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

Category: Science Communication & Education Page 1 of 18

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

By Zella Hanson

The evolutionary advantage of being friendly

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We’ve all heard the term “survival of the fittest,” which scientist Charles Darwin famously coined to explain how organisms with heritable traits that give them an advantage — such as avoiding predators or beating out others for the chance to mate — are able to survive and pass on these advantageous traits to their offspring.

In his talk with ClubEvMed last Tuesday, Brian Hare of Duke Evolutionary Anthropology explained key points from his new book that he co-authored with his wife and research partner, Vanessa Woods, entitled Survival of the Friendliest: Understanding Our Origins and Rediscovering Our Common Humanity

Image from Penguin Random House

The term “fittest” is often associated with animals who are physically stronger or of more value than others, but being “fit” can also include an organism’s ability to communicate well with others in its group, which can provide an evolutionary advantage. For example, more social animals can form alliances with each other and protect each others’ young, so the whole population stays stronger in terms of number.

Hare cited a comparison between chimpanzees and bonobos, both of which have the potential for infanticide by aggressive males in a group. However, bonobos have zero cases of infanticide because female bonobos are able to communicate well and form alliances to protect each others’ young from aggressive males. Since the high cost of aggression for males outweighs the benefit, the males are friendlier, and the young bonobos survive. While this is a specific case with wild animals, other species have adopted social skills as a method of survival through domestication or self-domestication. 

Image from brianhare.net

Hare referred to dogs as “exhibit A” of survival of the friendliest via domestication, because humans have bred dogs that are more playful, approachable and patient for centuries. Dogs are exceptionally good at understanding, responding to and communicating with humans as a result of domestication. Hare also explained one Russian study in which they began selecting foxes based on their friendliness towards people. They bred the most friendly foxes together and then compared the friendliness of their offspring to the offspring of randomly bred foxes. The results showed that friendlier foxes differed in physiology in addition to behavior, and were better at cooperating and communicating with humans. This is an example of self-domestication, which changes development patterns and has increased fitness via friendliness. Friendliness in this case means skill in cooperating and communication. 

Survival of the Friendliest argues that humans today are the friendliest species of human, which may be why we have lasted so long evolutionarily. However, with the new type of friendliness also comes a new type of aggression. Mother bears are kind and nurturing to their cubs, but also have the most potential for aggression when they feel their cubs are threatened. Similarly in humans, when we feel people who share our identity are threatened, we want to protect those individuals.

Hare and Woods reason that this desire to protect also reduces our ability to cooperate or communicate with those who we feel threaten us or threaten our “group”— whether this be our family, our race or another trait. When our ability to communicate is reduced, we begin to dehumanize those who we feel threaten the people who share our identity. This then becomes a cycle, where people dehumanize those who they believe are dehumanizing them.

In order to stop this cycle, Hare and Woods argue that humans will need to alter their view of who they believe “belongs” to their group to include more people. We need to communicate openly and build a desire to protect other humans, rather than dehumanize them.

By Victoria Priester

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

Dealing With Lead for Life

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

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

Aaron Reuben

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

Lead use in gasoline quickly increased after its initial introduction.

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

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

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

Findings from the Big Five Inventory of Dunedin participants.

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

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

Reuben’s take-away findings from his presentation.

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

Post by Cydney Livingston

We Are Not All Living The COVID Moment Equally

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diagram of telomere from a study conducted by Dr. Pearson

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

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

Post by Cydney Livingston

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

DAVIDE BONAZZI / SALZMANART

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

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

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

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

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

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

Marc Lipsitch

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

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

Cameron Wolfe

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

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

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

Nir Eyal

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Post By Zella Hanson

A Day of STEM for Girls

On any average weekday at Duke University, a walk through the Engineering Quad and down Science Drive would yield the vibrant and exciting sight of bleary-eyed, caffeine-dependent college students heading to labs or lectures, most definitely with Airpods stuck in their ears.

But on Saturday, February 22nd, a glance towards this side of campus would have shown you nearly 200 energetic and chatty female and female-identifying 4th to 6th graders from the Durham area. As part of Capstone, an event organized by Duke FEMMES, these students spent the day in a series of four hands-on STEM activities designed to give them exposure to different science, technology, engineering, and math disciplines.

Nina MacLeod, 10, gets grossed out when viewing fruit fly larvae through a microscope while her guide, Duke first-year Sweta Kafle, waits patiently. (Jared Lazarus)

FEMMES, which stands for Females Excelling More in Math, Engineering, and Science, is an organization comprised of Duke students with the aim of improving female participation in STEM subjects. Their focus starts young: FEMMES uses hands-on programming for young girls and hosts various events throughout the year, including after-school activities at nearby schools and summer camps. 

Capstone was a day of fun STEM exposure divided into four events stationed along Science Drive and E-Quad — two in the morning, and two in the afternoon, with a break for lunch. Students were separated into groups of around eight, and were led by two to three Duke undergraduates and a high school student. The day started bright and early at 8:45 A.M with keynote speaker Stacy Bilbo, Duke professor of Psychology and Neuroscience. 

Staci Bilbo

Bilbo explained that her work centers around microglial cells, a type of brain cell. A series of slides about her journey into a science career sparked awe, especially as she remarked that microglial cells are significant players in our immune system, but scientists used to know nearly nothing about them. Perhaps most impactful, however, was a particular slide depicting microglial cells as macrophages, because they literally eat cellular debris and dead neurons.

A cartoon depiction of this phenomenon generated a variety of reactions from the young audience, including but not limited to: “I’m NEVER being a doctor!”, “I wish I was a microglial cell!”, “Ew, why are brains so gross?”, and “I’m so glad I’m not a brain because that’s SO weird.”

Even in 2020, while fields like medicine and veterinary science see more women than men, only 20% of students that earn bachelor’s degrees in physical sciences, math, and engineering disciplines are female. What accounts for the dramatic lack of female participation in STEM disciplines? The reasons are nuanced and varied. For example, according to a 2010 research report by the American Association of University Women, girls tend to have more difficulty acquiring spatial thinking and reasoning skills – all because of the type of play young female children are more likely to engage in. 

Durham area students learned how to perform a blood pressure check during a FEMMES session taught by Duke EMS, an all-volunteer, student-run division of the police department and Duke Life Flight. Duke senior Kayla Corredera-Wells (center) put the blood pressure cuff on sophomore Pallavi Avasarala. (Jared Lazarus)

This creates a chicken-and-egg story: girls don’t enter STEM at the same rate as their male counterparts, and as a result, future generations of girls are discouraged from pursuing STEM because they don’t see as many accomplished, visibly female scientists to look up to. Spaces like Capstone which encourage hands-on activity are key to exposing girls to the same activities that their male counterparts engage in on a regular basis – and to exposing girls to a world of incredible science and discovery led by other females. 

After Bilbo’s talk, it was off to the activities, led by distinguished female professors at Duke — a nod to the importance of representation when encouraging female participation in science. For example, one of the computer science activities, led by Susan Rodger, taught girls how to use basic CS skills to create 3-D interactive animation.

An introduction to categorizing different minerals based on appearance was led by Emily Klein, while one of the medicine-centered activities involved Duke EMS imparting first aid skills onto the students. 

For one of the biology-themed activities, Nina Sherwood and Emily Ozdowski (dubbed “The Fly Ladies”) showed students fruit flies under a microscope. The activity clearly split the group: girls who stared in glee at unconscious flies, shrieking “It’s SO BIG, look at it!” and girls who exchanged disgusted looks, edging their swivel chairs as far as physically possible from the lab benches. Elizabeth Bucholz, a Biomedical Engineering professor, led one of the engineering activities, showing students how CT scans generate images using paper, a keychain light and a block (meant to represent the body). In math, meanwhile, Shira Viel used the activity of jump-roping to show how fractions can untangle the inevitable and ensuing snarls.

The day definitely wasn’t all science. During lunch in LSRC’s Love Auditorium, most groups spread out after scarfing down pizza and spent intense focus over learning (and recording) TikTok dances, and when walking down Science Drive under blue and sunny skies, conversations ranged from the sequins on someone’s Ugg boots to how to properly bathe one’s dog, to yelling erupting over someone confidently proclaiming that they were a die-hard Tar Heel.

Nina Sherwood, Associate Professor of Biology, showed Emma Zhang, 9, some fruit flies, which we study because they share 75% of their genes with humans. (Jared Lazarus)

A raffle at the end of the day for the chance to win Duke merchandise inspired many closed eyes and crossed fingers (“I want a waterbottle so bad, you have no idea!”) And as newfound friends said goodbye to each other and wistfully bonded over how much fun they had at the end of the day, one thing was clear: events like Capstone are crucial to instilling confidence and a love of STEM in girls. 

By Meghna Datta

Squirmy Science

Unearthing A New Way Of Studying Biology

Yes, students, worms will be on the test. 

Eric Hastie, a post-doctoral researcher in the David Sherwood Lab, has designed a hands-on course for undergraduates at Duke University in which biology students get to genetically modify worms. Hastie calls the course a C.U.R.E. — a course-based undergraduate experience. The proposed course is designed as a hands-on, semester-long exploration of molecular biology and CRISPR genome editing.

An image taken of the adult gonad structure of a C. elegans worm in the Sherwood Lab,

In the course, the students will learn the science behind genome editing before getting to actually try it themselves. Ideally, at the course’s end, each student will have modified the genome of the C. elegans worm species in some way. Over the course of the semester, they will isolate a specific gene within one of these worms by tagging it with a colored marker. Then they will be able to trace the inserted marker in the offspring of the worm by observing it through a microscope, allowing for clear imaging and observation of the chosen characteristic.

When taught, the course will be the third in the nation of its kind, offering undergraduates an interactive and impactful research experience. Hastie designed the course with the intention of giving students transferrable skills, even if they choose careers or future coursework outside of research.

“For students who may not be considering a future in research, this proposed class provides an experience where they can explore, question, test, and learn without the pressures of joining a faculty research lab,” he told me.

Why worms? Perhaps not an age-old question, but one that piqued my interest all the same. According to Hastie, worms and undergraduate scientific research pair particularly well: worms are cost-effective, readily available, take up little space (the adults only grow to be 1mm long!), and boast effortless upkeep. Even among worms, the C. elegans species makes a particularly strong case for its use. They are clear, giving them a ‘leg up’ on some of their nematode colleagues—transparency allows for easy visibility of the inserted colored markers under a microscope. Additionally, because the markers inserted into the parent worm will only be visible in its offspring, C. elegans’ hermaphroditic reproductive cycle is also essential to the success of the class curricula.  

Undergraduate researcher David Chen studying one of his worm strains under a microscope.

“It’s hard to say what will eventually come of our current research into C. elegans, but that’s honestly what makes science exciting,” says undergraduate researcher David Chen, who works alongside Hastie.  “Maybe through our understanding of how certain proteins degrade over time in aging worms, we can better understand aging in humans and how we can live longer, healthier lives.”

The kind of research Hastie’s class proposes has the potential to impact research into the human genome. Human biology and that of the transparent, microscopic worms have more in common than you might think— the results derived from the use of worms such as C. elegans in pharmaceutical trials are often shown to be applicable to humans. Already, some students working with Hastie have received requests from other labs at other universities to test their flagged worms. So perhaps, with the help of Hastie’s class, these students can alter the course of science.

“I certainly contribute to science with my work in the lab,” said junior Ryan Sellers, a research contributor. “Whether it’s investigating a gene involved in a specific cancer pathway or helping shape Dr. Hastie’s future course, I am adding to the collective body of knowledge known as science.”

Post by Rebecca Williamson

#UniqueScientists Is Challenging Stereotypes About Who Becomes a Scientist

University of North Carolina cell biologist Efra Rivera-Serrano says he doesn’t look like a stereotypical scientist: he’s gay, Puerto Rican, and a personal trainer.

Known on Twitter as @NakedCapsid or “the guy who looks totally buff & posts microscopy threads,” he tweets about virology and cell biology and aims to make science more accessible to the non-science public.

But science communication encompasses more than posting the facts of viral transmission or sending virtual valentines featuring virus-infected cells, Rivera-Serrano says. As a science communicator, he’s also committed to conveying truths that are even more rarely expressed in the science world today. He’s committed to diversity.

Rivera-Serrano’s path through academia has been far from linear — largely because of the microaggressions (which are sometimes not so micro) that he’s faced within educational institutions. He’s been approached while shopping by a construction work recruiter and told by a graduate adviser in biology to “stop talking like a Puerto Rican.”

Efra Rivera-Serrano, Ph.D.
He’s a scientist at UNC—and also a personal trainer.
Photo from @NakedCapsid Twitter

And the worst part is that he’s far from being the only one in this kind of position. That’s why Rivera-Serrano holds one simple question close to heart:

What would a cell do?

“I use this question to shape the way I tackle problems,” Rivera-Serrano says. After all, a key component of virology is the importance of intercellular communication in controlling disease spread. Similarly, a major goal of diversity-related science communication is “priming” others to fight stereotypes and biases about who belongs in science.

Virology’s “herd immunity” theory operates under the principle that higher vaccination rates mean fewer infections. For some viruses, a 90% vaccination rate is all it takes to completely eradicate an infection from existing in a population. Rivera-Serrano, therefore, hopes to use inclusive science communication as a vaccination tool of sorts to combat discriminatory practices and ideologies in science. He isn’t looking for 100% of the world to agree with him—only enough to make it work.

Herd immunity places value on community rather than individuals.
Image by Tkarcher via Wikimedia Commons

This desire for “inclusive science communication” led Rivera-Serrano to found Unique Scientists, a website that showcases and celebrates diverse scientists from across the globe. Scientists from underrepresented backgrounds can submit a biography and photo to the site and have them published for the world’s aspiring scientists to see.

Some Unique Scientists featured on Rivera-Serrano’s site!

Generating social herd immunity needs to start from an early age, and Unique Scientists has proven itself useful for this purpose. Before introducing the website, school teachers asked their students to draw a scientist. “It’s usually a man who’s white with crazy hair,” according to Rivera-Serrano. Then, they were given the same instructions after browsing through the site, and the results were remarkable.

“Having kids understand pronouns or see an African American in ecology—that’s all something you can do,” Rivera-Serrano explains. It doesn’t take an insane amount of effort to tackle this virus.

What it does take, though, is cooperation. “It’s not a one-person job, for sure,” Rivera-Serrano says. But maybe we can get there together.

by Irene Park

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

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