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

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Category: Global Health Page 1 of 14

The HIV/AIDS Epidemic: Revisiting the Early Days of a Global Health Crisis

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On June 5, 1981, the Centers for Disease Control and Prevention reported the first cases of a mysterious disease afflicting young, otherwise healthy men in a tiny suburb of Los Angeles, California. The disease, now known as AIDS, would go on to infect 85.6 million people around the world, sparking an epidemic that persists to this day.

On February 6, 2024, Duke’s Global Health Institute hosted a conversation with Dr. James Curran and Dr. Kevin M. De Cock, both former leaders at the CDC, about their experiences on the frontlines of the AIDS crisis in the earliest days of this epidemic. The conversation was moderated by Dr. Chris Beyrer and Dr. Nwora Lance Okeke, two Duke researchers in infectious disease.

Pictured from left to right: Dr. James Curran and Dr. Kevin M. De Cock

The Origin of the Epidemic

The first cases of AIDS were reported by Dr. Michael Gottlieb, a young immunologist from UCLA. His groundbreaking findings, published in the CDC’s Morbidity and Mortality Weekly Report, described “previously healthy gay men from Los Angeles, San Francisco, and New York, who presented with rare opportunistic infections,” said De Cock. These infections, known as PCP (Pneumocystis carinii pneumonia) and KS (Kaposi’s sarcoma), were extremely rare. Upon observation, Gottlieb identified a startling commonality among the cases: they were all sexually active gay men.

Michael Gottlieb: The Rutgers Alumnus Who First Identified the Deadly  Disease We Now Call AIDS | New Brunswick, NJ Patch

These findings “didn’t fit into any organizational unit at the CDC,” so a multispecialty task force was formed. Led by Curran, it recruited experts in STIs, parasitology, virology, cancer, and more.

Tracking the Epidemic

At the start of the epidemic, cases were phoned into the CDC by individual doctors. But this quickly became inadequate. The epidemic was growing fast, and CDC phone lines could not keep up. “The CDC, therefore, developed a surveillance case definition for the syndrome,” De Cock explained. “Cases meeting this definition were reported through health departments to the CDC.”

“I think we were able with the case definition for surveillance, to take advantage of the fact that all of these conditions were very serious and so unusual that the physician would say ‘I’ve never seen anything like it,’…,” Curran said. “The other conditions were far less specific and far less useful for tracking the disease.”

In October 1981, these tracking protocols helped identify AIDS as a sexually transmitted disease. A national case-control study found that sexual activity was a leading risk factor, and a cluster of cases in 10 US cities linked via sexual contact was discovered. “People just didn’t want to believe it,” Curran said. “They wanted to believe that it wasn’t something transmissible.” 

Expanding Epidemic

Over the next year, the epidemic expanded to include injection drug users, heterosexual partners of bisexual men, people of Haitian descent, and infants. But perhaps most surprising was the transmission occurring through blood transfusion. In December 1982, a case of AIDS-like illness was reported in a 20-month-old infant after receiving blood from a donor who later developed the virus.

“Until that December report of the infant, the mainstream media had actually paid very little attention to AIDS. But that suddenly changed,” said De Cock. “While AIDS was seen as a problem of marginalized groups… it was easy to ignore. But anyone might need a blood transfusion.”

In the following years, rumors surrounding transmission and contact sparked nationwide panic. Fear of contracting the disease caused AIDS patients to lose their jobs and housing. Although the CDC provided up-to-date information on the nature of the virus, quelling public fear was extremely difficult. “AIDS proved that you can’t separate prevention and treatment,” Curran explained.

Modern AIDS Era

As we get close… to 100 million HIV infections since the epidemic began- have we done as well as we should have?”

Dr. Kevin M. De Cock

In 1991, researchers successfully identified HIV (Human immunodeficiency virus) as the underlying cause of AIDS. Since then, scientific understanding of the disease has greatly improved. “Our success has made AIDS more normal, which has robbed the disease of some of its mystique,” De Cock expressed. However, there is still no known cure for AIDS. The disease is a lifelong battle that wreaks havoc on the people it infects.

HIV / AIDS - Our World in Data
Source: Our World in Data

De Cock and Curran’s contributions to the AIDS epidemic fundamentally shaped our understanding of the virus. Their work shines a light on the importance of frontline research and support. Their book, entitled ‘Dispatches from the AIDS Pandemic: A Public Health Story,’ is available to read here.

Written by Skylar Hughes, Class of 2025

International Experience Shaped Epidemiologist’s Career Path

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Note: Each year, we partner with Dr. Amy Sheck’s students at the North Carolina School of Science and Math to profile some unsung heroes of the Duke research community. This is the sixth of eight posts.

In the complex world of scientific exploration, definitive answers often prove elusive, and each discovery brings with it a nuanced understanding that propels us forward. Dr. Dana Kristine Pasquale’s journey in public health serves as a testament to the intricate combination of exploration and redirection that have shaped her into the seasoned scientist she is today.

Pasquale said her scientific path has been  “…a nonlinear journey, that’s been a series of over-corrections. As I’ve gone from one thing to another, that hasn’t turned out to be what I expected.”

Dana Pasquale Ph.D.

Anchored in her formative years in a study abroad experience in Angola, Africa during undergraduate studies, Pasquale’s exposure to clinical challenges left an indelible mark. She keenly observed the cyclic nature of treating infections by shadowing a local physician. 

“We would treat the same people from month to month for the same kinds of infections,” she recalled. 

Things like economic and social barriers weren’t as stark there – everyone was at the same level, and there was no true impact that she could make investigating them. This realization sparked a profound understanding that perhaps a structural, community-focused intervention could holistically address healthcare needs – water, sanitation, etc. It set the course for her future research endeavors.

Upon returning to the U.S., she orchestrated a deliberate shift in her academic trajectory, choosing to immerse herself in medical anthropology at the University of North Carolina-Chapel Hill. Her mission was clear: to unravel how local communities conceptualize health. Engaging with mothers and child health interventionists, she delved into health behavior, yet found herself grappling with persistent frustrations. 

“I found [health behavior] frustrating because there were still a lot of structural issues that made things impossible,” she says. “And even when you think you’re removing some of the barriers, you’re not removing the most important ones.”

 Rather than being a roadblock, this frustration became a catalyst for Pasquale, propelling her toward the realms of epidemiology and sociology. Here, the exploration of macro and structural factors aligned seamlessly with her vision for sustainable public health, providing the missing pieces to the intricate puzzle she was trying to solve. She didn’t expect to end up here until her mentor suggested going back to school for it.

As principal investigator of Duke’s RDS2 COVID-19 Research and Data Services project during the early months of the pandemic, Pasquale navigated the challenges associated with transitioning contact-tracing efforts online. Despite hurdles in data collection due to the project’s reliance on human interaction and testing, the outcome was an innovative online platform, minimizing interaction and invasiveness. This accomplishment beautifully intertwines with her ongoing work on scalable strategies to enhance efficiency in public health activities during epidemics. 

“We had a lot of younger people say that they would prefer to enter their contacts online rather than talk to someone… something that could be a companion to public health, not subverting contact-tracing, which is an essential public health activity.”

Pasquale’s expansive portfolio extends to an HIV Network Analysis for contact tracing and intelligent testing allocation. Presently, she is immersed in a project addressing bacterial hospital infections among patients and hospital personnel, a testament to her unwavering commitment to tackling critical health challenges from various angles.

When queried about her approach to mentoring and teaching, Pasquale imparts a valuable piece of wisdom from her mentor: “If you’re not completely embarrassed by the first work you ever presented at a conference, then you haven’t come far enough.” 

Her belief in the transformative power of mistakes and the non-linear trajectory in science resonates in her guidance to students, encouraging them to not only accept but embrace the inherent twists and turns in their scientific journeys. As they navigate their scientific journeys, she advocates for the importance of learning and growing from each experience, fostering resilience and adaptability in the ever-evolving landscape of scientific exploration.

Guest Post by Ashika Kamjula, North Carolina School of Math and Science, Class of 2024

Scientific Passion and the Aspirations of a Young Scientist

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Note: Each year, we partner with Dr. Amy Sheck’s students at the North Carolina School of Science and Math to profile some unsung heroes of the Duke research community. This is the fifth of eight posts.

Meet Dr. Oyindamola Adefisayo – Oyinda to her friends – a Postdoctoral Research Fellow at Duke. She’s exploring bacterial factors in host-pathogen interactions using mice. 

During our interview, parallels in our journeys became clear. Even as a high school senior, I could strongly identify with Dr. Adefisayo’s work and share similar passions. I envisioned myself evolving into an inspiring scientist just like her and felt a strong connection with my aspirations as a high school senior.

Originally from Lagos, Nigeria, Dr. Adefisayo came to the U.S. via the African Leadership Academy in Johannesburg. Like me, she left home at 16 for a two-year residential program for teenagers. It was filled with passionate and driven students like I’m with at NCSSM. Oyinda earned her B.A. in Biology at Clark University, specializing in the genetic basis of wing and eye development in the fruitfly Drosophila melanogaster.

Her Ph.D. at Memorial Sloan Kettering in New York City focused on Immunology and Microbial Pathogenesis.  She studied mycobacteria, examining DNA damage response pathways, antibiotic resistance, and mutagenesis. The work connected with her knowledge of Nigeria’s high tuberculosis burden as she sought practical applications. She found that a delay in the machinery of DNA copying itself triggered a damage repair pathway called PafBC. 

Beyond the lab, Oyinda’s passion for ballroom dancing reflects her belief that science is an art, since there’s so much creativity and artistic sense that goes into being a scientist. This resonated with me too. I use painting as an outlet during my research on environmental stressors and antibiotics at NCSSM.

I was inspired by Dr. Adefisayo’s beliefs and passions. She continues her scientific career by delving deeper into protocol development, data analysis, and global knowledge-sharing. Her goal is to learn from bacterial and host genetics and contribute to  simplifying and expediting life science research for professionals worldwide.

Guest post by Emily Alam, North Carolina School of Math and Science, Class of 2024.

Solving More Medical Device Challenges by Teaching Others How

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Note: Each year, we partner with Dr. Amy Sheck’s students at the North Carolina School of Science and Math to profile some unsung heroes of the Duke research community. This is the third of eight posts.

Eric Richardson is a professor of the practice in Biomedical Engineering and founding director of Duke Design Health. His research and teaching centers around medical device design and innovation, with a focus on underserved communities. 

Eric Richardson, Ph.D.

Richardson has always had a strong desire to enhance people’s wellbeing. Growing up, he wanted to be a doctor, but during high school, he was drawn towards the creative and problem-solving aspects of engineering. After earning a bachelor’s degree in mechanical engineering, he pivoted to biomedical engineering for graduate work. While pursuing his PhD degree, he developed a profound interest in cardiac devices. 

Through technology, Richardson has been able to impact the lives of many. He first worked in industry as a Principal R&D Engineer at Medtronic, where he helped develop transcatheter heart valves that have now helped over a million patients. However, it was his love for teaching that brought him to academia. Over the past decade as a professor, his interests have shifted towards global health and helping underserved communities. 

Richardson aims to design technology to fit the needs of people, and bridge the gap of “translation” between research and product development. During his time in industry, Richardson realized that the vast majority of medical device research doesn’t go anywhere in terms of helping patients. 

“That point of translation… is really where most technology and research dies, so I really wanted to be at that end of it, trying to figure out that pipeline of getting research, getting technology, all the way into the clinic,” Richardson says. “I would argue that is probably the hardest step of the whole process is actually getting a product together, developing it, doing the clinical trials, and doing the manufacturing and regulatory steps.” 

A prototype of Richardson’s latest device.

Through his teaching, Richardson emphasizes product design, interdisciplinary approaches, and industry-academia partnerships to best meet the needs of underserved communities. One of his favorite courses to teach is the Design Health Series, a four-course sequence that he was brought to Duke to develop. In this class, interdisciplinary teams of graduate students, ranging from medicine to business, work together to design medical devices. They learn how to identify problems in medicine, develop a solution, and translate that into an actual product. 

Richardson also encourages engineers to look at the broader picture and tackle the right problems. According to Richardson, challenges in global and emerging markets often aren’t due to a particular device, but rather, a multilayered system of care, ranging from a patient’s experience within a clinic to a country’s whole healthcare system. From this vantage point, he believes it’s important for engineers to determine where to intervene in the system, where the need is greatest, and to consider any unintended consequences. 

“I think that there is so much great talent in the world, so many exciting problems to go after. I wish and hope that people will think a little more carefully and deliberately about what problems they go after, and the consequences of the problems that they solve,” he says. 

Richardson is currently working on an abdominal brace for Postural Tachycardia Syndrome (POTS) patients – people who feel lightheaded after standing up – that is currently in clinical trials. While he is always eager to tackle different projects, as an educator, he believes the most important part of academia is training the next generation of engineers. 

“I can only do a couple projects a year, but I can teach a hundred students every year that can then themselves go and do great things.”

Guest Post by Arianna Lee, North Carolina School of Science and Mathematics, Class of 2025.

How to be a Global Inventor

Gadgets, devices, doo-dads, oh my! The Duke Global Health Institute (DGHI)  recently hosted three of its members to lead a panel on creating medical devices for low- and middle-income countries. The event was called “Global Medical Device Innovation: Three Models for Creation and Commercialization.”

Each sought to decrease costs and increase scalability for medical procedures. In short, they are expert inventors who are doing good in the world. 

Two of the most prominent inventors of our era. Image courtesy of Disney.

We’ll go step-by-step in a moment, but to start you on your journey to being just like our panelists, here’s a short glossary:

Standard-of-care: a public health term for the way things are usually done.

IRB: institutional review board, a group of people, usually based in universities, that protect human subjects in research studies. 

Screening: when doctors look at signs your body might show to determine
whether you need to be tested for certain conditions. 

Supply-chain: the movement of materials your product goes through before, during, and after manufacturing. It is a general term for a group of different suppliers, factories, vendors, advertisers, researchers, and others that work separately. 

Regulatory pathways: supply-chain for government approvals and other paperwork you need to have before introducing your product to the public.

Step 1: Meet your Mentors

Walter Lee is Chief of Staff of the Department of Head and Neck Surgery & Communication Sciences, Co-Director of the Head and Neck Program, and an affiliate faculty member at the Duke Global Health Institute. He presented ENlyT (pronounced like en-light), a newfangled nasopharyngoscope – a camera that goes down your nose and down your throat to screen for cancer. He wants to expand with partners in Vietnam and Singapore. 

Marlee Kreiger helped found the Center for Global Women’s Health Technologies at Duke in 2007. Since then, she has led the Center in many interdisciplinary and international ventures. In fact, the Center for Global Women’s Health Technologies spans both the Pratt School of Engineering and the Trinity College of Arts and Sciences. She presented on the Callascope, a pocket-sized colposcope – a camera device for cervical cancer screening. 

Julias Mugaga will soon be a visiting scholar at Duke – until then, he heads Design Cube at Makerere University in Uganda. He presented his KeyScope, a plug-and-play surgical camera with 0.3% of the cost of standard-of-care cameras. 

Kreiger’s presentation slides

Step 2: Name your Audience

DGHI has “global” in the name, so it is no surprise that these presenters serve communities around the world. Perhaps something that inventors like Dr. Doofenshmirtz often get wrong is that new innovation should come at the benefit of underserved communities, not at the cost of them. For Lee, that focus would be in his collaborations in Vietnam; for Mugaga it was his community in Uganda; and for Kreiger, it was the many studies conducted in Zambia, Tanzania, Kenya, Costa Rica, Honduras, and India.

Each of the presenters could agree that the main strategy is simple: find partners. Community members on the ground. Organizations that can benefit from your presence.

Another prominent–albeit villainous–inventor, Dr. Doofenshmirtz. Image courtesy of Disney.

Another notable aspect of your audience will be the certification you vie for. Depending on your location, you may need different permissions to distribute your product, or even begin on the journey to secure funding from certain sources.

In the United States, the most relevant regulatory pathway is FDA clearance, which is notably less restrictive than the CE mark distributed in the European Union. Both certifications are accepted in other countries, but many of the inventors on the panel opted to secure a CE mark to potentially appeal to a wider variety of governments around the world.

ISO is an international organization that is also necessary for certification, particularly if you are looking to test a medical product. No reason to be dragged down by the paperwork, though! When asked about securing Ugandan product certification, Mugaga declared, “This is one of the most exciting journeys I have taken.” His path to clearance was even more wrought with uncertainty – without steady sources of material in the Ugandan economy, it is harder to earn FDA or CE approval, two of the most widely-acknowledged certifications in the world. 

Mugaga’s presentation slides

Step 3: Test 

Now that you have permission, you can start changing lives. Many participants in our panelists’ studies were patients in community health clinics across the globe. Their partners in these clinics also had the opportunity to save tens to hundreds of thousands of dollars in equipment. While it seems like a no-brainer, there are ethical concerns that need to be addressed first. For that, you need to fill out…. You guessed it: more paperwork. IRB approval is usually granted by educational institutions (as you should recall from my handy glossary), and is crucial to secure before any testing with humans is started. In fact, the government (and most private investors) won’t even give you a second glance if you ask them for money without IRB approval. 

One big hurdle many of the panelists noted was a distrust of the technology and institution it came from – a foreign entity testing their products on you does not always invoke fear, but it certainly does not always promote trust. Kreiger noted that the work of their community health partners does the heavy lifting on that front; not only are they known community pillars, but they have authority to promote health technology through their existing relationships. If you run into trouble identifying partners in your inventorship journey–never fear. Lee has a message for you: “Ask around. At Duke, there’s always an expert around who’s willing to lend you their time.”

Step 4: Distribute

Now that you are an expert, your invention works, and you’re saving lives, you can attempt to cement your design as standard-of-care. This may look different depending on where in the world you want to distribute, but the next step is to contract a large-scale manufacturer. Your materials have been sourced by now (FDA says they better be) — so finding someone to put them together at an industrial scale should be easy! Your cost may fluctuate at this scale with the increased labor costs, but bulk production and distribution altogether should provide you, your institution, and your clients the best possible chance at changing the world. 

Lee did not receive NIH funding until his fourth attempt at applying. Kreiger did not settle on the first manufacturer contracted. Mugaga is still in the process of securing a CE mark. And yet, all of them are success stories. You can see the ENlyT saving lives in hospitals in Vietnam; you can track the reallocation of $18,000 in savings from purchasing a Calloscope; and if you’re lucky, you’ll catch Mulgaga on campus next year as a visiting scholar at Duke!

Post by Olivia Ares, Class of 2025

The Controversial Birth of American Gynecology

As a woman, I am familiar with the gynecologist. In fact, thinking about it right now, I may need to create an appointment for one soon. However, I am not just a woman; I am a black woman, and in addition to being familiar with what the gynecologist is, I am also familiar with the dangers of the gynecologist. I know that if I were to become pregnant, I would be three times more likely to die by pregnancy-related causes compared with my white counterparts. This phenomenon is not new; in fact, it is a symptom of the racism within American Gynecology. The founding of this system is not pretty, or pure; it is ugly and distasteful, and during her lecture, historian Deirdre Cooper Owens explains it perfectly.

Dr. Deirdre Cooper Owens and I after her wonderful lecture

Cooper Owens is an associate professor of History and African studies at the University of Connecticut, and earlier this semester, she gave an insightful talk on how slavery and modern American gynecology are interconnected.

The controversial “father of gynecology” was J. Marion Sims, who experimented on enslaved women in Alabama. When talking about the racism in gynecology today and in the past, Sims mainly gets the blunt end of the stick. However, it was not just Sims; it was much bigger than him, Cooper Owens said.

Dr. Samual Cartwright was the first doctor for the Confederacy. Through his experiences with enslaved people, he believed that black people did not feel pain. Furthermore, he created a theory that if an enslaved person ran away or thought about running away, then they had a mental illness. Through the use of a spirometer (a medical tool still used today), he noted that black people have smaller lung capacity than white people. His findings were used to prove that there was a biological difference between races, which is not true.

This idea separated people and placed them in a hierarchy where white people were perceived as superior and black people inferior. The thought of this is damaging in itself, but back then, and sometimes now, they used this ideology as an excuse for the pain they caused African Americans.

Ephriam McDowell, for instance, removed a tumor from the ovaries of a white woman. From this, he then decided to “perfect” this surgery on five black women; four were enslaved, and one was freed. From this group, one person died, and other than that, there is no record of the women’s personal lives.

Dr. Francis M Prevost performed C-sections on enslaved people. These experiments did not take the pain of these women into account; due to the fact that he believed black people did not feel pain, but they did and still do. Now one would hope that a black woman’s relationship with C-sections has improved, but, from 1832 until two years ago, Louisiana was the state where a black woman’s body was used the most for a C-section. Today, that state is Mississippi.

John Peter Mettauer performed experiments on a white woman and a black woman. After the experiment, he claimed that the white woman was cured, but the black woman was not. As a result, he operated on the black woman eight times and claimed that if she did not have intercourse, she would have been cured. However, he failed to take into account that the woman was enslaved and had no control of her body autonomy. So how could she say no to both unwanted sexual encounters and to him?

Lastly, there is James Marion Sims, who is notorious for his contributions to American gynecology. However, such contributions were based on the bodies of enslaved women who had no choice. He used these experiments to advance his techniques and deepen his understanding of gynecology. In fact, it even went to the point where he built a hospital for the sole purpose of experimenting on enslaved women.

J. Marion Sims with his assistants and the victims of his experiments

While the acts and experiments that these men conducted were atrocious, they raised a question for me, why black women? At that time, black people were viewed as an inferior race; they were not equal in physical components and intelligence compared to white people. Therefore, if they are genetically different, why experiment with black women to find cures for white women? When asking that question, the answer is obvious; they knew there was no difference, so they chose to ignore it. They chose to continuously bring harm to these women, and until recently, they were rewarded for it.

Image provided by  Harvard T.H. Chan School of Public Health

I learned a lot from this lecture, but if I had to choose only one thing that stuck with me, it would be that the victims of these heinous acts were only referred to as enslaved persons with no name and no story. The only story that was told was the point of view of those committing the acts.

I hope one day, the mortality rate of black women giving birth will decrease to the point that it is simply unheard of. Still, for society and our health system to reach that point, we must understand American gynecology’s true history.

By Jakaiyah Franklin, Class of 2025

Leveraging Google’s Technology to Improve Mental Health

Last Tuesday, October 10 was World Mental Health Day. To mark the holiday, the Duke Institute for Brain Sciences, in partnership with other student wellness organizations, welcomed Dr. Megan Jones Bell, PsyD, the clinical director of consumer and mental health at Google, to discuss mental health. Bell was formerly chief strategy and science officer at Headspace and helped guide Headspace through its transformation from a meditation app into a comprehensive digital mental health platform, Headspace Health. Bell also founded one of the first digital mental health start-ups, Lantern, where she pioneered blended mental health interventions leveraging software and coaching. In her conversation with Dr. Murali Doraiswamy, Duke professor of psychiatry and behavioral sciences, and Thomas Szigethy, Associate Dean of Students and Director of Duke’s Student Wellness Center, Bell revealed the actions Google is taking to improve the health of the billions of people who use their platform. 

She began by defining mental health, paraphrasing the World Health Organization’s definition. She said, “Mental health, to me, is a state of wellbeing in which the individual realizes his or her or their own abilities, can cope with the normal stresses of life, work productively and fruitfully, and can contribute to their own community.” Rather than taking a medicalized approach to mental health, she argued, mental health should be recognized as something that we all have. Critically, she said that mental health is not just mental  disorders; the first step to improving mental health is recognition and upstream intervention.

Underlining the critical role Google plays in global mental health, Bell cited multiple statistics: three out of four people turn to the internet first for health information. On Google Search, there are 100 million searches on health everyday; Youtube boasts 25 billion views of mental health content. Given their billions of users, Bell intimated Google’s huge responsibility to provide people with accurate, authoritative, and empathetic information. The company has multiple goals in terms of mental health that are specific to different communities. There are three principal audiences that Bell described Google’s goals for: consumers, caregivers, and communities. 

Google’s consumer-facing focus is providing access to high quality information and tools to manage their users’ health. With regards to caregivers, Google strives to create strong partnerships to create solutions to transform care delivery. In terms of community health, the company works with public health organizations worldwide, focusing on social determinants of health and aiming to open up data and insights to the public health community. 

Szigethy followed by launching a discussion of Google’s efforts to protect adolescents. He referenced the growing and urgent mental health crisis amongst adolescents; what is Google doing to protect them? 

Bell mentioned multiple projects across different platforms in order to provide youth with safer online experiences. Key to these projects is the desire to promote their mental health by default. On Google Search, this takes the form of the SafeSearch feature. SafeSearch is on by default, filtering out explicit or inappropriate results. On Youtube, default policies include various prevention measures, one of which automatically removes content that is considered “immitable.” Bell used the example of disordered eating content in order to explain the policy– in accordance with their prevention approach, YouTube removes dangerous eating-related content containing anything that the viewer can copy. YouTube also has age-restricted videos, unavailable to users under 18, as well as certain product features that can be blocked. Google also created an eating disorder hotline with experts online 24/7. 

Jokingly, Bell assured the Zoom audience that Google wouldn’t be creating a therapist chatbot anytime soon — she asserted that digital tools are not “either or.” When the conversation veered towards generative AI, Bell admitted that AI has enormous potential for helping billions of people, but maintained that it needs to be developed in a responsible way. At Google, the greatest service AI provides is scalability. Google.org, Bell said, recently worked with The Trevor Project and ReflexAI on a crisis hotline for veterans called HomeTeam. Google used AI that stimulated crises to help scale up training for volunteers. Bell said, “The human is still on the other side of the phone, and AI helped achieve that”. 

Next, Bell tackled the question of health information and misinformation– what she called a significant area of focus for Google. Before diving in, however, Bell clarified, “It’s not up to Google to decide what is accurate and what is not accurate.” Rather, she said that anchoring to trusted organizations is critical to embedding mental health into the culture of a community. When it comes to health information and misinformation, Bell encapsulated Google’s philosophy in this phrase: “define, operationalize, and elevate high quality information.” In order to combat misinformation on their platform, Google asked the National Academy of Medicine to help define what accurate medical sources are. The Academy then put together a framework of authoritative health info, which WHO then nationalized. YouTube then launched its “health sources” feature, where videos from the framework are the first thing that you see. In effect, the highest quality information is raised to the top of your page when you make a search. Videos in this framework also have a visible badge on the watch panel that features a  phrase like “from a healthcare professional” or “from an organization with a healthcare professional.” Bell suggested that this also helps people to remember where their information is coming from, acting as a guardrail in itself. Additionally, Google continues to fight medical misinformation with an updated medical misinformation policy, which enables them to remove content that is contradictory to medical authorities or medical consensus. 

Near the end of the conversation, Szigethy asked Bell if she would recommend any behaviors for embracing wellbeing. A prevention researcher by background, Bell stressed the importance of early and regular action. Our biggest leverage point for changing mental health, she asserted, is upstream intervention and embracing routines that foster our mental health. She breaks these down into five dimensions of wellbeing: mindfulness, sleep, movement and exercise, nutrition, and social connection. Her advice is to ask the question: what daily/weekly routines do I have that foster each of these? Make a list, she suggests, and try to incorporate a daily routine that addresses each of the five dimensions. 

Before concluding, Bell advocated that the best thing that we can do is to approach mental health issues with humility and listen to a community first. She shared that, at Headspace, her team worked with the mayor’s office and community organizations in Hartford, Connecticut to co-define their mental health goals and map the strengths and assets of the community. Then, they could start to think about how to contextualize Headspace in that community. Bell graciously entered the Duke community with the same humility, and her conversation was a wonderful commemoration of World Mental Health Day. 

By Isa Helton, Class of 2026

Doctors Share a Vision for Ending Preventable Blindness

Cataract surgery is often perceived as a garden-variety medical intervention akin to the colonoscopy, mammogram, or flu shot. But outside of higher-income countries, the following is not an understatement: eye care can be revolutionary. 

A cataract is described as “the clouding of the lens of the eye.”

It is estimated that, globally, 36 million people are blind; that around 90% of preventable blindness cases are demarcated within low and middle income countries; and that nearly 75% of blind individuals could regain their vision with medical intervention. 

Today, cataract surgery can be performed for $100 or less and, with a practiced hand, in as little as three minutes. 

In that context: a blind individual can completely regain their sight in the time it takes to brush their teeth. For the price of a discounted pair of running shoes. 

Dr. Geoffrey Tabin is an ophthalmologist and co-founder and chairman of the Himalayan Cataract Project. He is also the fourth person in the world to reach the tallest peak on each of the seven continents.

In late September, the Duke Global Ophthalmology Program hosted the A Vision for Ending Preventable Blindness panel to address the global scope of vision impairment, eye care interventions, and subsequent socioeconomic implications. Panelist Dr. Geoffrey Tabin, Professor of Ophthalmology and Global Medicine at Stanford University, characterized the nature of these eye conditions: “Glaucoma’s preventable, trachoma’s preventable, river blindness is preventable, vitamin A deficiency is preventable, even… diabetic changes [in vision] are preventable.” In fact, cataract surgery, in most cases, is a 100% and lasting cure.

What other health interventions boast similar statistics? 

Dr. Llyod Williams holds an ice cooler which will soon contain corneas for transplantation. Photo credit: Chris Hildreth/Rooster Media

Panelist Dr. Jalikatu Mustapha, new Deputy Minister of Health of Sierra Leone, and moderator Dr. Lloyd Williams, director of Duke Global Ophthalmology Program, established a corneal transplantation program in Sierra Leone. Pictured above with a box of corneas, Williams performed the country’s first corneal transplant in 2021. Mustapha and Williams recounted a clinical experience that well-represents their objectives:

Dr. Jalikatu Mustapha is an ophthalmologist, has overseen Sierra Leone’s Eye Care programme, and lectured at the University of Sierra Lione. She is currently the Deputy Minister of Health of Sierra Leone.

While operating in Sierra Leone, Mustapha and Williams worked with a patient completely blind since her teenaged years. After 29 years and a successful corneal transplant, she regained sight in one of her eyes. Walking out of the clinic, she saw a crying young woman and asked what was wrong. When the young woman responded, the patient recognized the woman’s voice, realizing that she was, in fact, her daughter. This would mark the first time she had physically seen one of her children. Her daughter was 19. 

Over the course of his career, Williams has performed thousands of eye surgeries in Africa including, of course, a number of corneal transplants. 

Despite the obvious efficacy of eye health interventions, blindness has little priority on the global health agenda nor in low income countries where preventable cases are disproportionately located. Tabin emphasized the “travesty” of this disconnect, describing blindness as “the lowest hanging fruit in global public health.”

Why is this the case? 

NGOs and governments point to the high mortality rates of infectious diseases like HIV, malaria, cholera, COVID. Blindness is not fatal, they argue, it is an apples and oranges comparison, cataracts to Ebola.

A glance at notable foundations and charities with health-related mission statements cements this sentiment. For example, among its laundry list of initiatives, the Gates Foundation funds the fight against enteric and diarrheal diseases, HIV, malaria, neglected tropical diseases, pneumonia, and tuberculosis; the Rockefeller Foundation “established the global campaign against hookworm… seeded the development of the yellow fever vaccine… supported translational research for tools ranging from penicillin to polio… spurred AIDS vaccine development;” and the Wellcome Trust financially supports infectious disease, drug-resistant infection, and Covid-19 research. 

Of course, this is not an effort to undermine the impact of these institutions but merely to point out a lack of urgency to redress blindness.  

The panelists challenged this “if not fatal then not urgent” thinking. Tabin cited two poignant WHO estimates: 1) vision impairment contributes to an annual $411 billion global productivity loss, and 2) the cost of providing eye care to every in-need individual would be around $25 billion.

The US Department of Defense’s proposed 2024 fiscal year budget is $842 billion. If this funding was allocated towards eye care, every case of preventable blindness could be mitigated 33 times over in one year.  

The downstream effects of blindness are substantial not only for the effected individual but for their family. In the absence of sufficient eye care, children with congenital cataracts, for example, will struggle/will not attend school; they will require care, potentially removing family members from the workforce; they will struggle to find employment; and, on average, they will have a life expectancy about a third of their age- and health-matched peers. Because 90% of preventable blindness is localized in low and middle income countries, community productivity and GDP may be significantly impacted by curable conditions. 

Tabin explained that “blindness really perpetuates poverty” and, on the flip side of the same coin, “poverty really accentuates the suffering of blindness.” Through his work at Stanford, Tabin identified pockets of agricultural Northern California with mass migrant workforces and high rates of preventable blindness. Documentation concerns, language barriers, and/or lack of healthcare often prevents seasonal workers and immigrants from accessing and benefiting from care, comparable to that in low and middle income countries. 

Dr. Bidya Pant is an ophthalmologist and director of  Geta Eye Hospital in Nepal. He has worked with HelpMeSee to lead a team of cataract specialists.

Dr. Bidya Pant, a leading ophthalmic surgeon, challenged this so-called eye care vacuum in a number of countries, including Myanmar, Uganda, and Nepal. His work speaks for itself. In 2016, Pant built six new hospitals, worked with a number of local monks to facilitate care, trained countless ophthalmology specialists, and completed 200,000 cataract surgeries. His high volume cataract surgery model dramatically decreased cost such that even individuals from the poorest communities in Nepal are still able to afford life-changing care. 

In 1984 the population prevalence of blindness in Nepal was 0.84%. In 2015, it was just 0.35%. 

Similar to Pant’s collaboration with the Myanmar monks, Mustapha, in her role as Sierra Leone’s Deputy Health Minister, has worked to increase access to eye care by training community healthcare workers who already provide maternal care, chronic disease management, vaccinations, etc. to rural communities lacking access to public health initiatives. Mustapha also advocates for a national prioritization and an integration of eye health “… into a strong health system that focuses on delivering quality healthcare that’s affordable to every Sierra Leonean across all life stages, whether they be pregnant women, babies, teenagers, adults, or elderly people, without financial consequences.”

Mustapha then posed the question: If you provide a child with a vaccine for measles or pneumonia and they later go blind from cataracts, have you really helped that child? 

Of course not!

Photo from the Himalayan Cataract Project

At face value, ending preventable blindness seems overly idealistic. But, let’s return to Tabin’s “low hanging fruit” analogy. As exemplified by the work of Tabin, Mustapha, Williams, and Pant, eye care is public health’s blueberry bush. Given proper investment and government initiative, this aim is arguably realistic. It’s just a matter of enough hands reaching for and plucking berries from the bush.

I will defer to Williams who best situated the scope of their mission. He said: “You could make a serious case that there [is] no intervention… for the dollar… that would send more girls in Africa to school than cataract surgery.”

If interested, you can watch the A Vision for Ending Preventable Blindness Panel here: https://www.youtube.com/watch?v=3fSw5w2nk6k

Post by Alex Clifford, Class of 2024

Is The World In Crisis?

According to a recent NPR/Ipsos poll, nearly 70% of Americans believe that U.S. democracy is “in crisis and at risk of failing.” Two out of every three respondents also agree that U.S. democracy is “more at risk” now than it was a year ago. 

These fears are not unfounded. For the past three years, the United Nations Human Development Report has issued increasingly grave warnings for the state of the world. The warnings focus specifically on the Anthropocene, rising inequality, and growing polarization, conveying themes of both uncertainty and hope.

Pictured above: The 2022 Human Development Report.

On March 22nd, the director of the United Nations Human Development Report Office, Dr. Pedro Conceição, discussed his perspective at Duke University. The fireside chat was hosted by the Duke Center for International Development and the South-North Scholars, and was moderated by Dr. Anirudh Krishna.

“People should be able to live their lives at their full potential,” Dr. Conceição began. “When you look at the world and see how people are living their lives compared to how they should be living their lives, you get the need for human development.”

First introduced in 1990, the Human Development Report focuses on improving the quality of human life, rather than just the economy in which human beings live. The report emphasizes three pillars: people, opportunity, and choice. “Living life to your full potential is essentially about human freedom,” Dr. Conceição said. It is these freedoms that are at risk as the conditions in the Human Development Report worsen.

Credit: 2021/22 United Nations Human Development Report.

“We need to dig more deeply into why we aren’t taking action,” Conceição maintains. He explains that current efforts to spark change are too factual. Governments and corporations are focused too heavily on raising awareness and should pivot to trying to take tangible steps.

Political division is also a major source of stagnation, as those who lie on either side of the spectrum tend to be more insecure in their views of the future. Because of these obstacles, it requires a “more complex and unusual way of trying to understand these problems.”

The report has citizens from around the world concerned about potential declines in the quality of well-being. But Dr. Conceição asserts that the reports are meant to communicate hope.

“It’s precisely because we are having this level of uncertainty that this becomes even more relevant,” he said. In fact, it is this uncertainty that the report will build off of for future publications. The literature will dig deeper into novel areas of uncertainty, to figure out the best way forward.

An analysis of the current global uncertainties. Credit: 2021/22 United Nations Human Development Report.

Dr. Conceição urges students to invest in the United Nations and its initiatives, as it is crucial in creating a better outlook on the future. As Abraham Lincoln once expressed, “The most reliable way to predict the future is to create it.”

Want to get involved with the United Nations? Click here!

Written by: Skylar Hughes, Class of 2025

Post-COVID Public Health is in a Trust Fall

Dr. Heidi Larson, director of the Vaccine Confidence Project, described data from a recent Pew Center study, instructing us to “HANDLE WITH CARE!” as if a jeweled Fabergé egg and not a series of sampled statistics. 

The study’s title: “Americans’ Trust in Scientists, Other Groups Declines.” 

“Pew Research Center conducted this study to understand how much confidence Americans have in groups and institutions in society, including scientists and medical scientists.”
Credit to: Brian Kennedy, Alec Tyson, and Cary Funk

“Once seemingly buoyed by their central role in addressing the coronavirus outbreak,” Pew Center researchers write, the public’s trust in scientists and health professionals has sunk. This phenomenon is not confined to remote corners of Twitter or the turbulent backwaters of a few Facebook community chats. No, it’s palpable in the media, in conversation, in our collective consciousness. Why is this? And why now? 

Last month, The Duke Global Health Institute hosted a few health experts to answer these questions in the “Building Trust in Public Health: A Post-COVID Roadmap” panel. Jack Leslie, a visiting fellow at the Duke-Margolis Center for Health Policy, contextualized declines in public trust, citing increased populism and anti-elitism. It’s not difficult to chart the evolution of this zeitgeist. In the past three decades alone, Americans have become completely cocooned in media. 

Jack Leslie joins Duke University as a Senior Visiting Fellow at the Duke Global Health Institute (DGHI) and Visiting Fellow at the Duke-Margolis Center for Health Policy

CNN’s Ted Turner (i.e. the ‘Mouth of the South’) is accredited with the genesis of the 24 hour news cycle. He notably “didn’t bargain for… [the] insomniacs,” writes journalist Lisa Napoli, nor did he bargain for its longevity, or our inability to escape it. From coverage of the Iraq War to the OJ Simpson investigation to political partisanship in Washington, and of course, to COVID-19. 

The erosion of institutional faith is not unique to the government but, like an acid rain, weathers indiscriminately. It eats away at trust in churches, corporations, media institutes, universities, K-12 schools, etc. In fact last semester, I attended another Duke panel entitled “Policing the Pages,” in which increased polarization across the US contributed to concerted efforts to bar certain books (often those with LGBT and minority characters) from elementary school libraries and syllabi. A kind of censorship akin to dress codes and mandatory veggies in bagged lunches. 

This sentiment, unlike COVID-19, is not novel. Leslie described a “trifecta” of events, slowly chipping away at public trust: 1) the great recession of ‘08, 2) waves of immigration in the United States and Europe, and finally, 3) the pandemic.

For decades, and with little exception, science was lauded as infallible, an authority, bridging turbulent seas of dis- and mis-information. It was well-mannered, professorial, clad in wire-rimmed glasses and bowtie. “We had pretty high trust in scientists and public health institutions prior to the pandemic… relative to other institutions which have taken a hit over the past twenty years,” Leslie acknowledged.

Of course, this no longer is the case.

Dr. Heidi Larson is a professor of anthropology, risk, and decision science London School of Hygiene and Tropical Medicine.

Dr. Heidi Larson collected this pathos in anecdotes for the Global Listening Project, an oral history of personal pandemic experiences. Many described “…a feeling of disconnect with the government. [They] would give us these directives, but people felt they had no connection with their reality, their situation.” Larson, for example, recognized patterns of isolation in schools. There was a pervasive sense that neither legislator nor scientist had stepped foot into these schools before creating policies. Bureaucratic deflection so to speak.

Larson consequently felt a shift in COVID-19 rhetoric. What once was “upholding global unity,” “encouraging communal cooperation,” and “assuring responsive governance” became, as Larson put it, “getting a jab in the arm.” The disconnect between the Joe Publics, the John Qs, and their public institutions began to feel especially cavernous as the pandemic stretched weeks, months, then years. 

This begs the question, how can we rebuild trust in public health? 

Dr. Rispah Walumbe is a health policy advisor at Amref Health Africa, to support the advancement of the universal health coverage (UHC) agenda.

Dr. Rispah Walumbe, a global health policy and advocacy specialist, described the “orchestration” of multisectoral partnerships during the pandemic (in Africa, specifically) that combined “state and non-state actors with public and private sector actors and, of course, those on the social, economic, and political sides.”

She found that, at the start of the pandemic, trust was enhanced. The virus was identified as a “key problem” and was, to some degree, universally threatening. A conduit of centralized communication followed. As the pandemic elongated, the discrepancy between the populations disproportionately burdened by COVID (poor and minority communities) and those not so much grew wider. Communication became less effective. Still, Walumbe advocated for the continuity of engagement between health institutions and the public in the aftermath of the pandemic. Peel back the Oz-like bureaucratic curtains and increase transparency.   

Dr. Mandy Cohen served as the Secretary of the North Carolina Department of Health and Human Services as well as the Chief Operating Officer and Chief of Staff at the Centers for Medicare and Medicaid Services. She has been elected to the National Academy of Medicine and is an adjunct professor at the UNC Gillings School of Global Public Health.

Dr. Mandy Cohen, Secretary of North Carolina’s Department of Health and Human Services, agreed. In recent studies, she explained, NC ranked 2nd among the states for its general safety during the pandemic, which she attributed to the state’s prioritization of public trust. “Before we even had our first case, we were talking about how our crisis response was going to hinge on whether we could build and maintain trust with the public… we tried to be really tactical about trust, which can feel ephemeral and fleeting… and really broke it down into three buckets. The first was transparency, the second was competency, and the third was relationships.” 

Rebuilding trust in public health, thus, seems less a roadmap and more a spigot. Institutions must continue to fill the buckets Cohen described.

As the pandemic ebbs, however, the ubiquity of isolation, anxiety, and turmoil cannot be understated. A recent WHO article characterized this pervasive fear as “contagious,” pathologic, a kind of virus itself.

In this political cartoon, Sisyphus pushes a stone (the Delta variant) up the hill

In an age of mass misinformation, public health officials, doctors, and scientists now stand with the Sisyphean task of restoring public trust. And the panelists concurred: it is fragile. Volatile even.

Yet, as illustrated in this article, it is not elusive. Prioritize communication. Prioritize transparency. Prioritize competency, relationships, and community engagement.

I will defer to Walumbe who put it best during the conversation: “These institutions do not operate in a vacuum. Community is pivotal in thinking through trust, it’s how we’re organized across the world… that’s something that is critical in how we approached COVID-19 challenges…” and, presumably, in how we should continue.

Thank you to the panelists, moderator Dr. Krishna Udayakumar, and Dr. Mark McClellan, Director and Robert J. Margolis, M.D., Professor of Business, Medicine and Policy at the Margolis Center for Health Policy.

Post by Alex Clifford, Class of 2024

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