on how to
lackIe HIV lhal is lased
on their global adherence
to norms ensuring hu-
man rights to vulnerable
populations, including
but not limited to wom-
en. While ensuring rights
to vulnerable groups is
undeniably important,
focusing most efforts on
vulnerable groups inevi-
tably leaves other groups
outside of the focus.
Majority groups such as
heterosexual males (who
hold considerably more
power than minority
groups) are outside of
this focus but could be
effectively engaged in
HIV pievenlion inilia-
tives in order to help
enable those in a vulner-
able position. While it is
important to focus some
efforts on those most at
risk, global adherence
strictly to the worldview
that prevention efforts be
centered on vulnerable
groups leads to a limited
worldview. Focus should
be expanded to also
include heterosexual
naIe gioups in lhe hghl
againsl HIV in Lasl
All of the different
organizations identify
inequalities as the driving
foice of lhe AIDS epi-
demic in Tanzania, but
they are limited in depth
on how they propose to
change this. All address
the devastation of gender
inequality in driving the
disparity of incidence
rates between men and
women. The documents
aII ießecl on lhe povei of
knowledge and educa-
tion in empowering
women and other vulner-
able groups to take
ownership over their
health and protect them-
seIves fion HIV. Hov-
ever, for full equality
between the sexes,
women need empower-
ment via knowledge as
well as agency via trans-
formative knowledge.
The IopuIalion Seivices
InleinalionaI docunenls
slale, ¨AnaIysis of gendei
role expectations, mis-
trust, and sexual violence
provides insight into how
all of these factors have
the potential to under-
nine HIV pievenlion
initiatives that are based
on faulty assumptions
about young women’s
sexuaI agency.¨

Many women in
strictly patriarchal societ-
ies may lose the ability to
act upon their education
of HIV/AIDS lo piolecl
their health. Those in
power need to be edu-
cated in the importance
of HIV pievenlion lolh
for themselves and their
partners before women
can act upon their knowl-
edge. Because current
global discourse focuses
mainly on empowering
marginalized groups,
there is consequently not
enough focus on engag-
ing heterosexual men. As
described previously,
these groups can be
effectively engaged in
HIV pievenlion inilia-
tives to help enable those
in a vulnerable position.
Organizations do ac-
knowledge that engaging
men should be a strategy,
but the rhetoric quickly
shifts back to the need to
empower marginalized
groups. For example, the
UNAIDS docunenls
slale, ¨liadilionaI ioIes
and societal values
related to masculinity
might encourage boys
and men to adopt risky
behaviors, including
excessive alcohol use and
concurrent sexual rela-
tionships, so increasing
their risk of acquiring
and liansnilling HIV.¨

This is lhe hisl nenlion
of men in the document
that suggests engaging
heterosexual men may be
a slialegy UNAIDS
proposes, but the next
sentence quickly switches
back to rhetoric about
vulnerable people,
saying, ¨Many hainfuI
norms related to mascu-
linity and femininity also
stigmatize transgender
people, men who have
sex with men, and other
sexuaI ninoiilies.¨

While focusing efforts on
women is unquestionably
A Support for International Change volunteer talks with
school children about HIV.
RAINS | with permission
Volume 2 Issue 1 Winter 2012 35
Emily graduated from Stanford in 2011 with a B.A. in Economics and Honors in the School of Education. She has spent
extensive time abroad, studying in both Japan and Russia and working to promote both education
in India and HIV prevention in Africa. Emily is passionate about issues in international development
especially public health. At Stanford, she was a Teaching Assistant for Education, Gender, and Devel-
opment, a Research Assistant for an Economics professor working with the World Bank, and she wrote
her honors thesis after spending a summer working on HIV prevention in Tanzania on how organiza-
tions incorporate gender into their HIV prevention education in East Africa. She currently works as a
consultant in New York City.
important in equipping
them with the skills they
need to protect them-
seIves fion HIV in
situations in which they
are able to make deci-
sions, global norms that
perpetuate focusing
mainly on women and/
or other vulnerable
groups fail to address the
harsh reality that even
when these vulnerable
people have the knowl-
edge and will to protect
themselves, they may not
always have the power to
do so. Organizations like
Iionundo in ßiaziI shov
that engaging men is an
effective strategy to
encourage equity, which
subsequently leads to a
reduction in risky behav-
ioi. If lhose in posilions
of power learn how to
renegotiate their ideolo-
gies in such a way that
allows more power to
vulnerable groups, then
women would have the
agency to use the skills
these programs give to
them in order to protect
themselves and others.

While policymakers
agree that gender inequi-
ties are driving the
disparity in prevalence
rates between men and
women, global norms
have dictated that focus
of prevention initiatives
be women-centered.
While increasing knowl-
edge and programs for
women is critically
important, programs that
focus on engaging men
are noticeably absent
from documents focused
on HIV pievenlion. LocaI
NCOs couId lenehl
substantially from ex-
panding programs in
order to include more
that engage heterosexual
men in discussion of
gendei equily. Covein-
mental organizations
couId aIso lenehl fion
expanding their focus.
InleinalionaI goveinnenl
agencies inform local
discourse, so including
men in their discourse
could alter the global
norms and frameworks
in which local entities
expIicilIy opeiale. If
international governmen-
tal organizations expand
their rhetoric to include
more support for pro-
grams working with
men, local actors who
implement policy on the
ground that engages men
would have more legiti-
CIolaI noins lhal
stress health as a human
right tend to skew focus
towards ensuring rights
for the most marginalized
people, but further
research and efforts
should be undertaken on
how engaging majority
groups like heterosexual
men could also have a
signihcanl inpacl on
mitigating the spread of
HIV/AIDS. Achieving
gender equality will
require a social revolu-
tion, and this means
everyone must be en-
1. World Health Organization. Data and Statistics 2011. Available at: Accessed March, 2011.
2. Tanzania Commission for AIDS. National Multi-Sectoral Strategy Framework for 2008-2012, Dar Es Salaam: Tanzania Commission
for AIDS; 2007.
3. Dimitriadis, G, Fetene, GT. Globalization, Public Policy, and “Knowledge Gap”: Ethiopian Youth and the HIV/AIDS Pandemic. Journal
of Education Policy. 2010; 25(4): 425-441.
4. Kabiru, CW, Orpinas, P. Factors Associated with Sexual Activity Among High School Students in Nairobi, Kenya. Journal of Adoles-
cense. 2009; 32(4):1023-1039.
5. Mutonyi, H, Norton, B. “Talk What Others Think You Can’t Talk”: HIV/AIDS Clubs as Peer Education in Ugandan Schools. Compare.
2007; 37(4): 479 –549.
6. Preece, J, Ntseane, G. Using Adult Education Principles for HIV/AIDS Awareness Intervention Strategies in Botswana. International
Journal of Lifelong Education. 2004; 23(1): 5-22.
7. Pascoe, SJ et. al. Increased risk of HIV-infection among school-attending orphans in rural Zimbabwe. AIDS Care. 2010; 22(2): 206-
8. Population Council. Promoting more gender-equitable norms and behaviors among young men as an HIV/AIDS prevention strategy.
Washington, DC: Population Council; 2006.
9. Kristof, N, WuDunn, S. Half the Sky. Nicholas D. Kristof and Sheryl WuDunn; 2009.
10. Meyer, B, Ramirez, T. World Society and the Nation State. American Journal of Sociology. 1997; 103(1): 144-181.
11. Inoue, K. Vive La Patiente! Discourse Analysis of the Global Expansion of Health as a Human Right. Stanford University Disserta-
tion. 2003.
12. Population Services International. Sexual Role Expectations, Mistrust, and Sexual Violence among Young People in East and
Southern Africa: Implications for HIV Prevention. Washington, DC: Population Services International; 2009.
13. Joint United Nations Programme on HIV/AIDS. Report on the Global AIDS Epidemic 2010. Geneva: UNAIDS; 2010.
36 Stanford Journal of Public Health
The World’s Largest Smoking Ban
China’s Upcoming Smoking Ban and its
Effect on Particulate Matter in China’s
Restaurants and Cafés
Kyle Wong
In China, an estimated 560 million suffer from constant secondhand smoke exposure putting almost half
of the population at a greater risk of heart disease and lung cancer. Ìn 2003 the Chinese government ratifed
the World Health Organization Framework Convention on Tobacco Control and promised to protect its people
from secondhand smoke exposure. Since then the Ministry of Health has passed a law effective January 1,
2011 that will ban smoking in indoor public places. However, many people are skeptical whether this
law will be effective.
This paper is an empirical study aimed to help the Chinese government make more informed decisions
while enforcing this smoking ban. It consists of several indoor air quality tests measuring PM
levels in res-
taurants, and a survey to gauge the public’s knowledge and attitudes toward the law. Based on this study an
effective smoking ban would signifcantly improve indoor air quality with regard to PM
concentrations in res-
taurants and cafes. Our survey also suggests that improved marketing of the smoking ban could increase the
likelihood of the laws implementation and reduce the health effects related to secondhand smoke.
Writer’s note: The smoking ban described in this paper has been delayed to a further date.
The sleieolype lhal Chi-
nese people like to smoke
might be an understate-
nenl. Theie aie aloul 35O
niIIion snokeis in China
that consume a third of
the world’s cigarettes
This smoking culture has
tremendous economic
lenehls foi poIicy nak-
ers, as in 2007 the state-
owned tobacco monopoly
accounted for almost US
$2 billion in government
This hnanciaI gain is
not without consequence
as high smoking rates
have Iead lo signihcanl
smoking related illnesses.
670,000 deaths each year
can be contributed to
smoking related ill-
and lhis hguie
is expected to rise to 2
million deaths each year
by 2020
If snoking is consid-
ered a threat to your
personal health, then
secondhand smoke
(SHS) shouId le seen as
a threat to the health of
the general public. Unlike
smoking, exposure to
secondhand smoke is not
a personal choice as ex-
posure occurs in indoor
pulIic pIaces. 9O° of lhe
population is exposed
to secondhand smoke in
ieslauianls and 58.4° of
the population has been
exposed in government
Secondhand smoke is
a known human car-
cinogen and conlains 25O
chemicals that are known
to be toxic
. One harm-
ful pollutant emitted by
snoking is IailicuIai
Mallei 2.5 (IM
), which
leads to decreased lung
function, aggravated
asthma, chronic bronchi-
tis, and other dangerous
health effects. The medi-
cal journal The Lancet
estimates that 600,000
people worldwide die
yearly from secondhand
smoke related illnesses,
with children and elderly
being the most vulner-
. In China, an esli-
naled 56O niIIion suffei
from constant second-
hand smoke exposure
putting almost half of the
population at a greater
risk of heart disease and
lung cancer.
The Chinese govein-
ment has taken measures
to protect its people
against the adverse ef-
fects of smoking and
exposure to secondhand
smoke by ratifying the
WoiId HeaIlh Oiganiza-
lion Iianevoik Conven-
lion on Tolacco ConlioI.
Since then the Ministry of
HeaIlh has passed a Iav
effective January 1, 2011
that will ban smoking
in indoor public places.
Hovevei, vilh a deepIy-
rooted smoking culture
many people are skepti-
cal whether this law will
be effective.
This paper is an em-
pirical study aimed to
heIp lhe Chinese gov-
ernment make more
informed decisions while
enforcing this smoking
lan. Il consisls of seveiaI
Volume 2 Issue 1 Winter 2012 37
indoor air quality tests
neasuiing IM
levels in
restaurants, and a sur-
vey to gauge the public’s
knowledge and attitudes
toward the law.
The present study is an
analysis of secondhand
smoke exposure in 18
randomly selected restau-
rant and cafes through-
oul China. Secondhand
smoke exposure was as-
sessed by measuring lev-
eIs of IM
using a laser
aerosol monitor called a
Sidepak (ModeI AM51O).
The data collected was
grouped into two main
categories: venues that
had smoking patrons and
venues without smoking
patrons. The purpose is
to measure the differ-
ence in air quality and
to extrapolate air quality
improvements if a smok-
ing ban became effective.
A common protocol
was applied to assess the
IeveIs of IM
was based off of the
CIolaI Aii Moniloiing
Sludy Indooi Aii Moni-
loiing IiolocoI and lhe
piolocoI used in }. Lee el
al.’s article Secondhand
smoke exposures in indoor
public places in seven Asian
countries. Iiioi lo each
measure, the Sidepak
was zero-calibrated with
a hIlei lo ensuie noie
consistent readings. The
aii ßov iale vas sel lo an
indusliy slandaid 1.7L/
nin and IM
were recorded each min-
In addilion lo iecoiding
concentration lev-
els, control variables that
affected concentration
levels were also moni-
tored. These control vari-
ables included: whether
smoking was permitted,
number of smokers, size
of restaurant, and if there
was central air present.
Restaurant size was ap-
proximated based on the
number of tables; restau-
rants with less than 10
lalIes veie cIassihed as
small, 11 to 20 tables were
cIassihed as nediun,
and greater than 20 tables
veie cIassihed as Iaige.
The second major
component of this study
was a survey of Beijing
residents to forecast the
effectiveness of the smok-
ing ban. The purpose of
the survey was to poll
people’s knowledge of
the smoking ban and
the likelihood of them
helping to enforce the
ban. Basic demographic
questions were asked to
record sex, income, age,
occupation, hometown
and education level.
Altogether 107 people
completed our survey in
its entirety. All of our sur-
veys and air quality tests
were conducted before
the smoking ban came
into effect from October
2010 until December

The US LIA ciealed
The US National Ambi-
ent Air Quality Standard
(NAAQS) to protect the
general population from
contaminants believed to
be the most harmful to
humans and the envi-
ronment. The NAAQS
foi IM
for 24 hours
is 35µg/n
. Of the 18
venues surveyed, the
average concentration of
was approximately
, which is about
2.3 times the acceptable
IeveI. These hndings aie
consislenl vilh Lee´s
research which found
aveiage IM
levels in
China lo le 98 µg/n
average concentrations
in restaurants in seven
Asian countries to be

Two thirds of the
venues we observed had
visible smokers (12/18).
These locations had an
average concentration
of 1O3µg/n
, which is
about 3 times higher than
the NAAQS level. The
venues without smok-
ers (6/18) had air quality
levels on par with the
NAAQS al 37µg/n
Thus lheie vas a signih-
38 Stanford Journal of Public Health
cant air quality difference
between restaurants with
and without smokers;
restaurants with smokers
had IM
levels about 2.8 times
greater than those with-
out smokers.
The survey adminis-
tered was moderately
representative of Beijing’s
population demographic.
Of the 107 people sur-
veyed the gender break-
dovn vas 56° naIe and
44° fenaIe, 69° had
income levels between
RMß O-5,OOO Yuan pei
month, 21 % between
RMß 5,OOO and 1O,OOO
Yuan per month, and 10%
had incomes above RMB
10,000 Yuan per month;
28 % had only middle
school diplomas, 24%
had high school diplo-
mas, 36% attended uni-
versity, and 12% attended
graduate school.Of the
surveyed participants
62% (66/107) have been
exposed to secondhand
smoke in restaurants in
the past 30 days. This rate
is leIov lhe 88.5° expo-
sure rate in restaurants
cIained ly lhe 2O1O CIol-
al Adult Tobacco Survey
vhich inleivieved 13,354
participants throughout
Awareness of the
smoking ban is an impor-
tant factor to the law’s
enforcement. According
to the survey results,
onIy 27° (29/1O7) of oui
participants have heard
of the law to be enforced
January 1, 2011. While
the law has appeared in
Chinese nedia, lheie is
still a misperception over
ils delaiIs. Iail of lhe
confusion~and najoi
chaIIenge~iegaiding lhe
Iav is ieIaled lo China´s
socially acceptable smok-
ing culture. 38% (3/8) of
the non-smoking restau-
rants observed had smok-
ers despite noticeable
¨No Snoking¨ signs.
To better enforce the
no smoking ban, one
of the most important
components is a hotline
to report smoking viola-
tions. From the survey
40% (42/107) of the par-
ticipants said they would
consider reporting smok-
ing violations and 64%
(69/1O7) vouId considei
asking people to stop
There are a number of
factors that contribute to
concentration levels
in restaurants and cafes
lhioughoul China~cook-
ing, heating, and out-
dooi IM
being a few.
Hovevei, sludies have
found that the presence
of smokers is one of the
strongest correlations to
indooi IM
tion levels. As seen in
equation one, factors
such as number of smok-
ers (source emission rate,
S) is positively correlated
with concentration levels
vheie as aii ßov (nun-
ber of air changes per
hour, n) and size of the
ioon (VoIune, V) aie
negatively correlated.
Since smoking is often
seen as a social activity
at venues such as restau-
rants, it is common to see
multiple smokers at the
same table. One reason
for high smoking levels
in China is lhe affoid-
ability of cigarettes. Since
199O disposalIe incone
has risen much faster
than the price of ciga-
rettes; currently cigarettes
can be purchased for only
RMß 5 Yuan a pack
In addilion lo high
smoking levels and poor
quality tobacco, the
luiIding codes in China
are less strict than the
building codes in the
United States leading
to worse air circulation.
This circulation is an
important factor in reduc-
ing IM
caused by secondhand
smoke. Of the venues
that we surveyed, one
third of them (6/18) did
not have evidence of cen-
tral air. The air quality in
these levels in these ven-
ues was noticeably poor,
vilh IM
aveiaging 129µg/n
This study shows that
the absence of smoking
signihcanlIy inpioves
indoor air quality in
iegaids lo IM
. Based
on the air quality tests
conducted in this re-
search and the health
effects of secondhand
smoke studied by medi-
cal communities, the
health effects of consis-
tent secondhand smoke
exposure in restaurants in
China can Iead lo signih-
cant health problems. The
cardiovascular effects
of secondhand smoke
are found to be nearly
as large as smoking,
thus putting the general
public at a greater risk of
heart disease
. Accord-
ing to a report produced
ly lhe Aneiican Heail
Association secondhand
smoke increases the risk
of coronary heart disease
by about 30%
. Other
effects of secondhand
smoke include lung can-
cer, respiratory disease
and pulmonary disease.
The upcoming smok-
ing ban in indoor public
pIaces is signihcanl le-
cause secondhand smoke
affects millions of inno-
cent bystanders in restau-
rants and cafes through-
oul China. Ils successfuI
implementation can
improve indoor air qual-
ity and prevent negative
health effects related to
secondhand smoke such
as cardiovascular disease
and Iung cancei. Il can
also reduce the economic
costs associated with sec-
ondhand smoke such as
medical costs (direct cost)
and decreases in produc-
tivity (indirect cost)
This law and its effects
could become a catalyst
for other smoking bans
Indoor Concentration Formula
Source: Masters, 2008
Volume 2 Issue 1 Winter 2012 39
Kyle is a senior at Stanford majoring in Atmosphere and Energy. He is originally from Brooklyn, NY
where he attended Brooklyn Technical High School. Kyle conducted his research while studying abroad
at Peking University during the fall of 2010. While at Stanford, Kyle has been active in many pre-
business organizations such as being Co-President at Alpha Kappa Psi and a Senior Project Director
at Stanford Consulting. In addition, he served as a Haas Philanthropy fellow where he interned at the
Skoll Foundation, a private foundation that supports social entrepreneurs. Prior to Stanford, Kyle was
very involved in entrepreneurship and co-founded three businesses. During his spare time he likes to
read the news and go to the gym.
throughout Asia.
The enforcement of this
ban will depend greatly
on the support of the
Connunisl Iaily. The
successful enforcement
of the smoking ban will
also depend upon the
Chinese consuneis lo
report smoking violations
and abide by the law.
The government cannot
depend solely on venue
owners to enforce this
ban because they have
an economic incentive to
allow smoking because it
appeases customers. 38%
(3/8) of the no smoking
restaurants observed did
not enforce their own
policy; some of these
restaurants even sold
cigarettes on their menu
and had ashtrays readily
Based on the survey
results we cannot de-
cisively conclude that
lhe Chinese popuIalion
will play an active role
in enforcing the law.
Hovevei, lhe hndings
are promising as 64% of
the participants stated
that they would consider
asking people to stop
smoking and 40% would
consider reporting smok-
ing violations. These
hguies can le peiceived
as high considering only
onIy 27° (29/1O7) of oui
participants have heard
of the smoking ban. With
greater knowledge of the
smoking ban, average
consumer enforcement
is expected to increase.
These hguies suggesl
lhal lhe Chinese popuIa-
lion~pailicuIaiIy non-
snokeis~suppoil lhe
smoking ban.
Based on this study an
effective smoking ban
vouId signihcanlIy in-
prove indoor air quality
in iegaids lo IM
centrations in restaurants
and cafes. Our survey
iesuIls shov lhal Chinese
citizens generally sup-
port this smoking ban
and may help with its
enforcement. To improve
the smoking ban’s effec-
liveness lhe Connunisl
Iaily shouId inciease
awareness of the ban.
By sending a clear mes-
sage through the media,
lhe Chinese goveinnenl
could increase the likeli-
hood of the laws imple-
mentation and reduce the
health effects related to
secondhand smoke.
1. World Health Organization. Cigarette Consumption. Available at: Accessed on November
12, 2010.
2. Liu T, Xiong B. Tobacco economy and tobacco control (in Chinese). Economic Science Press; 2004.
3. Gu D, Kelly T, Wu X, et al. Mortality attribution to smoking in China. N Engl J Med 2009;360:150-159
4. Liu BQ, Peto R, Chen ZM, et al. Emerging tobacco hazards in China: BMB 1998;317:1411÷22
5. Global Tobacco Surveillance System (GTSS), Global Adult Tobacco Survey (GATS): Fact Sheet China: 2010
6. National Toxicology Program.9th Report on Carcinogens 2000. Research Triangle Park, NC: U.S. Department of Health and Human
Services, National Institute of Environmental Health Sciences; 2000
7. Öberg M, Jaakkola M, Woodward A, et al. Worldwide burden of disease from exposure to second-hand smoke: a retrospective analy-
sis of data from 192 countries. The Lancet - 26 November 2010
8. Lee, J., et al., Secondhand smoke exposures in indoor public places in seven Asian countries. Int. J. Hyg. Environ. Health. 2010;
9. Masters, Gil. Air Pollution. In: Introduction to Environmental Science. Third ed. Upper Saddle River: Pearson Education, 2008.
10. Hu, TW. The Role of Taxation in Tobacco Control and Its Potential Economic Impact in China. Tobacco Control 2010; 19:58-64.
11. Barnoya, Joaquin, and Stanton A. Glantz. Cardiovascular Effects of Secondhand Smoke: Nearly as Large as Smoking. Circula-
tion 2005; 111:2684-698.
12. Barnoya, Joaquin, and Stanton A. Glantz. Cardiovascular Effects of Secondhand Smoke: Nearly as Large as Smoking. Circula-
tion 111 (2005): 2684-698.
13. Gu D, Kelly T, Wu X, et al. Mortality attribution to smoking in China. N Engl J Med 2009;360:150-159
14. Hu, TW. The Role of Taxation in Tobacco Control and Its Potential Economic Impact in China. Tobacco Control 2010; 19:58-64.
40 Stanford Journal of Public Health
Health Care Among Mexican
Undocumented Immigrants
Barriers to Access and Utilization
Tim Dang
On May 14, 2008,
farm worker María
Jiménez passed out from
heat exhaustion in a
CaIifoinian giape heId.
Hei supeivisois iniliaIIy
refused to take her to
a hospital, and when
lhey hnaIIy did, she
was already comatose.

María passed away
two days later, after her
hance discoveied lhal
she was two months
pregnant. Unfortunately,
tragedies like these are
not unique cases. Such
preventable loss of life
speaks to the failures of
the health care system to
address the needs of the
immigrant population.
Who is to blame? Was
it the fault of greedy
farm owners who feared
governmental scrutiny?
Was it the fault of María,
who willingly faced
risks by crossing the
border? Actually, these
are not the questions
we should be asking.
This kind of polarizing
iheloiic oveisinpIihes
the complexity of health
care and immigration,
fostering a hostile
climate that discourages
meaningful discourse.
The debate on
these two issues must
adopt a more holistic
approach before it
can possibly result in
an agreement. This
approach necessitates
a shift from the current
focus of citizenship status
to the more pressing
issue of health status.
Medical needs of millions
of undocumented
immigrants are not
met by the current
system. Regardless of
political attitudes on
immigration, these
are human tragedies
that we cannot ignore.
Hovevei, discussion
must also acknowledge
the distinction between
different barriers to
heaIlh seivices. Having
access to care is to meet
lhe quaIihcalions lo
be able to receive it.
Utilization is the actual
decision to make use
of care. Thus, access
is like holding the key
to a locked door, but
utilization is the decision
to walk through it.
This paper aims
to inform political
discourse to pave the
way for comprehensive
conversations on health
care and immigration
as a joint discussion. We
must avoid analyzing
either of these topics in a
vacuum. By addressing
the nature of the United
States health care system
and health crises of the
immigrant population,
it will become clear
why the debate must
prioritize health over
citizenship. Once the
primary importance
of health status is
evident, the differences
between barriers to
access and barriers to
utilization of services will
become more evident,
demonstrating that
health solutions in the
immigrant community
must emphasize use of
Immigrants and Our
Current Health Care
}ohn Cailei of Texas
commented that
¨voiking Aneiicans |.j
eain lheii heaIlhcaie¨
and decried provision
of ¨fiee heaIlhcaie lo
iIIegaI aIiens,¨
these statements fail
to acknowledge the
mechanisms of the
health care system
lhal nake ¨eaining¨
access extremely
difhcuIl. AIlhough
many people have a
basic understanding of
how the system works,
discussion on this
topic has become very
poIaiized and viII lenehl
from clearer information
and informed arguments.
To have meaningful
discourse, we must
understand how the
health care system works.
At the root of all health
care systems is a method
for connecting the patient
population with health
caie piovideis. In lhe
United States, private
insurance companies
largely play the role of
the middleman. Most
people with private
insurance receive it
through their employer,
though some buy their
own directly.

Coveinnenl insuiance
plans add an extra
layer of complexity
to the health care
matchmaking game,
particularly through
programs like Medicaid,
the joint federal-state
plan for lower-income
populations. All of
these intermediaries
collect funds from the
population and pool
them together to pay for
nedicaI cosls. LssenliaIIy,
sufhcienlIy Iaige gioups
can pool together their
risks and money to
replace the chance of
a ¨difhcuIl-lo-piedicl,
possibly large cost with
a certain, known, lower

Hovevei, cosls foi
the undocumented
immigrant population
are still high because they
cannot acquire insurance,
making it impossible
Volume 2 Issue 1 Winter 2012 41
foi lhen lo ¨eain¨
heaIlh caie lenehls.
The United States is an
outlier among developed
nations in that the role
of government in health
care is much smaller than
the private sector’s role,
resulting in a system
that relies heavily on the
socioeconomic status
of patients. We have
created a system where
health relies on wealth.
Lven vhen lhe heaIlh
care system can rely on
government funding,
patients must still meet
some basic prerequisites.
One of these
requirements is legal
residence, which creates
the health care crisis
for the undocumented
population. These
immigrants cannot
readily receive
government or
employment insurance
without legal status, nor
can they afford private
insurance with the low
wage-rates characteristic
of illegal employment.
immigrants face greater
medical problems and
issues with receiving

Health Crises in the
Immigrant Population
Mexican immigrants
face greater health
risks and complications
compared to other
ethnic groups,
and these
disparities illustrate
the failure of the health
care system to prioritize
the well-being of this
country’s residents.
Mexicans in the US
have twice the risk of
developing diabetes
compared to non-
Hispanic vhiles, and lhe
incidence of diabetes in
Hispanic chiIdien loin
after 2002 is roughly
one out of three.
facloi inßuencing lhese
statistics is the lack of
preventive care provided
to the undocumented
population, such as
nutritional education
and early detection. A
2006 study reported that
high blood pressure, a
preventable risk factor for
cardiovascular disease,
accounts for nearly eight
million preventable
deaths worldwide each
These deaths are
also associated with other
morbidities like non-
fatal heart attacks, which
piesenl a hnanciaI sliess
on the health care system
that earlier preventive
care could have reduced.
One cause of this
hnanciaI sliess is lhe
1986 Lneigency MedicaI
Treatment and Active
Laloi Acl (LMTALA),
which stipulates
that hospitals must
piovide ¨exaninalion
or treatment for an
emergency medical
condilion |.j iegaidIess
of an individual’s ability
lo pay.¨
To lhe lenehl
of undocumented
immigrants, these
conditions do not make
a distinction based on
IegaI slalus, lul LMTALA
does not allow for
preventive care. Thus, the
undocumented instead
must rely on corrective
care administered after
the development of a
disease. For individuals
with diabetes, this
could entail waiting for
devastating conditions
like kidney failure
instead of addressing
the problem early on.
These types of policies
are shortsighted in
creating a sustainable
health care system for the
general population and
affect the undocumented
Access versus
Several studies argue
that factors leading to
poor access to health
care include income,
insuiance slalus, LngIish
piohciency, and cuIluiaI
values, but a distinction
must be made between
access and utilization.
Incone and insuiance
status are major barriers
to access, but low-
paying jobs have other
effects that prevent
undocumented workers
from receiving health
care. They often fail to
provide sick-time hours
¨lo see a piovidei oi
to recuperate from an
the transient nature of
jobs and lack of stable
health plans affect
rates of having a usual
source of care. One-
third of undocumented
immigrants reported lack
of access to regular health
piovideis vhiIe ovei 9O°
of US-born whites report
having such access.

The undocumented
population also has about
half of the mean number
of physician visits per
year compared to US-
born whites. To what
extent can we attribute
this differential use of
care to barriers of access
and to what extent do
differences in utilization
play a role? To investigate
this question, we must
consider immigrant use
of accessible care and
barriers like language
differences that affect the
decision to walk through
the hospital door.
Mexican immigrants face greater health risks and complica-
tions compared to other ethnic groups in the US.
MILA RE | with permission
42 Stanford Journal of Public Health
Barriers to
Utilization of Care
immigrants do not
often utilize currently
accessible health care
due to unwillingness
and cultural differences,
and these factors are
distinct from barriers
to access. Fear has
historically played a
role in discouraging
use of seivices. In 1994,
CaIifoinia voleis passed
Iioposilion 187, vhich
stipulated that public
enpIoyees nusl ¨veiify
the legal residency of
an individual before
pioviding seivices.¨

Though the proposition
¨vas nol leing enfoiced¨
and federal courts
struck down the law
hve yeais Ialei, Spelz
et al. determined
lhal Iioposilion 187
had lasting effects on
deterring undocumented
immigrants from using
available services.
Some may have been
unaware that the law
was not enforced, feared
its enforcement and
subsequent deportation,
or may have avoided
heaIlh caie ¨lecause of
feai of iepiisaIs |oij pooi
Spetz et al. reported
that prenatal care use
declined, despite the
facl lhal CaIifoinia´s
Medicaid program covers
it. Unfortunately, other
investigations have
shown that farm workers
often do not wish to seek
medical attention because
of job security concerns.

Finding and using health
care services would force
them to take time off
work, and employers
could easily replace their
labor. Undocumented
immigrants have reduced
their participation in
programs that they are
eligible for because
of a hostile climate
discouraging their use of
public programs.
Language and cuIluie
play major roles in
facilitating the connection
between health care
providers and patients,
and communication
barriers have further
discouraged use of care.
Mexicans with limited
LngIish piohciency
may be uncomfortable
navigating the health
care system, and this
health illiteracy prevents
effective communication.
Lxisling Iavs nandale
health care providers
to provide verbal and
written information
in Spanish,
but in
practice, medically
underserved areas have
insufhcienl nunleis of
bilingual physicians.

CuIluiaI leIiefs can aIso
inßuence innunizalion
rates, alcohol intake,
and nutritional habits.

Failure to understand
and work with patients’
cultural backgrounds
may prevent the
development of strong
relationships with
health care providers.
The variety of barriers
to utilization indicates
that we will not
necessarily alleviate
health disparities
of undocumented
immigrants by
increasing access to care.
Accordingly, political
discourse on these
complex topics must

Reforming the
In contrast to the
alienating rhetoric
surrounding immigration
issues, it is imperative
that political discourse
recognizes the human
tragedy that the current
health care system causes
and acknowledges
that solutions to these
problems lie primarily
in the realm of health
policy. Undocumented
immigrants may be
voteless, but they are
neither faceless nor
nameless. Workers like
Maiía IsaleI enlei oui
country to labor for
wages that US citizens
would not accept, are
treated in ways that
US citizens would not
stand for, and utilize
eligible health resources
far less than their US-
born counterparts.
Nevertheless, public
concern about immigrant
overuse of health care
continues, despite
evidence to the contrary.
One change that
could relieve stresses on
the health care system
involves increasing
emphasis on preventive
care. Notably, this
shifl is nol specihc
to undocumented
immigrants. Anyone
who receives emergency
care for a previously
treatable, unchecked
condition requires
costly treatments. We
can avoid these costs by
encouraging preventive
care, which has the
addilionaI lenehl of
being much less invasive
One change that could relieve stress on the health care
system involves increasing emphasis on preventive care.
Public Health Image Library | PUBLIC DOMAIN
Volume 2 Issue 1 Winter 2012 43
than corrective care.
InleieslingIy, expanding
piogians Iike LMTALA
to cover preventive care
measures is actually in
the interest of those who
claim that undocumented
immigrants present a
hnanciaI luiden. A shoil-
term increase in funding
could potentially save
much more in long-term

Solutions and
Solutions to health
problems in the
immigrant community
must circumvent barriers
to access or target
barriers to utilization.
Connunily HeaIlh
Cenleis (CHCs) lhal
can receive federal and
state funding are viable
alternatives to emergency
departments. One study
on health disparities
noted that low-income
populations may actually
hnd lhal lhese cenleis aie
¨noie affoidalIe lhan
a piivale physician.¨

Ioi exanpIe, CHCs
can alleviate barriers
to prescription drug
access by partnering
with pharmaceutical
companies, which
have patient assistance
programs that reduce
costs of medications.
UnfoilunaleIy, CHCs aie
not nearly as common
as hospitals and private
practices, but their
current success provides
a model that others can
bilingualism of both
patients and providers
can also help build a
foundation for cultural
competency and medical
Iileiacy. Inleipieleis
contribute a valuable
service in bridging the
communication gap
between physicians
and patients, but direct
delivery of health
information is necessary
for developing a
professional rapport that
encourages immigrants
to regularly see a
physician. The Santa
CIaia ChiIdien´s HeaIlh
Inilialive in 2OO1 used
direct, multilingual
communication with
parents and expanded
coverage to 14,000
kids by Medicaid,
demonstrating the results
that community-based
organizations can yield.

These methods
largely work within the
established framework
created by current
immigration and health
care policy but are
limited by the extent
of existing resources.
If aII undocunenled
immigrants readily
utilized services that
they are eligible for,
the current health
care system could be
oveivheIned. In lhis
sense, the undocumented
population actually
could present a large
hnanciaI luiden lo lhe
goveinnenl. Hovevei,
political arguments
must come from an
informed and researched
background to maintain
productive discussion.
Arguments against
increasing health care
access for undocumented
immigrants do not have
substantial evidence
to back up the claim
that this would take
away health care
from naturally-born
US citizens. Due to
differences between
barriers to access and
utilization, increased
access may not actually
encourage use of services.
This would neither
improve health outcomes
for the undocumented
noi piesenl a hnanciaI
burden to health
providers. The medical
needs of millions
of undocumented
immigrants present a
challenge to politicians
and advocates. The 2010
Ialienl Iioleclion and
AffoidalIe Caie Acl, one
of the central pieces of
legislation in Obama’s
health care reforms, has
largely sidestepped the
issue of undocumented
immigrants despite
claims that it will expand
coverage to them.
Iiesidenl Olana caIIed
lhese cIains a ¨nylh¨
and slaled, ¨Thal idea
has not even been on
lhe lalIe.¨
To develop
solutions, it should be.
Only by maintaining a
holistic perspective on
immigration and how it
interacts with health care
can we hope to develop
sustainable solutions in
the future.
Undocumented immigrants do not often utilize currently
accessible health care due to unwillingness and cultural
TIM DANG | with permission
44 Stanford Journal of Public Health
Tim Dang is a junior majoring in Human Biology with a concentration in Preventive Medicine and Com-
munity Health. In 2010, he served as a Counselor for the Stanford Medical Youth Science Program,
a medically-focused college pipeline program for low-income students. He worked this past summer
designing and implementing a stealth intervention to increase vegetable consumption amongst ado-
lescents in the form of a summer camp at an 11-acre farm. In 2011, Tim will return as Co-Director of
1. All Things Considered. Teen Farmworker’s Heat Death Sparks Outcry [Web page]. National Public Radio Web site. http://www.npr.
org/templates/story/story.php?storyId=91240378. Accessed November 5, 2011.
2. Carter J. Free Healthcare for Illegal Aliens, Death for Baby Boomers, Jail for the Middle Class [Web page]. Texas Insider Web site. Accessed November 5, 2011.
3. Baker L. The General Structure of Health Care Systems, and Important Concepts Related to Risk. Human Biology 4B: Environmental
and Health Policy Analysis
Baker%20-%20slides%203%20may%202011%20intro%20-%20for%20posting.pdf. Accessed November 5, 2011.
4. Daniel M. Strategies for Targeting Health Care Disparities Among Hispanics. Fam Community Health. 2010;33(4):329-342.
5. Freeman JS. Treating Hispanic Patients for Type 2 Diabetes Mellitus: Special Considerations. JAOA: Journal of the American Osteo-
pathic Association. 2008;108(5 suppl 3):S5 -S13.
6. Lopez, AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic
analysis of population health data. The Lancet. 27 May;367(9524):1747-1757.
7. Centers for Medicare & Medicaid Services. EMTALA Overview [Web page]. U.S. Department of Health & Human Services Web site. Accessed November 5, 2011.
8. Ortega, AN, Fang H, Perez VH, et al. Health Care Access, Use of Services, and Experiences Among Undocumented Mexicans and
Other Latinos. Arch Intern Med. 2007;167(21):2354-2360.
9. Spetz J, Baker L, Phibbs C, Pedersen R, Tafoya S. The Effect of Passing an “Anti-immigrant” Ballot Proposition on the Use of Prena-
tal Care by Foreign-Born Mothers in California. J IMMIGR HEALTH. 2000;2(4):203.
10. California Assembly Access. California’s Harvest of Shame [Video]. Vimeo. Published August 18, 2008.
Accessed November 5, 2011.
11. Ladenheim K, Groman R. State Legislative Activities Related to Elimination of Health Disparities. Journal of Health Politics, Policy
and Law. 2006;31(1):153 -184.
12. Kuo DZ, O'Connor KG, Flores G, Minkovitz CS. Pediatricians' Use of Language Services for Families With Limited English Prof-
ciency. Pediatrics. 2007;119(4):e920 -e927.
13. Baker, L. Equity and Distributing Health Care: The problem of uninsurance. Human Biology 4B: Environmental and Health Policy
14. Offce of the Press Secretary. WEEKLY ADDRESS: President Obama Debunks "Phony Claims" about Health Reform; Emphasizes
Consumer Protections [Web page]. The White House Web site.
dent-obama-debunks-phony-claims-about-health-reform-emphasizes-. Accessed November 5, 2011.
Volume 2 Issue 1 Winter 2012 45
Over 13 million
Americans are currently
plagued by urogyneco-
IogicaI afßiclions
‚ an
escalating epidemiologi-
caI concein. LanenlalIy,
two critically important
issues in women’s health,
stress urinary inconti-
nence (SUI) and peIvic
oigan pioIapse (IOI),
are scarcely referenced
in popular literature,
let alone mentioned in
conversation. A silent and
growing pandemic, the
pievaIence of SUI synp-
toms among women over
the age of 20 has grown
lo a slaggeiing 49.6°
Furthermore, the average
American woman has
an 11.1% lifetime risk of
undergoing an operation
for pelvic organ prolapse
and urinary incontinence,
excluding the large
proportion of cases that
necessitate reoperation
Skyrocketing numbers of
procedures will be in-
feasible to accommodate
in the medical sphere.
Accordingly, research is
essenliaI lo hnding SUI
and IOI cuies.
This article delves into
the urogynecological
heId of sludy, highIighl-
ing contemporary re-
search approaches such
as analysis of ultrasound
images, and biomechani-
cal assessment with sen-
sor probes, each playing
a role in understanding
peIvic ßooi funclion.
Stress Urinary Incon-
tinence and Pelvic
Organ Prolapse
The InleinalionaI
Conlinence Sociely has
deemed urinary inconti-
nence ‚ the complaint of
any urinary leakage
exlends lhal dehnilion lo
incorporate involuntary
loss of urine subsequent
to physical exercise,
coughing, sneezing, or
. Inconlinence
risk increases with age
and complications such
as diabetes mellitus,
obesity, parity, and prior
hysterectomy contribute
to incontinence suscep-
. IeIvic oigan
prolapse, on the other
hand, is dehned as lhe
descent of one or more of:
the anterior vaginal wall,
the posterior vaginal
wall, and the apex of the
vagina (cervix/uterus) or
vault (cuff) after hyster-
. Risk factors for
IOI consisl of age, lody
mass index, and higher
vaginal parity. A study
fion lhe NalionaI Hos-
pital Discharge Survey
fion 1997 aIso eslinales
that per 10,000 women,
white women had a
threefold higher rate of
suigeiy foi IOI con-
pared with African Amer-
ican vonen (19.6 vs 6.4,
. Because
pelvic organ prolapse
can occur in association
with lower urinary tract
dysfunction, debilitated
abdominal muscles are
oulcones of IOI, as veII.
HeaIlhy individuaIs
will voluntarily, or invol-
untarily, activate abdomi-
nal muscles in order to
reign in potential leakage
during vigorous move-
ment. Unfortunately,
injury to lower abdomi-
nal muscles is common
following childbirth,
retarding the function of
major abdominal muscle
. In luin, sIovei
and weaker contraction
rates compromise the
aliIily of an SUI palienl
to restrain urinary leak-
age, and also increase her
probability of acquiring
IOI. DeIinealing peIvic
structures pertinent to
SUI and IOI eIucidale
hov peIvic ßooi aiInenls
are due to damage to
Ievaloi ani (LA) nuscIes.
This set of muscles,
located in the abdominal
cavity, consists of the
pubococcygeus, puborec-
talis, and iliococcygeus.
LA nuscIes snake lighlIy
around the entire abdo-
men area, maintaining
urethra and pelvic struc-
ture position, as can be
visualized by the coronal
view of Figure 2. All three
muscular components
also actively prevent
urethral leakage (see Fig.
1). Wonen vilh IOI and
SUI have Ievaloi ani and
periurethral muscle de-
nervation and decreased
neuropeptide activity
Unspoken Epidemics
Exploring Techniques for Understanding
Female Pelvic Floor Dysfunction
Liz Melton
Figure 1. Saggital view of the pubococcygeus, puborectalis, and
iliococcygeus LA muscles.
CONSTANTINOU LAB | with permission
46 Stanford Journal of Public Health
Latest Research
A veritable toolbox of
research methodologies,
the latest modus operan-
di include: (a) acquisition
and analysis of stream-
ing ultrasound images so
that non-invasive biome-
chanical measurements
can be made, (b) applica-
tion of a biosensor probe
which estimates pelvic
ßooi funclion in leins of
force of contraction, and
(c) biomechanical evalu-
ation of vaginal tissue to
map tissue elasticity rela-
tive to hormonal conse-
quences of maturity and
childbirth. An even more
alluring prospect, obtain-
ing tissue from patients
undeigoing IOI oi SUI
surgery, facilitates pro-
duction of regenerative
adult stem cells, prevent-
ing further vaginal tissue
wear and tear due to
aging. In sunnaiy, lhis
article presents an as-
semblage of innovative
instrumentation, which
can eventually be used by
the clinical community
to enable the prevention
and liealnenl of SUI and
Ultrasound images
serve as models through
vhich lo olseive LA
nuscIes in aclion. Con-
trasting muscle displace-
ment during voluntary
and involuntary contrac-
tions of continent versus
incontinent patients,
and IOI veisus non-
IOI palienls, is a piine
diagnostic, research, and
heaIing looI foi SUI and
IOI viclins
. CIips of
ultrasound imaging can
certainly expose displace-
ment of pelvic structures
in a 2-D projection. None-
theless, given the incred-
ibly short amount of time
duiing vhich a ießex aic
functions, an observer
will not fully capture
even a 2-D trajectory. To
that end, this paper un-
derscores two techniques
of revolutionary 3-D, as
opposed to 2-D, image
creation: sequential ultra-
sound images and color
representation of time to
iIIusliale lhe LA nuscIes
and pelvic organ behav-
ior in real-time.
Muscle displacement
in iesponse lo ießexes,
such as coughing, and
voluntary actions, such as
levator muscle contrac-
tions, are springboards
for exhibiting these two
3-D conversion forms.
Numerous chronologi-
cal images obtained from
a stream of ultrasound
hIn can endov a line-
sensitive, segmented
visualization of muscle
displacement. 3-D illus-
tration is conducive to
visualizing precise organ
position at any point
in time. A second 3-D
displacement portrayal
revolves around a sole ul-
trasound image. Time is
displayed in colors aris-
ing in succession: each
color denotes consecutive
outlines of displacement
(observed in Figure 3)
Applications of time-
color depictions of 3-D
ultrasounds are crucial to
lheoiizing cuies foi SUI
and prolapse victims.
Although ultrasound
relays spatial statistics
vital to the realm of
urogynecological explo-
ration, ultrasound fails to
convey intrinsic strength
of intact levator ani
muscles, thereby inhibit-
ing comparison to the
incapacilaled LA nuscIes
of SUI and IOI suffeieis.
Figure 3. The image on the left displays an anatomical view of
the pelvic foor, demonstrating typical locations of the urethra and
bladder. On the right are the same structures in action (during
cough). As mentioned above, color intensity demarcates the time
at which structures were at particular positions throughout a sub-
ject’s cough. In this case, yellow indicates initial position, where
a rich, orange color signifes position at the end of the 0.3 second
time interval. [yellow = light gray · orange = dark gray]
Figure 2. Coronal view of the pelvis corresponding to depictions of
LA muscles in Figure 1 by rotation of the pubic bone downwards.
The LA muscles wind around the lower abdomen, thwarting ure-
thral leakage during coughs or other pelvic muscle contraction.
CONSTANTINOU LAB | with permission
CONSTANTINOU LAB | with permission
Volume 2 Issue 1 Winter 2012 47
ConpIenenling lhe func-
tionality and convenience
of ultrasound imaging,
innovative biomechani-
cal probes have become
prominent tools in uro-
gynecological research
Researchers can quan-
lify peIvic ßooi nuscIe
function in terms of force
of contraction through
sensors located on alter-
nate sides of intravaginal
probes. Missing from or-
dinary ultrasound read-
ings, biosensors docu-
ment the force produced
in voluntary and invol-
untary contractions of the
LA nuscIes. These dala
may warrant physical
therapy exercises to alle-
viate diminished muscle
lone suslained ly SUI
and pioIapse. LvaIua-
tion of levator ani muscle
potency is analogous
to tracking an athlete’s
progress in reaching a
targeted bench press
goal. By quantifying force
dynamics of the pelvic
ßooi, physicaI lheiapisls
may quantitatively assess
patient growth over time,
in the hopes of diminish-
ing SUI and pioIapse
By using the discussed
technologies, research-
ers are able to acquire a
corporeal idea of biome-
chanics from ultrasound
and biomechanical force
statistics from vaginal
pioles. Hovevei, ie-
searchers are left with
little to no knowledge
on the characteristics
of peIvic ßooi lissue.
Infoinalion iegaiding
quality of tissue is central
to comprehending how
vaginal tissue subsides
lo lhe liink of IOI and
SUI. TacliIe Resonance
Sensors, a predominant
brand of tool on the uro-
gynecological research
market, are the compel-
ling, new-age equivalent
of doctor palpation.
Able to typify tissue of
patients with urinary
prolapse, Tactile Sensors
are equipped to measure
parameters of contact be-
tween sensor and object
of inleiesl. In lhe donain
of SUI and IOI ieseaich,
vaginal wall tissue. Fun-
damentally, Tactile Sensor
software controls move-
ment of a resonating sen-
sor against vaginal wall
tissue samples, collects
data streaming from the
sensor, and converts data
into a visual map demon-
strating elasticity discrep-
ancies in tissue between
patients and healthy
Preliminary Data
In accoidance vilh IRß
standards, recent experi-
menters have procured
small sections of tissue
from subjects’ vaginal
walls. Although this
process appears invasive,
subjects who already un-
dergoing surgery for pro-
lapse or urogenital cancer
are intentionally chosen.
Following vaginal wall
tissue acquirement, the
bulk of tissue is dissected
into even smaller pieces
(usually two or three),
and frozen at -80
C lo
capacitate future analysis
via the Tactile Resonance
Mapping System. The
substantiated evidence
available demonstrates
that Young modulus, a
measure of elastic mate-
rial stiffness (the ratio of
the uniaxial stress over
the uniaxial strain), of
vaginal tissues is higher
(stiffer tissues) in women
vilh IOI conpaied lo
controls, suggesting that
tissues from women
vilh IOI have Iosl lhe
ability to recoil
. Just
as the force of a shoot-
ing rubber band is de-
pendent on its ability to
recoil, decreased elastic-
ity (or decreased recoil)
of vaginal wall tissue
will generate less force.
Hence, dvindIing eIaslic-
ity of vaginal wall tissue
in elderly women permits
the gradual loosening
of peIvic sliucluie. Lven
from this preliminary
, it is clear that there
is considerable potential
for broadening the scope
of the Tactile Mapping
Resonance System, and
for formulating and
testing countless new
. IaiaIIeI ex-
periments may illuminate
the possibility of endog-
enous hormones having
a direct effect on tissue
elasticity, or may provide
new data integral to de-
veloping reconstructive
approaches with syn-
thetic materials. Finally,
a long-term prospect is
growing regenerative
adult vaginal wall stem
cells to substitute for fre-
quently unsuccessfuI SUI
and prolapse surgeries.
In fact, current surgi-
caI liealnenl foi SUI
in particular is, at best,
empirical in nature and
has major limitations
that often require re-
opeialions. Lven noie
disconcerting is the lack
of known preventative
measures and risk factors
foi IOI, iesuIling in lolh
extremely unnerving
day-to-day sensations,
and often eventual hys-
leieclony. Invesligalions
aiming to better under-
stand the mechanisms
responsible for both
SUI and IOI viII yieId
more fruitful, physical
therapy-like cures. Re-
cently, urogynecological
pioneers have conceived
a toolbox of modern
methods to evaluate and
further comprehend the
peIvic ßooi, conpiised
of: streaming time-mod-
ihed uIliasound inages,
force computing biosen-
sor probes, and mapping
tissue elasticity distribu-
tion via Tactile Resonance
Sensors. By identifying
functional anatomy of tis-
sue and muscles, elastic
properties, and cellular
constitution, research-
ers hope to generate a
framework for an ap-
pioach lo lieal SUI and
prolapse patients. On the
very forefront of current
medicine, urogynecologi-
cal research ultimately
aspires to promote better
diagnosis understanding
and cures for the unspo-
ken epidemics of stress
urinary incontinence and
48 Stanford Journal of Public Health
Liz Melton is a Human Biology major currently in her Junior year at Stanford University. Via summer intern-
ship, Liz was exposed to mounting incontinence cases by shadowing Stephanie Prendergast MPT at The
Pelvic Pain and Rehabilitation Center, by analyzing ultrasound images along with Dr. Christos Constantinou to
obtain biomedical framework for female pelvic foor dysfunction, and fnally, by conducting stem cell research
for potential prolapse cures at Dr. Bertha Chen Lab at Stanford University. Although chiefy focused on her
pre-medical career, Liz also dabbles in many other philanthropic and executive realms, holding leadership
posts as: Co-Director of Henry's Place (a student-run organization to promote scientifc learn-
ing amongst low-income elementary school students), VP of Administration of the Pi Beta Phi
Sorority, Director of Advocacy and Veterans Issues for United Students for Veterans Health,
and Head Ìntern for non-proft Upendo Village: HÌV and AÌDS Education, Prevention, and
Care. Liz aspires to attend Medical School, emerging with the tools to eventually establish
reconstructive surgery clinics as well as epidemic prevention facilities in destitute countries.
1. Sung VW, Rogers ML, Myers DL, et al. National trends and costs of surgical treatment for female fecal incontinence. Am J Obstet
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Guest Speaker. The thirty-sixth Annual Meeting of the International Urogynecological Association, Lisbon, Portugal, June, 2010.
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