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

Category: Global Health Page 1 of 10

Increasing Access to Care with the Help of Big Data

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

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

Panelist moderator, Lisa Turner

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

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

A screenshot from worldpop.org

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

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

This comes with many caveats.

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

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

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

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

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

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

Post by Cydney Livingston

Invisible No More, the Cervix

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

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

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

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

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

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

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

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

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

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

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

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

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

Post by Cydney Livingston

Widespread Vaccination Will Depend on Faith in Science

Two Covid vaccines have been approved via Emergency Use Authorizations. But, many scientists, health professionals, and regulatory members alike are left wondering how to best ensure the American and global public opt-in to getting vaccinated.

During Friday, December 18th Coronavirus Conversation hosted by the Duke Initiative for Science & Society, honored guests Anthony Fauci (M.D.) and Alan Alda discussed the restoration of faith in public science agencies, moderated by Hank Greely (J.D.). You can view the entire program here (40 min.)

Dr. Fauci has become a household name this year as a member of the White House Coronavirus Task Force but is more widely regarded as one of the most trusted U.S. medical figures and has been director of the National Institute of Allergy and Infectious Disease since 1984.

Mr. Alda, though popularized through his acting career, has been a life-long advocate for science. He hosted PBS show “Scientific American Frontiers,” founded the Alan Alda Center for Communicating Science at SUNY Stony Brook, and recently released a podcast titled “Soldiers of Science.” At Stanford, Mr. Greely is director for the Center for Law and Biosciences and the Program in Neuroscience and Society, as well as a Professor of Law.

Greely asked about the public’s current level of trust for science and what must be done to get it “where it should be.” Alda said that there “seems to be this awful fall off of trust in science … at the worst possible time.” But Dr. Fauci pointed out that we have seen the evolution of lack of trust in science over the previous couple of years. The pandemic fell in the middle of extreme American divisiveness, he said, leading to individuals “developing their own set of facts instead of interpreting [actual] data that exists.”

Alda and Fauci both emphasized the need for transparent and clear scientific communication as a main tactic for increasing public faith in science. This includes use of the words “I don’t know,” particularly in response to the question of vaccine longevity, a question Dr. Fauci said will be answered “in due time.”

Alda said scientific communicators should “communicate with audience[s] with respect … with personal contact where trust builds up more quickly.” He pointed out that this means communicators must become more familiar with their audiences, what terms would be best to use, and what their audiences are “ready to hear.” Dr. Fauci added that when someone is “speaking science” to any group, the objective should not be to “impress the [audience] as to how smart [they] are.” The two major objectives laid out by Fauci: 1) Know the audience and 2) know your message, avoiding granularity and inaccessible language.

Greely interjected that the though all three panelists agree on trust in science, they were three white guys “of mature years.” He continued to say that, “One of the saddest ironies [is that] people getting hammered hardest by [Covid] tend to be people from racial and ethnic minorities … those are also [the same] groups of people that have understandable historic reasons to have less trust [in scientific agencies].” How do we reach these groups?

To do this, Dr. Fauci proposed that we need to get messengers for vaccination to “to look like and understand to whom [we] we are delivering the message.” Leaning into an idea by Alda – that we should get celebrities and widely-respected and admired individuals to get vaccinated on television – Fauci described how Surgeon General Jerome Adams got publicly vaccinated Friday morning.

Adams also delivered a message to his “Black and Brown sisters and brothers” in support of vaccination. Dr. Fauci believes more positive messaging like this will be effective. Alda reinforced that “we can’t guess about the people we’re trying to talk to.” We have to know about their biases and cause for hesitancy in order to meet them where they are, as well as address their concerns in genuine, non-condescending ways.

Alda also proposed that individuals snap a quick shot of themselves getting vaccinated and post it to social media as a #vaccie – a play on the #selfie sensation – which Greely said was “brilliant.”

Alda and Fauci concurred that the most powerful proponents of restoring faith in science may lie in the impact of individual civilians who share their trust in and compliance with vaccination amongst family and friends. Fauci said individuals should not “underestimate the impact that they have in their own immediate environment.”

Sandra Lindsay, an Intensive Care Unit nurse in New York, was one of the first people in the U.S. to receive the Pfizer Covid vaccine.

This impact could be either positive or negative, though, as Alda pointed out the problem with social media algorithms. While working on “Soldiers of Science,” he learned that social media sites are designed to “keep your eyeballs on the screen” as long as possible. This means that social media sites keep “showing you what you want to see,” which is your own bias and affirmation that your ideas are correct. If #vaccie starts trending, this might provide necessary momentum for widescale vaccine uptake.

However, because we have become “addicted to [our] bias” and convinced “over and over again that only our view is right,” according to Alda, we must work intentionally to see commonalities across seemingly alienating lines. Reflecting on his work with AIDS, Dr. Fauci suggested that we take what scientific communicators and regulatory bodies learned during that time. “What do we all want?” Fauci said, ”And how do we get there in a way that is synergistic [instead of] opposing?”

In his parting thoughts, Alda stated simply that “science will save us.” It has and will continue to allow us to “counterattack the attacks we get from our mother nature.” Dr. Fauci said that in dealing with the current pandemic, “biomedical research and science has given us something that just a decade ago would have seemed unimaginable.”

“When this is over, and it’s going to be over,” Fauci said, “We’re [going to] look back and say, ‘It was science that got us out of this, pure science.’”

Greely said we have learned a lot about science communication this year – invaluable information that we must carry forward with us.

I, like so many others around the world, can’t wait for my turn to get the Covid vaccine and to kiss 2020 and the pandemic goodbye.

Post by Cydney Livingston

Phase 3 Trials: What We Know About a Covid Vaccine

As multiple drug companies in the United States speed towards Phase 3 trials for Covid-19 vaccinations, there remain many unanswered questions about these vaccines. 

Moderated by Professor of Law and Philosophy, Nita Farahany (J.D., Ph.D), principal investigators Cynthia Gay (M.D., M.P.H) and Emmanuel (Chip) Walter (M.D.) explored these lingering anxieties in a Science and Society hosted Coronavirus Conversation Thursday, November 6th. Dr. Gay is an Associate Professor of Medicine at the University of North Carolia Chapel Hill (UNC) and Medical Director of the UNC HIV Cure Center. Dr. Walter is a professor of Pediatrics with Duke’s Global Health Institute, as well as a member in the Duke Clinical Research Institute and Duke Human Vaccine Institute. Both Gay and Walter are currently overseeing trials for SARS-COV-2 vaccines. 

Farahany began the conversation by pointing out that though the previous ideal of a vaccine by the US presidential election did not come to fruition, Phizer and Moderna just reached full enrollment for their Phase 3 trials. “[The timeline question] is a million-dollar question,” said Dr. Gay, who is overseeing the Moderna trials at UNC. She said that soon statisticians who have no conflicts of interest with the trials will have a look at the unblinded trial data to see if there are any differences between those who received placebo injections and those who received vaccines. Gay believes this first “peek” may be too early to see a significant signal indicating success of the vaccines. Dr. Walter weighed in, saying that though he hopes “we’ll see something,” he concurs that Dr. Gay’s estimate that no significant signal will be present until January is an accurate one. 

As Gay and Walter explained, probed for clarification from Farahany, drug companies undertaking vaccine development enrolled portions of the population at higher risk for contracting Covid — typically on the basis of their form of employment. For example, someone working in healthcare statistically has a higher likelihood of contracting Covid because of increased exposure to environments where Covid-infected persons may be. Vaccine trial groups were either assigned to a placebo or to a vaccine. The drug companies will be able to test the success of the vaccines by evaluating whether those who received the vaccine contract Covid at some statistically significant lower amount than those who received the placebo. 

But as Farahany pointed out, a drug company could receive an Emergency Use Authorization (EUA) for their vaccine before trials are complete, prompting the question: Will Phase 3 trial placebo participants receive the vaccine if their company receives an EUA? Dr. Walter offered that this could be problematic because there would be a lack of long-term data on vaccines and Dr. Gay suggested that because blinding is the best sort of study design, there is tension around this question. However, Walter and Gay both agreed that study participants should be honored for the role they stepped into for these trials. Thus, the timing for the EUA may be the biggest determinant on whether or not placebo-receiving Phase 3 participants will receive the vaccines as soon as they are available or not.

Other concerns focus on the overall safety of the vaccines. All of the current Covid vaccines in development are mRNA vaccines, which have never before been approved for use in humans. Dr. Walter offered that before Covid, some companies were actually poised to start an mRNA vaccine in children for other respiratory pathogens and that mRNA vaccines are “pretty well studied.” Dr. Gay reinforced these notions by stating that she doesn’t have concerns about the vaccine safety, but rather whether or not the vaccines will actually work for the particular strand of virus and “produce enough effective antibodies to have an impact.” If Covid vaccines are successful, they may actually change the direction of vaccinology in a promising way.

Walter and Gay also addressed the concerns of side effects and generally conceded that most of the side effects seen, such as low-grade fevers and injection-site tenderness, are merely side effects seen with any sort of vaccine. As Farahany pointed out, these sorts of symptoms are actually often just a signal that the immune system is working and responding to the vaccine. Dr. Gay said that a lot of the concerns over vaccine side-effects can be thought about as cost-benefit analysis. She says we make these sorts of analyses all day, every day — whether we realize it or not. For Gay, one day of muscle soreness and a slight fever is highly preferential to weeks of potential immobilization from contracting Coronavirus. 

The concluding question: How do we ensure trials are met with public trust? “We have to remember we’re in the middle of a pandemic where things really have to move quickly,” Dr. Walter said. He also offered that though this has been the fastest vaccine development he’s ever seen – aside from H1N1 – all of the safety mechanisms in place have provided safety comparable to that we would normally see. 

“This is a global tragedy we’re dealing with,” Dr. Gay said. “There is a time to step back and think, ‘Isn’t it amazing that all these [amazing, talented, expert] people are working day and night’ …They’re making it happen to try to get us an answer and some effective vaccines.” 

Post by Cydney Livingston

Trust in Gynecology: The Impact of Race & Socioeconomic Status in Women’s Health

Nikki Mahendru’s mother didn’t go to the gynecologist for 45 years — and when she did, she regretted it. Ms. Mahendru felt “decades of anxieties and hesitancy reduced to five minutes of brisk interaction with her provider,” and left convinced that the “realm of women’s health was just not for her.” According to Nikki, a Duke University undergraduate, her mother’s “trust in the system was lost.” 

Mahendru joined Dr. Megan Huchko, the director of the Duke Center for Global Reproductive Health, and Dr. Chemtai Mungo, a Fogarty Global Health Fellow and OB-GYN doctor, on the Center for Global Women’s Health Technologies’ October 20 panel “Impact of Race and Socioeconomic Status in Women’s Health and Gynecology.” The panel was moderated by Ashley Deans and Alexandria Da Ponte.

Mahendru went on to detail an experience she had in the clinic with Carmen, a patient who spoke only Spanish and was also new to the gynecologist. The medical translator and Mahendru learned her story: she had been in pain for a year but had kept quiet due to money problems, had worked most of her life to send her kids to college, and was learning English via Rosetta Stone. With the details of Carmen’s story and an “equitable working relationship,” Mahendru and the translator could relay Carmen’s previous history to her provider. But Carmen’s provider knew only of her condition. 

Mahendru thinks gynecology done right has the potential to help women love their bodies and take care of their health, but gynecologists must earn the trust of their patients: “Acts of listening help bridge disparities.”

Dr. Huchko stated that throughout history, a male-dominated healthcare landscape saw the depiction of menses as ‘dirty,’ terms like ‘hysteria,’ and an overall lack of female control. The “father of gynecology” James Marion Sims exploited Black women in his development of the field, using unanesthetized slaves as subjects of experimentation. In general, Dr. Huchko sees a trend: “The lessening or decentering of women in women’s health corresponds to more discrimination.” In addition to the decentering of women, Dr. Huchko said that structural and individual factors “produce outcomes that prevent women from getting the care they need.” Like Mahendru, she identified trust as a central issue.

Dr. Megan Huchko, MD, MPH, is the director of the Duke Center for Global Reproductive Health

Dr. Huchko cited an experience in which she bore witness to the unattended consequences of racial bias in medicine. In Niger to repair women’s fistulas, which occur due to lack of postpartum care, Dr. Huchko felt she was attending to the downstream symptom of a much broader issue. She felt uncomfortable when the urogynecologist on her team ignorantly praised Sims without acknowledging his problematic history. Then, she saw this ignorance firsthand. 

Making a false assumption about the nature of the case, Dr. Huchko’s team chose to operate on a woman with a mass in her bladder. During the surgery, they realized the mass was a malignant tumor. With an unbiased eye and a complete exam and workup, this would have been clear. But because the team was looking at these women as “one-dimensional,” a woman with stage 4 cancer was subjected to a very invasive surgery that worsened her quality of life. 

Dr. Huchko experienced a similar lack of structural competency during her residency, where colleagues openly racially profiled people and overtly discussed disparities in pain tolerances among different ethnicities. Since then, “things have changed,” and she embraces this new culture of “being patient centered, exploring our own biases, and [having] zero tolerance for racial profiling.” She stresses the need for personal education and accountability alongside systemic change. Eventually, this will lead to women feeling “respected, seen, and heard.”

Coming to the US from Kenya, Dr. Mungo quickly came to appreciate the “sheer magnitude” of structural racism and its impact on health and healthcare. Dr. Mungo explained that “mutually reinforcing systems of disadvantage” for people of color, such as food deserts, are both the result and cause of healthcare disparities and result in enduring legacies of disadvantage.

Dr. Chemtai Mungo, MD, MPH, is a Fogarty Global Health Fellow and OB-GYN doctor

Dr. Mungo also observed that with healthcare in the US being so economically driven, the best care is often directed at those with racial and socioeconomic privilege. When she worked in a high resourced (read: white, wealthy) hospital, access to uterus-saving equipment such as interventional radiology meant that she only did one hysterectomy in four years. Doctors at the hospital also came in on weekends to get a person with cancer into the OR immediately.

Now, working at a “safety net hospital,” Dr. Mungo sees a stark difference. With non-existent interventional radiology and more part-time, “less invested” employees, Dr. Mungo has done three hysterectomies in three years — a 75% increase — and sees patients with time-sensitive conditions wait much longer before surgery. This “separate and unequal access to resources” is a cause for concern. 

Dr. Mungo also stressed the need to make practices “safe places” for patients of color by increasing minority representation. Dr. Mungo explained that while Black physicians make up only 5% of doctors and 3% of faculty, there is strong evidence that patients who are cared for by someone of their own race or ethnicity have better outcomes. “We live in a racist society,” Dr. Mungo stated, “so we need specific anti-racist policies.” 

Dr. Mungo also acknowledged that healthcare providers work within “templates” like 15 minute appointments, and posed the closing question, how can we make patients feel safe and heard within the constraints of modern medicine? 

Answering questions from the audience, Dr. Mungo and Huchko discussed medical algorithms that are based on race, like the VBAC calculator and GFR. 

Dr. Mungo indicted these algorithms as “an example of how institutionalized some [racial] biases are.” There is “no concrete evidence” on why these corrections for race — which typically act to reduce the probability of success for a procedure or favorability of an outcome — exist. Dr. Mungo would urge providers “not to stop at, ‘well, African Americans have an increased risk of diabetes.’ Ask why. Have them explain food deserts… and structural and environmental racism.”

Dr. Huchko stated that giving aspirin throughout pregnancy reduces preeclampsia, and is thus traditionally offered based on risk factors for preeclampsia, like low socioeconomic status and African American race. Sometimes, healthcare providers may not be able to address these risks without the acknowledgement of race as a risk factor. Dr. Huchko is right, African American women are at a higher risk for preeclampsia, and ignoring this correlation would probably do more harm than good. 

But per Dr. Mungo’s appeal, providers must interrogate these associations more deeply — and be ever anti-racist in their efforts — if they are to create the safe spaces and trusting relationships that Mahendru, Dr. Huchko, and Dr. Mungo each hope to see.

By Zella Hanson

Wednesdays, My New Favorite Day

After my freshman fall, I swore I’d never take another 8AM class. Yet, when a microbiology lab was the only opportunity I had for an in-person course in Duke’s disrupted Fall 2020 semester, I jumped at the chance to take it. Wednesdays have become my on-campus days, and though they start at 7AM and are often jam-packed until 7PM, they are my favorite days of the week.  

I’m usually the first to arrive in sub-basement of the Biological Sciences building on Wednesdays. As my six lab-mates join me, we stand in line on top of stickers spaced according to 6-foot social-distancing guidelines and talk about questions from class or the lab we’re going to perform that day. Sometimes it’s difficult to hear one another through our masks. When our TA is ready for us to enter the classroom, we do so one at a time, only after she’s verified our Symptom Monitoring status and taken our temperature.

Our lab stations are spaced so that we are appropriately distanced from one another, but able to work and collaborate as a team as best we can. We have a no-contact drop-zone for placing and picking up shared lab items, though each students’ space is equipped with most everything we need for our lab on most occasions. The stations are close enough so that we can chat, compare results, and ask each other for assistance as we work. Everyone wears a face shield over a face mask. Each lab session we exchange our “home” face mask for a disposable “lab” face mask. Since we work with potentially pathogenic microbes, this step is for our safety to make sure we don’t carry harmful bacteria out of our lab space. Unlike previous years, gloves are worn at all times, but the lab coats we wear have always been a standard part of the microbiology lab attire.  

The infamous “no contact drop zone” for use of shared materials during lab.

What used to be two, two-hour lab sessions twice a week has been condensed into a single four-hour lab-session to minimize exposure to one another. At the beginning of the semester it felt strange and uncomfortable to wear a mask for the whole lab period and for the rest of the day on campus. But like many changes due to Covid-19, I’ve simply gotten used to it. It’s worth it to have face-to-face interactions with fellow students and to have hands-on experience in the lab. In many ways, these experiences feel much more real and meaningful than my fully online classes, in which I interact exclusively virtually with peers and instructors.

This semester we’ve also been doing science at home, having been tasked with an independent research project to be performed outside of lab. The kitchen in my apartment has become a makeshift space for inoculating TSA plates and perplexing my roommate with my experiment.

At home experimental set-up and data collection in my apartment.

After microbiology, I grab a quick lunch at West Union…which I’m still figuring out how to navigate. There’s more online ordering and different routes for lines I haven’t gotten used to. Though it’s significantly less crowded than it used to be – which has its advantages – the energy and fervor that made up Duke is certainly missing. Though I feel it in spurts when I run into the rare upperclassman on the Plaza or in the Bryan Center while trying to find a spot to study, campus is unequivocally not the same.

I leave the central part of campus and return to the basement of BioSci to work in my research lab, the Steve Nowicki Lab. According to our Covid plan, a grad student must be present to supervise me at all times and each of us works on opposite sides of the lab space. It’s really not all that different than it used to be.

In the Nowicki Lab, I test the categorical color perception of Zebra finches. After being trained for the trials, the birds are tested to see if they can detect color differences between a background color and two “odd color out” chips. Colors one and eight are most starkly different, but when comparing colors seven and eight, for example, I sometimes struggle to tell the two colors apart.

Background color 8 versus odd-color-out 7. Can you tell the difference? (Color 7 is in wells 1 and 7)

Following a five-month hiatus from running trials, I was pleasantly surprised to find myself in the rhythm of things with only a few marginal mishaps. Within a half-hour of being back in the lab, I was running experiments at full speed again. For a moment it felt like I’d never left, and like it could have been the Wednesday before spring break, before the pandemic took full effect. Sometimes still when I’m running trials, I imagine I could walk out of BioSci’s basement and find that everything would be just as it had been when I left in March.

I spend three hours with the birds, running a refresher round followed by five experimental trials. And usually, I listen to podcasts while I work. The time passes quickly, sometimes more quickly than I’d hope.

Example of bird during experiments.

Since I’m already on campus, most Wednesdays I stick around and attend my online history seminar from a spot around campus. Though I can’t perch myself on the third floor of Perkins Library these days, I’ve found a new spot I like on the second level of the Bryan Center and I’ve made it work for me.

On Wednesdays, I am reminded of the reasons I fell in love with Duke and of all the things I miss about it in these strange and uncertain times. I wonder if the Duke I knew will ever be the same. Or if something has fundamentally shifted in our institution, and more largely in each of us individually, that only leaves us with a path forward to a new Duke, rather than a return to the old.

I am team Crystal Violet #2 and this is my bag for placing my “home mask” in when gearing up for lab.

As I return to my car in Blue Zone, I take a longing look at the Chapel. Then I make my way to my car, turn on some tunes for the drive home, and patiently wait for my alarm to wake me at 7AM the next Wednesday morning.

Most of the time I’m left thinking about the Duke that used to be, despite the fact that I certainly admire the socially-responsible and safe Duke that is. We’re doing well, all things considered. But still, it’s not the same. The Duke that the first years know is not the Duke I remember.

Post by Cydney Livingston, Trinity 2022

Emergency Use Authorization for Covid Vaccine: One Hurdle of Many

Who will be the first company to secure an Emergency Use Authorization for a Covid-19 vaccine, and when? This question has circulated in the popular press for a few months and is at the forefront of many Americans’ minds with the upcoming presidential election on November 3rd.

Arti K. Rai (J.D.) moderated a dialogue between former FDA Commissioner and distinguished Professor of Cardiology, Robert Califf (M.D., M.A.C.C.), and Founder and Director of Scripps Research Translational Institute, Eric Topol (M.D.), in which the pair discussed emergency use authorization, public trust, and vaccines. The discussion was part of the Science & Society Initiative’s ongoing series of “Coronavirus Conversations.”

Emergency Use Authorizations (EUAs) strengthen American public health protections by speeding the availability and use of medical countermeasures during public health emergencies. Dr. Califf explained that in addition to events like nuclear catastrophes that EUAs were designed to provide protections for, pandemics were also thought about in conceiving the emergency measure. “[The pandemic] is not a surprise,” Califf said, “We knew it was going to happen at some point.”

The panelists examined the possible use of EUAs for a Covid vaccine and monoclonal antibody treatments given the EUAs issued earlier this year for hydroxycholoroquine and convalescent plasma, the former of which was revoked due to proven risks. Both of these experimental treatments lacked sufficient evidence at the time the EUAs were approved.

Dr. Topol said that the EUA case for the antibodies treatment is a good one with growing evidence that suggests their effectiveness as a viable treatment measure. Dr. Califf concurred, saying that with 1,000 people predicted to die every day in the U.S. through the end of December, there’s a strong case for the FDA to exert its judgment. One issue with antibodies, however, is that they cannot be made in large quantities and are very expensive, meaning they would be inaccessible for many.

The question of EUA use for vaccines is less straightforward. Dr. Topol argued that though the protocols released by four drug companies, including Moderna and Pfizer, are pretty far along, “there is a very questionable ethical story here.” He continued, “How can we say it’s good enough to give to essential workers, healthcare works, high-risk individuals, but they won’t even give it to trial participants? They received placebo vaccines.” Across the board, the trials currently underway only include about 150 individuals.

These initial trials are only the first hurdles to the production of a vaccine, according to both Califf and Topol. Dr. Califf pointed out that there will be issues of manufacturing and distributing, lots of concerns with post-market assessments, and how to determine which vaccines will be the best. Dr. Topol reinforced these ideas, suggesting that because no single company will be able to fill the vaccine demands, we need multiple vaccines to be successful. Further, Dr. Topol admitted his concern about the major extrapolations of data we will face, going from trials of 150 individuals to potential distribution numbers of vaccines reaching the hundreds of millions, if not billions of people.

And even once an initial round of vaccines is developed, Dr. Califf inserted the question, “What happens after people get vaccinated?” The simple truth is, the vaccination will probably not completely eradicate the virus, there could be late post-vaccination reactions, and the vaccine could potentially end up creating asymptomatic carriers. Both doctors agreed, masks and social distancing will be needed for at least the next year.

The potential of a Covid-19 vaccination has been popular in the media over the last few months.

Public opinion and politics are also key players in vaccine debates and development. “The point of public trust is essential because if something happens with the first vaccine that gets out,” Dr. Topol said, “it’s going to be a real damaging blow to vaccine rollout.” Like mask-wearing, Topol suggested that vaccines are part of a larger social contract in which these sorts of preventative measures not only help oneself but those around them.

Rai pointed out that as tensions between the FDA and the U.S. department of Health and Human Services grow, as well as between the FDA and the Trump administration, we could face “doomsday” scenarios where the FDA is coerced into certain actions and their powers become limited. However, new FDA guidelines for vaccine development have extended the potential timeline for a Covid vaccine, meaning that the chances of a EUA being issued before the election and being utilized as a political tool for Trump’s reelection are quite unlikely at this point.

Dr. Califf closed by emphasizing the need for solidarity among the biomedical community as influential to the success or failure of potential vaccines and public trust. Dr. Topol offered that we “need education, government that supports science, and need to get [support from] people of all diverse backgrounds to get [the public] to buy in.”

While Dr. Topol maintained a more skeptical and sometimes grim tone, Dr. Califf said that though he’s worried about “everything,” he’s “preparing for the worst but hoping for the best.”

It seems that as many people grow both accustomed to and tired of our new normal, most of us are caught somewhere in the middle of these outlooks.

Post by Cydney Livingston

Dealing With Lead for Life

Though lead has been widely eliminated from use in products due to proven health risks, the lifelong consequences of childhood lead exposure for children born in the era of lead use in gasoline are still unknown.

Aaron Reuben, fifth-year Ph.D. candidate in clinical psychology at Duke, spoke about the long-term implications of childhood lead exposure Friday, September 18th through the Nicholas School’s Environmental Health and Toxicology Seminar series. He conducts research as a member of the Moffitt and Caspi Lab, studying genes, environment, health, and behavior.

Aaron Reuben

Reuben started with a brief history of lead exposure. After the United States’ initial use of lead in gasoline in 1923, the practice became widespread with the U.S. Public Health Services approval for expansion. Five decades later, in the mid-1970s, the Environmental Protection Agency issued the first restrictions on lead use in gasoline products. Simultaneously, surveillance of population-level blood-lead levels indicated cause for concern. Though lead was phased of out of gas completely by 1995, the peak led exposures in the 70s were on average three to four times higher than current levels that demand clinical attention. Despite lead regulations, the impacts of exposure did not miraculously cease as well.

Lead use in gasoline quickly increased after its initial introduction.

The research Reuben covered in his talk centers on the Dunedin Study. This study of 1,037 people born between April 1972 and March 1973 in Dunedin, New Zealand is an ongoing longitudinal research project comprised of over 30 years of data. The cohort of participants provide a unique chance for research in which social and economic factors do not have to be detangled from findings as they represent the full range of socioeconomic statuses in their city.

Reuben’s first question was about the impact of lead exposure on psychiatric and personality differences in adulthood. Study members were asked about symptoms such as substance dependence, depression, fears and phobias, or mania. These reports were transformed into a continuous measure of general psychopathology, which indicated that children with high lead levels experienced more psychiatric problems across adulthood. Though the developmental differences were modest, the associations between lead and psychopathological issues are of a similar magnitude to other known risk factors like childhood maltreatment and family history of mental illness. Yet, unlike the latter two risk factors, Reuben said, “Lead exposure is not preordained – it’s modifiable.”

The research team also measured participant personality using the Big Five Inventory and found that individuals with high-blood level levels as children exhibited more difficult personality styles as adults. The biggest difference between groups with high and low childhood blood-lead level was the trait of conscientiousness, which has impacts on goal obtainment within one’s education and occupation, as well as overall satisfaction with relationships.

Findings from the Big Five Inventory of Dunedin participants.

The next question of the presentation centered on differences in adulthood cognitive ability. At midlife, defined as age 38 for this question, children with higher blood-lead levels had lower cognitive ability, experiencing a deficit of two IQ points per five microgram per deciliter increase of blood-lead level. Once again, though these findings were relatively modest, the loss of IQ points was accompanied by downward social mobility compared to participants’ parents. Further, when evaluations that took place at age 45 were included in the data, researchers saw even larger declines in IQ points between exposure-level groups, which Reuben predicts may even represent a trend of acceleration. He believes that as the study continues with the participants, they will find rapid decline around age 65, with higher levels of dementia symptoms among participants compared to same-aged peers.

The last question evaluated the structural integrity of the brain at midlife. The team found that children with higher lead exposure had lower gray-matter integrity, lower white-matter integrity, and older estimated brain age at age 45. Estimated brain age was predicted by an algorithm based on MRI scans, as brains look physically different as they age and gray- and white-matter integrity refers to the conditions of physical structures in the brain. These findings suggest that childhood led exposure may result in an overall lowered brain integrity at midlife, as well as accelerated brain aging.

Reuben’s take-away findings from his presentation.

Reuben’s work is important for understanding how childhood exposure to this neurotoxin has the ability to influence continued development, behavior, emotion, and life outcomes decades later. It is crucial to evaluate long-term ramifications of childhood lead exposure – a phenomena experience by hundreds of millions of people across the globe during the era of lead in gasoline who are likely unknowingly dealing with impacts now.

Post by Cydney Livingston

We Are Not All Living The COVID Moment Equally

We are all living within the Covid moment, but we are not living within the Covid moment equally. The pandemic has exposed a recurrent rift in the United States’ healthcare system: Black Americans and other people of color (POC) are both disproportionately impacted by health issues and disproportionately lack access to care.

In a recent study on North Carolina conditions, Duke researchers found that the “odds of testing positive for [Covid] were higher for both Black and Hispanic individuals as well as within neighborhoods with a higher proportion of Black or Hispanic residents – confirming that Black and Hispanic communities are disproportionately affected.”

In a Coronavirus Conversation sponsored last week by the Science & Society Initiative, Thomas Williams J.D. discussed this and related issues with Duke scholars Keisha L. Bentley-Edwards, Ph.D. of medicine and Jay A. Pearson, M.P.H., Ph.D of public policy.

Williams opened the panel by emphasizing the relevance of this moment: Current Covid impacts are directly informed by historical inequities and intricately span into the future. This is but one system of plaguing racism.

To speak about the intimate intersection of race and healthcare in America, Pearson offered grounding insight to systemic and structural racism. The United States is a country filled with patterns that produce and reproduce systematic advantages for those who are white while simultaneously disadvantaging people of color, most often Black and indigenous populations. Racism in America greatly transcends personal acts of racialized discrimination and harassment, he said. Racism in America is multiplex, foundational, and rooted within our society’s core.

“The U.S. national identity is tied to structural racism. …This is who we are, this is who we’ve been since the beginning of this country,” Pearson said, “The racialized inequities of Covid are simply the latest [manifestations]. We shouldn’t be surprised.”

A recently circulating figure states that 96% of people with severe outcomes or death from Covid had comorbidities, the presence of health conditions in addition to Covid. But Bentley-Edwards cautioned against misuse of this claim: “Many of these people would be alive if not for Covid.”

Though many who have died from the virus had underlying conditions, it is ultimately the virus that killed them. Communities of color often have disproportionate prevalence of underlying conditions, making them more susceptible to complications from Covid. But even when the prevalence of underlying conditions is the same among white and non-white populations, people of color are more likely to be more negatively affected by them.

For example, cardiovascular disease is similarly distributed between white and Black people, yet Black people are more likely to die of it, and at a younger age, compared to white people. Similarly, Black and other POC populations who contract Covid are more likely to die despite similar rates of contracting the virus in certain regions of the country.

Dr. Bentley-Edwards speaking during Friday’s virtual Coronavirus Conversation

Pearson and Bentley-Edwards also offered their insights on who is seen as essential and who is seen as dispensable in the United States.

Those who have been on the front lines with the most exposure and risks have been laborers who are most often under-valued Black and Brown peoples, Bentley-Edwards said. Though Covid terminology has come to dub them essential, it is undeniable that our society continues to see these types of workers as dispensable or replacable, and thus does not protect the people responsible for protecting us. Because many people of color live in multi-generational households as a culturally protective factor, increased chance of contracting Covid has led to uncertainties on the safety of returning home to young and elderly family members, she said. Further, the disproportionate unemployment rate of 13% for Black Americans compared to the 8.4% national rate is a staggering one. Since insurance is tied to employment, Black and Brown communities often avoid treatments due to the financial burden of unaffordable and inaccessible care.

Within the pandemic, we have seen the ever-present epidemiological impacts of police brutality and murder in the U.S with fresh eyes, the panelists said. In many ways, Black peoples’ experiences with healthcare mirrors that of their experiences with police – likely because both systems are anchored by an unjust nucleus.

“[Covid and police brutality] are slightly different manifestations of the same phenomenon,” Pearson said. We are able to easily identify the murders of individuals such as Breonna Taylor, George Floyd, and Ahmaud Arbery as stolen lives due to racist actions, however the slow burn of a racist health care system is less easily conceptualized or reconciled with, he said. Either way, the cause is one and the same.

Racism within systems that are meant to protect have generated a deep mistrust from Black and Brown people. Williams brought up the issue of a potential Covid vaccination amongst communities of color. “You have to know the history and why they would hesitate,” Bentley-Edwards said, bringing up the Tuskegee experiments and the work of J. Marion Sims. These accounts offer grim revelation of a heinous, racist history of exploiting vulnerable people for scientific and medical explorations.

Bentley-Edwards said that governments and healthcare institutions must address the rightful apprehensions of Black and Brown people in order to decrease vaccine hesitancy and serve at-risk communities. “What are they going to do differently?”

Williams also proposed the notion of data collection as a source of bias: In what ways are the data informatics that are collected reflections of an inequitable system? Bentley-Edwards and Pearson both suggest that to understand the current moment, as well as the healthcare system more largely, there needs to be collection and analysis of racial data. Additionally, there simply needs to be measurements for indicators beyond conventional ones which do not properly account for impacts on communities of color.

The push for new and different kind of data is supported by a growing evidence for the manifestations of inequality within biological bodies. For example, Pearson spoke about his own research on telomeres, a protective structure on the ends of chromosomes that protect DNA from degradation. Telomeres are telling both of stress and aging. Pearson’s work found that the average Black American woman is six to seven biological years older than a white American woman of the same age by evaluating telomere lengths, controlling for income, education, and other important socioeconomic factors. This indicates physiological affects linked to the stresses and disproportionalities of race down to the cellular level. Through genetics, mental health, and other physical degradations, the impacts of racism and racist healthcare quite literally last a lifetime and are even intergenerational.

Diagram of telomere from a study conducted by Dr. Pearson

Pearson closed the panel by urging attendees to take action where they find themselves. Though the need for animated policy which reflects recent discussions and protests is dire, the local spaces we find ourselves in need to be reshaped as well – including our universities.

In this moment, our responsibilities to one another have become more obvious than ever before. We must become more adept in thinking about and taking action for the communities in which we live and are connected to, whether they are comprised of people who look like us or not.

Post by Cydney Livingston

“Do No Harm to Whom?” Challenge Trials & COVID-19

DAVIDE BONAZZI / SALZMANART

Imagine: you wake on a chilly November morning, alarm blaring, for your 8:30 am class. You toss aside the blankets and grab your phone. Shutting the alarm off reveals a Washington Post notification. But this isn’t your standard election headline. You almost drop your phone in shock. It can’t be, you think. This is too good to be true. It’s not — a second later, you get a text from the SymMon app, notifying you of your upcoming appointment in the Bryan Center.

A vaccine for COVID-19 is finally available, and you’re getting one.

This scenario could be less far-fetched than one might think: the Centers for Disease Control and Prevention has told officials to prepare for a vaccine as soon as November 1st. To a country foundering due to the economic and social effects of COVID-19, this comes as incredible news — a bright spot on a bleak horizon. But to make a vaccine a reality, traditional phase 3 clinical trials may not be enough. What are challenge trials? Should they be used? What’s at stake, and what are the ethical implications of the path we choose?

At Duke Science and Society’s “Coronavirus Conversations: The Science and Ethics of Human Challenge Trials for COVID-19” on Aug. 24, Kim Krawiec of the Duke School of Law posed these and other questions to three experts in health.

Dr. Marc Lipsitch, Director of the Center for Communicable Disease Dynamics at the Harvard School of Public Health, began by comparing traditional phase 3 trials and challenge trials. 

In both kinds of trials, vaccines are tested for their “safety and ability to provoke an immune response” in phases 1 and 2. In phase 3 trials, large numbers (typically thousands or tens of thousands) of individuals are randomly assigned either the vaccine being tested or a placebo. Scientists observe how many vaccinated individuals become infected compared to participants who received a placebo. This information enables scientists to assess the efficacy — as well as rarer side effects — of the vaccine. 

Marc Lipsitch

In challenge trials, instead of random assignment, small numbers of low-risk individuals are deliberately infected in order to more directly study the efficacy of vaccine and treatment candidates. Though none are underway yet, the advocacy group 1Day Sooner has built a list of more than 35,000 volunteers willing to participate.

Dr. Cameron Wolfe, an Infectious Disease Specialist, Associate Professor of Medicine, and Clinical Expert In Respiratory and Infectious Disease at the Duke Medical School, provided an overview of the current vaccine landscape.

Cameron Wolfe

There are currently at least 150 potential vaccine candidates, from preclinical to approved stages of development. Two vaccines, developed by Russia’s Gamelaya Research Institute and China’s CanSinoBIO, have skipped phase 3, but are little more than an idiosyncrasy to Dr. Wolfe, as there is “minimal clarity about their safety and efficacy.” Three more vaccines of interest — Moderna’s mRNA vaccine, Pfizer’s mRNA vaccine, and Oxford and AstraZeneca’s adenovirus vaccine — are all in phase 3 trials with around 30,000 enrollees. Scientists will be watching for a “meaningful infection and a durable immune response.”

Dr. Nir Eyal, the Henry Rutgers Professor of Bioethics and Director of The Center for Population-Level Bioethics at Rutgers University, explained how challenge trials could fit into the vaccine roadmap.

According to Dr. Eyal, challenge trials would most likely be combined with phase 3 trials. One way this could look is the use of challenge trials to weed out vaccine candidates before undergoing more expensive phase 3 trials. Additionally, if phase 3 trials fail to produce meaningful results about efficacy, a challenge trial could be used to obtain information while still collecting safety data from the more comprehensive phase 3 trial.

Nir Eyal

Dr. Eyal emphasized the importance of challenge trials for expediting the arrival of the vaccine. According to his own calculations, getting a vaccine — and making it widely available — just one month sooner would avert the loss of 720,000 years of life and 40 million years of poverty, mostly concentrated in the developing world. (Dr. Eyal stressed that his estimate is extremely conservative as it neglects many factors, including loss of life from avoidance of child vaccines, cancer care, malaria treatment, etc.) Therefore, speed is of “great humanitarian value.”

Dr. Wolfe added that because phase 3 trials rely on a lot of transmission, if the US gets better at mitigating the virus, “the distinction between protective efficacy and simple placebo will take longer to see.” A challenge study, however, is “always a well defined time period… you can anticipate when you’ll get results.” 

The panelists then discussed the ethics of challenge trials in the absence of effective treatment — as Krawiec put it, “making people sick without knowing if we can make them better.”

Dr. Wolfe pointed to the flu, citing challenge trials that have been conducted even though current treatments are not uniformly effective (“tamiflu is no panacea”). He then conceded that the biggest challenge is not a lack of effective therapies, but the current inability to “say to a patient, ‘you will not have a severe outcome.’ It varies so much from person to person, I guess.” (See one troubling example of that variance.)

Dr. Eyal acknowledged the trouble of informed consent when the implications are scarcely known, but argued that “in extraordinary times, business as usual is no longer the standard.” He asserted that if people volunteer with full understanding of what they are committing to, there is no reason to assume they are less informed than when making other decisions where the outcome is as yet unknown. 

Dr. Lipsitch compared this to the military: “we are not cheating if we cannot provide a roadmap of future wars because they are not yet known to us.” Rather, we commend brave soldiers (and hope they come home safe). 

Furthermore, Dr. Eyal asserted that “informed consent is not a comprehensive understanding of the disease,” lest much of the epidemiological research from the 1970s be called into question too. Instead, volunteers should be considered informed as long as they comprehend questions like, “‘we can’t give you an exact figure yet; do you understand?’”

Agreeing, Dr. Wolfe stated that when critics of challenge trials ask, isn’t your mission to do no harm?, he asks, “Do no harm in regards to whom?” “Who is in front of you matters,” Dr. Wolfe confirmed, “that’s why we put up safeguards. But as clinicians it can be problematic [to stop there]. It’s not just about the patient, but to do no harm in regards to the broader community.”

The experts then discussed what they’d like to see in challenge trials.

Dr. Wolfe said he’d like to see challenge trials carried out with a focus on immunology components, side effect profiles, and a “barrage” of biological safety and health standards for hospitals and facilities. 

Dr. Eyal stated the need for exclusion criteria (young adults, perhaps age 20-25, with no risk factors), a “high high high” quality of informed consent ideally involving a third party, and access to therapies and critical care for all volunteers, even those without insurance. 

Dr. Lipsitch stressed the scientific importance of assessing participants from a “virological, not symptom bent.” He mused that the issue of viral inoculum was a thorny one — should scientists “titrate down” to where many participants won’t get infected and more volunteers will be needed overall? Or should scientists keep it concentrated, and contend with the increased risk? 

Like many questions pondered during the hour — from the ideal viral strain to use to the safest way to collect information about high risk patients — this one remained unanswered. 

So don’t mark November 1st on your calendar just yet. But if you do get that life-changing notification, there’s a chance you’ll have human challenge trials to thank.

Post By Zella Hanson

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