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Scholars Examine Duke’s History of Unequal Medical Care for Black People

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Conversations on and actions toward making American medicine less racist continue to grow. At Duke, that includes looking at our own history as a hospital and medical center serving a diverse community.

In a Sept. 22 virtual conversation, Duke physicians Damon Tweedy M.D., Associate Professor of Psychiatry and Behavioral Sciences, and Jeffrey Baker M.D., Ph.D., Director of the Trent Center for Bioethics, Humanities, and History of Medicine, spoke about the history of Duke’s legacies of race and memory. (Watch the presentation here.)

The career of Dr. Baker, who is a professor of both pediatrics and history, has taken him around the globe, right back to his hometown of Durham –where he said he has found the most interesting story of all.

After becoming Director for the Trent Center in 2016, he was approached with “hunger” by Durham natives to know their hometown’s story. Through oral and archival sources, Dr. Baker has broached Duke hospital’s history with humility in hopes of uncovering and contextualizing the historical roles of race in Duke medicine and Durham.

Dr. Tweedy, author of Black Man in a White Coat, attended Duke for medical school in the 1990s. He was warned that it was a plantation and an institution built on tobacco and slave money.

Though Dr. Baker proposed that in many ways the hospital structure often reflects plantation hierarchies in which there is racialization of who holds what jobs and power, he said Duke’s endowment money actually came from technological progress within tobacco production rather than slavery or plantations directly.

The Duke family’s vision for the hospital was quite different from actual outcomes in practice, Dr. Baker said. The Dukes were considered racial progressives in their time and the endowment they provided to launch the Duke Medical School and Hospital in 1930 was meant to improve health and education in North Carolina and train primary care doctors for the state.

“However,” Dr. Baker said, “there were two realities: Jim Crow and the Great Depression.”

Dr. Tweedy and Dr. Baker via Zoom

During the era of Jim Crow segregation, Duke’s primary care doctors were all white, and nearly all male. Though the hospital cared for both Black and white patients, they were segregated by race. Black patients had separate wards, and waiting areas for pediatric care were separated racially by days of the week. Waiting areas for adult patients functioned without appointments, but only white people were seen before noon. It’s likely that the care granted to white people in the first half of the day was superior to that of Black people receiving care at 4 pm or told to return the next day, he said.

Original floor plans for the Duke Hospital.

The Great Depression also generated a diversion from plans in the 1940s. When the Duke Hospital came close to bankruptcy, it chose to open private clinics on the side for revenue – which had an unintended consequence. The clinics brought a lot of money into Duke, Dr. Baker said, but it also reinforced distinctions between those who could pay for treatment and those who couldn’t. Over time, the disparities expanded with shifts towards hospital beds for insured and private patients.

In one terrible example, Maltheus “Sunny” Avery, a North Carolina A & T graduate who got into a car wreck in Burlington, NC in 1950, was diagnosed with an epidermal hematoma — a clot near his brain — and sent to Duke for emergency brain surgery. But he was refused treatment due to inadequate room in the “colored” ward.

Avery was redirected to Lincoln Hospital, Durham’s Black hospital, where he died shortly after admission. Though Dr. Baker said this story quickly faded from white memory, it is something that has retained severe importance in the popular memory of Black Durhamites. This narrative is also often conflated with a similar story about Dr. Charles Drew, the Black inventor of blood banking, who died despite attempts at rescue at a white hospital in Alamance, NC. He is often misremembered as having died from the refusal of care in a racially divided South, even though he was not.

News coverage of Sunny’s death.

Duke’s first Black medical student, Delano “Dale” Meriwether, arrived the same year the hospital began desegregation, 1963, and he was the first Black M.D. in 1967. Meriwether was the only Black medical student for four years before other brave pioneers joined the school.

Dr. Tweedy reflected on his own medical school experiences at Duke during clinical rotations just a little more than 20 years ago.

“I was asked to help suture a deep gash on a Black patient’s forehead,” he said, “The patient asked if we were experimenting on him since I was still a student.” In the private clinics, he once “couldn’t go anywhere near” a white patent with a minor lesion on their arm, let alone suture that patient.

Dr. Baker said there are two narratives surrounding Duke Hospital’s desegregation. One assumes that desegregation was quick and easy and uneventful, while the other proposes that systems of racial segregation were simply transformed rather than eradicated. The latter narrative better applies to the public and private clinics that had become nearly completely racialized over time, Baker said.

Even though segregation was no longer legal,  Black patients received care from less experienced medical residents in the public clinics, while white patients received care from attending physicians in the nicer, private environments.

Dr. Baker said that Duke has a complicated relationship with the community of Durham. He said the merger of Durham Regional Hospital with Duke Health in the late 1990s tapped into some long-term tensions and distrust between Duke and other medical facilities of Durham.

Dr. Tweedy pointed out that Duke researchers always have trouble recruiting Black patients for clinical studies, despite the fact that Durham County is about half Black and Hispanic. There is some distrust to overcome, but a diverse patient population is essential to creating robust study data that ensures that treatments will work for everyone, he said.

Medical professionals “need more than just science,” Baker concluded. He said that being trained as scientists often inclines doctors to think that they are above the larger contexts and histories they exist within, and that they can somehow remain objective.

“We have come out of specific stories and backgrounds,” Dr. Baker said. “[When we treat patients], we have to think about what story we are walking into.”

“We all carry our bags of ‘stuff'” that complicate patient prognosis and care, Dr. Tweedy concurred.

As Ann Brown (M.D., M.H.S), Vice Dean for Faculty, stated at the beginning of the conversation, “In order to move forward, we must understand where we come from.”

This is true of our nation as a whole, and Duke is certainly no exception.

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

Contaminated Drinking Water in Our Backyard

About 70% of the human body is made up of water. Water is something we consume on a daily basis. Therefore, when a community’s water source is threatened or contaminated it can be extremely detrimental. 

In 2017, it became apparent that there was water contamination in eastern North Carolina. Specifically, PFAS or per- and polyfluoroalkyl Alkyl chemicals were found in the water supply. As a result, several legislative mandates were issued in 2018 establishing a PFAS Testing Network to investigate the contamination.

Lee Ferguson, an Associate Professor of Civil and Environmental Engineering at Duke and Kathleen Gray, a professor at UNC’s Institute for the Environment, are testing PFAS water contamination and communicating any risks to the public. 

Gray is part of the network’s risk communication team. She explained that PFASs are hard to address because the health effects are unknown and they have yet to determine a standard or guideline for these substances. However, because this water contamination affects the lives of everyone connected to the water supply it is extremely important to communicate risk to the affected community but without eliciting panic. 

Gray explained that people often ask, “Are my family and I safe?” “What can I do to protect myself and my family?” “Why did this happen?” and “Why wasn’t it prevented?”

In the last year Ferguson and his research team have tested 409 sites in North Carolina for PFAS compounds.

He explained that PFAS substances are particularly dangerous because they are non-degradable, potentially toxic and constantly changing. Long-chain PFASs are being replaced by fluorinated alternatives.

Ferguson described this phenomenon as “playing environmental ‘whack-a-mole’ with different substances.”

Ferguson and his testing team have found two contaminated water supply sites in North Carolina. Dangerous contamination is based on the EPA health advisory level of 70ng/Liter. The exceedances were found in Maysville and Orange Water and Sewer Authority. Maysville was able to switch to the Jones County water source once the problem was identified.

New data that came in within the last couple weeks found high month-to-month variability in PFAS in the Haw River near Pittsboro. Ferguson and his team predict that it is coming downstream from a waste treatment plant. 

Brunswick County is shown having the worst PFAS concentrations. However, Dr. Ferguson and his team have recently found that the contamination in Haw River is even worse.

While all of this information may seem very alarming, Gray and Ferguson both reiterated that it is not necessary to panic. Instead, people should make sure they are drinking filtered water or invest in a water filter. 

Ferguson added, “The best choice is reverse osmosis.”

Gray and Ferguson presented their work at a SciComm Lunch-and-Learn, a monthly event sponsored by Duke Science & Society Initiative that explores interesting and innovative aspects of science communication. The event is free and open to anyone in the Duke community.

By Anna Gotskind

Republican to RepublicEn: Climate Change for Conservatives

My mom’s calling—we talk every day. She asks me if I’ve eaten, and I complain about the usual: essays, exams, horrifying clumps of hair on the shower floor. 

Bob Inglis, former Congressman and speaker at the Change My Mind Symposium during Duke Energy Week.

I sit on the steps of the chapel, a warm yellow against a silent sky. Durham is chilly tonight. Cloudy, starless, I feel rain coming. My fingers — naked, against my phone and ear —fare worst, somewhere between cold and numb. They crave my pocket’s warmth, and I tell my mother goodbye.

“Wait, Mom, before I go, did you see the climate change report?”

And with a single sentence, cordial relations are over, and little things like “familial love” fall away. Constructed arguments become a battle of volume. Mom, if we don’t do anything, millions will die. But, Jeremy, she says, climate change is natural — and these summits, they’re PR moves, politicians don’t actually care. In the ring, it’s Me vs. Mother, Ali vs. Frazier, Democrat vs. Republican. An hour in, I’ve forgotten the cold — hell, I’m sweating in self-righteous anger.

These little spats parallel increasingly intense partisanship in the United States. Hot-button topics fuel the divide, with gun control, abortion rights, and impeachment splitting Democrats and Republicans along party lines. Particularly contentious is climate change. While 84% of Democrats “consider climate change a ‘major threat,’” only a fourth of Republicans feel the same. 

Enter Bob Inglis, former US Congressman and 1981 Duke alumnus. Inglis represented South Carolina’s 4th House district, one of the reddest regions in the nation. Initially, he wasn’t so hot on global warming himself. “For years, I was in Congress saying climate change was nonsense,” he says, laughing. “I didn’t know anything about it except that Al Gore was for it.

But what changed his mind?

“Inglis 2.0,” as he calls it, began with his son in 2004, who pushed him to adopt greener policies. Next was the increasing body of evidence that proved climate change undeniable. But it would take a spiritual awakening to transform Inglis’s views. On a snorkeling trip to the Great Barrier Reef, Inglis met oceanographer Scott Heron. The two were kindred spirits, and in Heron’s conservation work, Inglis saw a love for God. For Inglis, “Conservation became loving God and loving people,” he says.        

Inglis addresses free-enterprise solutions to climate change
(Source: Duke University Energy Initiative)

In 2009, he introduced the “Raise Wages, Cut Carbon Act” designed to curb global warming. Central to the bill was a carbon tax, which puts a price on carbon-based fuel use. Voter backlash was swift. “They were having a Tea Party— and I was specifically uninvited,” Inglis chuckles. In the 2010 election, he was soundly defeated in a primary race against Trey Gowdy, largely in response to the carbon tax. 

But Inglis didn’t stop there. In 2012, he founded republicEn, an organization that promotes free enterprise solutions to global warming. republicEn targets a right-wing audience—those most hesitant to accept global warming. 

The core of republicEn is its online community. Thousands of members convene in local events and write letters to Congress advocating a carbon tax solution. Dedicated spokespeople also tour the nation to promote the need for conservative leadership. Both benefit from republicEn’s media wing, which gives conservative voices a platform for climate change.

Inglis firmly believes that conservative solutions are key to fighting climate change. Citing the explosion of smartphones, he poses a question: would the cell phone industry have grown as rapidly had it been intensely regulated? He doubts it. Similarly, he sees free market solutions as the fastest way to slow global warming.

republicEn has no set timeline, no five-year plan. But Inglis is hopeful: “You weren’t there when we marched in Selma, but you can be there when we solve climate change.” 

Post by Jeremy Jacobs

From Jails to Detention Centers: a Disconcerting Immigration History

The political climate for the past ten years has been anything but calm, and central to political struggles in D.C. and elsewhere has been the ethical issues surrounding immigrant detention. But for Brianna Nofil (T ‘12), there has never been a better time to research the questions that intrigue her the most.  

A native of South Florida, Nofil has felt the undercurrent of immigration tensions throughout her life as a resident of a region with a large population of immigrants. Central to this tension was Krome Detention Center — a looming, overpowering presence in her community. Krome, which was a missile testing facility for most of 20th century, has only recently been converted to an institution to house detained immigrants. Krome had always been there, but exactly what its existence meant in her hometown was not usually acknowledged, and as Nofil remarked, “There was a reason people living there had a hazy understanding of what was going on.” 

While at Duke, Nofil, who double majored in history and public policy studies with a minor in education, let her experiences growing up lead her to a senior thesis on the history and privatization of U.S. immigration detention — which, according to Duke history professor Gunther Peck, was nothing less than “stunning.” In a round-table forum on October 1, Nofil delved deeper into her central academic interests — of which she has written about in publications such as Time and Atlas Obscura — as well as her current studies as a doctoral candidate at Columbia University.

Jose A. Iglesias for the Miami Herald

Coming to Duke, Nofil used the resources and classes in the history department to answer two chief questions: what power structures were in place to confirm an institution like Krome’s significance in the community? And where exactly did this power come from?  

These questions lead her to her current focus at Columbia, which is the history of immigrant detention centers in the 20th century. Her main argument? “U.S immigration has always really relied on jails.” 

By the early 1900s, immigration was taking hold as a major historical event in the U.S and the federal government took its chances on what it saw as the perfect solution — let local communities handle immigration, and thus control what could (and eventually would become) a growing problem. This led to a network of contracts in the 20th century that paid sheriffs of small, lower-income towns all over America a nightly rate to “board” immigrants in jails. 

One case study, as Nofil points out, centered around Chinese immigrants in the early 1900s who came to northern New York from Canada. They were held in local jails all throughout the county while their cases were processed, and communities see the booming immigrant detention business as net-positive for the community. Within mere months, these Chinese jails had created an arms race of sorts. Communities competed and clamored for more contracts from the federal government as they saw incomes in their town continue to grow. 

It’s easy to see the moral dilemma of profiting off of detaining immigrants, but what is even more concerning is why the federal government pawned off a federal responsibility to communities, thus ensuring a lack of standardization in immigrant treatment across the country. So while there was relative support surrounding the business, unease soon began to emerge. As quota laws and anti-trafficking measures were created, Canadian and European immigrants also made their way over to the U.S, prompting foreign countries to finally notice  — and ask — whether communities utilizing prisons as detention centers was ethically sound. Newspapers around this time started publishing op-eds and editorials, and soon a resistance against profiting off of jailing immigrants cropped up — something Nofil adds is “inspiring” to see, especially in the context of our own times. 

The perpetual failure of jails has allowed immigration in the modern day to position big detention centers as a humane alternative. But what does that mean for immigration detention today? As Nofil posits, early forms of resistance are inspiring because it assures us that jailing immigrants was always questioned by communities, even at that time. Communities were capable of distinguishing right from wrong, even amidst the issue of immigration where the makeup and economy of their communities were at risk of changing. As the conversation concluded, one central theme seemed to stand out — that to understand the consequences of immigration detention centers, we must look to the past to see how detention started, and only by understanding the origins can we work toward a better solution. 

By Meghna Datta
By Meghna Datta

Vaping: Crisis or Lost Opportunity?

Wikimedia Commons

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

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

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

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

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

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

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

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

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

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

However, according to Davis, there is a flipside. 

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

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

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

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

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

So where do we go from here? 

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

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

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

By Zella Hanson

Innocent Until Proven Guilty? Well, That Depends

This is the last of eight blog posts written by undergraduates in PSY102: Introduction to Cognitive Psychology, Summer Term I 2019.

In the criminal justice system, one might imagine that the more serious a crime is, the more extensive the evidence should be to support the verdict. However, a recent study conducted at Duke University finds that jurors assessment of guilt is less reliant on the type of evidence and more on the severity of the crime.

Mock jurors in the study were more likely to find someone charged with murder guilty than someone charged with robbery.

A still from the movie “Twelve Angry Men” (1954), a tense drama about jury deliberations.

Numerous scholars have looked at how flawed forensic evidence, mistaken eyewitness identifications and defendants’ prior criminal convictions can introduce errors in criminal prosecutions.

But John Pearson, an assistant professor in four Duke departments including neurobiology, and his colleagues in law wanted to know whether the type of crime can also lead to a greater chance of wrongful conviction. It may be that jurors use moral and emotional responses to various crimes as reasoning for the decisions they make regarding the defendant’s guilt.

The researchers aimed to understand the relationship between crime severity and confidence in guilt by seeing how mock jurors, practicing prosecutors, and other practicing lawyers weigh various types of evidence in order to make a decision on guilt.

John Pearson

Participants in the study were subjected to about 30 crime scenarios, each one paired with a random variety of types of evidence. After participants read through each respective scenario, they rated the strength of the case on a 0-100 scale and their emotional and moral responses.

It appeared that the more threat or outrage they felt toward crime type, the more likely they were to find the defendant guilty.

The authors also tested different types of evidence’s potential interaction with people’s beliefs.

They found that both DNA and non-DNA physical evidence had the highest amount of influence on participants, but the difference between how the participants weighed them was small. The jurors appeared to place very similar, if not the same amount of weight onto these two types of evidence in terms of their confidence.

Pearson refers to juror’s equal weight of DNA and non DNA evidence as the “CSI effect.” But DNA evidence is far more reliable than non DNA evidence. The CSI effect lays out that jurors tend to give more weight to conclusions based on traditional evidence. The study found that no matter one’s position, the pattern of similar weight between the DNA and non DNA evidence was found across all groups. The study also states that “subjects tend to overweight widely used types of forensic evidence, but give much less weight than expected to a defendant’s criminal history.”

Along with finding similar patterns between confidence in guilt and evidence type, researchers also discovered an intense link between the subject’s confidence in guilt with the severity of the crime.

Notably for jurors, crime type highly influenced their perception of confidence in guilt. The study showed a positive correlation between personal, emotional, and moral biases and “adjudicative bias,’ or the likelihood of conviction.

And while jurors did show more of a trend in this finding, practicing lawyers and prosecutors also exhibited a crime-type bias correlation with the seriousness of crime, even though it was much smaller.

The study’s results model how punishment, outrage, and threat are almost entirely dependent on crime effect and crime scenario. This indicates that despite how much evidence was presented, crime type alone influenced jurors decisions to charge someone as guilty of that crime more frequently.

(Bang) Guilty!

This could mean that regardless of how much evidence or what type of evidence is present, innocent people wrongly charged of crimes could more easily be convicted if it is a more severe offense.

These findings indicate how easy it is to reach wrongful convictions of severe crimes within the US criminal justice system.

Guest post by Casey M. Chanler

A How-To Guide for Climate-Proof Cities

Roughly 400 miles separate Memphis and New Orleans. Interstate 55 connects the two cities, snaking south parallel to the Mississippi River. The drive is dull. There are few cars. The trees are endless.

South of the Louisiana border, the land turns flat, low, and wet. The air grows warmer, and heavy with moisture. I-55 cuts through the center of Maurepas Swamp, a 100,000-plus acre tract of protected wetlands. Groves of gumball and oak are rare here—instead, thin swamps of bald cypress and tupelo trees surround the highway on either side. At night, only their skeletal silhouettes are visible. They rise from the low water, briefly illuminated by passing headlights. Even in the dark, the trees are unmistakably dead.

*  *  *

A healthy cypress swamp in Lake Martin, Louisiana (Source: U.S. Geological Survey)

Traditionally, Maurepas Swamp serves as a natural barrier against flooding that threatens New Orleans each year. Native flora soaks up the rainfall, spreading it across a network of cypress roots and cattail. But centuries of logging and canal construction have drastically altered the swamp’s ecological composition. The Mississippi levee system compounded the issue, isolating the swamp from vital sources of fresh water and nutrients. Flooded with saltwater, much of the existing cypress withered and died. Young trees, now, are few and scattered. 

Maurepas Swamp highlights the danger of even the most well-intentioned changes to the  environment. This problem is hardly unique to the wetlands. “Many of the issues that we are experiencing today were seen as solutions in the past,” says Nancy Grimm, a professor of ecology at Arizona State University. “What we want to do now is to think about the future, so that the solutions of today don’t become the problems of tomorrow.”

Nancy Grimm addresses urban sustainability at the 2019 Henry J. Oosting Memorial Lecture in Ecology. (Source: Nicholas School of the Environment)

Grimm is the co-director of the UREx Sustainability Research Network. UREx aims to climate-proof urban municipalities without sacrificing environmental stability. To do so, UREx has partnered with several cities across the United States and Latin America. Each city hosts a workshop geared towards municipal decision makers, such as government officials,  environmental NGOS, and more. Together, these participants design different “futures” addressing their cities’ most pressing concerns. 

Phoenix, Arizona is one of the nine initial cities partnering with UREx. One of the hottest cities in the United States, Phoenix is already plagued with extreme heat and drought. By 2060, Phoenix is projected to have 132 days above 100°F—a 44 percent increase from data collected in 2010.  

UREx doesn’t dwell too much on these statistics.  “We’re bombarded constantly by dystopian narratives of tomorrow,” says Grimm, with a slight smile. “Instead, what we want to think about are ways we can envision a more positive future.”

The Phoenix workshop produced five distinct visions of what the city could look like in sixty years. Some scenarios are more ambitious than others—“The Right Kind of Green,” for example, imagines a vastly transformed city defined by urban gardens and lush vegetation. But each vision of Phoenix contains a common goal: a greener, cooler city that retains its soul. 

A visualization accompanies each scenario. In one, a family walks about a small orchard. The sky is blue, and the sun is out. But no one seems bothered by the heat. The oranges are vibrant; the trees thick, and full. It’s an idyllic future. But it’s one within grasp.  

Post by Jeremy Jacobs

‘Death is a Social Construct’

Of the few universal human experiences, death remains the least understood. Whether we avoid its mention or can’t stop thinking about it, whether we are terrified or mystified by it, none of us know what death is really like. Turns out, neither do the experts who spend every day around it.

Nobody who sees this guy reports back, so we can only guess.

This was the overarching lesson of Dr. Robert Truog’s McGovern Lecture at Trent Semans Center for Health Education, titled “Defining Death: Persistent Problems and Possible Solutions.”

Dr. Truog is this year’s recipient of the McGovern Prize, an award honoring individuals who have made outstanding contributions to the art and  science of medicine. Truog is a professor of medical ethics, anesthesiology and pediatrics and director of the center for bioethics at Harvard Medical School. He is intimately familiar with death, not only through his research and writings, but through his work as a pediatric intensive care doctor at Boston Children’s Hospital. Truog is also the author of the current national guidelines for end-of-life care in the intensive care unit.

In short, Truog knows a lot about death. Yet certain questions about the end of life remain elusive even to him. In his talk, he spoke about the biological, sociological, and ethical challenges involved in drawing the boundary between life and death. While some of these challenges have been around for as long as humans have, certain ones are novel, brought on by technological advancements in medicine that allow us to prolong the functioning of vital organs, mainly the brain and the heart.

The “irreversible cessation of function” of these organs results in brain and cardiac death, respectively. When both occur together, the patient is declared biologically dead. When they don’t, such as when all brain function except for those that support the patient’s digestive system is lost, for instance, the patient can be legally alive without any hope of recovery of consciousness.

Robert Truog teaching (Harvard photo)

According to Truog, it is in these moments of life after the loss of almost every brain function that we realize “death is a social construct.” This claim likely sounds counterintuitive, if not entirely nonsensical, as dying is the moment we have the least control over our biology. What Dr. Truog means, however, is that as technology continues to mend failures of biology that would have once been fatal, our social and philosophical understanding of dying, what he calls “person death” will increasingly separate from the end of the body’s biological function.  

Biologically, death is the moment when homeostasis, the body’s internal state of equilibrium including body temperature, pH levels and fluid balance, fails and entropy prevails.

Personhood, however, is not mere homeostasis. Dr. Truog cited Robert Veatch, ethicist at Georgetown University, in defining person death as the “irreversible loss of that which is essentially significant to the nature of man.” For those patients who are kept alive by ventilators and who have no hope of regaining consciousness, that essentially significant nature appears to have been lost.

Nonetheless, for loved ones, signs like spontaneous breathing, which can occur in patients in persistent vegetative state, intuitively feel like signs of life. This intuitive sign of life is what made Jahi McMath’s parents refuse an Oakland California hospital’s declaration that their daughter was dead. A ventilator kept the 13-year-old breathing, even though she had been declared brain-dead. After much conflict, McMath’s parents moved her to a hospital in New Jersey, one of just two states where families can reject brain death if it does not align with their religious beliefs. In the end, McMath had two death certificates that were five years apart.


Muslim cemetery at sunset in Marrakech Morocco.
(Mohamed Boualam via Wikimedia commons)

The emotional toll of such an ordeal is immense, as the media outcry around McMath made more than clear. There are more concrete, quantifiable costs to extending biological function beyond the end of personhood: the U.S. is facing an organ shortage. As people are kept on life support for longer periods, it is going to become increasingly difficult for patients who desperately need organs to find donors.

In closing, Dr. Truog reminded us that “in the spectrum between alive and dead, we set the threshold… Death is not a binary state, but a complex social choice.” People will likely continue to disagree about where we should set the threshold, especially as technology develops.

However, if we want to have a thoughtful discussion that respects the rights, wishes, and values of patients, loved ones, and everybody else who will one day face death, we need to first agree that there is a choice to be made.

Guest Post by Deniz Ariturk, Science & Society graduate student

Meet the Researcher Who Changed How We Care for Rape Survivors

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

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

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

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

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

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

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

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

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

Post by Anne Littlewood, Trinity ’21

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