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

Category: Responsible Conduct

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

Covid Tested the Resilience of Duke’s Research

Like nearly all other aspects of life, the normal routines of Duke research labs came to a grinding halt due to COVID-19. Duke researchers shared their reflections on the struggles and insights the process of research shutdown and reboot has had within their labs during a Virtual Research Town Hall on Thursday, September 3rd.

The Town Hall, titled “The Impact of COVID 19 on Research at Duke, Overcoming Challenges and Pressures” was moderated by Duke Vice President for Research, Larry Carin (Ph.D.). Dr. Carin mentioned that discussion of shutting down the research enterprise began in February, and at that point in time it seemed nearly hysterical. However, by mid-March shut-down plans were fully in progress, leaving labs out of commission until mid-June. To get research at Duke back underway, labs were forced to significantly reduce the density of people in facilities and no undergraduate students were allowed to participate.

Though most of the basic science labs are back in operation now, human subjects research trials have had a slower return. In no way is it business as usual. Detailed planning and scheduling, a focus on social distancing, and daily health surveys are all part of the new normal. “There is almost a Big Brother feel to this,” Dr. Carin said, comparing the moderated tracking of who enters facilities through their DukeCard swipes to George Orwell’s 1984 dystopian society.

Associate Professor Debra Silver Ph.D. spoke about her neurodevelopmental lab in molecular genetics and microbiology (MGM). In the three-month shutdown, lab members focused on writing reviews, grants, manuscripts, and took online classes to improve skills. Since re-opening, Silver’s lab has implemented lab shifts, pre-scheduled experiments, and coordinated use of shared equipment. Some of the biggest issues are the trainees missing out on critical networking and undergraduates forced to transition to nearly exclusively online work. Silver also voiced serious concern for the mental and physical health of lab members, logistical coordination of childcare and homeschooling, challenges faced by international trainees, and the need for flexibility. However, there were some silver linings as well. The Silver Lab engaged with lots of seminars, had joint lab meetings, and the mutual support for one another grew immensely under the unique circumstances.

Dr. West points out the enduring emotional impacts of COVID.

Both Silver’s lab and the West Lab, led by professor Anne West Ph.D. in neurobiology, are heavily reliant on mice for wet lab work. The mandates to reduce their mouse colonies by more than 50% was a large task and now that the labs are up and running, re-expanding the colonies has been a primary focus. West said that, similar to the Silver Lab members, half of her team picked up writing or a computational project while the other half attended online classes or meetings during shutdown. Undergraduates read and presented research papers – which turned out to be a very fruitful training experience.

One major roadblock for the West Lab’s reopening were the murders of George Floyd, Breonna Taylor, and Ahmoud Arbery. The civic unrest surrounding these deaths and the revivalism of the Black Lives Matter movement became a frequent point of discussion in lab meetings. Some members of the West Lab were unable to work during this time. West emphasized the importance of lowered expectations. She asked everyone to focus on one core experiment and to try to come into the lab for at least a few hours a day, a few days a week. The lab has been gaining traction with new data and research papers nearing completion. Like other panelists, West discussed prevailing issues including anxiety and depression, continued societal uncertainties, and the questionable financial future for research.

Assistant professor of anesthesiology Jamie R. Privratsky MD, Ph.D. highlighted COVID’s impact on clinical and critical care research. Among the positive impacts are the Society of Critical Care Medicine’s COVID-19 registry database, the abilities to do observational and database research work, and research opportunities for working with COVID patients. However, the rest of critical care research has been completely sidelined, clinician-scientists have been moved to mostly clinical duties, and there have been lots of administrative hurdles for conducting COVID related research.

A slide from Dr. Pivratsky’s presentation.

Many colleagues share Dr. Privratsky’s mixed thoughts on the gains and losses during the halt of critical care research. For those who were able to conduct some research, the risks to personal health also posed looming anxiety and danger. Dr. Privratsky chose to do what he could being physically away from his lab and worked to update protocols, maintain electronic lab notebooks, write methods sections of papers, and care for his mouse colony. He also submitted three grant proposals and said that he left the shutdown with a clearer vision and direction for his research.

The School of Medicine’s Vice Dean for Basic Science, Colin S. Duckett Ph.D. closed the town hall with encouraging reflections. Out of 17,000 Duke administered COVID tests, there have been very few positives. Duckett emphasized how seriously the Duke community and its recently returned students are taking the continued threat of Coronavirus. Though communications persist as a challenge and many argue that life right now just doesn’t feel right, Duckett called attendees’ attention to the fact that the research enterprise was successfully ramped down, ramped back up, and lab activities have made a nearly completely return. This was and continues to be no small feat and is possible due to highly collaborative efforts, he said.

Good news from Dr. Duckett about the state of Duke’s research enterprise.

Further, there were large insights gleaned from this collective experience; those of researchers’ resiliency, the importance of community, and the need to look beyond work and check in on each other as human beings. Research and the people who make it possible do not exist in a vacuum away from society. Their work and their well-being are subject to the pandemic just like everyone else. Yet, similar to the broader global public, researchers and their research are emerging stronger than before in the face of COVID-19.

Post by Cydney Livingston

World Bank takes on big data for development

Apparently, data is the new oil.

Like oil, data might be considered a productive asset capable of generating innovation and profit. It also needs to be refined to be useful. And according to Haishan Fu, Director of the World Bank’s Development Data Group, data is, much like oil, a development issue. She was the keynote speaker for a Feb. 25 program at Duke, “Rethinking Development: Big Data for Development.”

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Haishan Fu, Director of the World Bank Development Data Group

While big data is… well, big, Fu explains that it has a more focused quality as well. “When you go deeper, you can see something really personal,” she says. Numbers don’t have to be quite so intimidating in their largesse and clutter: everything is integrated in some way. All of the numbers address the same questions: who, what, when, where?

That’s why the World Bank and countless other organizations and individuals across the globe have begun moving toward big data for the purpose of social and economic development studies. It helps tackle the whowhat-when-where of real and complex global issues with increased precision, greater efficiency, and a fresh perspective.

For example, the World Bank’s 2019 Tanzania Poverty Assessment integrated household survey results and geospatial data to estimate poverty within a small region of Tanzania. Despite lacking exact data for that area, using big data to make this estimation was still extremely powerful. In fact, its precision increase was equivalent to doubling the survey’s sample size.

A bit further northwest in Africa, the World Bank has also been using big data in Cote d’Ivoire to predict population density based on cellphone subscriber data.

In Cote d’Ivoire, making predictions from big data (figure on right) has actually allowed for more precision than predictions from census data (left).

In Yemen, integrated data from multiple sources is being used to determine road networks and physical accessibility of hospitals. The World Bank can estimate this kind of information without actually having any ground contact, improving both time- and money-efficiency. Studies have made it evident that less road access is linked to poverty, so they’re hoping to improve road networks as well as update population estimates and further other local developments.

And Brazil has served as a case study in “how social media can provide economic insight,” Fu explains. There, the World Bank has been using Twitter to detect early variations in labor market activities, searching for key words and hashtags in tweets and determining if users’ later employment statuses future have any sort of relationship to the content of their earlier tweets. Interestingly, the Twitter index and unemployment rates in Brazil display similar trends.

These examples are just a few of many big data initiatives the World Bank has been working toward. And though they have proven valuable for lower-income countries across the world, the lack of data in certain areas still poses a huge problem. The data deficit has been contributing to global inequalities, with higher-income countries being able to provide and have access to more data and thus also new improvement technologies. Ending poverty requires eradicating data deprivation, Fu says.

Image result for world bank twin goals
The World Bank’s twin goals: (1) end poverty, (2) promoted shared prosperity.
Image from the World Bank

Eradicating data deprivation is a collaborative effort between the public and private sectors, which is also an issue of its own. On the one hand, there’s a major under-investment in public sector data. On the other, today’s winner-take-most economics and the dominance of select superstar firms have led some private companies to avoid sharing data and favored only those companies able to produce the biggest of datasets.

Fu says working toward data partnerships is a learning process for everyone involved; it’s still a work in progress and probably will be for a while. The potential of big data is already there—it’s just waiting to be totally harnessed. “We will collectively have this platform to increase efficiency, promote responsible use, and come up with sustainable initiatives,” Fu says of the future.

In other words, the World Bank is just getting started.

by Irene Park

On ‘Things We Already Know,’ Checklists and Mindfulness

I recently spoke to the Academic Council about my new role overseeing Duke’s entire research enterprise – medical and campus –  and I reiterated for them the messages in my first blog post: that all of us should take part in the quality and rigor of Duke’s research efforts and that everyone should participate in activities like Responsible Conduct of Research (RCR) training and other activities that will help us to improve.

Not all the faculty are persuaded, I soon learned.

“I read your recent blog post about quality. Clearly that was not meant for me,” one senior faculty member said to me. He suggested that my reminding the community of such matters was beneath him, and probably beneath many other faculty. “Of course we treat people with respect! Of course we always do research the right way!”

In response, let me share with you an important lesson from a book I read recently, “The Checklist Manifesto,” by Atul Gawande. He’s a general and endocrine surgeon at Brigham and Women’s Hospital in Boston who advocates the use of checklists for surgeons, just as pilots and space programs have used.

Dr. Atul Gawande

Checklists impose structure, they force us to think more slowly and carefully, and to systematically address specific questions of relevance to the mission, even if it’s a procedure we’ve done countless times before. Pilots and astronauts aren’t insulted by them.

At the end of his book, Gawande writes about his personal use of checklists in his surgical practice and a very important lesson he learned by using them.

When he first started thinking about checklists, Gawande thought it was an interesting subject, and that it was highly relevant to the average surgeon. However, with respect to himself, a top-flight surgeon, a former Rhodes Scholar and a MacArthur Fellow, he felt the exercise was probably redundant.

But since he had written and spoken so much about checklists, Gawande always went through the motions, just to avoid looking like a hypocrite. That is, until a particular surgery humbled and changed his perspective on checklists forever.

Gawande was about to perform a surgery, and the head nurse was going down the list of items needed for this particular procedure. All items checked off as expected until they came to the need for a substantial supply of blood in case of a rare complication that could cause severe bleeding.

This item surely was added after a prior disaster and a root-cause analysis that refined the checklist for this type of surgery. But as they went down the checklist, the extra blood was absent. So the team quickly got the blood, and the surgery commenced.

To Gawande’s horror, this particular surgery triggered that rare complication. But because they had the substantial supply of extra blood on hand, the surgical team was able – with great effort — to save the patient’s life.

Gawande says he was chastened by this experience. Without attention to the checklist, this patient would have died on the table.

But academic research isn’t anything like flying a plane or opening an abdomen, or is it? I think the stakes for university research are very high. Duke just settled a case related to research misconduct that cost the university more than $100 million, and damaged our reputation. It might have been prevented.

Pilots routinely use checklists before and during flight.

We have a responsibility to be good stewards of the more than $1 billion in annual funding that allows us to do this important work. The organizations that entrust us with those resources (often the federal government) are counting on us to use those resources well, and to engage in research of the highest quality. The stakes are high, and so should be our responsibilities.

While they aren’t a perfect analogue to things like RCR training, safety checklists address predictable human fallibility, which is often a result of thinking instinctually rather than carefully. RCR training, conflict of interest forms, institutional review boards and other research controls seek to address issues in the same way, by identifying problems that have come up in the past at Duke or other institutions and trying to prevent these lessons from having to be learned again (analogous to the need for extra blood).

I also think it’s important that another key component of checklists is cultural: Anyone on the surgical team is allowed to question anything before or during the surgery. This means that a junior nurse on the team can challenge the lead surgeon if they see something that is in conflict with best practice or the checklist. If you see something, say something.

Anyone at Duke who sees behavior that challenges the values connected to the principles of our checklists – conflict of interest, institutional review board, responsible conduct of research — has the right, and the responsibility, to say something.

Inviting faculty, trainees and staff to engage with training does not mean we feel our people are unaware of these issues. It does not mean we feel that Duke researchers lack integrity. It is just that we are all very busy and focused on many things, and we are human.

I’m asking all of us to slow down for a moment, and to remind ourselves of our responsibility to ourselves, to the broader Duke community, and to our research sponsors. We want to set a tone and a culture that will help all of us push the Duke research enterprise to even higher levels of excellence.

Post by Larry Carin, Vice President for Research

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