Following the people and events that make up the research community at Duke

Category: Global Health Page 1 of 11

The COVID-19 ‘Endgame’ Depends on Where You Live

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In February of 2020, no one could have fathomed that the very next month would usher in the COVID-19 pandemic – an era of global history that has (to date) resulted in 5 million deaths, 240 million cases, trillions of dollars lost, and the worsening of every inequality imaginable.

And while scientists and governments have worked together to make incredible advances in vaccine technology, access, and distribution, it goes without saying that there is more work to be done to finally put the pieces of an exhausted global society back together. On Tuesday, October 12th, the Duke Global Health Institute (DGHI) brought together three leaders in global health to discuss what those next steps should be.

The panel discussion, which was moderated by Dr. Krishna Udayakumar of the DGHI, was titled “The COVID-19 Endgame: Where are we headed, and when will we get there?” The panelists were Dr. Ann Lindstrand, who is the World Health Organization’s unit head for the Essential Program on Immunization; Dr. Ayoade Alakija, who is the co-chair of the African Vaccine Delivery Alliance and founder of the Emergency Coordination Center in Nigeria; and Alberto Valenzuela, who is the Executive Director of the Pan American and Parapan American Games Legacy Project.

Dr. Ayoade Alakija
Dr. Ann Linstrand
Alberto Valenzuela

Dr. Lindstrand began by setting the stage and highlighting what are undoubted successes on a global level. 6.5 billion doses of the vaccine have been administered around the world, and the vaccines have impressive effectiveness given the speed with which they were developed. Yet undergirding all of this is the elephant in the room that, sitting in a 1st-world country, we don’t think about: high-income countries have administered 32 times more doses per inhabitant compared to low-income countries.

Graph from Dr. Ann Lindstrand

This vaccine inequity has been exacerbated by already weak health security systems, vaccine nationalism, and lackluster political commitment. And while the WHO is slated to enormously ramp up supplies of vaccines in Q4 of 2021 and Q1 of 2022, it doesn’t mitigate the damage to the socioeconomic welfare of people that COVID-19 has already had. Dr. Lindstrand outlines the three waves of socioeconomic impact we will see, but expressed concern that “we’re already beginning to see the first wave pan out.” 

Diagram from Dr. Ann Lindstrand

Dr. Alakija took this discussion a step further, asserting that COVID-19 is poised to become the disease of low-income countries. “If you’re living in the US or EU,” she remarked, “You’re heading into the ‘Roaring 20s’. If you live in the Global South, COVID-19 is going to become your future.”

To this point, Dr. Alakija emphasized that the only reason this is the status quo is because in her eyes, the world failed to do what was right when it should have. In her home country of Nigeria, she highlighted that out of a population of 210 million people, 5.1 million people have received the vaccine – and of those 5.1 million, just 2 million — one percent — have been double-vaccinated. “It really is a case of keeping those down further down, while giving booster doses to those that have already been vaccinated,” she said. “We don’t have diagnostic data, so people are slipping underwater and the world has no idea.”

It’s worth noting that Nigeria houses some of the megacities of the world, not just in the African continent. So according to Dr. Alakija, “we don’t solve this with a medical lens, we solve this with a whole-of-society lens.” We must, she argued, because in an interconnected world, no one exists in isolation.

Alberto Valenzuela’s work is a great example of this. In 2019, his team led organizing efforts for the Pan American Games in Lima, relying on extensive partnerships between public organizations and corporations. In 2020, though, as the world shifted, the government called on the team to transition into something much different – COVID-19 relief efforts in the country.

The results are staggering. In just 5 weeks, the Pan American and Parapan American Games Legacy Project built 10 hospitals in 5 regions of the country. The implementation of 31 vaccination centers throughout the country resulted in a tripling of the number of people vaccinated per day in Lima. To him, this work “proves what’s possible when private and public sectors merge.” In other words, remarkable things happen when all of society tackles a societal issue.

Slide from Alberto Valenzuela

So where do we go from here? Perhaps the biggest thing that stood out was the need to empower low-income countries to make decisions that are best for them. In Dr. Alakija’s words, “we need to lose the charity model in favor of a partnership model.” Dr. Lindstrand pointed out that there’s a deep know-how in the Global South of how to roll out mass-vaccination efforts – but only when we “lay down our organizational hats” can we move to what Dr. Lindstrand termed “more coordination and less confusion.” Valenzuela emphasized the need to integrate many sectors, not just healthcare, to mobilize the COVID-19 response in countries. But above all, Dr. Alakija said, “there will be no endgame until we have equity, inclusion, and health justice.” 

Post by Meghna Datta, Class of 2023

Dr. Laura Richman is Defining Health by its Social Determinates

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In 2010, the Affordable Care Act sparked a nationwide debate on the extent of responsibility the American government has over our healthcare. But Dr. Laura Richman has been asking that question since long before that. 

Richman is a health psychologist. “I examine psychosocial factors that have an impact on health behaviors and health outcomes,” she explains, sitting across from me at the Law School café. (Neither of us were wearing a cardigan. It was rather hot outside). 

Laura Richman Ph.D. is an associate professor in population health sciences. (image: Scholars@Duke)

Richman is an associate professor at Duke in the Population Health Sciences, an associate of the Duke Initiative for Science & Society, and, coincidentally, my professor in the Science & the Public FOCUS cluster. She co-teaches the course Science, Law, and Policy with Dr. Yousef Zafar, in which we examine the social determinants of health through the lens of cancer screening, diagnosis, and treatment.

After graduating from the University of Virginia in 1997 with a Ph.D. in social psychology, Richman worked at a sort of think-tank for health professionals collaborating on social issues. This inspired her to pursue health research through the lens of social determinants.

“There was a lot of work on substance use, on mental health, on behavioral disorders. That certainly contributed to my continued interest in factors that have an influence on these [health] outcomes,” she said. 

Continuing in this work, she became a research associate at the School of Public Health at Harvard University; Richman described her time at Harvard as “exciting,” which is not a word used by many to describe empirical research environments. “Certainly there’s that really robust relationship between low income, low education, low job status and poor health outcomes, but a lot of those pathways— like the ones we talk about in class, Olivia— had not been studied.” 

She’s referring to the public health concept of ‘upstream’ and ‘downstream’ solutions. (The river parable goes as follows: when you observe a trend in people drowning in a certain river, you are presented with different ways of solving the problem. You can start pulling people out of the river and saving them one at a time, which is called a “downstream” solution in public health. You can also prevent people from falling into the river, which is called an “upstream” solution.)

(courtesy of SaludAmerica!)

Richman’s professional research explores another crucial social determinant of health we discussed in class: perceived versus actual discrimination. She asked whether marginalization — objectively or subjectively — can affect functioning, “both psychologically and cognitively. Like, how does it affect their thought processes? Their decision-making? Then, how does that affect their health?” You can read her study here

One thing I noted immediately was Richman’s affinity for creative research design. In a lab she headed at Duke, she conducted one experiment with a student that tested the aforementioned effect of marginalization on health decisions. They provided subjects with a choice between unhealthy and healthy snack options after watching a video of, reading a passage about, or imagining members of their community experience discrimination.

In one study we read for Science, Law, and Policy, the stress effect of discrimination towards Arabic-named individuals after 9/11 was measured through the birth outcomes of Arabic-named mothers pregnant during that time. When I asked her about this, she said, “Particularly working with students, I think that they just bring so much energy and creativity to the research. Surveys serve their purpose — I think they’re really important, but I think there are just lots of opportunities to do more with research designs and research questions. I like trying to approach things from a different angle.” 

Richman is also working on a book. She is studying relational health — health as determined by the opioid epidemic, the obesity crisis, and social isolation associated with aging. She hopes her project will be used in classrooms (and by the interested layman), and that the value of social determinants of health is reflected in increased funding dollars, more people interested in health disparities, more focus in medical education on the screening and referral system, and stimulating dialogue among people in positions of power on a policy level.

Post by Olivia Ares, Class of 2025

New Blogger Vibhav Nandagiri: The Curious Student Blogger

Hey everyone! My name is Vibhav Nandagiri, I use he/him/his pronouns, and I’m currently a first-year student at Duke. Amidst the sea of continuous transition brought upon by college, one area of my identity that has stayed fairly constant is my geography. I’ve lived in North Carolina for sixteen of my eighteen years, and my current home lies just twenty minutes from campus in sunny, suburban Cary, NC.

The two missing years are accounted for through my adventures in my parents’ hometown–Hyderabad, India–as a toddler. Spending some of my earliest years surrounded by a large and loving family impacted my life profoundly, forever cementing a strong connection to my emotional, cultural, and linguistic roots.

The latter had a secondary impact on me, one I wouldn’t discover until my parents enrolled me in preschool after returning to the States. With hubris, I marched into my first day of class, ready to seize the day, until I soon discovered an uncomfortable fact: I couldn’t speak English. I am told through some unfortunate stories that I struggled considerably during my first month in a new, Anglicized environment; however, I soon learned the quirks of this language, and two-year-old me, perhaps realizing that he had some catching up to do, fully immersed himself in the English language.

Nowadays, I read quite a bit. Fiction and journalism, academic and satire, I firmly believe that all styles of literature play a role in educating people on the ebbs and flows of our world. In recent years, I’ve developed a thematic fascination with the future. The genre of far-future science fiction, with its rich exploration of hypothetical advanced societies, has led me to ask pressing questions about the future of the human species. How will society organize itself politically? What are the ethical implications of future medical advancements? Will we achieve a healthy symbiosis with technology? As a Duke Research Blogger, I hope to find answers to these questions while getting a front-row, multidisciplinary seat to what the future has to offer. It’s an invigorating opportunity to grow as a writer and communicator, to have my curiosity piqued on a weekly basis, to understand the futuristic visions of innovators at the top of their field.

Prior to Duke, I had the opportunity to conduct research at the Appalachian State University Pediatric Exercise and Physiology Lab, where I co-authored a published paper about adolescent fat metabolism. Not only was I introduced to the academic research process, but I also learned the importance of communicating my findings clearly through writing and presentations. I intend to bring these valuable lessons and perspectives to the Duke Research Blog.

Beyond exercise science, I am intrigued by a diverse range of research areas, from Public Health to Climate Change to Business to Neuroscience, the latter of which I hope to explore further through the Cognitive Neuroscience and Law FOCUS. I was drawn to the program for the opportunity to build strong relationships with professors and investigators; I intend to approach my work at the Duke Research Blog with a similar keenness to listen and connect with researchers and readers alike. When I’m not reading or typing away furiously at my computer, you can find me hitting on the tennis courts, singing Choral or Indian Classical music, or convincing my friends that my music taste is better than theirs.

Post By Vibhav Nandagiri, Class of 2025

In the World Capital of Vanilla Production, Nearly Three out of Four Farmers Say They Don’t Have Enough to Eat

A new study investigates why and what they can do about it

Madagascar, famous for its lemurs, is home to almost 26 million people. Despite the cultural and natural riches, Madagascar is one of the poorest countries in the world. Over 70% of Malagasy people are farmers, and food security is a constant challenge. Rice is the most important food crop, but lately an internationally-prized crop has taken center stage: vanilla. Most of the world’s best quality vanilla comes from Madagascar. While most Malagasy farmers live on less than $2 per day, selling vanilla can make some farmers rich beyond their dreams, though these profits come with a price, and a new study illustrates it is not enough to overcome food insecurity.

In a paper published June 25, 2021 in the journal Food Security, a team of scientists collaborating between Duke University and in Madagascar set out to investigate the links between natural resource use, farming practices, socioeconomics, and food security. Their recently published article in the journal Food Security details intricate interactions between household demographics, farming productivity, and the likelihood of experiencing food shortages.

Vanilla beans, Wikimedia Commons

The team interviewed almost 400 people in three remote rural villages in an area known as the SAVA region, an acronym for the four main towns in the region: Sambava, Andapa, Vohemar, and Antalaha. The Duke University Lemur Center has been operating conservation and research activities in the SAVA region for 10 years. By partnering with local scientists, the team was able to fine-tune the way they captured data on farming practices and food security. Both of the Malagasy partners are preparing graduate degrees and expanding their research to lead the next generation of local scientists.

Farmers harvesting the rice fields in Madagascar. Credit: Wikimedia Commons.

The international research team found that a significant proportion of respondents (up to 76%) reported that they experienced times during which did not have adequate access to food during the previous three years. The most common cause that they reported was small land size; most respondents estimated they owned less than 4 hectares of land (<10 acres), and traditional farming practices including the use of fire to clear the land are reducing yields and leading to widespread erosion. The positive side is that the more productive the farm, especially in terms of rice and vanilla harvests, the lower the probability of food insecurity. There was an interaction between rice and vanilla harvests, such that those farmers that produced the most rice had the lowest probability of food insecurity, even when compared to farmers who grew more vanilla but less rice. Though vanilla can bring in a higher price than rice, there are several factors that make vanilla an unpredictable crop.

The vanilla market is subject to extreme volatility, with prices varying by an order of magnitude from year to year. Vanilla is also a labor- and time-intensive crop; it requires specific growing conditions of soil, humidity, and shade, it takes at least 3 years from planting to the first crop. Without the natural pollinators in its home range of Mexico, Malagasy vanilla requires hand pollination by the farmers, and whole crops can be devastated by natural disasters like disease outbreaks and cyclones. Further, the high price of vanilla brings with it ‘hot spending,’ resulting in cycles of boom and bust for impoverished farmers. Because of the high price, vanilla is often stolen, which leads farmers to spend weeks in their fields guarding the vanilla from thieves before harvesting. It also leads to early harvests, before the vanilla beans have completely ripened, which degrades the quality of the final products and can exacerbate price volatility.

In addition to the effects of farming productivity on the probability of food insecurity, the research revealed that household demographics, specifically the number of people living in the household, had an interactive effect with land size. Those farmers that had larger household sizes (up to 10 in this sample) had a higher probability of experiencing food insecurity than smaller households, but only if they had small landholdings. Those larger families that had larger landholdings had the lowest food insecurity. These trends have been documented in many similar settings, in which larger landholdings require more labor, and family labor is crucial to achieving food sovereignty.

The results have important implications for sustainable development in this system.  The team found that greater rice and vanilla productivity can significantly reduce food insecurity. Therefore, a greater emphasis on training in sustainable, and regenerative, practices is necessary. There is momentum in this direction, with new national-level initiatives to improve rice production and increase farmers’ resilience to climate change. Further, many international aid organizations and NGOs operating in Madagascar are already training farmers in new, regenerative agriculture techniques. The Duke Lemur Center is partnering with the local university in the SAVA region to develop extension services in regenerative agriculture techniques that can increase food production while also preserving and even increasing biodiversity. With a grant from the General Mills, the Duke Lemur Center is developing training modules and conducting workshops with over 200 farmers to increase the adoption of regenerative agriculture techniques.

Further, at government levels, improved land tenure and infrastructure for securing land rights is needed because farmers perceive that the greatest cause of food insecurity is their small landholdings. Due to the current land tenure infrastructure, securing deeds and titles to land is largely inaccessible to rural farmers. This can lead to conflicts over land rights, feelings of insecurity, and little motivation to invest in more long-term sustainable farming strategies (e.g., agroforestry). By improving the ability of farmers to secure titles to their land, as well as access agricultural extension services, farmers may be able to increase food security and productivity, as well as increased legal recognition and protection.

To move forward as a global society, we must seek to achieve the United Nation (UN) Sustainable Development Goals (SDGs). One of the SDGs is Goal #2, Zero Hunger. There are almost one billion people in the world who do not have adequate access to enough safe and nutritious food. This must change if we expect to develop sustainably in the future. Focusing on some of the hardest cases, Madagascar stands out as a country with high rates of childhood malnutrition, prevalence of anemia, and poverty. This year, more than one million people are negatively impacted by a three-year drought that has resulted in mass famine and a serious need for external aid. Sadly, these tragedies occur in one of the most biodiverse places on earth, where 80-90% of the species are found no where else on earth. This paradox results in a clash between natural resource conservation and human wellbeing.

Achieving the UN’s SDGs will not be easy; in fact, we are falling far short of our targets after the first decade. The next ten years will determine if we meet these goals or not, and our collective actions as a global society will dictate whether we transform our society for a sustainable future or continue with the self-destructive path we have been following. Further research and interventions are still needed to conserve biodiversity and improve human livelihoods.

Black Americans’ Vaccine Hesitancy is Grounded in More Than Mistrust

Covid-19 is considered a “general pandemic,” but its impacts have been disproportionate along the lines of race and ethnicity. Though vaccines may serve as our best chance to put an end to Covid, the problem of vaccine hesitancy amongst Black people in the U.S. is particularly pervasive and grounded by more than simple mistrust.

Gary Bennett (Ph.D.) discussed the issue of complex determinants of vaccine hesitancy among Black Americans Monday, April 5. Bennett is a Professor of Psychology, Neuroscience, Global Health, and Medicine at Duke, as well as director of Duke Digital Health and Vice Provost for Undergraduate Education.

Gary Bennett, Ph.D.

“At the end of the day, we are dealing with an issue that demands pragmatic attention,” Bennett said, “How do we get shots in arms?” It turns out, the answer is quite complex and historically confounded.

While Black people have experienced much higher burdens from Covid-19 despite contracting the disease at a similar rate to whites, they have been disproportionately vaccinated at lower rates than white people.

“Access matters and it matters a lot,” Bennett said. One clear example of decreased access for Black Americans is that fewer vaccination sites are located in areas with high concentrations of Black people.

However, Bennett said, access does not simply equal place. “How much friction are you creating in this process?” he prompted, pointing to examples of complicated registration systems, inadequate public transportation to vaccine sites, or overall distance from a location. All of these factors already limit who is able to access vaccinations without the added influences of reduced vaccine uptake due to vaccine hesitancy.

A slide from Dr. Bennett’s presentation which outlines the plethora of impactors on access.

Vaccine hesitancy was listed by the World Health Organization as a top 10 global threat in 2019, when vaccines were preventing 2-3 million deaths per year in the pre-Covid era. Though Bennett said that vaccine hesitancy “has been with us for a long time,” there “are real consequences” to continued reluctance and refusal to get vaccinated with heightened risks due to the nature of the pandemic.

Bennett said that many claims around hesitancy blame communities for their inability to access vaccines, but this fails to consider or to change the underlying behaviors that drive hesitancy. Bennett outlined these underlying drivers as 1) mistrust, 2) social norms, and 3) understandable uncertainties.

A slide from Dr. Bennett’s presentation showing the unequal distribution of vaccination sites in Atlanta GA in predominantly white areas.

“It’s not just mistrust of the medical system, it’s mistrust of institutions,” Bennett said, “There’s a lot of reasons for [Black people] to mistrust institutions.” The murder of George Floyd stands as one poignant contemporary example, but “Tuskegee [still] looms large in the minds of Black Americans.” The Tuskegee experiment exploited 600 Black men working as sharecroppers who had syphilis by knowingly withholding treatment and simply seeing what happened to their bodies as a result of the disease for over 40 years.

This experiment was not the first of its kind: Whole body radiation was tested on Black people. Fistula surgery was developed on enslaved Black women by the “father of modern gynecology.” The immortal cells of Henrietta Lacks, a Black woman, have been used far and wide to advance science after a sample of her cancerous cervix was unknowingly stolen from her. Modern studies have also shown how different implicit biases of Black patients shape their treatment outcomes due to skewed physician perceptions.

The capital riot, the murder of George Floyd, and the Jim Crow Era all exemplify the pervasive institutionalized racism that erodes Black trust in U.S. institutions of all kinds.

Our social networks are also vitally important to influencing our feelings about receiving the Covid vaccine. In Black communities, Bennett said, fewer people in their networks have gotten vaccinations and those who have received vaccines are less vocal about it leading to a collective lack of interest in receiving vaccinations.

These two factors, paired with understandable uncertainties about the side effects of the vaccine or potentially getting Covid itself, generate the need to change our approaches to vaccine hesitancy and increased uptake amongst Black communities in the U.S.

White people have been disproportionately vaccinated over all other racial/ethnic categories in the U.S.

To do this we need to lead with empathy and appreciate the fact that changing attitudes towards vaccines is a process. “Shaming people is bad,” Bennett said. “Stigmatizing people will actually lead to the converse of what we expect.”

Over time, we can work to correct misconceptions, contextualized uncertainties, and share stories rather than statistics to push people further from vaccine refusal and closer to vaccine demand.

And when more Black Americans are ready, “vaccination should be an easy choice.” By implementing opt-out policies, rather than opt-in and by taking more direct actions like making vaccination appointments for people, Covid vaccines may indeed be the key to ending the pandemic – in an equitable and proportionate way.

Post by Cydney Livingston

Duke Researcher Busts Metabolism Myths in New Book

Herman Pontzer explains where our calories really go, and what studying humanity’s past can teach us about staying healthy today.

Photo by Elena Georgiou, My City /EEA

Duke professor Herman Pontzer has spent his career counting calories. Not because he’s watching his waistline, exactly. But because, as he sees it, “in the economics of life, calories are the currency.” Every minute, everything the body does — growing, moving, fighting infection, even just existing — “all of it takes energy,” Pontzer says.

In his new book, “Burn,” the evolutionary anthropologist recounts the 10-plus years he and his colleagues have spent measuring the metabolisms of people ranging from ultra-athletes to office workers, as well as those of our closest animal relatives, and some of the surprising insights the research has revealed along the way.

Much of his work takes him to Tanzania, where members of the Hadza tribe still get their food the way our ancestors did — by hunting and gathering. By setting out on foot each day to hunt zebra and antelope or forage for berries and tubers, without guns or electricity or domesticated animals to lighten the load, the Hadza get more physical activity each day than most Westerners get in a week.

So they must burn more calories, right? Wrong.

Herman Pontzer
Herman Pontzer, associate professor of evolutionary anthropology at Duke

Pontzer and his colleagues have found that, despite their high activity levels, the Hadza don’t burn more energy per day than sedentary people in the U.S. and Europe.

These and other recent findings are changing the way we understand the links between energy expenditure, exercise and diet. For example, we’ve all been told that if we want to burn more calories and fight fat, we need to work out to boost our metabolism. But Pontzer says it’s not so simple.

“Our metabolic engines were not crafted by millions of years of evolution to guarantee a beach-ready bikini body,” Pontzer says. But rather, our metabolism has been primed “to pack on more fat than any other ape.” What’s more, our metabolism responds to changes in exercise and diet in ways that thwart our efforts to shed pounds.

What this means, Pontzer says, is you can walk 16,000 steps each day like the Hadza and you won’t lose weight. Sure, if you run a marathon tomorrow you’ll burn more energy than you did today. But over time, metabolism responds to changes in activity to keep the total energy you spend in check.

Pontzer’s book is more than a romp through the Krebs cycle. For anyone suffering pandemic-induced pangs of frustrated wanderlust, it’s also filled with adventure. He takes readers on an hours-long trek to watch a Hadza man track a wounded giraffe across the savannah, to the rainforests of Uganda to study climbing chimpanzees, and to the foothills of the Caucasus Mountains to unearth the 1.8 million-year-old remains of some of the first people who trekked out of Africa.

His humor shines through along the way. Even when awoken by a chorus of 300-pound lions just a few hundred yards from his tent, he stops to ponder whether his own stench gives him away, and what he might do if they come for his “soft American carcass, the  warm triple crème brie of human flesh.”

Pontzer spoke via email with Duke Today about his book:

Q: What’s the lesson the Hadza and other hunter-gatherers teach us about managing weight and staying healthy?

A: The Hadza stay incredibly fit and healthy throughout their lives, even into their older ages (60’s, 70’s, even 80’s). They don’t develop heart disease, diabetes, obesity, or the other diseases that we in the industrialized world are most likely to suffer from. They also have an incredibly active lifestyle, getting more physical activity in a typical day than most Americans get in a week.

My work with the Hadza showed that, surprisingly, even though they are so physically active, Hadza men and women burn the same number of calories each day as men and women in the U.S. and other industrialized countries. Instead of increasing the calories burned per day, the Hadza physical activity was changing the way they spend their calories — more on activity, less on other, unseen tasks in the body.

The takeaway for us here in the industrialized world is that we need to stay active to stay healthy, but we can’t count on exercise to increase our daily calorie burn. Our bodies adjust, keeping energy expenditure in a narrow range regardless of lifestyle. And that means that we need to focus on diet and the calories we consume in order to manage our weight. At the end of the day, our weight is a matter of calories eaten versus calories burned — and it’s really hard to change the calories we burn!

Q: You’re saying that exercise doesn’t matter? What’s the point, if we can’t eat that donut?

A: All those adjustments our bodies make responding to exercise are really important for our health! When we burn more calories on exercise, our bodies spend less energy on inflammation, stress reactivity (like cortisol), and other things that make us sick.

Q: What’s the biggest misunderstanding about human metabolism?

A: We’re told — through fitness magazines, diet fads, online calorie counters — that the energy we burn each day is under our control: if we exercise more, we’ll burn more calories and burn off fat. It’s not that simple! Your body is a clever, dynamic product of evolution, shifting and adapting to changes in our lifestyle.

Q: In your book you say we’re driven to magical thinking when it comes to calories. What do you mean by that?

A: Because our body is so clever and dynamic, and because humans are just bad at keeping track of what we eat, it’s awfully hard to keep track of the calories we consume and burn each day. That, along with the proliferation of fad diets and get-thin-quick schemes, has led to this idea that “calories don’t matter.” That’s magical thinking. Every ounce of your body — including every calorie of fat you carry — is food you consumed and didn’t burn off. If we want to lose weight, we must eat fewer calories than we burn. It really comes down to that.

Q: Some people say that if the cavemen didn’t eat it, we shouldn’t either. What does research show about what foods are “natural” for humans to eat?

A: There’s no singular, natural human diet. Hunter-gatherers like the Hadza eat a diverse mix of plant and animal foods that varies day to day, month to month, and year to year. There’s even more dietary diversity when we look across populations. Humans are built to thrive on a wide variety of diets — just about everything is on the menu.

That said, the ultra-processed foods we’re inundated with in our modern industrialized world really are unnatural. There are no Twinkies to forage in the wild. Those foods are literally engineered to be overconsumed, with a mix of flavors that overwhelm our brain’s ability to regulate our appetites. Now, it is still possible to lose weight on a Twinkie diet (I’m not recommending it!), if you’re very strict about the calories eaten per day. But we need to be really careful about how we incorporate ultra-processed foods into our daily diets, because they are calorie bombs that drive us to overconsume.

Q: If we could time travel, what would our hunter-gatherer ancestors make of our industrialized diet today?

A: We don’t even need to imagine — We are those hunter-gatherers! Biologically, genetically, we are the same species that we were a hundred thousand years ago, when hunting and gathering were the only game in town. When we’re confronted with modern ultra-processed foods, we struggle. They are engineered to be delicious, and we tend to overconsume.

Q: Has the COVID-19 pandemic brought any of these lessons home for you? What can we do to keep active and watch what we eat, even while working from home?

The pandemic has been a tragedy on so many levels — the loss of life, those suffering with long-term effects, the social and economic impacts. The impact on diet and exercise have been bad as well, for many of us. Stress eating is a real phenomenon, and the stress and emotional toll of the pandemic — along with having easy access to the snacks in our kitchen — have led many to gain weight. Physical activity seems to have declined for many. There aren’t easy answers, but we should try to make a point to get active every day. And we can help ourselves make better decisions about food by keeping ultra-processed foods out of our houses. You can’t plow through a bag of chips if you don’t have chips in your cupboard.

Q: You’ve measured the energy costs of activities ranging from taking a breath to doing an Ironman. What is one of the more extreme or surprising calorie-burning activities that you’ve measured, or would like to measure, in humans or some other animal?

A: With colleagues from Japan, I measured the energy cost of a heartbeat – a tricky bit of metabolic measurement! Turns out each beat of your heart burns about 1/300th of a kilocalorie! Amazing how efficient our bodies can be.

Q: What is something people have questions about that we just don’t know the answer to yet? What would it take to find out?

A: Right now we’re excited about measuring the adjustments our bodies make when we increase our exercise: how exactly does burning more energy on physical activity impact our immune system, our stress response, our reproductive system? It will take a long-term study of exercise to see how these systems change over time.

Robin Smith - University Communications
Robin Smith – University Communications

Centering Patients and Expanding Access in the Opioid Epidemic

We are still in the midst of an opioid epidemic. In 2019, an average of six North Carolinians died each day from unintentional medication or drug overdose. A striking 79% of drug overdose deaths in NC in 2018 involved opioids. This has garnered attention from many organizations and institutions in the state and prompted new concerns relating to patient-centered care.

A Duke Global Health discussion on March 17 concluded that the social response can be aided by a refined focus on mental health, as well as the use of telehealth – the delivery of health care and education remotely through various technologies.

Moderated by Brandon Knettel (Ph.D.), the Duke Global Health Institute panel considered treatment, community engagement, and public policy in addressing the opioid epidemic with panelists Nidhi Sachdeva (MPH), Padma Gulur (M.D.) Hilary Campbell (PharmD, J.D.), and Theresa Coles (Ph.D.)

Sachdeva is a Senior Research Program Leader with the Department of Population Health Sciences at Duke Medical School. Dr. Gulur is a Professor of Anesthesiology and Population Health with Duke Medical School and Executive Vice Chair of the Pain Management and Opioid Surveillance with Duke University Health System. Campbell is director of Sheps Health Workforce Health Professions Data System at UNC-Chapel Hill. Coles is Assistant Professor in Population Health Sciences with Duke Medical School.

Sachdeva opened the panel with a discussion of the Duke Opioid Collaboratory. The Collaboratory currently houses 25 different projects relating to improving data surveillance, health system quality, and public health in the realm of research on opioids.

“We’re losing more and more folks every day,” said Sachdeva. Duke’s projects represent a systems approach to the opioid epidemic, meaning there is lots of valuable overlap and connectivity between projects, and external partnerships that have provided a unique opportunity for academic and community collaboration.

Dr. Gulur stated that Duke Health has seen improvements in opioid use and prescription over the last five to six years: the ambulatory prescribing rate has gone down, fewer patients are requiring high-dose opioids overall, and there has been significant increase in availability to offer medication-assisted treatment for opioid use disorder. Like Sachdeva, Gulur’s work with Duke’s Pain Management and Opioid Surveillance exists within a larger network of organizations dedicated to the opioid issue.

“We have a very committed and collaborative infrastructure with [other] initiatives in the state,” said Gulur, who added that she is dedicated to making “sure we have all the voices at the table.”

A collective display of the Duke Opioid Collaboratory projects

Simply decreasing opioid prescriptions “doesn’t necessarily work” and solving this issue will not be a quick fix. Campbell said that her own research found that at the same time the “supply side” of opioids was shrinking, the state was “seeing the crisis getting worse.”

Enter telehealth and the need for expanded support to mental health resources. Coles explained their pertinence through discussion of her work with Granville-Vance Public Health. Coles has been working on an expanding project that assesses training, operational challenges, patient centered goals, and success from the patient’s perspective within Granville-Vance’s opioid program.

Coles found that inconsistent funding lead to lapses in access to mental health support and the “dropout of someone there to help [with behavioral health] was challenging for patients.” Telehealth bridges the gaps of inconsistent access. Further, in the case of Coles’ study, it also played a large role in increased access for patients who experienced transportation issues since the investigation took place in conjunction to Covid-19, which lowered patients’ abilities to physically attend the program in-person.

Because “no one person experiences opioid abuse … in a vacuum,” as Sachdeva said, it is important to get a comprehensive “assessment of what a person’s life looks like and their priorities for treatment” before jumping into treatment.

This map displays the concentration of unintentional medication and drug overdose death rates across the 100 counties of North Carolina.

Though the last year living under the Covid-19 pandemic has been difficult for the entire globe, the increased need for access to resources through the internet and various technologies has been positively reinforced. With new understandings of relationships to others and limited physical access to in-person healthcare, telehealth has emerged as a means to resolve decreased access. It can also serve as a way to expand access for populations who have historically suffered from inadequate access to healthcare resources, like rural populations.

Opioids “have and will continue to play a role in pain management,” Dr. Gulur said. However, better efforts to involve patients and their families in decision making around opioids, as well as more fully informed understandings of the potential risks and side effects, is necessary for centering patient priorities in care management.

Sachdeva emphasized a “nothing about us without us” philosophy for approaching the opioid epidemic. This means that the systems of care being changed to address opioid crises must depend directly on people who use opioids. It is important to center “lived experience through the whole thing.” Because each community is different, it is inadequate to make assumptions about “what a community is, what it might need, or what its story is.”

The self-described objectives of the Duke Opioid Collaboratory, which overlaps largely with other initiatives discussed during the panel.

Underlying this work is a question from Dr. Gulur, “What are you trying to treat?”

To treat the opioid epidemic, we need to treat people as complex, multi-dimensional people living complicated lives. Opioid use is only one facet of this narrative, making it pertinent to understand the rest of the story to adequately tackle this problem our nation faces. Mental health and access to care are central to this collective narrative more largely.

Post by Cydney Livingston

Bass Connections Teams Tackling COVID-19 Problems, from Food Security to Voting-by-Mail

Most people at Duke are familiar with Bass Connections, the powerhouse interdisciplinary research program that brings together students and faculty from a wide variety of backgrounds to tackle complex problems.

Like most people, when the country went on COVID-19 pandemic lockdown, team leaders and members within Bass Connections needed to adapt their approach.

Instead of merely adapting, though, some Bass Connections teams saw a problem-solving opportunity. They pivoted to address some of the most pressing problems that the pandemic has created or exacerbated. On Tuesday, March 2nd, eight teams gathered to present their research at the first Bass Connections Works in Progress Symposium.

Equity and Efficiency of Using Wearables Data for COVID-19 Monitoring was one team that presented at the Symposium.

These teams tackled issues ranging from the ethics of contact tracing to the availability and access to contraception.

One team focused on the issue of food security amongst Latinx populations in Durham. Their presentation was lead by Elaijah Lapay, Faraan Rahim, and Karina Moreno Bueno. The team aimed to tackle three major goals: “How is the pandemic affecting the food security of Latinx residents, and how do environmental public health factors contribute to this population’s risk for COVID-19 infection? How does the incorporation of fresh, local foods mitigate these effects? How is the pandemic affecting the food assistance services locally, nationally, and internationally for the Latinx community?”

Of the Hispanic/Latinx respondents to the 2019 Durham Community Health Survey, 20.9% said they sometimes skipped or limited their meals. Combining that with the fact that 36% of the total number of COVID-19 cases in Durham have been within the Hispanic population, it’s fairly clear that there is a link between food security and health outcomes.

To this end, the Bass Connections team partnered with Root Causes to help advance their project goals through Root Cause’s Fresh Produce Program. Root Causes is an organization started by Duke Medical School students prior to the pandemic that previously provided fresh produce to food-insecure patients at the Duke Outpatient Clinic. But in order to adapt to contactless delivery and new needs due to COVID-19, Root Causes and the Bass team partnered to expand its reach to nearly 150 households in Durham.

Pipeline for Fresh Produce Program, taken from the symposium presentation of Improving Food Security to Increase Resiliency to COVID-19 for Latinx Populations

This expansion was aided immensely by the Duke Campus Farm, which despite the pandemic mobilized to change the produce it grew to be more culturally relevant to the households they were supporting.

In the future, the team hopes to continue to expand their survey data in the Triangle and continue to assess the impact of the Fresh Produce Program.  

Another Bass Connections team broadly addressed the challenges COVID-19 posed to the election process, through three sub-projects focusing on absentee balloting, organizing, and overall voter participation. The symposium presentation for the absentee balloting research was lead by Chase Johnson, Emma Shokeir, and Kathryn Thomas.

To hear more about the work of this Bass Connections team, watch the presentation above.

The 2020 election saw more people than ever relying on absentee voting, either by the one-stop process or by voting through mail. However, this team aimed to address the many voters that are disenfranchised because their votes are rejected due to errors in their ballot. While NC courts ruled that voters are required to be notified if their ballot needs curing, the difficulty of curing one’s ballot often dissuades people from even starting the process, leading to those votes not being counted.

The team utilized the app BallotTrax, a company that the North Carolina State Board of Elections hired to track these ballots. The team then focused on phone banking to increase BallotTrax usage, and then analyzed voter outcomes.

In the future, they hope to analyze the effect that BallotTrax outreach had on voting success, the efficacy of BallotTrax for voters in North Carolina, and the efficiency of North Carolina’s vote-by-mail system compared to other states.

A goal of this symposium for many teams was to ask audience members for suggestions on ways to direct their research further. The beauty of seeing research midway through the process is that it opens the door for collaborative thinking, out-of-the-box ideas, and being open about obstacles and mistakes.

This virtual Symposium is a testament not just to Duke’s collaborative research spirit, which is alive and well despite the pandemic, but to the adaptability of Duke student researchers and faculty. There’s no doubt that these eight Bass Connections Teams, among the many other teams part of the program this year, have been generating relevant and impactful knowledge and will continue to do so.

Post by Meghna Datta

Increasing Access to Care with the Help of Big Data

Artificial intelligence (AI) and data science have the potential to revolutionize global health. But what exactly is AI and what hurdles stand in the way of more widespread integration of big data in global health? Duke’s Global Health Institute (DGHI) hosted a Think Global webinar Wednesday, February 17th to dive into these questions and more.  

The webinar’s panelists were Andy Tatem (Ph.D), Joao Vissoci (Ph.D.), and Eric Laber (Ph.D.), moderated by DGHI’s Director of Research Design and Analysis Core, Liz Turner (Ph.D.).  Tatem is a professor of spatial demography and epidemiology at the University of South Hampton and director of WorldPop. Vissoci is an assistant professor of surgery and global health at Duke University. Laber is a professor of statistical science and bioinformatics at Duke.

Panelist moderator, Lisa Turner

Tatem, Vissoci, and Laber all use data science to address issues in the global health realm. Tatem’s work largely utilizes geospatial data sets to help inform global health decisions like vaccine distribution within a certain geographic area. Vissoci, who works with the GEMINI Lab at Duke (Global Emergency Medicine Innovation and Implementation Research), tries to leverage secondary data from health systems in order to understand issues of access to and distribution of care, as well as care delivery. Laber is interested in improving decision-making processes in healthcare spaces, attempting to help health professionals synthesize very complex data via AI.

All of their work is vital to modern biomedicine and healthcare, but, Turner said, “AI means a lot of different things to a lot of different people.” Laber defined AI in healthcare simply as using data to make healthcare better. “From a data science perspective,” Vissoci said, “[it is] synthesizing data … an automated way to give us back information.” This returned info is digestible trends and understandings derived from very big, very complex data sets. Tatem stated that AI has already “revolutionized what we can do” and said it is “powerful if it is directed in the right way.”

A screenshot from worldpop.org

We often get sucked into a science-fiction version of AI, Laber said, but in actuality it is not some dystopian future but a set of tools that maximizes what can be derived from data.

However, as Tatem stated, “[AI] is not a magic, press a button” scenario where you get automatic results. A huge part of work for researchers like Tatem, Vissoci, and Laber is the “harmonization” of working with data producers, understanding data quality, integrating data sets, cleaning data, and other “back-end” processes.

This comes with many caveats.

“Bias is a huge problem,” said Laber. Vissoci reinforced this, stating that the models built from AI and data science are going to represent what data sources they are able to access – bias included. “We need better work in getting better data,” Vissoci said.

Further, there must be more up-front listening to and communication with “end-users from the very start” of projects, Tatem outlined. By taking a step back and listening, tools created through AI and data science may be better met with actual uptake and less skepticism or distrust. Vissoci said that “direct engagement with the people on the ground” transforms data into meaningful information.

Better structures for meandering privacy issues must also be developed. “A major overhaul is still needed,” said Laber. This includes things like better consent processes for patients’ to understand how their data is being used, although Tatem said this becomes “very complex” when integrating data.

Nonetheless the future looks promising and each panelist feels confident that the benefits will outweigh the difficulties that are yet to come in introducing big data to global health. One cool example Vissoci gave of an ongoing project deals with the influence of environmental change through deforestation in the Brazilian Amazon on the impacts of Indigenous populations. Through work with “heavy multidimensional data,” Vissoci and his team also have been able to optimize scarcely distributed Covid vaccine resource “to use in areas where they can have the most impact.”

Laber envisions a world with reduced or even no clinical trials if “randomization and experimentation” are integrated directly into healthcare systems. Tatem noted how he has seen extreme growth in the field in just the last 10 to 15 years, which seems only to be accelerating.

A lot of this work has to do with making better decisions about allocating resources, as Turner stated in the beginning of the panel. In an age of reassessment about equity and access, AI and data science could serve to bring both to the field of global health.

Post by Cydney Livingston

Invisible No More, the Cervix

How many people have seen their cervix? Obscured from view and stigmatized socially, the cervix is critical to women’s, transgender-men’s, and non-binary folks’ health — and potential reproductive health issues. A team formed through Duke’s Center for Global Women’s Health Technologies (GWHT) has created a device that not only holds immense medical potential but the potential to empower people with cervixes across the globe: It makes visible a previously invisible organ. 

Nimmi Ramanujam (Ph.D.), founder of GWHT and Professor of Engineering at Duke University, heads the team. Mercy Asiedu (Ph.D.), Gita Suneja (M.D.) Wesley Hogan (Ph.D.), and Andrea Kim have all been integral members of the interdisciplinary collaboration. Dr. Suneja is Associate Professor of Radiation Oncology at the University of Utah School of Medicine and a clinical researcher. Asiedu, former PhD student with Dr. Ramanujam and current postdoc at MIT, was integral to the development of Callascope.

The Callascope allows women and others who have cervixes, along with health professionals, to perform cervical exams without use of traditional examination tools that are larger, cannot be used for self-examinations, and often scary-looking.

When Wesley Hogan, director of Duke’s Center for Documentary Studies and research professor, heard about the idea “she was hooked.” Andrea Kim graduated from Duke University in 2018. Her senior thesis was a 12 minute documentary focused on the Callascope and its potential uses. Following graduation, over the last two years, she expanded the film to a 50-minute piece titled  “The (In)visible Organ” that was screened January 14, 2021. Kim moderated a panel with Ramanujam, Asiedu, Suneja and Hogan January 28th, 2021. 

Callascope: A handheld device that can be used to conduct cervical screenings. All that’s needed is a smart phone.

The Callascope addresses a dire global health need for better women’s reproductive health. Further, it empowers women as self-advocates of their own gynecological and reproductive health through reinvention of gynecological examination. Cervical cells have an “orderly progression,” says Suneja, we have a “great idea” of how cells become cancerous over time, “with multiple places to intervene.” Cervical examinations, however, are necessary for assessing cervical health and potential disease progression.

Originally from Ghana, Dr. Asiedu was interested in using her engineering skills to develop technology to “improve health outcomes,” particularly in countries like her own, which may lack adequate access to preventative healthcare and could benefit most from Callascope. Many women in underserved countries, as well as underserved areas of the United States, suffer disproportionately from cervical cancer — a preventable disease. 

Dr. Ramanujam, who served as a voluntary test-subject for Asiedu’s Callascope prototypes, says that it’s a really important tool “in actually changing [the cervix’s] narrative in a positive way” — it is an organ “that is indeed invisible.”

The hope is that with more awareness about and use of Callascope, cervical screenings, and vaginal health, cervixes may become more de-stigmatized and cultural norms surrounding them may shift to become more positive and open. Dr. Hogan stated that when Ramanujam pitched her the Callascope idea they were in a public restaurant. Hearing Ramanujam say words like “vagina” and “cervix” loud enough for others to hear made Hogan recognize her own embarrassment surrounding the topic and underscored the importance of the project. 

The project and the team serve as a wonderful example of intersectional work that bridges the sciences and humanities in effective, inspiring ways. One example was the Spring 2019 art exhibit, developed in conjunction with the team’s work, presented at the Nasher Museum which exposed the cervix through various mediums of art.

Multidisciplinary Bass Connections research teams contributed to this work and other interdisciplinary projects focused on the Callascope. Dr. Asiedu believes documentaries like Kim’s are “really powerful ways to communicate global health issues.” Kim who directed and produced “The (In)visble Organ” hopes to continue exploring how “we can create more cultures of inclusion …when it comes to reproductive health.” 

A piece of artwork from the (In)visible Organ art exhibit at Duke’s Nasher Museum in the spring of 2019.

Ramanujam emphasized the need to shift biomedical engineering focus to create technologies that center on “the stakeholders for whom [they] really [matter].” It is multi-dimensional thinkers like Ramanujam, Asiedu, Hogan, and Kim who are providing integrative and inventive ways to address health disparities of the 21st century — both the obvious and the invisible. 

Post by Cydney Livingston

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