It’s that most wonderful time of the year: The official list of Clarivate’s Most Highly Cited Scientists came out this morning. Scientists all over the world came racing down the stairs in their PJs to see if Clarivate had left a treat under the tree for them.
Good news – there are 30 Duke names on the list!
Being highly cited is a point of pride for researchers. To make the cut, a paper has to be ranked in the top 1 percent for its field for the last decade. Clarivate’s “Institute for Scientific Information” crunches all the numbers.
Mostly, the names on this year’s list of Duke authors are the usual titans. Oddly, some returning names have changed categories since last year — but that’s okay, they’re still important.
And there are three fresh faces: Cardiologist Renato Delascio Lopes, MD Ph.D., who studies atrial fibrillation; David R. Smith Ph.D. of physics and electrical engineering, who’s a leading light in the field of metamaterials; and Dan Scolnic Ph.D. of physics, who’s measuring the expansion of the universe and trying to figure out the dark energy that apparently drives it.
Five of the Duke names on the list this year are co-authors in the Terrie Moffit and Avshalom Caspi lab, a hugely influential group of psychologists and social scientists. Honnalee Harrington, Renate Houts, Caspi, Moffitt, and UC Irvine professor and Duke adjunct Candice Odgers are studying human development from cradle to grave using two cohorts of life-long study participants in New Zealand and England.
Two other longitudinal scientists, Jane Costello and William Copeland of the Great Smoky Mountains Study, are also on the list.
There are 6,938 highly cited scientists this year, from 69 countries and regions. Several appear in more than one division. The United States still dominates with 38 percent of the honorees, but Chinese scientists are on the rise at 16 percent.
The most highly cited Duke authors are:
Biology and Biochemistry
Charles A. Gersbach
Christopher Bull Granger
Adrian F. Hernandez
Renato D. Lopes
Tony Jun Huang
David B. Mitzi
Christopher B. Newgard
Michael J. Pencina
Bryce B. Reeve
Pratiksha I. Thakore
Mark R. Wiesner
Barton F. Haynes
Neuroscience and Behavior
Quinn T. Ostrom
Pharmacology and Toxicology
Evan D. Kharasch
David R. Smith
Plant and Animal Science
Sheng Yang He
Psychiatry and Psychology
E. Jane Costello
Terrie E. Moffitt
Po-Chun Hsu – University of Chicago, Adjunct Assistant Professor in Mechanical Engineering and Materials Science at Pratt School of Engineering
Candice Odgers, UC Irvine, Adjunct at Duke
Environment and Ecology
Robert B. Jackson, Stanford University, Adjunct Professor of Earth and Ocean Science at Nicholas School of the Environment
William E. Copeland, University of Vermont, adjunct in psychiatry and behavioral sciences, School of Medicine.
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.
At 12 years old, I scribbled in my brand new pink notebook, covered in owls. I dubbed it my “question notebook,” filled with about twenty other easily-googleable questions. “A blueprint to our bodies,” was the result of my first internet search for the definition of a gene. But this blueprint had failed so many, even my own grandfather. Could it fail me down the road? Could I one day find an explanation?
By 16, I had been steadfast for years in my decision to pursue medicine. But, on the other side of perseverance is tunnel-vision. At Lyons Township High School in Western Springs, Illinois, I refused to stray the path I had meticulously designed for myself. I confined myself to chemistry, math, and biology. I bounded my limits to only APs, and only extracurriculars that “made sense.”
Perhaps the only time I strayed from the path was by pursuing competitive gymnastics until I graduated, despite 20-hour weeks and numerous insistences from my parents to quit. I was determined to keep something that did not belong to my future.
It wasn’t until class selection for my first Duke semester that I allowed myself to magnify this idea of straying from my path. I wasn’t loading up my schedule with Organic Chemistry or Physics, seeking to check off requirements for the MCAT. Instead, I was selecting Computer Science 101.
Upon beginning my new life at Duke, I felt a strange taste in my mouth whenever I was asked what I was studying. I was no longer “pre-med.” My years spent taking rigorous STEM classes and conducting independent research projects felt like a waste. I wasn’t even a gymnast anymore.
Two huge pieces of my identity had been excised, leaving gaping holes that I felt clueless at how to fill.
Sophomore year, I have been seeking out more ways in which I can stray. In pursuit of the elusive software engineering internship, I felt myself settling into a familiar mindset of: “What is most practical?” I refuse to enter this rut again. So, I enrolled in film editing, a class that has long-since sparked my interest.
I love the quote: “the best ideas are the most disruptive.” This summer, I fell in love with hiking, the solitude enveloping me in a cocoon of my wildest ideas. Alone, I can craft a business idea, or conceive an unusual plot for a movie. I can weave together the bits and pieces of my imagination.
I was drawn to film editing because of the analogy that the editor clears a path in a forest. With so many directions to go, they are responsible for compelling emotion out of the audience. I’ve found that a disruptive idea will do the same.
My draw to the Duke Research Blog stemmed from two places. First, I wanted to continue to stray from my path by re-exploring my childhood love for writing. Second, I craved time to learn about other’s disruptive ideas, in hopes of getting inspiration for some of my own.
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.
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.
In late September, the Duke Global Ophthalmology Program hosted the A Vision for Ending Preventable Blindnesspanel 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?
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:
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, 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.
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!
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
We didn’t know we needed another way to rank the importance of Duke’s scientists, but the folks at research.com have gone ahead and developed one anyway. And in its second year of data, several Duke people come out in the top ten nationally and globally. So, okay, maybe we did need a new ranking system!
Duke Psychology and Neuroscience swept the U.S. medals in psychology: Terrie E. Moffitt Ph.D., first, Michael Tomasello, Ph.D. second, and Avshalom Caspi, Ph.D. third. Duke University’s psychology is overall ninth in the world, according to this ranking.
Moffitt, the Nannerl O. Keohane University Distinguished Professor of P&N, and Caspi, the Edward M. Arnett Distinguished Professor of P&N,are frequent co-authors on a lifelong psychology and health study of 1,000 people born in Dunedin, New Zealand. Moffitt ranks fourth in the world in psychology, with 207,903 citations of her 582 works. Caspi’s 159,598 citations of 507 papers were good enough for 10th in the world.
Developmental psychologist Tomasello, the James F. Bonk Distinguished Professor of P&N, has focused his work on cognitive development, social cognition and language acquisition. He has 147,951 citations on an even 800 works, placing him second in the U.S. and ninth in the world.
Nobel laureate Robert Lefkowitz M.D., the chancellor’s distinguished professor of medicine, is ranked second in the nation and third in the world for Biology and Biochemistry with 198,000 citations of his 881 papers. The rankings reflect the importance of Lefkowitz’s discovery and characterization of the 7-transmembrane g-coupled protein receptor (GPCR), a fundamental signaling port on the surface of cells that is targeted by a third to a half of all prescription drugs.
Psychiatry and Behavioral Sciences professor and Co-Director of Duke’s Center for Spirituality, Theology and Health, Harold G. Koenig M.D., was ranked seventh in the nation and 10th in the world for Social Sciences and Humanities for his work on spirituality and health. His 703 publications have earned 66,404 citations.
Many other Duke scholars finished in the top 100 worldwide in their respective fields, some even making a mark in multiple fields. Check it out.
Methodology: Research.com’s ranking of the best scholars by discipline relies on data consolidated from various sources including OpenAlex and CrossRef. The bibliometric data for estimating the citation-based metrics were collected on Dec. 21, 2022. Position in the ranking is based on a researcher’s D-index (Discipline H-index), which includes exclusively papers and citation metrics for an examined discipline.
And just to prevent some letters to the editor, we acknowledge that the H-index has its critics, including its inventor. We don’t make the rankings folks, we just share them.
This annual celebration of Bass Connections research projects featured more than 40 interdisciplinary teams made up of Duke faculty, graduate students, undergraduate students, and even partners from other research institutions.
Research teams presented posters and lightning talks on their findings. You might have heard from students aiming to increase representation of women in philosophy; or perhaps you chatted with teams researching physiotherapy in Uganda or building earthquake warning systems in Nepal. Below, meet three such teams representing a wide variety of academic disciplines at Duke.
Building sustainable university-community partnerships
As Bass Connections team member Joey Rauch described, “this is a poster about all of these other posters.” Rauch, who was presenting on behalf of his team, Equitable University-Community Research Partnerships, is a senior double-majoring in Public Policy and Dance. His interest in non-profit work led him to get involved in the team’s research, which aims to offer a framework for ethical and effective university-community research collaboration – exactly what teams do in Bass Connections. The group looked at complicated factors that can make equitable relationships difficult, such as university incentive structures, power dynamics along racial, socioeconomic, and ethnic lines, and rigid research processes.
Along the lines of rigid research, when asked about what his favorite part of Bass Connections has been, Rauch remarked that “research is oddly formal, so having a guiding hand through it” was helpful. Bass Connections offers an instructive, inclusive way for people to get involved in research, whether for the first or fourth time. He also said that working with so many people from a variety of departments of Duke gave him “such a wealth of experience” as he looks to his future beyond Duke.
For more information about the team, including a full list of all team members, click here.
The project has been around for three years and this year’s study, which looked at improving female sexual wellness after pelvic radiation procedures, was in fact a sister study to a study done two years prior on reducing anxiety surrounding pelvic exams.
As Huang described, graduate students and faculty conducted in-depth interviews with patients to better understand their lived experiences. This will help the team develop interventions to help women after life events that affect their pelvic and sexual health, such as childbirth or cancer treatment. These interventions are grounded in the biopsychosocial model of pain, which highlights the links between emotional distress, cognition, and pain processing.
For more information about the team, including a full list of all team members, click here.
From dolphins to humans
Sophomores Noelle Fuchs and Jack Nowacek were manning an interactive research display for their team, Learning from Whales: Oxygen, Ecosystems and Human Health. At the center of their research question is the condition of hypoxia, which occurs when tissues are deprived of an adequate oxygen supply.
Hypoxia is implicated in a host of human diseases, such as heart attack, stroke, COVID-19, and cancer. But it is also one of the default settings for deep-diving whales, who have developed a tolerance for hypoxia as they dive into the ocean for hours while foraging.
The project, which has been around for four years, has two sub-teams. Fuchs, an Environmental Science and Policy major, was on the side of the team genetically mapping deep-diving pilot whales, beaked whales, and offshore bottlenose dolphins off the coast of Cape Hatteras to identify causal genetic variants for hypoxia tolerance within specific genes. Nowacek, a Biology and Statistics double-major, was on the other side of the research, analyzing tissue biopsies of these three cetaceans to conduct experiences on hypoxia pathways.
The team has compiled a closer, more interactive look into their research on their website.
And when asked about her experience being on this team and doing this research, Fuchs remarked that Bass Connections has been a “great way to dip my toe into research and figure out what I do and don’t want to do,” moving forward at Duke and beyond.
For more information about the team, including a full list of all team members, click here.
I recently had the pleasure of attending Professor Janet Malek’s lecture: Only Mostly Dead? The Evolving Ethical Evaluation of Death by Neurologic Criteria, a lecture sponsored by the Trent Center for Bioethics, Humanities & History of Medicine.
Dr. Malek is an associate professor in the Duke Initiative for Science & Society, and at the Baylor College of Medicine Center for Medical Ethics and Health Policy.
We don’t often talk about death. On the surface, it seems like it would be a straight-forward concept. You’re either dead, or you’re not dead. Right? It turns out that clinically defining death is not so simple.
Popular media has some grasp on the ambiguity of the definition of death. Remember this scene from the popular movie, The Princess Bride? Suspecting that the protagonist is dead, his friends bring him to a miracle-worker and have the following conversation.
Miracle Max: “Whoo-hoo-hoo, look who knows so much. It just so happens that your friend here is only MOSTLY dead. There’s a big difference between mostly dead and all dead. Mostly dead is slightly alive. With all dead, well, with all dead there’s usually only one thing you can do.
Inigo Montoya: What’s that?
Miracle Max: Go through his clothes and look for loose change.
In real life, death used to be determined by cardiopulmonary criteria – when the heart and lungs stop working. In recent decades the idea that death can be determined using neurologic criteria – when the brain stops working – has gained acceptance. As neuroscience and technology has evolved, so too have our definitions. Now that we know more about how the brain works, we know that there may be some brain activity even after a person has met the criteria for death by neurologic criteria (DNC). This leads to philosophically rich and practically relevant questions of ethics – for example, when do we stop providing life-sustaining care? In the field of bioethics and beyond, there is high demand for discussion on this topic.
There has been controversy over defining death since the 1650’s — when a woman named Anne Greene woke up after being hanged. It wasn’t until the 1980’s that a consensus definition of death was first identified. Here is a brief history:
Widespread availability of ventilators led to the identification of a state described as death of the neurological system.
Advances in organ transplantation foster discussion on the ethics of defining death.
A committee at Harvard Medical School examined the definition of Brain Death. They created a definition of “Irreversible Coma,” which focused on loss of neurological function.
The 1980 Uniform Determination of Death Act (UDDA) provided a legal basis for clinically determining death as: an individual who has sustained either 1) irreversible cessation of circulatory and respiratory functions OR 2) irreversible cessation of functions of the entire brain.
1981: President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research report. Findings are centered on questions of functioning of the organism as a whole and the brain’s role in coordinating it.
Clinicians arrive at general agreement that a patient in a state of coma or unresponsiveness, without brainstem reflexes and who fails an apnea test is dead by neurologic criteria. Largely it is accepted that “brain death is death” but there is not complete consensus.
2013: Case of Jahi McMath. A 13-year old girl was declared “brain dead” in California, and a death certificate was issued. However, the family fought to have her maintained on life support. They moved to New Jersey, the only state which recognized objections to brain death, and the “brain dead” declaration was reversed. Jahi lived there for 4 years before passing away. This famous case caused people to reconsider the concept of brain death.
Recent innovations in heart transplantation technology will likely challenge the acceptance of the Dead Donor Rule (DDR) which requires that an individual is clinically declared dead before vital organs are removed for transplantation.
2021: Assembly of the Determination of Death Committee, tasked with updating the Uniform Determination of Death Act (UDDA). Duke faculty (and founding director of Science & Society) Nita Farahany, is involved with this process.
What ethical issues and practical questions challenging Death by Neurologic Criteria (DNC) today? Dr. Malek shared the following case.
Following a tragic car accident, Ms. Jones, a 20-year-old college student, was brought to the hospital, having suffered significant anoxic brain injury. The medical team determined that she met criteria for DNC. However, her family refused to allow for further testing. Several days passed. Ms. Jones was maintained on life support, during which she did not show signs of improvement. After several difficult conversations, the family consented for assessment and Ms. Jones was declared dead — using the criteria associated with DNC.
What is the proper amount of time to continue life-sustaining treatment if a physician suspects the patient will never recover?
Although this may sound like an uncommon occurrence, nearly half of neurologists have been asked to continue neurologic support for patients that may meet criteria for DNC.
Obligating life support for patients suspected of meeting DNC, either through the family’s refusal for testing or by direct request, would likely result in ethical harms such as violation of the dignity of decedent, unjustly using scarce resources, or causing moral distress in caregivers.
However, it may be permissible to maintain life support in these situations. Dr. Malek says that we do not yet have a good ethical framework for this. Reasonable accommodations that are in line with professional guidelines probably have minimal impact, and might provide some psychosocial benefits to families.
Is consent required to test for DNC? Should it be?
These are extremely difficult questions, and there is continuing controversy over what the correct answers should be. Dr. Malek advises medical experts to work with healthcare administrators to develop clear institutional policies.
Post by Victoria Wilson, 2023 MA student in Bioethics & Science Policy
If you’re a doe-eyed first-year at Duke who wants to eventually become a doctor, chances are you are currently, or will soon, take part in a pre-med rite of passage: finding a lab to research in.
Most pre-meds find themselves researching in the fields of biology, chemistry, or neuroscience, with many hoping to make research a part of their future careers as clinicians. Undergraduate student and San Diego native Eden Deng (T’23) also found herself plodding a similar path in a neuroimaging lab her freshman year.
At the time, she was a prospective neuroscience major on the pre-med track. But as she soon realized, neuroimaging is done through fMRI. And to analyze fMRI data, you need to be able to conduct data analysis.
This initial research experience at Duke in the Martucci Lab, which looks at chronic pain and the role of the central nervous system, sparked a realization for Deng. “Ninety percent of my time was spent thinking about computational and statistical problems,” she explained to me. Analysis was new to her, and as she found herself struggling with it, she thought to herself, “why don’t I spend more time getting better at that academically?”
This desire to get better at research led Deng to pursue a major in Statistics with a secondary in Computer Science, while still on the pre-med track. Many people might instantly think about how hard it must be to fit in so much challenging coursework that has virtually no overlap. And as Deng confirmed, her academic path not been without challenges.
For one, she’s never really liked math, so she was wary of getting into computation. Additionally, considering that most Statistics and Computer Science students want to pursue jobs in the technology industry, it’s been hard for her to connect with like-minded people who are equally familiar with computers and the human body.
“I never felt like I excelled in my classes,” Deng said. “And that was never my intention.” Deng had to quickly get used to facing what she didn’t know head-on. But as she kept her head down, put in the work, and trusted that eventually she would figure things out, the merits of her unconventional academic path started to become more apparent.
Research at the intersection of data and health
Last summer, Deng landed a summer research experience at Mount Sinai, where she looked at patient-level cancer data. Utilizing her knowledge in both biology and data analytics, she worked on a computational screener that scientists and biologists could use to measure gene expression in diseased versus normal cells. This will ultimately aid efforts in narrowing down the best genes to target in drug development. Deng will be back at Mount Sinai full-time after graduation, to continue her research before applying to medical school.
But in her own words, Deng’s most favorite research experience has been her senior thesis through Duke’s Department of Biostatistics and Bioinformatics. Last year, she reached out to Dr. Xiaofei Wang, who is part of a team conducting a randomized controlled trial to compare the merits of two different lung tumor treatments.
Generally, when faced with lung disease, the conservative approach is to remove the whole lobe. But that can pose challenges to the quality of life of people who are older, with more comorbidities. Recently, there has been a push to focus on removing smaller sections of lung tissue instead. Deng’s thesis looks at patient surgical data over the past 15 years, showing that patient survival rates have improved as more of these segmentectomies – or smaller sections of tissue removal – have become more frequent in select groups of patients.
“I really enjoy working on it every week,” Deng says about her thesis, “which is not something I can usually say about most of the work I do!” According to Deng, a lot of research – hers included – is derived from researchers mulling over what they think would be interesting to look at in a silo, without considering what problems might be most useful for society at large. What’s valuable for Deng about her thesis work is that she’s gotten to work closely with not just statisticians but thoracic surgeons. “Originally my thesis was going to go in a different direction,” she said, but upon consulting with surgeons who directly impacted the data she was using – and would be directly impacted by her results – she changed her research question.
The merits of an interdisciplinary academic path
Deng’s unique path makes her the perfect person to ask: is pursuing seemingly disparate interests, like being a Statistics and Computer Science double-major on the pre-med, track worth it? And judging by Deng’s insights, the answer is a resounding yes.
At Duke, she says, “I’ve been challenged by many things that I wouldn’t have expected to be able to do myself” – like dealing with the catch-up work of switching majors and pursuing independent research. But over time she’s learned that even if something seems daunting in the moment, if you apply yourself, most, if not all things, can be accomplished. And she’s grateful for the confidence that she’s acquired through pursuing her unique path.
Moreover, as Deng reflects on where she sees herself – and the field of healthcare – a few years from now, she muses that for the first time in the history of healthcare, a third-party player is joining the mix – technology.
While her initial motivation to pursue statistics and computer science was to aid her in research, “I’ve now seen how its beneficial for my long-term goals of going to med school and becoming a physician.” As healthcare evolves and the introduction of algorithms, AI and other technological advancements widens the gap between traditional and contemporary medicine, Deng hopes to deconstruct it all and make healthcare technology more accessible to patients and providers.
“At the end of the day, it’s data that doctors are communicating to patients,” Deng says. So she’s grateful to have gained experience interpreting and modeling data at Duke through her academic coursework.
And as the Statistics major particularly has taught her, complexity is not always a good thing – sometimes, the simpler you can make something, the better. “Some research doesn’t always do this,” she says – she’s encountered her fair share of research that feels performative, prioritizing complexity to appear more intellectual. But by continually asking herself whether her research is explainable and applicable, she hopes to let those two questions be the North Stars that guide her future research endeavors.
At the end of the day, it’s data that doctors are communicating to patients.
When asked what advice she has for first-years, Deng said that it’s important “to not let your inexperience or perceived lack of knowledge prevent you from diving into what interests you.” Even as a first-year undergrad, know that you can contribute to academia and the world of research.
And for those who might be interested in pursuing an academic path like Deng, there’s some good news. After Deng talked to the Statistics department about the lack of pre-health representation that existed, the Statistics department now has a pre-health listserv that you can join for updates and opportunities pertaining specifically to pre-med Stats majors. And Deng emphasizes that the Stats-CS-pre-med group at Duke is growing. She’s noticed quite a few underclassmen in the Statistics and Computer Science departments who vocalize an interest in medical school.
So if you also want to hone your ability to communicate research that you care about – whether you’re pre-med or not – feel free to jump right into the world of data analysis. As Deng concludes, “everyone has something to say that’s important.”
Imagine a robot small enough to fit on a U.S. penny. Or even small enough to rest on Lincoln’s chest. It sounds preposterous enough. Now, imagine a robot small enough to rest on the chest of Lincoln – not the Lincoln whose head decorates the front side of the penny, but the even tinier version of him on the back.
Before it was changed to a Union Shield, the tail side of pennies contained the Lincoln Memorial, including a miniscule representation of the seated Lincoln statue that rests inside. Barely visible to the naked eye, this miniature Lincoln is on the order of a few hundred micrometers wide. As incredible as it sounds, this is the scale of robots being built by Professor Itai Cohen and his lab at Cornell University. On February 22, Cohen shared several of his lab’s cutting-edge technologies with an audience in Duke’s Schiciano Auditorium.
To begin, Cohen describes the challenge of building robots as consisting of two distinct parts: the brain of the robot, and the brawn. The brain refers to the microchip, and the brawn refers to the “legs,” or actuating limbs of the robot. Between these two, the brain – believe it or not – is the easy part. As Cohen explains, “fifty years of Moore’s Law has solved this problem.” (In 1965, Gordon Moore theorized that roughly every two years, the number of transistors able to fit on microchips will double, suggesting that computational progress will become exponentially more efficient over time.) We now possess the ability to create ridiculously small microcircuits that fit on the footprint of a few micrometers. The brawn, on the other hand, is a major challenge.
This is where Cohen and his lab come in. Their idea was to use standard fabrication tools used by the semiconductor industry to build the chips, and then build the robot around the chip by folding the robot into the 3D shape they desired. Think origami, but at the microscopic scale.
Like any good origami artist, the researchers at the Cohen lab recognized that it all starts with the paper. Using the unique tools at the Cornell Nanoscale Facility, the Cohen team created the world’s thinnest paper, including one made out of a single sheet of graphene. To clarify, that’s a single atom thickness.
Next, it came to the folding. As Cohen describes, there’s really two main options. The first is to shrink down the origami artist to the microscopic level. He concedes that science doesn’t know how to do that quite yet. Alas, the second strategy is to have the paper fold itself. (I will admit that as an uneducated listener, option number two sounds about as absurd as the first one.) Regardless, this turns out to be the more reasonable option.
The basic process works like this: a seven nanometer thick platinum layer is coated on one side with an inert material. When put in a solution and voltage applied, ions that are dissociated in the solvent will absorb onto the platinum surface. When this happens, a stress is created that bends the device. Reversing the voltage drives away the ions and unbends the device. Applying stiff elements to certain regions restricts the bending to occur only in desired locations. Devices about the thickness of a hair diameter can be created (folded and unfolded) using this method.
As incredible as this is, there is still one defect: it requires a wire to an external power source that attaches onto the device. To solve this problem, the Cohen lab uses photovoltaics (mini solar panels) that attach directly onto the device itself. When light is shined on the photovoltaic (via sunlight or lasers), it moves the limb. With this advance and some continuous tweaking, the Cohen lab was able to develop the world’s smallest walking robot.
The Cohen Lab also achieved “BroBot” – a microrobot that “flexes his muscles” when light is shined on the front photovoltaics and truly “looks like he belongs on a beach somewhere.”
The Cohen Lab successfully eliminated the need for any external wire, but there was still more left to be desired. These robots, including “BroBot” and the Guinness World Record-winning microrobot, still required lasers to activate the limbs. In this sense, as Cohen explains, the robots were “still just marionettes” being controlled by “strings” in the form of laser pulses.
To go beyond this, the Cohen Lab began working with a commercial foundry, X-Fab, to create microchips that would act as a brain that could coordinate the limb movements. In this way, the robots would be able to move on their own, without using lasers pointed at specific photovoltaics. Cohen describes this moment as “cutting the strings on the marionette, and bringing Pinocchio to life.”
This is the final key step in the development of Ant Bot: a microrobot that moves all on its own. It uses a hexapod gate, meaning a tripod on each side. All that has to be done is placing the robot in sunlight, and the brain does the rest of the coordination.
The potential for these kinds of microrobots is nearly limitless. As Cohen emphasizes, the application for robots at the microscale is “basically anything you can imagine doing at the macroscale.” Cleaning surfaces, transporting cargo, building components. Perhaps conducting microsurgeries, or exploring new worlds that appear inaccessible. One particularly promising application is a robot that mimics that movement of cilia – the microscopic cellular hair responsible for countless locomotion and sensory functions in the body. A cilia-covered chip could become the basis of new portable diagnostic devices, enabling field testing that would be much easier, cheaper, and more efficient.
The researchers at the Cohen Lab envision a possible future where microscopic robots are used in swarms to restructure blood vessels, or probe large swathes of the human brain in a new form of healthcare based on quantum materials.
Until now, few would have imagined that the ancient art of origami would predict and enable technology that could transform the future of medicine and accelerate the exploration of the universe.
We live in a country where 80% of both Democrats and Republicans believe that the other political party “poses a threat that if not stopped will destroy America as we know it.” Lovely.
A 2020 study found that only 3.5% of voters would avoid voting for their preferred candidate if that candidate engaged in undemocratic behavior. In 2022, 72% of surveyed Republicans said that Democrats are more immoral than other Americans, and 83% of Democrats said that Republicans are more close-minded than other Americans. Political polarization is apparently increasing faster in the U.S. than in other democracies, but Americans aren’t just divided along political lines. Other aspects of identity, like religious beliefs, can spawn discord as well. In the U.S., 70% of atheists think religious organizations “do more harm than good,” but 44% of Americans still think that you must believe in God “in order to be moral and have good values.”
Most Americans agree that polarization is a problem. But what can be done about it? The Trent Center for Bioethics, Humanities, and History of Medicine recently hosted a conversation between two people who have spent much of their careers engaging with many different beliefs and perspectives. A recording of the talk can be found here.
Molly Worthen, Ph.D., Associate Professor of History at UNC and a freelance journalist, grew up in a “secular, totally nonreligious home,” but courses she took in college made her realize that “for a huge swath of humanity, over the course of our history,” religion has helped people find meaning and community. She has explored religion extensively through her work as a historian, author, and journalist. Worthen says she has “way too risk-averse a temperament to be a full-time journalist,” but one advantage of journalism is that it provides “an excuse to ask people questions.”
Emma Green, a journalist at The New Yorker, has also covered religion in her writing and spent time engaging with people and communities who hold a wide variety of beliefs. Green believes that “the most interesting stories are often about the debates communities are having within themselves.” These debates aren’t just about religion. In communities of all kinds, people with different and often opposing beliefs navigate disagreements with their best friends, neighbors, and family members as they engage with polarizing issues and try to find ways to coexist.
The process of interviewing people with differing worldviews and beliefs can bring challenges, but both Worthen and Green have found that those challenges are not insurmountable. “If you do your homework and you really make a good-faith effort to learn where a person is coming from,” Worthen says, “they will tell you their story. They will not shut down.”
Worthen has spent time with a community of Russian Orthodox Old Believers in Alberta. It was an opportunity to make a “concerted effort to really get inside the worldview of someone very different from myself.”
Green has also spent time talking to and learning from religious communities. She published an article about Hyattsville Mennonite Church in Pennsylvania, which had been welcoming gay members for over a decade and had originally been “disciplined” by the Allegheny Mennonite Conference for its open acceptance of homosexuality. A decade later, the Conference gathered to determine whether the Hyattsville church should be allowed to rejoin the Conference or be removed from it altogether. (A third option, according to Green’s article, was to dissolve the Conference.) Green was struck by how the Mennonite community approached the dispute. They followed the formal “Robert’s Rules of Order,” but they also sang together in four-part harmony. The central dispute, Green says, was “about whether they could stay in community with one another.” Ultimately, the gay members were allowed to stay, though Green says that some people left the congregation in protest.
Polarization is a word we hear a lot, but why is it that we seem to have such a hard time finding common ground when it comes to important—or even seemingly unimportant—issues? Worthen points out that there seems to be a new survey every few years showing that “humans are generally impervious to evidence” that goes against our existing beliefs.
“Barraging a human with evidence doesn’t really work,” Worthen says. According to her, theologians and philosophers have long said that “we are depraved, irrational creatures, and the social science has finally caught up with that.”
This hesitancy to even consider evidence that conflicts with our existing beliefs has implications on public trust in science. Too often, “believing in science” takes on political implications.
According to Pew Research Center, only 13% of Republicans have “a great deal” of confidence in scientists, compared to 43% of Democrats. “Many people on the left think of the universities as belonging to them,” says Worthen, leading to a greater sense of trust in science. “There is a desire on the left to want science to line up” with their political views, Green agrees, but good science isn’t inherently aligned with a particular political party. Science involves uncertainty and “iterative self-correction,” Worthen says, but even acknowledging uncertainty can spawn controversy. And when science doesn’t perfectly align with someone’s political or ideological beliefs, it can make people uncomfortable. For instance, Worthen believes that “the retreating date of viability” for fetuses and better fetal imaging technology is “provoking… discomfort on the left” in conversations about abortion.
Similarly, evidence from evolutionary biology can be hard to reconcile with deeply held religious beliefs. Worthen describes an interview she did with Dr. Nathaniel Jeanson. He has a Ph.D. from Harvard in cell and developmental biology, but he is also a Young Earth creationist who believes the earth was created by God in six days. There are “plenty of conservative Christians who understand those days as metaphors,” Worthen says, but Jeanson takes the six-day timeframe described in the Bible literally. In Worthen’s article, she says that Jeanson “dutifully studied evolutionary biology during the day and read creationist literature at night.” One thing Worthen admired in Jeanson was his willingness to be “honest about who we are”: not very open to new evidence.
“I think very few humans are anti-science,” Worthen says. “It’s more that humans are selectively pro-science.”
It isn’t just politics that can cause people to distrust science. Green points out that people who have had frustrating experiences with traditional healthcare may look for “other pathways to achieving a sense of control.” When patients know that something is wrong, and mainstream medicine fails them in some way, they may turn to alternative treatments. “That feeling of not being understood by the people who are supposed to know better than you is actually pretty common,” Green says, and it can fuel “selective distrust.”
It can be helpful, Worthen says, for a clinician to present themselves as someone trustworthy within a larger system that some patients view as “suspect.”
Distrust in public health authorities has been a recurring theme during the Covid pandemic. Green recalls interviewing an orthodox Jewish man in New York about his community’s experiences during the pandemic. Many Orthodox Jewish communities were hit hard by Covid, and Green believes it’s important to recognize that there were many factors involved. Even well-meaning health officials often lacked the language skills to speak dialects of Yiddish and other languages, and the absence of strong, pre-existing relationships with Orthodox communities made it harder to build trust in the middle of a crisis.
Worthen spoke about vaccine hesitancy. “For most of the population who has gotten the [Covid] vaccine,” she says, “it’s not because they understand the science but because they’re willing to ‘outsource’” their health decisions to public health authorities. It is “important not to lose sight of… how much this is about trust rather than understanding empirical facts.”
Finally, both speakers discussed the impacts of social media on polarization. According to Green, “information ecosystems can develop in social media and become self-contained.” While “there are a lot of people out there who are quacks who purport to be experts,” social media has also created public health “stars” who offer advice and knowledge to a social media audience. Even that, however, can have downsides. “There isn’t a lot of space for uncertainty, which is a huge part of science,” Green says.
Worthen, meanwhile, believes that “social media is one of the main assets destroying our civilization…. I would encourage everyone to delete your accounts.”
Polarization is pervasive, dangerous, and difficult to change. “As a journalist, I basically never have answers,” Green says, but maybe learning from journalists and their efforts to understand many different perspectives can at least help us begin to ask the right questions. Learning to actually listen to each other could be a good place to start.