In most of the cases I've seen, sexual networks are created during the process of partner identification when there is an outbreak of a particular STD. One instance I remember because it was so interesting was an outbreak in 2014 of occupational HIV transmission among male adult film performers.¹ It turns out that even though barrier protection use has been mandated among adult film performers, it's not always enforced. Unfortunately this particular outbreak also resulted in HIV exposure of individuals outside of the workplace.

The possible use of sexual networks in understanding adolescent community dynamics is just as, if not more, interesting to me. In my limited experience in public health I have yet to see determining a sexual network as part of a health prevention approach, but I think that on the community level it would be quite helpful. In many STD-prevention campaigns I've seen, like one that attempts to reduce HIV and HSV-2 incidence among communities of adolescents in rural South Africa,² information regarding number of sexual partners within a specific time period, age at sexual debut, and engagement in transactional sex - sex in exchange for food, money, or other commodities - is gathered. In a campaign aimed at reducing incidence of a disease or of a particular behavior, such as transactional sex, within a defined community, the creation of a sexual network would be helpful. Not only would information that is already being gathered still be gathered (instances of transactional sex, incidence of STDs) but also patterns may begin to appear. Perhaps there is a group of individuals frequently transmitting STDs or frequently engaging in transactional sex. If there is, more targeted methods could be used to resolve issues, like approaching groups encouraging others to engage in sex for money. I may be thinking on too individual a level for public health, but it seems to me that both a population-wide approach combined with a more targeted approach would provided the greatest chance at eliminating diseases and harmful behaviors.

1. Wilken JA, Ried C, Rickett P, et al. Occupational HIV Transmission Among Male Adult Film Performers — Multiple States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:110–114. DOI: http://dx.doi.org/10.15585/mmwr.mm6505a3
2. Jewkes, R., et al. "Impact of Stepping Stones on Incidence of Hiv and Hsv-2 and Sexual Behaviour in Rural South Africa: Cluster Randomised Controlled Trial." BMJ 337 (2008): a506. Print.
* photo taken by my SO

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Next Generation Sequencing (NGS) is just a fancy term for super fast genome sequencing. The first generation was Sanger Sequencing, in which elongating DNA strands were terminated when a specific base showed up. Basically, the same elongating DNA strand would be placed in four separate reactions, each meant to terminate when a specific base appeared (A, G, C, or T). Then, the entire sequence could be visualized either by running each reaction side-by-side on a gel or adding a radioactive label for a computer to read. This process takes a long time, and while still used today, is generally used as a backup for Next-Gen sequencing or for smaller genomes. Next Gen sequencing is much faster. A human genome can be sequenced in a matter of days. A human genome can be sequenced simultaneously with a bunch of other human genomes to gain more information about a specific population (say, people who live in a specific geographic region) in a matter of days to weeks.

Genome-wide association studies (GWAS) are where NGS really becomes relevant to epidemiology. Researchers can look across the entire genomes of multiple individuals to determine if there is an association between a specific gene variant and a specific trait. For example, it can be used to determine if a particular mutation is found in individuals with a specific disease more than it is found in those who do not have that disease.

The first successful GWAS was published in Science in 2005. It investigated the genetic associations with age-related macular degeneration, and found that two single-nucleotide polymorphisms (single-nucleotide variations found consistently among a number of people) that were present in individuals with age-related macular degeneration but not in healthy controls.1

There are, of course, challenges in these kinds of studies. When dealing with genetics - especially entire genomes - the study methodology must be as close to flawless as humanly possible. Extreme care has to be taken when interpreting statistical analyses. Even when an association has been determined by a GWAS, further, less theoretical research should be carried out to investigate the biological plausibility of an association. Although there may be an association with a particular SNP with a disease, that does not necessarily mean that the identified SNP is causally related to that disease. Still, GWAS with all its speed and power looks to me like the future of genetic epidemiology.

1. Klein, Robert J. et al. “Complement Factor H Polymorphism in Age-Related Macular Degeneration.” Science (New York, N.Y.) 308.5720 (2005): 385–389. PMC. Web.

I am, as the saying goes, "actual millennial trash". This means I don't buy diamonds or eat cereal for breakfast and that people seem to be obsessed with how, where, and why I use social media. Why what is called a generation of "entitled narcissists" refers to itself as "trash" and "garbage" I don't know, but it amuses me just as much as attempts to appeal to my generation through social media amuse me.

It seems that social media has become so vital a platform for reaching my generation that in addition to businesses using it as an advertising outlet (see: my favorite example of this, the Denny's tumblr account) various health organizations have also incorporated it into their health communications campaigns. Some excel at this, but others leave me staring at the computer and crying in silent laughter at how horribly they miss the target.

dress: Matilda Jane Clothing cardigan: taken from my mom's closet socks: H&M shoes: Dr. Martens

In a departure from work outfits - and fitting in with this post I think - I'm sharing a Sunday brunch outfit. The wrinkles are part of my "I'm a grad student and everyone else in this restaurant is still hungover" aesthetic. This kind of outfit is generally what I put together when I get dressed in 5 minutes right after I wake up, which seems like a pretty millennial thing to do when a lot of us are working multiple jobs and involved in many different activities while also constantly keeping up with current events and networks on social media.

I'd like to start with the campaign that inspired this post, The Real Cost. One day I was scrolling through my tumblr dashboard as usual and happened upon a sponsored post from a blog titled "Know the Real Cost". For those who don't know, tumblr is a microblogging platform, and half of its user base is under 25 years old. The dashboard is the curated "front page" for a user, where followers view content posted by the users they follow (like the homepage of Facebook or the Twitter feed). Since tumblr's buyout by Yahoo in 2013, sponsored posts now show up on users' dashboards. These posts are not from people users are following, but from whatever companies decide to pay for advertising space on tumblr.

The Real Cost is an FDA-run campaign aimed at youth ages 12-17 who are open to trying smoking or who are already using tobacco products. In short, its goal is to prevent teenage tobacco use. It does this through a series of commercials, a website (where you can play a game where you shoot teeth to show the damage cigarettes can cause), an instagram, a Facebook page, and this rather hilarious tumblr.

Actual image from knowtherealcost.tumblr.com

The photo above is what originally attracted me to the page, and it was from the tumblr that I discovered that The Real Cost is run by the FDA and they hired someone who thought that this image appealed to ages 12-17 and would help prevent smoking. Obviously, I'm outside the target demographic, but the fact that this image exists made me struggle not to laugh out loud at my computer in a public place. On the one hand, I'm glad that the FDA is still trying to prevent tobacco use among teens and is doing so through social media, especially after the failure that was the My Anti-Drug campaign. On the other hand, how does this image and others like it on the blog prevent tobacco usage? I don't care if a cat with an eyepatch is judging me, or if a cookie loses chocolate chips, or if smoking will make me look old enough to get a senior discount. Actually, the last one might be a positive because then my rebellious and at-risk 12-17 year-old self could potentially get away with purchasing cigarettes and maybe alcohol by myself.

This blog and others like it make it clear that those trying to reach that tricky millennial demographic are making real attempts to do so, but for the most part are just barely missing the target. In the case of this tumblr, the FDA is clearly trying to use meme culture and internet culture at large to appeal to millennials, but ends up just sounding like a middle aged parent trying to sound hip and using slang incorrectly. Cat memes are pretty much only used on Facebook nowadays, and even then for the most part they are used either ironically or by Facebook "wine moms". The same goes for cake wrecks, and while "MFW" and "MRW" ("my face when" and "my reaction when") are still en vogue, whoever is running this tumblr seems to have missed that now those captions are generally coupled with either ironic or extremely literal photos.

Maybe I'm being overly critical. After all, their online pages are only part of the overall campaigns, and it's clear that much more money is being spent on video content. Still, I think if an organization like the FDA or the CDC is going to use social media to reach millennials, they might want to spend a little more time on research, or failing that hire an actual millennial who spends a lot of time on their target websites within their target communities. There's not much data on the efficacy of The Real Cost, other than that 89% of its target audience was aware of the campaign's existence within its first six months, but I hope that unlike My Anti-Drug, this campaign and others like it will at least not encourage its target audiences to smoke.1,2

Thankfully, divisions of the Department of Health and Human Services do have some social media campaigns that I think are really well done. This Free Life, another smoking prevention campaign run by the FDA and targeted towards LGBT young adults aged 18-24, has a tumblr and website that come much closer to hitting the mark. They use real people and real experiences, as well as pop culture figures. I've been told those drag queens are contestants on RuPaul's Drag Race - which I don't watch because I'm not a fan of reality shows - but I know is really popular amongst the campaign's target demographic.

from @ActAgainstAids on instagram

The fantastically named "Doing It" campaign, which is part of Act Against AIDS and run by the CDC, is aimed at encouraging HIV testing among adults, and posts punny images to instagram like the one above, as well as equally punny tweets under the Twitter handle @TalkHIV. I especially like that they often reframe HIV testing as an issue of personal health responsibility and a sign of respect in a relationship in an attempt to destigmatize HIV/AIDS. One of my favorite CDC-run social media accounts is the Twitter account @CDCSTD, which also does this, in addition to posting STD facts. On May 4th, that account - and individuals within the CDC - post hilarious and punny Star Wars themed tweets that also relate to health.

Unfortunately, I couldn't find any data on the effectiveness of any of these social media campaigns, although it's entirely possible that they're too new for there to be any data. However, I can say that I love the use of social media by individuals, especially CDC director Dr. Tom Frieden and Surgeon General Dr. Vivek Murthy. Both tweet health facts, but they also engage with the public. In particular, during the Step It Up! Challenge late last month, which had the goal of encouraging Americans to walk more, Dr. Murthy tweeted his step count and challenged others to get in more steps than him. However, their follower counts are currently 104k for Dr. Frieden and 82.7k for Dr. Murthy. For a better visualization of the scale of Twitter fame, Kim Kardashian has over 48.9 million followers, NASA has 19.7 million, and the director of the upcoming third Thor movie, Taika Waititi, has a follower count of 95.4k. I know there are much more important things these men have to do than tweet, but it's still interesting to see what kind of a social media presence they have. After all, both men are the faces of public health in the United States.

Social media seems to be here to stay (well, except for Vine...) and I believe its use by the Department of Health and Human services is an important part of health communication, but I hope it grows to be more effective than it is currently. I understand budget constraints are difficult to deal with, and in that respect health organizations will likely always be at a disadvantage when it comes to things like tobacco prevention campaigns, and I understand that there are certain rules when it comes to using social media as a method of health education and communication. Still, I also believe there are ways to use social media wisely for maximum impact, and there is still much room for improvement. I suspect it may be difficult for the FDA and CDC to get young social media and marketing minds - after all, they have student loans to pay off and there's money to be made working for companies like Buzzfeed and YouTube - and it's expensive to hold focus groups and spend time doing lots of marketing research. I still like to think there's hope for HHS and its divisions when it comes to reaching young people. After all, they are at least trying.

1. Duke JC, Alexander TN, Zhao X, Delahanty JC, Allen JA, MacMonegle AJ, Farrelly MC. Youth's Awareness of and Reactions to The Real Cost National Tobacco Public Education Campaign. PLOS One. 10(12): e0144827. doi: 10.1371/journal.pone.0144827
2. United States Government Accountability Office. "Contractor's National Evaluation Did Not Find That the Youth Anti-Drug Media Campaign Was Effective in Reducing Youth Drug Use". http://www.gao.gov/new.items/d06818.pdf

I don't know what it is about October, but every year around this time my interest in movies grows to become something about which I am absolutely incapable of staying quiet. That's not to say I don't love movies the other 11 months of the year. I do. I watch them constantly (Though not as constantly as some of my more film career-minded friends. I once knew someone who claimed to have watched over 360 movies in one year. He went on to get an advanced degree in film studies from a rather prestigious university.) and I think it's fair to say that the majority of my everyday conversations focus on movies.

The movies and shows I've seen this month have begun to make me think quite a bit about the portrayal of adolescence in film, and whether or not that portrayal is truthful. In particular, I'm referring to The Witch (after a young Puritan girl and her family are banished from town and forced to build a homestead in the woods, their youngest child disappears), Stranger Things (a young boy goes missing at the same time that a young girl appears. The boy's friends team up with the girl to investigate his disappearance.), and Hunt for the Wilderpeople (an adolescent boy ends up on the run in the New Zealand bush with his new foster father.). They are all fantastic and I recommend them to anyone who enjoys movies. They are also all different genres - horror, adventure/mystery/horror, and comedy respectively.

No spoilers ahead!

The concept that links these three different pieces of media together is that they all focus on children who have been exposed to extreme stress. For the sake of avoiding spoilers, I won't specify what kind of stress, but I will say that they are rather extreme stressors. In any case, it is the response to stress that I find interesting. In all three cases, the children react in a way that not only brings them closer to those important to them, but also helps them to face additional stress - a concept known in public health as resilience.

I wanted to know what data there was detailing childhood response to stress, so I decided to do a short literature search. Now, maybe I'm not that good at doing psychological literature searches (I've never had to do one before) but I found very little data on this. Most of the articles I found were based on studies on childhood stress during or after a particular event (chronic pain, sexual abuse, living through a natural disaster) or focused on a particular stress response (suicidal ideation, paranoia, eating disorder). These studies also looked at an individual child's responses and perceptions rather than on interpersonal relationships. 

I did find an abstract, though not the full paper, on the social buffering provided by friends in childhood and adolescence, which found that friends do not provide social buffering until the mid-teenage years (15-16 years old).¹ I also found a study on 3-5 year-old children in daycare facilities, which found that children who were socially rejected had higher levels of salivary cortisol.2 However, I did not find a paper on the effect of childhood stress on interpersonal relationships, which is what I was looking for. A Google search was a bit more helpful for this. A very short informational article published by the American Psychological Association briefly mentioned that parents should "be aware" of how their children and teenagers interact with others but did not mention specific behaviors or activities that parents should watch out for.3 Another short article on MedlinePlus mentioned that stressed children may be unwilling to participate in social activities, and may exhibit aggressive or stubborn behavior.4

This leaves me to draw one of two conclusions. Either 1) I am bad at psychological literature searches, or 2) There is little known on the "normal" interpersonal relationship response to stress in children. I would surmise that depending on temperament, children likely have different responses to stress and relationships.

So, with my lack of scientific evidence of childhood response to stress, I instead decided to look to these artworks as examples. It should be remembered that they are works of art, and therefore are subjective interpretations of the world as seen by the artists, but I also believe that these particular works of art have a definite element of truth to them. 

One in particular, the Netflix series Stranger Things, is incredibly reminiscent of - and admittedly inspired by - the films of Steven Spielberg, who is so well-known for the truth of his depictions of children that there is at least one book written entirely about how he tells the stories of children.5 One notable review for his film E.T. the Extra-Terrestrial described it as "so deep into the special alertness, loyalty, and ardor of children that it makes you see things you had forgotten or blotted out and feel things you were embarrassed to feel".6  Stranger Things shows children and adolescents forging stronger relationships not only in spite of stressful events, but I would suggest because of these events. Without the stressors, I doubt that some of the characters would even come into contact at all, much less become friends.

The other works, The Witch and Hunt for the Wilderpeople are incredibly different. One is the most terrifying movie I have ever seen (I cried and then didn't sleep for a day, then had to sleep with the lights on for a week.) and the other is hilarious and heartwarming. However, I think both show believable changes to family relationships in the face of a traumatic event. It's a bit more difficult to talk about these works without spoiling the plot, but I will say that the differences in family structure show the differing roles that family members may need to play to protect children from harm. Though I believe the protagonists might be of similar age (I'm not quite sure how old Thomasin in The Witch is supposed to be) they differ in terms of gender, relationship to caregivers, and reaction to family members under times of stress. 

All the works mentioned in this post show the importance of support systems for children, especially in the wake of trauma. I would suggest that whether or not children have strong social relationships can affect their resilience. One review article related the importance of social support in resilience across a number of population types.7 Even when only comparing these artworks and considering the differences in social support available to the children in them along with the fates of these children by the ends of their respective films/series, it would seem that social support played a critical role in their successes or failures. 

These three examples of art depicting children in stressful, often life-threatening situations seem to me to be truthful to the childhood experience. Watching them, I believe wholeheartedly that these children on screen are reacting in a way that real children would react in a similar situation, given that those children have similar environments and personalities. Truth is, I believe, one of the most important aspects of good art, and I would absolutely argue in defense of the truthfulness of these artworks in regards to childhood and social relationships.

(There may be spoilers in some of these references!)
1. Doom JR, Doyle CM, Gunnar MR. "Social stress buffering by friends in childhood and adolescence: Effects on HPA and oxytocin activity." Social Neuroscience. 2016 Feb 25:1-14. [Epub ahead of print]
2. Gunnar MR, Sebanc AM, Tout K, et al. "Peer Rejection, Temperament, and Cortisol Activity in Preschoolers". Developmental Psychobiology. 43.4 (2003):346-368.
3. American Psychological Association. "Identifying signs of stress in your children and teens". Accessed 21 Oct 2016. http://www.apa.org/helpcenter/stress-children.aspx
4. "Stress in childhood" Accessed 21 Oct 2016. https://medlineplus.gov/ency/article/002059.htm
5. Schober, Adrian and Debbie Olson, editors. Children in the Films of Steven Spielberg. Lexington Books, 2016.
6. Denby, David. "The Visionary Gleam." New York Magazine, 14 Jun 1982, pp. 73-75.
7. Ozbay, F, Johnson DC, Dimoulas E, Morgan CA, Cherney D, Southwick S. "Social Support and Resilience to Stress: From Neurobiology to Clinical Practice." Psychiatry (Edgmont). 2007;4(5):35-40.

Some may have become aware that Médecins Sans Frontières (MSF), also known in the United States as Doctors Without Borders, has recently turned down a large donation of pneumonia vaccines from Pfizer. I originally had no plans to write about this, but given that it keeps popping up on almost all of my social media, I now feel like I have to at least mention it.



Before I get into that, let me briefly mention that I absolutely adore this apparel item I received in the most recent Stylish Surprise from Modcloth. It's a teeny bit big for an XS, but that's about what I'd expect from Modcloth's sizing, which is rarely consistent. Still, it's incredibly soft and I'm going to be wearing it a lot with this crazily variable weather that starts the day at 50 degrees and then gets up to 90.

I follow MSF on Twitter, so it was from them that I first heard the story, published by Jason Cone, the Executive Director of Doctors Without Borders and titled "There is no such thing as 'free' vaccines: Why we rejected Pfizer's donation offer of pneumonia vaccines". I later became aware of this article in The Atlantic, which added more information from Pfizer's side but still seemed to come down on the side of MSF.

First, a bit of background. In 1999, MSF launched its Access Campaign to push for access to medications and for medication development for those most in need. One of the major areas this campaign focuses on is vaccine access. According to MSF, the high cost of vaccines and the patents held on vaccines prevent aid organisations from being able to administer those vaccines to the populations with which they work. For the past few years, MSF has been in negotiations with GlaxoSmithKline (GSK) and Pfizer - two manufacturers of pneumonia vaccines - to reduce the price of the vaccine for nongovernmental organizations. Earlier this year GSK agreed to offer the vaccine at a discounted price, for about $9 per child for all doses. However, Pfizer has still not agreed to lower the cost of the vaccine. Instead, they offered to donate 1 million free vaccines to MSF.

Here is where the debate begins. Should MSF have accepted the donation? (Pfizer mentions it is still available, should MSF decide to accept.) Accepting the donation may have translated to saving the lives of hundreds of thousands of children who would otherwise have died of pneumonia. Or did MSF make the correct decision in refusing, at the cost of human lives?

Personally - and I may be biased because of my belief in MSF's value of témoignage, "witnessing" or "speaking out" about injustices and institutional oppression - I think that MSF made the best choice from the options it was given. Yes, MSF turned down a donation in order to make a statement, but I think that statement is perfectly valid. Because there is such little competition for pediatric pneumonia vaccines, accepting a donation from a company that refuses to lower its prices to a competitive price would encourage the maintenance of a harmful status quo. In the past, MSF accepted a donation of vaccines, but that was before GSK lowered its price. Accepting a donation now that GSK has more competitive pricing would be tantamount to saying to Pfizer "It's ok that you refuse to lower the price, as long as you give us vaccines for free." and would effectively be throwing away the years of work MSF has put into fighting for vaccine access. Refusing the donation says to Pfizer, "What you are doing is not enough. If you refuse to negotiate, we will not pay you - because we cannot afford your prices - and our money will go to your competitor."

Then there is of course the issue that there tend to be stipulations placed on donations, regarding which populations can receive the vaccines. Neither MSF nor Pfizer have released a statement noting whether there were any restrictions place on the donation, or if there were population-specific restrictions. Instead both parties leave that up to speculation. In Jason Cone's blog he mentions that such restrictions have been placed on donations in the past, but intuitively I would think that he would mention what restrictions may or may not have been placed on this vaccine donation, unless he were legally restricted from doing so.

Will this decision come at the cost of the deaths of those who need that vaccine but will not receive it? Maybe. I even hesitantly will say that probably children will die. I really don't want to devalue these lives that may be lost. I also want to be clear in expressing the fact that in relief work lives will be lost because much of the time it is not possible to give aid to everyone who needs it. Costs are high, number of personnel is low. MSF was faced with a difficult decision and chose the option that they believed would result in the greatest good for the least cost, and that aligned with their core organizational values. In the long run, I can only think that MSF believes this decision will encourage Pfizer - and likely other companies that may be in a similar situation in the future - to price their products competitively for NGOs or risk losing business (and potentially the accompanying good faith of the general populace and maybe even that of their stockholders) and that this will in turn increase the amount of aid NGOs are able to give because they will be able to afford to do so.

This outfit made me realize two things: 1) I need to invest in a dress slip STAT, because skirt slips don't fit well, don't work very well under completely sheer dresses, and make me paranoid that they're showing. 2) I need to wear heels more often. I love feeling tall! Also, these shoes are comfortable enough to walk around all day (I went to class, work, did some shopping, then went to dinner in these) without feeling like dying.


The topic we're currently studying in biochemistry is protein folding, and at first glance this topic may seem uninteresting to those more interested in genetics and infectious disease, like me. However, malfunctions in the process of protein folding can result in a few interesting diseases. One of those diseases is Kuru, caused by consuming the brain matter of infected persons, and known for causing bouts of uncontrollable laughter, tremors, and death. As far as I am aware, this disease has only been found amongst tribal peoples in Papua New Guinea, which I think makes it fairly clear that it could be considered a global health issue. Infectious disease in another country = obviously global health concern, it seems. I find it more interesting to consider what else can be called "global health".

One other disease of infectious misfolded protein that is more relevant to most people, considering that Kuru is contracted by consuming the brain matter of an infected person, is bovine spongiform encephalopathy (BSE), also known as mad cow disease. One instance of host cellular prion protein (PrP^C) misfolding can cause other proteins in the organism to misfold, becoming a new form of protein known as PrPSc. Some may remember that an epidemic of BSE in England and the US caused a meat recall. The disease is spread when infected cows died and their bodies were then ground and used in the feed for the other cows.* Healthy cattle consumed the misfolded protein in the meat and bone meal and contracted the disease. The meat was recalled because consumption of infected meat could cause illness in humans, in the form of a similar disease called Creutzfeldt-Jakob disease (CJD).

There are four different forms of CJD, though the most common are sporadic CJD and familial CJD. In sporadic CJD, the normal PrP^C protein spontaneously misfiles, becoming PrPSc and causing other proteins to misfold. Familial CJD is genetic, and for the most part is caused by a mutation in the gene coding for PrP.

There are very few cases of CJD every year. France's Institute for Health Surveillance (InVS) tracks cases of CJD within the country, and in 2016 there have been only 32 suspected cases of CJD, 31 of which were spontaneous. The other one was genetic. The last French case of probable vCJD - the form likely to be caused by consumption of infected meat - was in 2014.**

I mention Creutzfeldt-Jakob and BSE both because I am fascinated by prion diseases and the science behind them, and because I Feel that when people think of global health they think of neglected tropical diseases (e.g Chagas disease, African sleeping sickness) or emerging infectious diseases (e.g MERS-CoV, Chikungunya) but don't consider rarer diseases that may or may not be infectious (e.g CJD, phenylketonuria) as falling under the umbrella of global health. Global health can define health issues affecting people worldwide, not just developing countries and not just infectious disease. I tend to focus on infectious disease because that's what I find most interesting - there's nothing quite like developing an in-depth understanding of both a pathogen and human physiology - but I just wanted to take a little time to mention in this short post that science, especially biology, is integral to global health, as is a consideration of what is included under the global health umbrella, including non-infectious diseases.

* "Bovine Spongiform Encephalopathy (BSE) Questions and Answers" fda.gov
** "Nombre de cas décédés certains ou probables de MCJ en France par année de signalement pour les suspicions, par année de décès pour les cas de MCJ décédés" invs.santepubliquefrance.fr