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

Category: Global Health Page 1 of 11

LowCostomy: the Low-Cost Colostomy Bag for Africa

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It’s common for a Pratt engineering student like me to be surrounded by incredible individuals who work hard on their revolutionary projects. I am always in awe when I speak to my peers about their designs and processes.

So, I couldn’t help but talk to sophomore Joanna Peng about her project: LowCostomy.

Rising from the EGR101 class during her freshman year, the project is about building  a low-cost colostomy bag — a device that collects excrement outside the patient after they’ve had their colon removed in surgery. Her device is intended for use in under-resourced Sub-Saharan Africa.

“The rates in colorectal cancer are rising in Africa, making this a global health issue,” Peng says. “This is a project to promote health care equality.”

The solution? Multiple plastic bags with recycled cloth and water bottles attached, and a beeswax buffer.

“We had to meet two criteria: it had to be low cost; our max being five cents. And the second criteria was that it had to be environmentally friendly. We decided to make this bag out of recycled materials,” Peng says. 

Prototype of the LowCostomy bag

For now, the team’s device has succeeded in all of their testing phases. From using their professor’s dog feces for odor testing, to running around Duke with the device wrapped around them for stability testing, the team now look forward to improving their device and testing procedures.

“We are now looking into clinical testing with the beeswax buffer to see whether or not it truly is comfortable and doesn’t cause other health problems,” Peng explains.

Poster with details of the team’s testing and procedures

Peng’s group have worked long hours on their design, which didn’t go unnoticed by the National Institutes of Health (NIH). Out of the five prizes they give to university students to continue their research, the NIH awarded Peng and her peers a $15,000 prize for cancer device building. She is planning to use the money on clinical testing to take a step closer to their goal of bringing their device to Africa.

Peng shows an example of the beeswax port buffer (above). The design team of Amy Guan, Alanna Manfredini, Joanna Peng, and Darienne Rogers (L-R).

“All of us are still fiercely passionate about this project, so I’m excited,” Peng says. “There have been very few teams that have gotten this far, so we are in this no-man’s land where we are on our own.”

She and her team continue with their research in their EGR102 class, working diligently so that their ideas can become a reality and help those in need.

Post by Camila Cordero, Class of 2025

The Most Important 26 Hours of My First Term at Duke

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As any first-year will tell you, the scramble for joining new clubs can be a daunting one. As the dust settled from the Involvement Fair, I looked at the fistful of flyers overflowing from my desk. One of these flyers stood out to me in particular: Student Collaborative on Health Policy (SCOHP). The program, backed by the Duke Margolis Center for Health Policy, seeks to educate, serve, and research within the Duke and Durham community regarding the social, economic, and political determinants of health care.

The Four Committees of SCOHP

Intrigued, I ventured to the Social Sciences building the following Sunday afternoon for their inaugural GBM. The event was lively, filled with a dizzying number of avenues for involvement. One such avenue that was the SCOHP-organized Health Policy Case Competition, advertised as a two-day team sprint to develop and pitch solutions to a pressing health care problem. The prizes were handsome: $1,000 for 1st place, $500 for 2nd place, and $250 for 3rd place, courtesy of the Margolis Center and RTI International. Furthermore, participants would be given access to mentors and industry leaders with vast experience in the area of public health.

Six teams, each consisting of three to five members, participated in the case-writing festivities. On Friday, September 10 at 5:00 PM, the case document was released. Our task: to develop a five-year plan aimed at increasing the screening for human papillomavirus (HPV) in either Malawi, South Africa, or Eswatini via a novel imaging technology known as microbeads. A considerably complex task given the vast number of social, institutional, and political barriers lying between the new technology and the women who needed it the most, not to mention the potential for HPV developing into cervical cancer if left undetected and untreated.

The Case Competition Title Document

Our team, Team J, assumed the role of a local NGO partnering with the Eswatini government. The preliminary hours of the competition were spent sifting through a sea of research. We read reviews of tissue imaging technology, feasibility studies on drug distribution networks, and mathematical projections of healthcare costs. At once invigorating and ceaselessly frustrating, the process of developing a comprehensive solution required significant mental and physical rearrangement. The nine hours following the release of the case were spent in a variety of popular campus study spots, from Bostock to Rubenstein Library, The Coffeehouse to dorm common rooms. In the early morning hours, our plan had finally begun to take shape.

A meager five hours of rest separated Day One of the competition from Day Two. After a night of brainstorming and research, we were left with three hours to finalize our five-minute proposals before a hard 12:00 PM deadline. As the deadline approached, we changed into our best attire from the clavicle up (the marvels of Zoom) and sat down. For the next hour and change, ideas flowed thickly and quickly; eager and persuasive tones emanating from our screens, tense silence as the judges moved into breakout rooms for deliberation.

The top three teams, Team J included, were selected for a final presentation round. The guidelines for this round: strengthen the argument, lengthen the presentation. We were in the final stretch. What followed was two hours of remarkably focused work, the likes of which I had never experienced in a team setting. As we sat down for the deciding presentation of the competition, I felt an immense sense of pride, not only in our solution, but also in our twenty-six hour transformations from perplexed receivers to confident presenters. This confidence and breadth of knowledge was visible in all three teams over the course of their fifteen-minute presentations and subsequent five-minute Q&A’s.

Team J’s Final Round Presentation Over Zoom

As the clock struck 7:00 PM on Saturday, September 11, the judges had submitted their verdict, at which point the teams turned towards the screen with rapt attention. The SCOHP organizers began reading the final standings. In what was described as an extremely close decision for the judges, Team J ended up winning first place. Battling the equally powerful forces of disbelief and sleep deprivation, we let out a collective breath. It was all over.

At the time of the competition, I had yet to complete a month at Duke. I didn’t know it then, but those twenty-six hours would end up being some of the most impactful in my first semester. The competition offered an entirely different approach to learning, one that was grounded in interdisciplinary inquiry and effective collaboration. And to think–it all started with a flyer buried underneath many other flyers.

Post by Vibhav Nandagiri, Class of 2025

Nobel Laureate Dr. Jennifer Doudna and Groundbreaking Applications of CRISPR

In 2011, Dr. Jennifer Doudna began studying an enzyme called Cas9. Little did she know, in 2020 she would go on to win the Nobel Prize in Chemistry along with Emmanuelle Charpentier for discovering the powerful gene-editing tool, CRISPR-Cas9. Today, Doudna is a decorated researcher, the Li Ka Shing Chancellors Chair, a Professor in the Department of Chemistry and Molecular as well as Cell Biology at the University of California Berkeley, and the founder of the Innovative Genomics Institute.

Doudna was also this year’s speaker for the MEDx Distinguished Lecture in October where she delivered presented on “CRISPR: Rewriting DNA and the Future of Humanity.”

“CRISPR is a system that originated in bacteria as an adaptive immune system” Doudna explained.

Dr. Jennifer Doudna holding the Nobel Prize in Chemistry

When bacterial cells are infected by viruses those viruses inject their genetic material into the cell. This discovery, a couple decades ago, was the first indication that there may be ways to apply bacteria’s ability to acquire genetic information from viruses.

CRISPR itself was discovered in 1987 and stands for “Clustered Regularly Interspaced Short Palindromic Repeats.” Doudna was initially studying RNA when she discovered Cas-9, a bacterial RNA-guided endonuclease and one of the enzymes produced by the CRISPR system. In 2012, Doudna and her colleagues found that Cas9 used base pairing to locate and splice target DNAs when combined with a guide RNA.

Essentially, they designed guide RNA to target specific cells. If those cells had a CRISPR system encoded in their genome, the cell is able to make an RNA copy of the CRISPR locus. Those RNA molecules are then processed into units that each include a sequence derived from a virus and then assemble with proteins. This RNA protein then looks for DNA sequences that match the sequence in the RNA guide. Once a match occurs, Cas9 is able to bind to and cut the DNA, leading to the destruction of the viral genome. The cutting of DNA then triggers DNA repair allowing gene editing to occur.

“This system has been harnessed as a technology for genome editing because of the ability of these proteins, these CRISPR Cas-p proteins, to be programmed by RNA molecules to cut any desired DNA sequence,” Doudna said.

Jennifer Doudna holding a Model of CRISPR-cas9

While continuing to conduct research, Doudna has also been focused on applying CRISPR in agriculture and medicine. For agriculture, researchers are looking to make changes to the genomes of plants in order to improve drought resistance and crop protection. 

CRISPR-cas9 is also being applied in many clinical settings. In fact, when the COVID-19 pandemic hit, Doudna along with several colleagues organized a five-lab consortium including the labs of Dan Fletcher, Patrick Hsu, Melanie Ott, and David Savage. The focus was on developing the Cas13 system to detect COVID-19. Cas13 is a class of proteins, that are RNA guided, RNA targeting, CRISPR enzymes. This research was initially done by one of Doudna’s former graduate students, Alexandra East-Seletsky. They discovered that if the reporter RNA is is paired with enzymes that have a quenched fluorophore pair on the ends, when the target is activated, the reporter is cleaved and a fluorescent signal is released. 

One study out of the Melanie Ott group demonstrated that Cas13 can be used to detect viral RNA. They are hoping to apply this as a point-of-care diagnostic by using a detector as well as a microfluidic chip which would allow for the conduction of these chemical reactions in much smaller volumes that can then be read out by a laser. Currently, the detection limit is similar to what one can get with a PCR reaction however it is significantly easier to run.

Graphical Abstract of Cas13 Research by the Melanie Ott lab

“And this is again, not fantasy, we’ve actually had just fabricated devices that will be sitting on a benchtop, and are able to use fabricated chips that will allow us to run the Cas13 chemistry with either nasal swab samples or saliva samples for detection of the virus,” Doudna added.

Another exciting development is the use of genome editing in somatic cells. This involves making changes in the cells of an individual as opposed to the germline. One example is sickle cell disease which is caused by a single base pair defect in a gene. Soon, clinicians will be able to target and correct this defect at the source of the mutation alleviating people from this devastating illness. Currently, there are multiple ongoing clinical trials including one at the Innovative Genomics Institute run by Doudna. In fact, one patient, Victoria Gray, has already been treated for her sickle cell disease using CRISPR.

Victoria Gray being treated for Sickle Cell Anemia
Meredith Rizzo/NPR

“The results of these trials are incredibly exciting and encouraging to all of us in the field, with the knowledge that this technology is being deployed to have a positive impact on patient’s lives,” Doudna said.

 Another important advancement was made last summer involving the use of CRISPR-based therapy to treat ATR, a rare genetic disease that primarily affects the liver. This is also the first time CRISPR molecules will be delivered in vivo.

In just 10 years CRISPR-cas9 has gone from an exciting discovery to being applied in several medical and agricultural settings. 

“This powerful technology enables scientists to change DNA with precision only dreamed of a few years ago,” said MEDx director Geoffrey Ginsburg, a Professor of Medicine at Duke. “Labs worldwide have redirected the course of research programs to incorporate this new tool, creating a CRISPR revolution with huge implications across biology and medicine.”

Examples of further CRISPR-Cas9 research can also be found in the Charles Gersbach lab here at Duke. 

By Anna Gotskind, Class of 2022

How is Universal Healthcare Like the Waterboarding Debate?

The Duke Medical Ethics Journal (DMEJ) is an undergraduate publication started in Spring of 2020 that examines conversations around universal patient-doctor responsibility. In other words, they’re training the next generation of healthcare providers to ask big questions and make informed decisions. So, we owe them a huge thank-you in advance. 

On Sunday, October 24th, DMEJ hosted Dr. Gopal Sreenivasan to speak with current members. The event was open to the public as part of the club’s mission to promote ethical practices across all fields. Dr. Sreenivasan is a moral philosopher, but he is also a professor of medicine at Duke Medical School. His position as the “Crown Professor of Ethics at the Trent Center for Bioethics, Humanities & History of Medicine,” is part of an initiative to connect societal arts and sciences aspects of Duke University to the Medical School. 

Dr. Gopal Sreenivasan

“Today, I want to talk to you all about the human right to health,” he opened. 

Sreenivasan’s talk was focused on the question of how individual countries can provide healthcare or insure health.  “One division within the human right to health is the division between health and healthcare,” he clarified. “Another is the difference between a regular right and a human right.” 

As a philosopher, Sreenivasan took the issue of access to health and placed it on a universal scale. He addressed the social determinants of health (callback time!) as part of the solution, alongside more direct-but-still-indirect healthcare actions like vaccinations. His conclusion? We are ultimately moving away from the narrative that we have a right to healthcare and towards the narrative that we have a human right to health

“You have a right to health, but that does not necessarily mean you are going to be healthy. There are still factors that affect this which are under no one’s control. It doesn’t mean that if you don’t live to be 80 or 85 that your right has been violated. But you’re still entitled to a broader range of things than just health.”

To help illustrate this for my fellow visual learners, I’ve made a fun little visual aid. 

Sreenivasan laid out a verbal map to demonstrate the confusion policy makers face about addressing the wellbeing of their constituents. If you believe healthcare is a right, you believe the government has a different role to play than if you believe health is a right. You may expect less of them in terms of handling indirect factors like social determinants and vaccines. If you believe healthcare is a human right, you expect all governments to provide healthcare access universally. This is different from Sreenivasan’s preferred view: health is a human right. All people are entitled to all aspects of their health being addressed all the time in every way in every place. 

The word human in “human right” indicates universality the same way removing the care from “healthcare” does; they both broaden the scope. 

After that lovely philosophical grammatical discussion (Do colorless green ideas sleep furiously?) as our foundation, Sreenivasan moved on to a challenging analogy: waterboarding

“It does not belong to the nature of a right that everyone has to have it. But it does seem to belong to the nature of a human right that everyone has to have it. Take the human right to not be tortured, for example.”

Your moral view may differ on whether or not it is a human right not to be tortured. You may think the right should apply to all people, or no people, or only some people. But you also may think that the right should apply to only certain aspects of torture; maybe you think that specifically waterboarding doesn’t count.

(The debate around whether or not waterboarding counts as torture and whether or not it is prohibited under human rights legislation is one that has been around for a long time. Torture has been banned by multiple American presidents in multiple environments, but the language around waterboarding in particular is highly controversial. You can read more about the debate here.)

“It’s not that some people have a human right not to be tortured which protects them from waterboarding, and other people have a human right not to be tortured but it is somehow lesser and does not protect them from waterboarding. You can’t pick and choose the content based on the person for whom the right belongs.”

So, how is the waterboarding debate like universal healthcare?

For one, it’s a matter of exclusion. It’s a matter of moral philosophy. It’s a matter of definition. 

The question of whether there should be universal healthcare goes far beyond the question of whether healthcare is a right. 

How do we improve access? Who is at fault for rising drug prices? How is America’s healthcare system different than other countries? These questions must start with questions of definition. Who is our target audience? Who is included? Who is excluded? What is included? What is excluded? 

“It seems intuitive that human rights are all or nothing.” Sreenivasan explained. “Either everyone has them or no one has them. But then you must say that their content also has to be the same.”

Post by Olivia Ares, Class 2025

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Integrating Pediatric Care in NC: Behavioral Health Perspectives

In healthcare, developing a new treatment is often half of the battle. The other half lies in delivering these treatments to those communities who need them the most. Coordinating care delivery is the goal of NC Integrated Care for Kids (InCK), an integrated pediatric service delivery and payment platform looking to serve 100,000 kids within five counties — Alamance, Orange, Durham, Granville, and Vance — in central North Carolina. The project is a collaborative effort between Duke, UNC, and the NC Department of Health and Human Services (DHHS) funded by a federal grant from the Centers for Medicare and Medicaid Services (CMS). The program’s executive director is Dr. Charlene Wong (MD, MSPH), a Duke researcher, physician, and professor who leads an interdisciplinary team of researchers and policy experts as they explore ways to reduce costs via integrating care for North Carolina youth enrolled in Medicaid and Children’s Health Insurance Program (CHIP).

The five counties that are part of NC InCK

I recently had the opportunity to speak with two of InCK’s service partners: Dr. Gary Maslow (MD, MPH) and Chris Lea (Duke ’18). Both work within the Behavioral Health group of InCK, which seeks to use behavioral health expertise through collaborative care and training providers to help support pediatric care. Maslow, a professor at the Duke Medical School, has focused heavily on child and developmental psychiatry throughout his career. Having entered medical school with a desire to work in pediatric hematology, Maslow recalls how a conversation with a mentor steered him in the direction of behavioral health. At the time, Maslow was part of the Rural Health Scholars program at Dartmouth College; while discussing his aspirations, one of his professors asked him to consider conditions outside of cancer, leading Maslow to consider chronic illness and eventually child psychiatry. “Kids have other problems,” Maslow’s professor told him.

Dr. Gary Maslow (MD, MPH)
Chris Lea (Duke ’18)

When looking at healthcare networks, especially those in rural areas in North Carolina, Maslow noticed a disaggregated service and payment network where primary care providers were not getting the necessary education to support the behavioral health needs of children. His work with Lea, a third-year medical student at Duke, has centered around looking at Medicaid data to understand provider distribution, medication prescription, and access to therapy based one’s area of residence. Lea’s path to NC InCK began as an undergraduate at Duke, where he obtained a B.S. in psychology in 2018. As he explains, mental health has been a vested interest of his for years, a passion reinforced by coursework, research at the Durham VA Medical Center, and NC InCK. He discussed the important of appropriate crisis response, specifically how to prepare families and providers in the event of pediatric behavioral health crises such as aggression or suicidality, as critical in improving behavioral health integration. These safety plans are critical both before a potential crisis and after an actual crisis occurs.

Two main goals of Maslow and Lea’s work are to increase the implementation of safety plans for at-risk youth and expand follow-up frequency in primary care settings. The focus on primary care physicians is especially critical considering the severe shortage of mental health professionals around North Carolina.

The behavioral health group is but one subset of the larger NC InCK framework. The team is led by Chelsea Swanson (MPH). Other collaborators include Dr. Richard Chung (MD), Dan Kimberg, and Ashley Saunders. NC InCK is currently in a two-year planning period, with the program’s launch date slated for 2022.

Services provided by NC InCK

What does the World Need from Future Policy Leaders?

The Sanford School of Public Policy’s David Rubenstein endowed lecture on Oct. 15 was like a conversation between two old friends.

In fact it was. Former World Bank president Jim Yong Kim and Duke alumnus and donor David Rubenstein got together on stage in celebration of the school’s 50th anniversary to catch up, and the audience was able to listen in. (Watch full video here)

Rubenstein had been a long-time mentor to Kim, offering him advice and aid along his journey.

The conversation began with Kim opening up about his childhood in Korea and the U.S.

“My dad was born in North Korea, and after he escaped he never saw his parents again.” His mom, also a refugee, was born in South Korea.

When Kim was just five years old, his parents made the decision to move from South Korea to the U.S. in hopes of a better future for him. He studied at the University of Iowa for a year before transferring to Brown University. After graduating from Brown and getting an MD from Harvard, Kim and a friend, Duke alumnus Paul Farmer MD, came up with the idea to start a nonprofit.

“I remember my close friend Paul said to me, ‘Now that we’ve had the opportunity to be involved in ridiculously elaborate educations, what’s our responsibility to the poor?’ and that’s how Partners in Health was created.”

The nonprofit aimed to grant accessible healthcare in Haiti, and then eventually to other countries around the world. After his time with Partners in Health, Kim became the President of Dartmouth University, and then became President of the World Bank.

“I had a coach in high school who told me, ‘You have to know when to leave.’ I’ve had many careers in my lifetime, and I’m grateful for that.”

Kim Yong Jim (pictured on the left) in conversation with David Rubenstein (pictured on the right).

Kim also talked about his views on the pandemic from a policy standpoint, questioning, “Why are we taking such a passive view on how to tackle this pandemic?” He explained how the U.S. was completely unprepared as a nation to tackle an epidemic like this, as only 2.5% of health spending had been allocated towards public health.

Rubenstein continued the conversation, asking Kim what his advice for future world policy leaders is. “You’ve made a fantastic choice coming to Duke, but try to come out with a skill. You have to learn new things,” he said.

He explained how Duke was the perfect environment to foster education and skill simultaneously, and how this kind of opportunity enhances your ability to give back to the world. “My medical degree from Harvard helped me with Partners in Health and gave me a skill I could fall back on and learn from.”

Kim argued that versatility is a good thing, not a bad thing, and that future policy leaders need to hone in on this strength to make the most out of their career.

Kim pictured with President Obama during his time as President of the World Bank.

Excitingly enough, I had the rare opportunity to ask these brilliant men a question towards the end of the lecture: “How do you release any self-doubt you have when going after such a big goal, like starting your own non-profit?” Kim responded by saying that “regardless of how my goal turned out, I knew I had to try.”

The message of this lecture was clear. Schools like Duke hold the world’s future leaders, and at a time like this, it is crucial that we as students develop ourselves in a well-rounded way.

Post by Skylar Hughes, Class of 2025

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

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

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.

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