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Understanding and Addressing Vaccine Hesitancy

On November 18, 2019

In Field Research, Global Health, Lecture, Medicine

In the midst of increasing outbreaks of vaccine-preventable disease, Duke global health researcher Lavanya Vasudevan (PhD, MPH, LPH) is investigating the reasons for vaccine hesitancy with focus on America and Tanzania.

Vaccine hesitancy refers to the refusal of or delay in accepting vaccinations, despite their availability. Vasudevan hopes to figure out what interventions will change the minds of target populations on such a heated topic.

She presented at Duke’s Global Health Institute on November 15^th about her “big 5 research areas:” identification of sub-optimal vaccine uptake, contextualization of barriers to uptake, measuring parental concern, debunking misinformation, and developing and testing strategies aimed at addressing vaccine hesitancy.

Lavanya Vasudevan presenting at Duke’s Global Health Institute.

Globally, Vasudevan says that there are too many kids playing catch-up with their vaccines, meaning that even when children are getting vaccinated, the vaccinations they receive are not on time with the scheduled progression of immunizations, putting them at risk for contracting disease. Different countries measure vaccination coverage in different ways and on different timelines, which makes it harder to understand where sub-optimal vaccine uptake is happening. A better standard for assessing timeliness of vaccines is crucial. Vasudevan is working to confront this issue to gain better understanding of who and where hesitancy is coming from.

Identification of specific regions of vaccine hesitancy is crucial to navigating interventions, she added. Vasudevan wants to be able to pinpoint areas and understand the context-specific issues that vary across time, place, and vaccine type in order to be most effective.

She said that her work in Tanzania has provided insight to the problem of geographic accessibility and lack of proper supplies in the country, prompting delayed and missed vaccinations among 72% of children, according to self-reporting by their mothers. Tanzanian mothers expressed their frustrations during interviews. They frequently arrange to go to a clinic where vaccinations are offered on specific dates and travel long distances to get there. However, if there are not enough kids who come to be vaccinated, the facilities just won’t vaccinate those who did manage to show up for immunizations.

Though the qualitative data gained through extensive interviewing and group discussions has been extremely useful and rich, Vasudevan says there is a need for quantitative tools that can rapidly screen for parent’s concerns when it comes to the vaccination of their children. Qualitative data is simply not informative on a large scale.

A review of pre-existing measures evaluated 159 studies, but the quantitative scales found were often complex and context-specific, as well as designed and validated for high-income settings. On this basis, Vasudevan and her larger research team decided to design a scale for use in Tanzania because of its specificity in addressing the contexts of the region. Tailored counseling is also being used to address the local concerns and issues.

Another parallel research project that Vasudevan is involved with aims to identify common vaccine myths, creating a taxonomy to tag these myths and developing and testing an intervention that will highlight and debunk misinformation found on the internet. The current end-goal for the work being done is a “vaccine fact-checker” that could be used on web browsers to identify the myths in vaccine-related information found online.

A common example of needles and vials containing immunization products (Creative Commons).

In closing, Vasudevan identified three main areas for developing and testing intervention strategies. She says these are behavioral nudges, educational strategies, and vaccination policy and legislation.

There is a need for parent-focused strategies that recognize parental concern for their child’s safety on all sides of the vaccination issue, she said. Stringent policies are likely to alienate hesitant parents rather than increasing vaccine uptake. This is why Vasudevan is so focused on understanding and contextualizing issues specific to hesitancy among parents. It seems that increase of vaccinations and improvement of immunization timeliness lies in hearing and reconciling with parental apprehensions and underlying root causes of these hesitations.

One area of focus that Vasudevan feels is underutilized is pre-natal care. Reduction of the divide between obstetrician/gynecologists (OBGYNs) and pediatric care may be a crucial component to educate parents and enrich their understanding about vaccinations following the birth of the child.

Beyond everything else, she said, building trust is essential; simply providing information to parents is not enough. It takes time and empathy to be enable parents to make healthy vaccination choices. Providing credible resources in a safe environment while tuning in to the causes of hesitancy may be the next step to the reduction of vaccine-preventable disease, a current top ten threat to global health.

Post by Cydney Livingston

Malaria Hides In People Without Symptoms

By Anna Gotskind

On November 11, 2019

In Biology, Field Research, Genetics/Genomics, Global Health, Science Communication & Education, Students

It seems like the never-ending battle against Malaria just keeps getting tougher. In regions where Malaria is hyper-prevalent, anti-mosquito measures can only work so well due to the reservoir that has built up of infected humans who do not even know they carry the infection.

In high-transmission areas, asymptomatic malaria is more prevalent than symptomatic malaria. Twenty-four percent of the people in sub-Saharan Africa are estimated to harbor an asymptomatic infection, including 38 to 50 percent of the school-aged children in western Kenya. Out of the 219 million malaria cases in 2017 worldwide, over 90% were in sub-Saharan Africa.

Using a special vacuum-like tool, Kelsey Sumner, a former Duke undergraduate now completing her Ph.D. at UNC-Chapel Hill, collected mosquitoes in households located in rural western Kenya. These weekly mosquito collections were a part of her pre-dissertation study on asymptomatic, or invisible, malaria. She visited Duke in September to catch us up on her work in Data Dialogue event sponsored by the mathematics department.

Sumner and colleague Verona Liao, in front of a sticky trap for mosquitoes

People with asymptomatic malaria carry the infection but have no idea they do because they do not have any indicators. This is incredibly dangerous because without symptoms, they will not get treated and can then infect countless others with the disease. As a result, people with an asymptomatic infection or infections have become a reservoir for malaria — a place for it to hide. Reservoirs are a group that is contributing to transmission at a higher rate or proportion than others.

Sumner’s study focused on examining the effect of asymptomatic malaria on malaria transmission as well as whether asymptomatic malaria infections would protect a person against future symptomatic infections from the same or different malaria infections. They were particularly looking into Plasmodium falciparum malaria. In Kenya, more than 70% of the population lives in an area with a high transmission of this potentially lethal parasite.

“P. falciparum malaria is very diverse in the region,” she said. “It’s constantly mutating, which is why it’s so hard to treat. But because of that, we’re able to actually measure how many infections people have at once.”

The researchers discovered that many study participants were infected with multiple, genetically-distinct malaria infections. Some carried up to fourteen strains of the parasite.

Participants in the study began by filling out an enrollment questionnaire followed by monthly questionnaires and dried blood spot collections. The project has collected over nearly 3,000 dried blood spots from participants. These blood spots were then sent to a lab where DNA was extracted and tested for P. falciparum malaria using qPCR.

“We used the fact that we have this really diverse falciparum species in the area and sequenced the DNA from falciparum to actually determine how many infections people have,” Sumner said. “And then, if there’s a shared infection between humans and mosquitoes.”

Sumner and her team also visited symptomatic participants who would fill out a behavioral questionnaire and undergo a rapid diagnostic test. Infected participants were able to receive treatment.

While people in the region have tried to prevent infection through means like sleeping under insecticide-treated nets, malaria has persisted.

One of the Kenyan staff members hanging a CDC light trap for mosquitoes

Sumner is continuing to analyze the collected DNA to better understand asymptomatic malaria, malarial reservoirs and how to best intervene to help stop this epidemic.

“We’re basically looking at how the number of shared infections differ between those that have asymptomatic malaria versus those that have symptomatic malaria.”

She and her team hypothesize that there are more asymptomatic infections that would result in and explain the rapid transmission of malaria in the region.

Post by Anna Gotskind

Vaping: Crisis or Lost Opportunity?

By Zella Hanson

On October 11, 2019

In Behavior/Psychology, Global Health, Medicine, Policy, Science Communication & Education

Whether you’re doing vape tricks for YouTube views or kicking yourself for not realizing that “USB” was actually your teenager’s Juul, you know vaping is all the rage right now. You probably also know that President Trump has called on the FDA to ban all flavored e-cigarettes to combat youth vaping. This comes in reaction to the mysterious lung illness that has affected 1,080 people to date. 18 of them have died.

At Duke Law School’s “Vaping: Crisis or Lost Opportunity” panel last Wednesday, three experts shared their views.

Jed Rose, a professor of psychiatry and behavioral sciences and director of the Duke Center for Smoking Cessation, has worked in tobacco research since 1979, focusing on smoking cessation and helping pioneer the nicotine patch. Rose also directs Duke’s Center for Smoking Cessation.

According to Rose, e-cigarettes are more effective than traditional Nicotine Replacement Therapy (NRT). A recent study found that e-cigarettes were approximately twice as effective as the state-of-the-art NRT in getting smokers to quit combustible cigarettes (CCs). This makes sense because smokers are addicted to the action of puffing, so a smoking cessation tool that involves inhaling will be more successful than one that does not, like the patch.

Rose also took issue with the labeling of the current situation surrounding vaping as an “epidemic.” He called it a “crisis of exaggeration,” then contrasted the 18 deaths from vaping to the 450 annual deaths from Tylenol poisoning.

Even in the “pessimistic scenario,” where e-cigarettes turn out to be far more harmful than expected, Rose said deaths are still averted by replacing cigarettes with e-cigarettes.

The enemy, Rose argued, is “disease and death, not corporations”, like the infamous (and under-fire) Juul.

James Davis, MD, an internal medicine physician and medical director for the Center for Smoking Cessation, works directly with patients who suffer from addiction. His research focuses on developing new drug treatments for smoking cessation. Davis also spearheads the Duke Smoke-Free Policy Initiative.

Davis began by calling for humility when using statistics regarding e-cigarette health impacts, as long-term data is obviously not yet available.

Davis did present some known drawbacks of e-cigarettes, though, stating that e-cigarettes are similarly addictive compared to conventional cigarettes, and that a whopping 21% of high school students and 5% of middle school students use e-cigarettes. Davis also contended that “When you quit CCs with e-cigarettes, you are merely transferring your addiction to e-cigarettes. Eighty-two percent [of test subjects who used e-cigarettes for smoking cessation] were still using after a year.”

However, according to Davis, there is a flipside.

Similar to Rose, Davis looked to the “potential for harm reduction” — e-cigarettes’ morbidity is projected to be only 5-10% that of CCs. If the main priority is to get smokers off CC, Davis argues e-cigarettes are important: 30-35% of CC smokers say they would use an e-cigarette to quit smoking, where only 13% would use a nicotine patch.

Furthermore, Davis questioned whether the mysterious lung disease is attributable to e-cigarettes themselves — a recent study found that 80% of a sample of afflicted subjects had used (often black-market) THC products as well.

Lauren Pacek, an assistant professor in psychiatry and behavioral sciences at Duke, examines smoking in the context of addiction and decision-making.

Pacek stated that flavored electronic nicotine delivery systems (ENDS) are important to youth: 61-95% of current youth ENDS users use flavored products, and 84% of young users say they would not use the products without flavors. So, banning flavored ENDS would ostensibly reduce young adults’ use, potentially keeping them off nicotine entirely.

However, Pacek pointed to the importance of flavors for adult users too: the ones that are purportedly using ENDS not for recreation or social status (as young people have been known to do), but for smoking cessation. Many former CC smokers report that flavored ENDS were important for their cessation. By banning flavored ENDS, the products look less appealing, and smokers are more likely to return to much more harmful cigarettes.

So where do we go from here?

Pacek did not take a concrete stance, but said her “take-home message” was that policymakers need to consider the impact of the ban on the non-target population, those earnest cigarette smokers looking to quit, or at least turn to a less harmful alternative.

Rose also did not offer a way forward, but made clear that he does not support the FDA’s impending ban on flavored e-cigarettes and thinks the hysteria around vaping is mostly unfounded.

Davis did not suggest a course of action for the US, but as leader of Duke’s Smoke-Free Policy Initiative, he certainly suggested a course of action for Duke. The Initiative prohibits combustible forms of tobacco at Duke, but does not (yet) prohibit e-cigarettes.

By Zella Hanson

Researchers Urge a Broader Look at Alzheimer’s Causes

By Karl Bates

On September 20, 2019

In Behavior/Psychology, Data, Global Health, Neuroscience

Just about every day, there’s a new headline about this or that factor possibly contributing to Alzheimer’s Disease. Is it genetics, lifestyle, diet, chemical exposures, something else?

The sophisticated answer is that it’s probably ALL of those things working together in a very complicated formula, says Alexander Kulminski, an associate research professor in the Social Science Research Institute. And it’s time to study it that way, he and his colleague, Caleb Finch at the Andrus Gerontology Center at the University of Southern California, argue in a recent paper that appears in the journal Alzheimer’s and Dementia, published by the Alzheimer’s Association.

Positron Emission Tomography scan of a brain affected by cognitive declines . (NIH)

“Life is not simple,” Kulminski says. “We need to combine different factors.”

“We propose the ‘AD Exposome’ to address major gaps in understanding environmental contributions to the genetic and non-genetic risk of AD and related dementias,” they write in their paper. “A systems approach is needed to understand the multiple brain-body interactions during neurodegenerative aging.”

The analysis would focus on three domains, Kulminski says: macro-level external factors like rural v. urban, pollutant exposures, socio-economcs; individual external factors like diet and infections; and internal factors like individual microbiomes, fat deposits, and hormones.

That’s a lot of data, often in disparate, broadly scattered studies. But Kulminski, who came to Duke as a physicist and mathematician, is confident modern statistics and computers could start to pull it together to make a more coherent picture. “Twenty years ago, we couldn’t share. Now the way forward is consortia,” Kulminski said.

The vision they outline in their paper would bring together longitudinal population data with genome-wide association studies, environment-wide association studies and anything else that would help the Alzheimer’s research community flesh out this picture. And then, ideally, the insights of such research would lead to ways to “prevent, rather than cure” the cognitive declines of the disease, Kulminsky says. Which just happens to be the NIH’s goal for 2025.

Global Health is Local Too

By Vanessa Moss

On August 7, 2019

In Global Health, Students

DGHI interns, left to right: Gabrielle Zegers (C’19), Ashley Wilson (C’20), and Rachel Baber (C’20).

When Duke senior Rachel Baber began her freshman year, she was under the impression that legitimate research had to involve a white lab coat and a microscope.

But this summer she worked to study human health without a pipette in sight, instead spending her time in a computer lab, which was empty besides her and two fellow interns. A few yards away from her shared workspace, blue metal double doors swing into a linoleum-floored cafeteria.

As she sits at a table near the entrance, dozens of men and women walk past in ones and twos, some with oil smeared on their jeans and others pushing carts with cleaning supplies, talking with one another and nodding to acknowledge Baber.

She’s been working all summer at the Triangle Residential Options for Substance Abusers, Inc., better known as TROSA, and everyone passing is a resident.

TROSA is acclaimed for their whole-person approach to substance-abuse recovery and trauma resiliency, with multi-year programming that provides treatment, educational opportunities, and vocational training for their clients. TROSA has been providing services for 25 years and, like most non-profit organizations, they have a running list of projects with limited number of staff hours to commit to them.

“It’s not that they’re back-burner issues,” explains Karen Kelley, the Chief Program Officer at TROSA. “It’s just that we don’t have enough front burners.”

This summer, Duke’s undergraduates stepped in to provide a little more stove space for TROSA’s needs.

Duke’s Global Health Institute (DGHI) requires all students to spend one summer in a research training program, which associate professor Sumi Ariely believes is a vital opportunity for students to “work deeply with a community partner and their vision, and to help disparities or inequities in their community.”

Program options range from looking at health impacts of gold mining in Ghana to screening for glaucoma in Honduras, but 2019 was DGHI’s first season offering TROSA as a research site, opening new avenues for students to give back to the Durham community.

“We have a responsibility to our neighbors,” Ariely says. “‘Global is Local’ holds two meanings. As a geographic term, it focuses on the Triangle or Durham area. It also holds philosophical value. We in high-resource areas don’t have all the answers, and entering global arenas flaunting our ‘solutions’ is just hubris,” she adds. “Working to solve pockets of deep inequalities in our state and our country allows for multi-directional learning. Local is Global acknowledges that we are all fundamentally the same and in it together.”

Duke University and TROSA have had a long history of collaboration. TROSA moving services are a common sight on Duke’s campus, and Duke Health also contracts with providers who work on-site at TROSA to give primary, behavioral health, and psychological care for clients.

Having three DGHI interns allowed TROSA to begin answering questions that they’d long been speculating about: How does cigarette smoking impact the community as a rehabilitation center? How could the program integrate sustainable practices like recycling and composting on an institutional scale? How accessible are the classes that TROSA offers residents and how do they affect resident growth and recovery?

Baber spent her time tackling the last question, first classifying the full curriculum of TROSA’s courses into three major categories: Therapeutic, vocational, and educational. Looking at past courses that residents had taken, she began the process of setting course standards for residents – what number of therapeutic courses are expected to be completed at nine months into the program compared to 15 months, for example.

This number-crunching project also provided an opportunity for the administration to reflect on course access. Baber was able to find some patterns in curriculum, like how most residents register for more classes as they advance through the program, and how female residents often register for more therapeutic courses than men.

“I’d love to qualitatively look at residents’ impressions of the classes,” Baber explains. “Some people really enjoy a certain category of courses, while others benefit more from working on a job and dealing with problems as they come up.” Baber envisions that question, along with identifying which classes have the highest graduation rate and asking why that is, as possible projects for future interns.

Rebecca Graves, TROSA’s Director of Clinical Operations, sees data and demographic review like this as a critical means of assessment and improvement. “As a nonprofit, we use a quarterly review to pay close attention to demographic changes. If 80% of applicants were female and only 20% of our population was women, we’d need to review — What’s keeping people out of the door? Are we inhibitive in some way?”

After working with often-incomplete data, Baber and fellow interns Ashley Wilson (C’20) and Gabrielle Zegers (C’19) were able to realize what information is missing, refine what TROSA should keep collecting, and find what they could from the data they did have.

“Check them off as huge successes,” Graves reiterates. “They’re making marked achievements, finding new data, extrapolating new information, and creating new policies here. They all took ownership as self-motivated researchers, and my dream is that they’d all stay.”

Beyond working on their assigned projects, the three students were eager to invest themselves in the TROSA community, attending a dance with new women in the program, volunteering at the TROSA thrift store on weekends, volunteering at the medical center, and helping with GED tutoring each Tuesday evening.

“Getting to learn from residents about their recovery and what they’re doing to help themselves has been the best part of this job,” Baber says. In global health, students often face large and looming statistics surrounding the opioid epidemic. “It’s easy to dehumanize that problem. It’s easy in global health to think ‘Oh, these numbers are so huge. I’ll never make a difference.’ But talking to individuals personalizes the matter, it makes you realize that positive change can happen.”

For more information about TROSA, visit: www.trosainc.org

By Vanessa Moss

Don’t Drink the Tap

By Will Sheehan

On April 25, 2019

In Cancer, Chemistry, Climate/Global Change, Environment/Sustainability, Global Health

Have you ever questioned the quality of the water you drink every day? Or worried that cooking with tap water might be dangerous? For most of us, the answer to these questions is probably no. However, students from a Bass Connections team at Duke say we may want to think otherwise.

From bottle refilling stations to the tap, drinking water is so habitual and commonplace that we often take it for granted. Only in moments of crisis do we start worrying about what’s in the water we drink daily. The reality is that safe drinking water isn’t accessible for a lot of people.

Image result for pink hog farm water — Pig waste discoloring lagoon water

Images like this hog farm motivated the Bass Connections project team DECIPHER to take a closer look at the quality of water in North Carolina. On April 16 they presented their concerning findings from three case studies looking at lead contamination, coal ash impoundments, and aging infrastructure at the Motorco Music Hall.

Motorco in Durham. The talk was inside, though.

Nadratun Chowdhury, a Ph.D. student in Civil and Environmental Engineering, investigated lead contamination in water. Lead is an abundant and corrosion-resistant material, making it appealing for use in things like paint, batteries, faucets and pipes. While we’ve successfully removed lead from paint and gasoline, a lot of old water pipes in use today are still fashioned from lead. That’s not good – lead is very toxic and can leach into the water.

Just how toxic is it? Anything over a blood-lead level concentration of fifty parts per billion – fifty drops of water in a giant Olympic swimming pool – is considered dangerous. According to Duke graduate student Aaron Reuben, this much lead in one’s blood is correlated with downward social mobility, serious health concerns, diminished capacity to regulate thoughts and emotions, and hyperactivity. Lower income and minority areas are more at risk due to the higher likelihood of owning contaminated older homes.

Rupanjali Karthik, a Master of Laws student, conducted research on the intersection of water and aging infrastructure in Orange County. Breaks in water pipes are common and can result in serious consequences, like the loss of 9 million gallons of drinkable water. Sometimes it takes 8 or 9 months just to find the location of a broken pipe. In 2018, the UNC-Chapel Hill water main break caused a huge shortage on campus and at the medical center.

Excess fluoridation is also an issue caused by aging infrastructure. In February 2017, a combination of human and machine error caused an excessive fluoride concentration coming out of an Orange County Water Treatment Plant. People were advised not to use their water even to shower. A UNC basketball game had to move locations, and stores were completely swept of bottled water.

Another issue is that arsenic, a known carcinogen, is often used as the fluoridation agent. We definitely don’t want that in our drinking water. Fluoridation isn’t even that necessary these days when we have toothpaste and mouthwash that supports our dental health.

Tommy Lin, an undergraduate studying Chemistry and Computer Science, topped off the group’s presentation with findings surrounding coal ash in Belmont, NC. Coal ash, the residue after coal is burned in power plants, can pollute rivers and seep into ground water, affecting domestic wells of neighboring communities. This creates a cocktail of highly concentrated heavy metals and carcinogens. Drinking it can cause damage to your nervous system, cancer, and birth defects, among other things. Not so great.

Forty-five plastic water bottles. That’s how much water it takes Laura, a Belmont resident, to cook her middle-sized family Thanksgiving. She knows that number because it’s been her family’s tradition the past three years. The Allen Plant Steam Station is a big culprit of polluting water with coal ash. Tons of homes nearby the station, like Laura’s, are told not to use the tap water. You can find these homes excessively stockpiled with cases on cases of plastic water bottles.

These issues aren’t that apparent to people unless they have been directly impacted. Lead, aging infrastructure, and coal ash all pose real threats but are also very invisible problems. Kathleen Burns, a Ph.D. student in English, notes that only in moments of crisis will people start to care, but by then it may be too late.

So, what can people do? Not much, according to the Bass Connections team. They noted that providing clean water is very much a structural issue which will require some complex steps to be solved. So, for now, you may want to go buy a Brita.

How the Flu Vaccine Fails

By Sarah Haurin

On April 22, 2019

In Biology, Global Health, Immunology, Lecture, Medicine

Influenza is ubiquitous. Every fall, we line up to get our flu shots with the hope that we will be protected from the virus that infects 10 to 20 percent of people worldwide each year. But some years, the vaccine is less effective than others.

Every year, CDC scientists engineer a new flu virus. By examining phylogenetic relationships, which are based on shared common ancestry and relatedness, researchers identify virus strains to target with a vaccine for the following flu season.

Sometimes, they do a good job predicting which strains will flourish in the upcoming flu season; other times, they pick wrong.

Pekosz’s work has identified why certain flu seasons saw less effective vaccines.

Andrew Pekosz, PhD, is a researcher at Johns Hopkins who examines why we fail to predict strains to target with vaccines. In particular, he examines years when the vaccine was ineffective and the viruses that were most prevalent to identify properties of these strains.

A virus consists of RNA enclosed in a membrane. Vaccines function by targeting membrane proteins that facilitate movement of the viral genome into host cells that it is infecting. For the flu virus, this protein is hemagglutinin (HA). An additional membrane protein called neuraminidase (NA) allows the virus to release itself from a cell it has infected and prevents it from returning to infected cells.

The flu vaccine targets proteins on the membrane of the RNA virus. Image courtesy of scienceanimations.com.

Studying the viruses that flourished in the 2014-2015 and 2016-2017 flu seasons, Pekosz and his team have identified mutations to these surface proteins that allowed certain strains to evade the vaccine.

In the 2014-2015 season, a mutation in the HA receptor conferred an advantage to the virus, but only in the presence of the antibodies present in the vaccine. In the absence of these antibodies, this mutation was actually detrimental to the virus’s fitness. The strain was present in low numbers in the beginning of the flu season, but the selective pressure of the vaccine pushed it to become the dominant strain by the end.

The 2016-2017 flu season saw a similar pattern of mutation, but in the NA protein. The part of the virus membrane where the antibody binds, or the epitope, was covered in the mutated viral strain. Since the antibodies produced in response to the vaccine could not effectively identify the virus, the vaccine was ineffective for these mutated strains.

With the speed at which the flu virus evolves, and the fact that numerous strains can be active in any given flu season, engineering an effective vaccine is daunting. Pekosz’s findings on how these vaccines have previously failed will likely prove invaluable at combating such a persistent and common public health concern.

Post by undergraduate blogger Sarah Haurin

Meet the Researcher Who Changed How We Care for Rape Survivors

By Anne Littlewood

On February 26, 2019

In Behavior/Psychology, Field Research, Global Health, Medicine, Policy

One of the first things I was told during freshman orientation was that two out of every five young women at Duke experience some form of sexual assault during their four years as an undergraduate. Shortly after that, I was informed that as a Duke student, I was not allowed to protect myself with pepper spray, because it is banned by university policy.

At the 2019 Harriet Cook Carter Lecture, Ann Burgess, a professor of psychiatric mental health nursing at Boston College, reported that 25 to 30 percent of women and 10 percent of men will be sexually assaulted in their lifetimes, statistics that make our campus standard of 40 percent seem strikingly high in comparison. Burgess has devoted her life to the support of sexual assault survivors, and pioneered treatments for victims of such abuse. For the past fifty years, she has studied the traumatic effects of rape and violence on patients of all ages, and worked closely with the FBI Academy to research the underlying causes of such crimes. Her work at the FBI was so impactful, Netflix decided to write a TV series about her, a crime drama called “Mindhunter.” Talk about a powerful woman.

Ann Wolbert Burgess, DSNc, APRN, BC, FAAN (Photo from Duke University School of Nursing)

When she began her work with rape survivors in the 1970s, the world was a very different place. Public attitudes towards sexual assault were unsupportive and disapproving of victims. Rape thrived on prudery, silence, and misunderstanding. There were very few reported cases, low conviction rates of criminals, and plenty of victim blaming. “We just didn’t talk about these kinds of things,” Burgess recalled. “There was no public recognition.”

So have we advanced? Yes, absolutely. Throughout the years, Burgess says she has seen a crucial shift towards more support for survivors. She has helped the FBI develop better systems for criminal profiling, and testified countless times in court to ensure justice for survivors of all ages. Burgess has witnessed these court cases changing policies, and affecting the genesis of laws that will better protect citizens against rape and other violent crimes. She has studied lasting trauma in survivors, and used this research to implement new culturally and developmentally appropriate services for victims. She believes that, as a society, we are doing a much better job today to reduce stigma and support survivors, but that the work is not even close to finished.

Sexual assault is still an intensely pervasive issue in society. Rape can happen anywhere, to anyone, and Burgess thinks it all boils down to the cultural emphasis on aggression. “We’ve all become complacent to the violence in the world that we live in,” as panelist Lynden Harris put it. As a society, we perpetuate aggressive masculinity, often without even realizing it. And especially in communities like the military, where women and men alike are highly regulated and taught to avoid showing weakness at all costs, the stigma surrounding sexual assault is intense. Commander Alana Burden-Huber, director of public health services at the Cherry Point Naval Health Clinic, shared her perspective that it can be very difficult to come forward in such a world of conformity. She also mentioned that female jurors in sexual assault cases tend to be much harsher on female survivors than male jurors, and attributes this to the fact that female members of the military are constantly trying to be harder and more stoic, so as to parallel military men.

Mindy Oshrain and Ann Burgess listen intently to the contributions of other panelists

Panelist Mindy Oshrain, a consulting associate in the Duke Department of Psychiatry, quieted the crowd by sharing a moving quote from Maya Angelou: “There is no greater agony than bearing an untold story inside of you.” She reminded us that it is so important to listen to patients, and slow down enough to ask someone multiple times if they are doing okay. It is easy to forget this at a place like Duke, where we are all constantly moving 100 miles a minute, checking boxes as we rush from one activity to the next, but it can make all the difference to stop, and take the time to ask again- How are you really doing? What can I do to support you? Empathy has the power to change the world.

As a sophomore, I now live in a building full of young women on the edge of Central Campus, on a street that is only serviced by Duke transportation in one direction. Just a few months ago, I woke up to a Duke Alert message on my phone, which informed me that a violent rape crime had occurred in the night, just fifty yards from my apartment. While we may have come a long way since the 1970s, the unavoidable fact remains that as young women living in this world, we are not safe. Let’s change that.

HIV Can Be Treated, But Stigma Kills

By Anne Littlewood

On December 6, 2018

In Faculty, Global Health, Immunology, Medicine

Three decades ago, receiving an HIV diagnosis was comparable to being handed a death sentence. But today, this is no longer the case.

Advances in HIV research have led to treatments that can make the virus undetectable and untransmittable in less than six months, a fact that goes overlooked by many. Treatments today can make HIV entirely manageable for individuals.

However, thousands of Americans are still dying of HIV-related causes each year, regardless of the fact that HIV treatments are accessible and effective. So where is the disconnect coming from?

On the 30th anniversary of World AIDS Day, The Center for Sexual and Gender Diversity at Duke University hosted a series of events surrounding around this year’s international theme: “Know Your Status.”

One of these events was a panel discussion featuring three prominent HIV/AIDS treatment advocates on campus, Dr. Mehri McKellar, Dr. Carolyn McAllaster, and Dr. Kent Weinhold, who answered questions regarding local policy and current research at Duke.

From left to right: Kent Weinhold, Carolyn McAllaster, Mehri McKellar and moderator Jesse Mangold in Duke’s Center for Sexual and Gender Diversity

The reason HIV continues to spread and kill, Dr. McKellar explained, is less about accessibility, and more about stigma. Research has shown that stigma shame leads to poor health outcomes in HIV patients, and unfortunately, stigma shame is a huge problem in communities across the US.

Especially in the South, she said, there is very little funding for initiatives to reduce stigma surrounding HIV/AIDS, and people are suffering as a result.

In 2016, the CDC reported that the South was responsible for 52 percent of all new HIV diagnoses and 47 percent of all HIV-related deaths in the US.

If people living with HIV don’t feel supported by their community and comfortable in their environment, it makes it very difficult for them to obtain proper treatment. Dr. McKellar’s patients have told her that they don’t feel comfortable getting their medications locally because they know the local pharmacist, and they’re ashamed to be picking up HIV medications from a familiar face.

HIV/AIDS Diagnoses and Deaths in the US 1981-2007 (photo from the CDC)

In North Carolina, the law previously required HIV-positive individuals to disclose their status and use a condom with sexual partners, even if they had received treatment and could no longer transmit the virus. Violating this law resulted in prosecution and a prison sentence for many individuals, which only enforced the negative stigma surrounding HIV. Earlier this year, Dr. McAllaster helped efforts to create and pass a new version of the law, which will make life a lot easier for people living with HIV in North Carolina.

So what is Duke doing to help the cause? Well, In 2005, Duke opened the Center for AIDS Research (also known as CFAR), which is now directed by Dr. Kent Weinhold. In the last decade, they have focused their efforts mainly on improving the efficacy of the HIV vaccine. The search for a successful vaccine has been long and frustrating for CFAR and the Duke Human Vaccine Institute, but Dr. Weinhold is optimistic that they will be able to reach the realistic goal of 60 percent effectiveness in the future, although he shied away from predicting any sort of timeline for this outcome.

Pre-exposure prophylaxis or PrEP (photo from NIAID)

Duke also opened a PrEP Clinic in 2016 to provide preventative treatment for individuals who might be at risk of getting HIV. PrEP stands for pre-exposure prophylaxis, and it is a medication that is taken before exposure to HIV to prevent transmission of the virus. Put into widespread use, this treatment is another way to reduce negative HIV stigma.

The problem persists, however, that the people who most need PrEP aren’t getting it. The group that has the highest incidence of HIV is males who are young, black and gay. But the group most commonly receiving PrEP is older, white, gay men. Primary care doctors, especially in the South, often won’t prescribe PrEP either. Not because they can’t, but because they don’t support it, or don’t know enough about it.

And herein lies the problem, the panelists said: Discrimination and bias are often the results of inadequate education. The more educated people are about the truth of living with HIV, and the effectiveness of current treatments, the more empathetic they will be towards HIV-positive individuals.

There’s no reason for the toxic shame that exists nationwide, and attitudes need to change. It’s important for us to realize that in today’s world, HIV can be treated, but stigma kills.

Post by Anne Littlewood

Considerations about AIDS from Brazilian literature

By Victoria Priester

On October 24, 2018

In Biology, Global Health, Medicine, Science Communication & Education

To know what illness is, you have to be ill first.

This was one of the points that post-doctoral student and essayist Milena Mulatti Magri emphasized in her talk on Oct. 15. She was discussing Brazilian writer Caio Fernando Abreu’s writings about AIDS and its effect on groups who already faced societal prejudice before the breakout of AIDS in the 1980’s and 90’s, when patients were identified mainly as homosexual.

By studying research done by Professor Vladimir Safatle and physician and philosopher Georges Canguilhem, Magri has pieced together that health is seen as a form of normativity and disease as a deviation. Thus, ostracizing and excluding those who contract disease is seen as justifiable because they have deviated from what is seen as normal, even when the disease is not the fault of the patient.

Magri has also analyzed essays about the relationship between disease, metaphor and patient stigma, such as cancer patients who, in addition to combating the illness growing unwelcome inside their own bodies, also have to deal with social stigmas that come with disease, such as cancer as a representation for evil.

Brazilian author and columnist Caio Fernando Abreu. (Image from KD Frases.)

However, while Magri emphasized that social metaphors of different diseases should be deconstructed, she has also found that literature and personal writing can be a way to discuss and otherwise “incommunicable experience.”

During a time when it was seen as shameful to have AIDS, Caio Fernando Abreu began a biweekly publication of his health chronicles in the newspaper O Estado de São Paulo, which was one of the first instances of someone publicly discussing their experience with AIDS from the perspective of the ill person, as opposed to from the perspective of doctors or health experts.

Abreu’s columns confronted the difficulty of living with disease and living in proximity to death, and discuss the increased social prejudice as a result of the disease. Abreu also wrote a play called “O homem e amancha” (in English, “The Man and the Stain”), which is an intertextual reading of the famous Spanish novel Don Quijote de la Mancha. In her talk, Magri explained that “Mancha,” which in English means “stain,” can refer to both the home of Don Quijote before he sets off of on his adventures and the rare skin cancer that often accompanies AIDS called Kaposi Sarcoma, which forms lesions on the skin that resemble stains.

Abreu intended to use his own experiences to question the social prejudice against AIDS, and there Magri highlighted a marked change, even between his own writings at the beginning of his diagnosis compared to those at the end of his life, when he spoke openly and without metaphor about suffering that is amplified by social exclusion.

Magri believes that Abreu’s writings were pioneering acts of courage, and that from his writing we learn to empathize rather than to judge and stigmatize.

Post by Victoria Priester

Victoria Priester

Duke Research Blog

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

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Considerations about AIDS from Brazilian literature

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