Tag: COVID-19

Post-COVID Public Health is in a Trust Fall

On February 20, 2023

Dr. Heidi Larson, director of the Vaccine Confidence Project, described data from a recent Pew Center study, instructing us to “HANDLE WITH CARE!” as if a jeweled Fabergé egg and not a series of sampled statistics.

The study’s title: “Americans’ Trust in Scientists, Other Groups Declines.”

“Pew Research Center conducted this study to understand how much confidence Americans have in groups and institutions in society, including scientists and medical scientists.”
Credit to: Brian Kennedy, Alec Tyson, and Cary Funk

“Once seemingly buoyed by their central role in addressing the coronavirus outbreak,” Pew Center researchers write, the public’s trust in scientists and health professionals has sunk. This phenomenon is not confined to remote corners of Twitter or the turbulent backwaters of a few Facebook community chats. No, it’s palpable in the media, in conversation, in our collective consciousness. Why is this? And why now?

Last month, The Duke Global Health Institute hosted a few health experts to answer these questions in the “Building Trust in Public Health: A Post-COVID Roadmap” panel. Jack Leslie, a visiting fellow at the Duke-Margolis Center for Health Policy, contextualized declines in public trust, citing increased populism and anti-elitism. It’s not difficult to chart the evolution of this zeitgeist. In the past three decades alone, Americans have become completely cocooned in media.

Jack Leslie joins Duke University as a Senior Visiting Fellow at the Duke Global Health Institute (DGHI) and Visiting Fellow at the Duke-Margolis Center for Health Policy

CNN’s Ted Turner (i.e. the ‘Mouth of the South’) is accredited with the genesis of the 24 hour news cycle. He notably “didn’t bargain for… [the] insomniacs,” writes journalist Lisa Napoli, nor did he bargain for its longevity, or our inability to escape it. From coverage of the Iraq War to the OJ Simpson investigation to political partisanship in Washington, and of course, to COVID-19.

The erosion of institutional faith is not unique to the government but, like an acid rain, weathers indiscriminately. It eats away at trust in churches, corporations, media institutes, universities, K-12 schools, etc. In fact last semester, I attended another Duke panel entitled “Policing the Pages,” in which increased polarization across the US contributed to concerted efforts to bar certain books (often those with LGBT and minority characters) from elementary school libraries and syllabi. A kind of censorship akin to dress codes and mandatory veggies in bagged lunches.

This sentiment, unlike COVID-19, is not novel. Leslie described a “trifecta” of events, slowly chipping away at public trust: 1) the great recession of ‘08, 2) waves of immigration in the United States and Europe, and finally, 3) the pandemic.

For decades, and with little exception, science was lauded as infallible, an authority, bridging turbulent seas of dis- and mis-information. It was well-mannered, professorial, clad in wire-rimmed glasses and bowtie. “We had pretty high trust in scientists and public health institutions prior to the pandemic… relative to other institutions which have taken a hit over the past twenty years,” Leslie acknowledged.

Of course, this no longer is the case.

Dr. Heidi Larson is a professor of anthropology, risk, and decision science London School of Hygiene and Tropical Medicine.

Dr. Heidi Larson collected this pathos in anecdotes for the Global Listening Project, an oral history of personal pandemic experiences. Many described “…a feeling of disconnect with the government. [They] would give us these directives, but people felt they had no connection with their reality, their situation.” Larson, for example, recognized patterns of isolation in schools. There was a pervasive sense that neither legislator nor scientist had stepped foot into these schools before creating policies. Bureaucratic deflection so to speak.

Larson consequently felt a shift in COVID-19 rhetoric. What once was “upholding global unity,” “encouraging communal cooperation,” and “assuring responsive governance” became, as Larson put it, “getting a jab in the arm.” The disconnect between the Joe Publics, the John Qs, and their public institutions began to feel especially cavernous as the pandemic stretched weeks, months, then years.

This begs the question, how can we rebuild trust in public health?

Dr. Rispah Walumbe is a health policy advisor at Amref Health Africa, to support the advancement of the universal health coverage (UHC) agenda.

Dr. Rispah Walumbe, a global health policy and advocacy specialist, described the “orchestration” of multisectoral partnerships during the pandemic (in Africa, specifically) that combined “state and non-state actors with public and private sector actors and, of course, those on the social, economic, and political sides.”

She found that, at the start of the pandemic, trust was enhanced. The virus was identified as a “key problem” and was, to some degree, universally threatening. A conduit of centralized communication followed. As the pandemic elongated, the discrepancy between the populations disproportionately burdened by COVID (poor and minority communities) and those not so much grew wider. Communication became less effective. Still, Walumbe advocated for the continuity of engagement between health institutions and the public in the aftermath of the pandemic. Peel back the Oz-like bureaucratic curtains and increase transparency.

Dr. Mandy Cohen served as the Secretary of the North Carolina Department of Health and Human Services as well as the Chief Operating Officer and Chief of Staff at the Centers for Medicare and Medicaid Services. She has been elected to the National Academy of Medicine and is an adjunct professor at the UNC Gillings School of Global Public Health.

Dr. Mandy Cohen, Secretary of North Carolina’s Department of Health and Human Services, agreed. In recent studies, she explained, NC ranked 2nd among the states for its general safety during the pandemic, which she attributed to the state’s prioritization of public trust. “Before we even had our first case, we were talking about how our crisis response was going to hinge on whether we could build and maintain trust with the public… we tried to be really tactical about trust, which can feel ephemeral and fleeting… and really broke it down into three buckets. The first was transparency, the second was competency, and the third was relationships.”

Rebuilding trust in public health, thus, seems less a roadmap and more a spigot. Institutions must continue to fill the buckets Cohen described.

As the pandemic ebbs, however, the ubiquity of isolation, anxiety, and turmoil cannot be understated. A recent WHO article characterized this pervasive fear as “contagious,” pathologic, a kind of virus itself.

In this political cartoon, Sisyphus pushes a stone (the Delta variant) up the hill

In an age of mass misinformation, public health officials, doctors, and scientists now stand with the Sisyphean task of restoring public trust. And the panelists concurred: it is fragile. Volatile even.

Yet, as illustrated in this article, it is not elusive. Prioritize communication. Prioritize transparency. Prioritize competency, relationships, and community engagement.

I will defer to Walumbe who put it best during the conversation: “These institutions do not operate in a vacuum. Community is pivotal in thinking through trust, it’s how we’re organized across the world… that’s something that is critical in how we approached COVID-19 challenges…” and, presumably, in how we should continue.

Thank you to the panelists, moderator Dr. Krishna Udayakumar, and Dr. Mark McClellan, Director and Robert J. Margolis, M.D., Professor of Business, Medicine and Policy at the Margolis Center for Health Policy.

Post by Alex Clifford, Class of 2024

Modeling the COVID-19 Roller Coaster

By Robin Smith

On January 3, 2023

In Data, Mathematics, Students

*A Duke team looks at the math behind COVID’s waves as new coronavirus variants continue to emerge.* *Credit: @ink-drop*

DURHAM, N.C. — First it was Alpha. Then Delta. Now Omicron and its alphabet soup of subvariants. In the three years since the coronavirus pandemic started, every few months or so a new strain seems to go around, only to be outdone by the next one.

If the constant rise and fall of new coronavirus variants has left you feeling dizzy, you’re not alone. But where most people see a pandemic roller coaster, one Duke team sees a mathematical pattern.

In a new study, a group of students led by Duke mathematician Rick Durrett studied the calculus behind the pandemic’s waves.

Published Nov. 2022 in the journal Proceedings of the National Academy of Sciences, their study got its start as part of an 8-week summer research program called DOmath, now known as Math+, which brings undergraduates together to collaborate on a faculty-led project.

Their mission: to build and analyze simple mathematical models to understand the spread of COVID-19 as one strain after another popped up and then rose to outcompete the others.

In an interview about their research, project manager and Duke Ph.D. student Hwai-Ray Tung pointed to a squiggly line showing the number of confirmed COVID cases per capita in the U.S. between January 2020 and October 2022.

*The COVID-19 pandemic has unfolded in waves. Adapted from The New York Times, July 18, 2022*

“You can see very distinct humps,” Tung said.

The COVID pandemic has unfolded in a series of surges and lulls — spikes in infection followed by downturns in case counts.

The ups and downs are partly explained by factors such as behavior, relaxation of public policies, and waning immunity from vaccines. But much of the roller coaster has been driven by changes to the coronavirus itself.

All viruses change over time, evolving mutations in their genetic makeup as they spread and replicate. Most mutations are harmless, but every so often some of them give the virus an edge: Enabling it to break into cells more easily than other strains, better evade immunity from vaccines and past infection, or make more copies of itself in order to spread more effectively.

Take the Delta variant, for example. When it first started going around in the U.S. in May 2021, it was responsible for just 1% of COVID cases. But thanks to mutations that helped the virus evade antibodies and infect cells more easily, it quickly tore across the country. Within two months it had outcompeted all the other variants and rose to the top spot, causing 94% of new infections.

“The natural question to ask is: What’s going on with the transition between these different variants?” Tung said.

For their study the team developed a simple epidemic model called an SIR model, which uses differential equations to compute the spread of disease over time.

SIR models work by categorizing individuals as either susceptible to getting sick, currently infected, or recovered. The team modified this model to have two types of infected individuals and two types of recovered individuals, one for each of two circulating strains.

The model assumes that each infectious person spreads the virus to a certain number of new people per day (while sparing others), and that, each day, a certain fraction of the currently infected group recovers.

In the study, the team applied the SIR model to data from a database called GISAID, which contains SARS-CoV-2 virus sequences from the pandemic. By looking at the coronavirus’s genetic code, researchers can tell which variants are causing infection.

Study co-author Jenny Huang ’23 pointed to a series of S-shaped curves showing the fraction of infections due to each strain from one week to the next, from January 2021 to June 2022.

When they plotted the data as points on a graph, they found that it followed a logistic differential equation as each new variant emerged, rose steeply, and — within six to 10 weeks — quickly displaced its predecessors, only to be taken over later by even more aggressive or contagious strains.

Durrett said it’s the mathematical equivalent of something biologists call a selective sweep, when natural selection increases a variant’s frequency from low to high, until nearly everyone getting stick is infected with the same strain.

“I’ve been interested in epidemic modeling since the end of freshman year when COVID started,” said Huang, a senior who plans to pursue a Ph.D. in statistics next year with support from a prestigious Quad Fellowship.

They’re not all typical math majors, Durrett said of his team. Co-author Sofia Hletko, ’25, was a walk-on to the rowing team. Laura Boyle ’24 was a Cameron Crazie.

For some team members it was their first experience with mathematical research: “I came in having no idea what a differential equation was,” Boyle said. “And by the end, I was the person in the group explaining that part of our presentation to everyone.”

Boyle says one question she keeps getting asked is: what about the next COVID surge?

“It’s very hard to say what will happen,” Boyle said.

The teams says their research can’t predict future waves. Part of the reason is the scanty data on the actual number of infections.

Countries have dialed back on their surveillance testing, and fewer places are doing the genomic sequencing necessary to identify different strains.

“We don’t know the nature of future mutations,” Durrett said. “Changes in people’s behavior will have a significant impact too.”

“The point of this paper wasn’t to predict; rather it was to explain why the waves were occurring,” Huang said. “We were trying to explain a complicated phenomenon in a simple way.”

This research was supported by a grant from the National Science Foundation (DMS 1809967) and by Duke’s Department of Mathematics.

CITATION: “Selective Sweeps in SARS-CoV-2 Variant Competition,” Laura Boyle, Sofia Hletko, Jenny Huang, June Lee, Gaurav Pallod, Hwai-Ray Tung, and Richard Durrett. Proceedings of the National Academy of Sciences, Nov. 3, 2022. DOI: 10.1073/pnas.2213879119.

COVID and Our Education

By Jakaiyah Franklin

On November 28, 2022

In Biology, Global Health, Lecture, Science Communication & Education

With mask mandates being overturned and numerous places going back to “normal,” COVID is becoming more of a subconscious thought. Now, this is not a true statement for the entire population, since there are people who are looking at the effects of the pandemic and the virus itself.

I attended a poster presentation for the “The Pandemic Divide” event hosted here at Duke by the Samuel Dubois Cook Center on Social Equity. To me, all the poster boards conveyed the theme of how COVID-19 had affected our lives in more ways than just our health. One connection that particularly caught my eye would be the one between American Education and COVID.

As a student who lived through COVID while attending high school, I can safely say that the pandemic has affected education. However, based on the posters I saw, it is important to know that education, too, has a strong and impactful impact on COVID-19.

Dr. Donald J. Alcendor after a great presentation

The first evidence I saw was from Donald J. Alcendor, an associate professor of microbiology and immunology at Meharry Medical College in Nashville. His poster was about the hesitancy surrounding COVID-19 vaccines. One way he and his team figured out to lessen the hesitance from the public was to improve the public’s trust. To achieve this, Alcendor and his team sent trusted messengers into the community. One of the types of messengers they provided was scientists who studied COVID-19. These scientists were able to bring factual information about the disease, how it spreads, and the best course of action to act against it. Alcendor and his research team also brought in “vaccine ambassadors” to the community and a mobile unit to help give the community vaccines. He noted that this was accomplished with support from the Bloomberg Foundation’s Greenwood Initiative, which addresses Black health issues.

With this mobile unit, Alcendor and his team were able to reach people and help those who were otherwise unable to receive help for themselves because of their lack of transportation. They provided people from all backgrounds with help and valuable information.

Alcindor said he and his team planned pop-up events based on where the community they were trying to reach congregates. With the African American community, he planned pop-up events at churches and schools. Then for the Latino community, he planned pop-events where families tend to gather, and he held events in Latin0 neighborhoods. In addition, he made sure that the information was available in Spanish at all levels, from the flyers and the surveys, to the vaccinators themselves.

All of these amenities that he and his group provided were able to educate the community about COVID-19 and improve their trust in the scientists working on the disease. Alcendor and his team were able to impact COVID-19 through education, and by going to the event, it was evident to me that he was not the only one who accomplished this.

Colin Cannonier, an associate professor of economics at Belmont University in Nashville, asked and answered the question, “does education have an impact on COVID? Specifically, does it change health and wellbeing?” To answer this question, he researched how education about COVID can affect a person. He discovered that when a person is more educated about COVID, how it is spread, and its symptoms, they are more likely to keep the pandemic in check through their behavior. He came to this conclusion because he realized that when higher educated people know more about COVID, they exhibit behaviors to remain healthy, meaning that they would follow the health protocols given by the health officials.

While this may seem like common sense that the more educated a person is, the more they make smart choices pertaining to COVID, this shows how important education is and how deadly ignorance is. Cannonier’s research gave tangible evidence to show that education is a weapon against diseases. Unfortunately, it is evident that some officials did not believe in educating the public about the virus or the virus itself, and that proved to be extremely deadly.

To fully capture the relationship between COVID and education, one must also talk about how COVID-19 affected education.

Ms. Stacey Akines and her wonderful poster

Stacey Akines, a history graduate student at Carnegie Mellon University, studied how education was changed by the pandemic.

First, she realized that COVID schooling crossed over with homeschooling. Then she uncovered that more Black people started to research and teach their children about Black history. This desire to teach youth more about their history caused an increase in the number of Black homeschoolers. In fact, the number of Black homeschoolers doubled during the fall of 2020. While to some, this change to homeschooling may have a negative impact on one’s life, it actually gives the student more opportunities to learn things.

It is no secret that there are many books being banned here in the U.S., and there are many state curriculums that are changing to erase much of Black history. Homeschooling a child gives the parent an opportunity to ensure that the education they receive is true to and tells their history

Unlike me, where during high school, education felt lackluster and limited because of COVID, some parents saw an opportunity to better their child’s education.

I hope that it is clear that the relationship between COVID and education is a complex one. Both can greatly impact each other, whether it’s for the better or for the worse. COVID thrives when we are uneducated, and it very nearly destroyed education too, but for the efforts of some dedicated educators.

Post by Jakaiyah Franklin, Class of 2025

American Epidemics and the Viral Underclass

By Alex Clifford

On October 26, 2022

In Global Health, History, Lecture

March 2020. The subsequent blur of months. Of spring into summer, fall into winter, a year into another and likely into the next. Like millions of humans around the world, 2020 itself feels infected, as if wrapped up with yellow caution tape. Virus dominates the current zeitgeist; pandemic won Merriam-Webster’s 2020 word of the year; vaccine in 2021.

We are all proto-virologists, sludging through the constant slew of “viral” media: novel variants, outbreaks, booster shots, mutations (a jargon in which we’re collectively fluent).

Monkeypox on the left, COVID-19 on the right.

In the somewhat-receding wake of COVID-19, like floodwater, viral fear recently surged again when the World Health Organization began reporting monkeypox (MPX) outbreaks in Europe and North America. The stigmatization of MPX patients as “disease-spreaders” (in the media, on the internet, in conversation, etc.) suggests these individuals have a kind of authority over the virulent strands of DNA in their bodies. This belief aligns with the etymology of “virus” from the Latin “poison,” a word that functions as both noun and verb. Passive and active. Culpable.

Alan Krumeweide in *Contagion* (Claudette Barius / Warner Bros.)

I’m reminded of Jude Law’s fear-mongering character in Contagion, Alan Krumewiede, the conspiracy theorist who conjectured MEV-1, the film’s fictional virus, was “Godzilla, King Kong, Frankenstein, all in one.”

Of course, this sentiment did not bud from MPX or COVID-19 like a novel variant. No, it has existed in the United States for decades, if not longer, and it has not been dormant.

Dr. Stephen Thrasher, a scholar of the criminalization of HIV/AIDS at Northwestern University, stood in Duke’s anthropology lecture hall this month and drew parallels between the recent MPX/COVID-19 epidemics and that of HIV/AIDS in the 1980s-90s and stretching into the new millennium. He asked us to raise our hands if we personally knew someone with HIV/AIDS. A few did. If we knew someone who had died from HIV-related causes. A few less. What about COVID? The entire audience raised hands as if to signal the new era of viral infection.

Dr. Steven Thrasher is the inaugural Daniel H. Renberg Chair of social justice in reporting (with an emphasis on issues relevant to the LGBTQ community) and an assistant professor of journalism at Northwestern. His research focuses on HIV in America.

Since the start of the HIV/AIDS epidemic in 1981, more than 700,000 people have died from HIV-related illness in the United States, a disproportionate number of whom were men who had sex with men and injection drug users (with poverty exacerbating the likelihood of acquisition).

As Thrasher historicized, the stigma that encapsulated HIV/AIDS significantly delayed life-saving interventions on the local and national scale. Prejudice hindered research funding, drug distribution, and government health agency mobilization. The rising tide of the HIV/AIDS epidemic was concurrent with increased violence towards the LGBTQ community, and gay men in particular, analogous to a king tide flooding the coastline.

Thrasher exemplified this taboo through the “patient zero” misconception, which was propagated by the media during the epidemic and embedded like a splinter in pop culture’s thumb (i.e. the film Patient Zero with Matt Smith, Stanley Tucci, and Natalie Dormer).

Gaëtan Dugas was miscredited as Patient Zero of the HIV/AIDS epidemic in America
Credit: Fadoo Productions

Gaëtan Dugas, a Québécois Canadian flight attendant, was inappropriately labeled “patient zero” of the HIV/AIDS epidemic in America. As Thrasher and other researchers have debunked, Dugas was, in fact, not the first person to bring HIV to the United States. Further, Dugas was not even included in the early infection group. And Dugas was Patient O (like oh), not zero, for Out-of-State. Yet, this contextualization of the virus endures despite being disproved. Upon diagnosis, many infected individuals will experience shame.

In the 1980s and 90s, HIV/AIDS was characterized as the “gay plague,” setting ablaze a moral panic in America comparable to that of the Satanic Panic, rock ‘n’ roll, and fear of razor blades stuffed into gooey 3 Musketeers bars at Halloween (and there’s an interesting overlap in the timing of these hysterias in the collective American consciousness). And just two months ago even, many people were characterizing MPX in the same accusatory and morally dubious way.

Like with the AIDS epidemic, Thrasher said the US government failed to mobilize public health initiatives early enough to proactively stifle MPX outbreaks in spite of the disease’s well-documented diffusion across Europe and into neighboring Canada.

“We could’ve tapped the Strategic National Stockpile,” he argued. Thrasher listed multiple public health interventions that could have and should have been implemented with the first faint smoke signals of MPX in the United States (as they were in the past for meningitis and polio outbreaks).

For context, the Strategic National Stockpile (SNS) is a cache of medicines, antibiotics, and vaccines that the government started to accumulate just prior to 9/11 in 2001 and, seemingly, in an exponential manner after — almost like doomsday preppers hoarding freeze-dried beef stroganoff and cans of beans in their underground bunkers. Born from the smoking rubble and smoke of New York City following the terrorist attack, fear of biological warfare, especially the weaponization of smallpox, paralyzed the US (i.e. the Anthrax scare).

The SNS was tapped after 9/11, for 12 major hurricanes, COVID-19, and the swine flu (to name a few), but not for monkeypox.

As historically evidenced, mass vaccination and herd immunity effectively prevent the spread of viral infections, especially for slow-mutating viruses like MPX.

“We should have quickly vaccinated queer men and transmasc people,” Thrasher said, “building on a very historic anomaly which is that adults have been socialized to take vaccines en masse in a way that has not happened in many decades.” And because MPX and smallpox are closely related viruses, a rollout of the stockpile’s smallpox vaccine could have nipped the outbreak in the bud.

But, the SNS was not tapped. 100 million doses remain stockpiled. There are nearly 28,000 total monkeypox cases documented in the United States.

A large focus of Thrasher’s research is on who is affected by viruses, and how, and why. Nearing 6.6 million COVID-19 deaths worldwide, many would argue that viruses — these ancient, non-life forms — are Earth’s “great equalizers,” as acknowledged by Thrasher in multiple publications. Evolution has pushed them to infect, replicate, and spread: machine-like and non-discriminatory.

But, he added, viruses are not great equalizers. Infection is inherently unequal. Again, we must ask the question who?

Thrasher’s book *The Viral Underclass: The Human Toll When Inequality and Disease Collide* was recently long-listed for the 2023 Andrew Carnegie Medal for Excellence in nonfiction.

Viral infections disproportionately burden marginalized bodies and communities, a concept Thrasher framed as the viral underclass (coined by activist Sean Strub and reshaped by Thrasher to describe this phenomenon). Writing in his book of the same name, “… the viral underclass can help us think about how and why marginalized populations are subjected to increased harms of viral transmission, exposure, replication, and death.”

Let’s return to the MPX vaccine. The Biden administration did not tap the SNS for mass vaccination. Instead, it rolled out meager health interventions at a snail’s pace (like Sisyphus pushing his stone up the hill). Still, many at-risk individuals, in particular men who have sex with men, opted to receive a two-shot regimen to protect themselves from the virus. Considering the viral underclass, Thrasher posed the following questions:

Who is disproportionately burdened by MPX in the US? He answered, “Black and Latino men who have sex with men.”

And, who is receiving the medical interventions to protect themselves from the painful infection? He answered again, “I got one MPX vaccine shot, almost everyone in line but me and a friend were white.” He describes the discrepancy between those receiving the vaccine and those most at-risk of acquiring MPX in his Scientific American article “Monkeypox Is a Sexually Transmitted Infection, and Knowing That Can Help Protect People.”

And his years of HIV research corroborate this trend.

From the *New York Times*, Michael Johnson has been working to overturn laws criminalizing HIV in the United States.

He spoke (and wrote in The Viral Underclass) about his time reporting the Michael Johnson court case in St. Louis, Missouri. Michael Johnson, a black, gay, former college wrestler, was sentenced to 30 years in prison after failing to disclose his HIV status to his sexual partners — a criminal offense. The prosecution had sought a maximum 60.5 years, practically a life sentence.

For context, in the state of North Carolina, the maximum sentence for voluntary manslaughter is a little under five and a half years. In the courtroom, Thrasher was privy to the prosecution’s smoking gun: Johnson had previously signed a legally-binding acknowledgment of his HIV diagnosis. With the flick of a pen, nondisclosure was a criminal offense.

In his interviews, however, Thrasher found that Michael Johnson was semi-illiterate and had not been properly informed of the legal implications of the document he had signed. Nor had he been informed of the consequences of breaking the legal contract. Nor had he been counseled or given any legal advice prior to being charged.

Michael Johnson was released from prison 25 years early after his ruling was overturned. His is a body in the viral underclass.

Excerpted from Thrasher’s book *The Viral Underclass: The Human Toll When Inequality and Disease Collide*

Vito Russo speaks at the 1988 ACT UP demonstration at the Department of Health and Human Services in Washington, D.C.
Credit: Rick Gerharter/HBO Documentary Films

Concluding his lecture, Thrasher quoted AIDS activist Vito Russo’s Why We Fight speech from the 1988 ACT UP Demonstration at the Department of Health and Human Services. In reading the entire transcript, I found that Russo was aware of the viral underclass, as Thrasher theorized, despite the term not yet existing in the academic ethos. He said in his address:

“If I’m dying from anything — I’m dying from the fact that not enough rich, white, heterosexual men have gotten AIDS…. Living with AIDS in this country is like living in the twilight zone. Living with AIDS is like living through a war which is happening only for those people who happen to be in the trenches. Every time a shell explodes, you look around and you discover that you’ve lost more of your friends, but nobody else notices. It isn’t happening to them.”

Is it possible to ever resolve the viral underclass in the US? As long as systemic inequities continue to exist, no. This may seem pessimistic or even cynical, but Thrasher concluded his lecture (and his book) with reserved optimism. “Let’s get to work,” he implored.

If we can identify and actively dismantle the systems that disproportionately burden certain populations with viruses and diseases, like a spool of yarn, we can begin to unravel the viral underclass in America.

Yes, infections should be treated with accessible and affordable medicine. Yes, healthcare should be expanded. Yes, we should continue to improve the efficacy of drugs and diagnostics. But, health interventions alone do not cure communities of disease.

Thrasher found that marginalized bodies will continue to be infected, in spite of medicinal intervention, if the inequities from which the viral underclass emerge are not concurrently cured. Let’s get to work.

If interested, here’s a link to Thrasher’s website and book: http://steventhrasher.com/

Post by Alex Clifford, Class of 2024

Nursing’s Trial by Fire: COVID-19 and the Path Forward

By Vibhav Nandagiri

On October 12, 2022

In Medicine, Policy, Science Communication & Education

The list of professions that have been pushed to the brink during the pandemic is ever-expanding. However, the sea change that swept over nursing in the past three years rivals that of almost any occupation, said panelists in a Sept. 28 event hosted by Duke University School of Nursing.

Already one of the most overworked professions, the pandemic only seemed to magnify nursing’s enduring problems, according to panelist and journalist Lauren Hilgers. A few months into the pandemic, nurses around the country began quitting in droves due to both burnout and undervaluation by their employers. As the front lines dwindled, hospitals working at full capacity needed to meet patient demand by any means necessary.

Enter travel nursing agencies, independent staffing organizations that matched nurses from across the country with hospitals dealing with acute labor shortages. Already increasing in popularity in the lead-up to the pandemic, demand for travel nurses in recent times has exploded. As this fundamental change in the make-up of the nursing labor pool occurred, people started to take notice.

In February of 2022, an article was published in the New York Times titled “Nurses Have Finally Learned What They’re Worth”. In the piece, Hilgers chronicles the major trends in the nursing workforce over the past three years. Hilgers describes the unique proposition facing the nurses who chose not to quit: remain as a staff nurse on their current salaries or sign up with a traveling agency and uproot their lives, albeit for higher pay. And the pay bump was substantial. Certain travel nurse jobs paid up to $10,000 a week, many times what staff nurses were earning. These nurses would often stay at a hospital anywhere from a couple of weeks to months, providing much-needed relief to healthcare systems. However, as the practice spread, questions soon began to emerge about the disparities in pay between staff and travel nurses, the sustainability of travel nurse programs, and, moreover, how the American healthcare system enabled travel nursing to rise to such prominence in the first place?

These questions served as the foundation of the Dean’s Lecture Series event, “The Value & Importance of the Nursing Health Care Workforce for U.S. Health and Wellbeing”. Moderated by Dean Vincent Guilano-Ramos PhD, the event featured Hilgers alongside a panel of distinguished speakers including Solomon Barraza, CCRN, cardiac ICU nurse at Northwest Texas Hospital, Benjamin Smallheer, PhD, Associate Professor at the School of Nursing, and Carolina Tennyson, DNP, Assistant Professor at the School of Nursing.

From left to right: Solomon Barraza, Lauren Hilgers, Vincent Guilano-Ramos, Benjamin Smallheer, Carolina Tennyson. Photo by Andrew Buchanan.

“Nursing is the largest segment of the healthcare workforce…yet what we contribute to the health and wellbeing of our country is invisible,” mentioned Dean Ramos at the discussion’s outset.

Smalheer agreed, adding that nurses today are contributing to patient care in ways that were vastly outside of their scope of practice just twenty years ago. A unique combination of technical proficiency, aptitude during crisis response, and ability to provide feelings of care and comfort, Hilgers describes nursing as one of, if not the only, profession in healthcare that considers the “entirety of a patient.”

A frequently cited statistic during the panel presentation referenced results from a Gallup poll indicating that nursing was rated as the most trusted profession for the 20th year in a row. While nurses were always aware of their influence and worth, getting healthcare systems to agree proved to be a much larger effort, one that only grew in importance as COVID-19 progressed.

“The pandemic has hardened us,” explains Smallheer. No longer were nurses willing to tolerate slights against their treatment as a profession. And they had tolerated plenty. Barraza, one of the protagonists of Hilgers’ piece, described the relentless search for purpose amidst constant burnout, especially during the pandemic’s heaviest waves. From finding efficient triage methods during a surge of cases to celebrating patient discharges, Barraza actively sought out ways to be “consistent when there was no consistency.” A charge nurse located in a region with severe labor shortages, Barraza had seen the influx of travel nurses firsthand every week. What ultimately kept him from traveling across the country in the pursuit of a more lucrative job, however, was the relationships he had forged within the hospital. Nurses, students, patients-they had all left an indelible mark on Barraza and enabled him to push through the long and grueling hours. Tennyson reinforced Barraza’s story by claiming that “you can be burnt out and still find value in a profession.” This seemingly contradictory duality may have proved sufficient to retain nurses during the pandemic, but as for long-term solutions, the panelists agree that significant change must occur at a systemic level.

Hilgers (pictured right) spent months speaking to nurses around the country, including Barraza (pictured left). Photo by Andrew Buchanan.

One of the central tensions of Hilgers’ article is that between the hospital and the worker. The explosion of travel nursing during the pandemic was but a manifestation of decades of undervaluation by hospitals of nurses. In order to undo this narrative and enact concrete change, Tennyson argues that nurses must be represented in more interdisciplinary professional spaces, from healthcare administration to policy to business. Hilgers restates this idea more broadly, saying that nurses “need to have a seat at the table” in reshaping the healthcare system post-COVID-19.

Much of this work begins at the level of the educational institution. Smallheer and Tennyson spoke at length about how nurses can better be prepared to navigate the ever-changing healthcare workforce. They both highlighted a few of the Duke School of Nursing’s novel instructional methods, including early exposure to complicated patient cases, extensive practice with end-of-life scenarios, and recognition of overstimulation points in the field. Also important for nurses-in-training and existing nurses, according to all panelists, was collective action. Through supporting state and national nursing associations, writing to local politicians, and speaking to healthcare administrators, they argued that nurses will be better equipped to voice their demands.

Christine Siegler Pearson Building at Duke University School of Nursing

As the panel reached its closing stages, one of the main talking points centered around changing the narrative of nursing as solely a burnout profession. Hilgers in particular remains critical of the portrayal of nurses, and more broadly those involved in care work, in popular media. She strongly advocates for authentic storytelling that including the voices of actual nurses, nurses such as Barraza. Ramos describes Barraza as someone who “represent[s] the best in nursing,” and the panelists maintained a strong desire to see such stories of resilience and passion spotlighted more frequently.

There is no simple formula to reform the nursing profession in the United States. However, through a combination of effective storytelling, more current educational standards, greater interdisciplinary involvement, and collective action, the panelists of the Dean’s Lecture Series firmly believe that lasting change is possible.

Post by Vibhav Nandagiri, Class of 2025

The COVID-19 ‘Endgame’ Depends on Where You Live

By Meghna Datta

On October 20, 2021

In Business/Economics, Global Health, Medicine, Statistics

In February of 2020, no one could have fathomed that the very next month would usher in the COVID-19 pandemic – an era of global history that has (to date) resulted in 5 million deaths, 240 million cases, trillions of dollars lost, and the worsening of every inequality imaginable.

And while scientists and governments have worked together to make incredible advances in vaccine technology, access, and distribution, it goes without saying that there is more work to be done to finally put the pieces of an exhausted global society back together. On Tuesday, October 12^th, the Duke Global Health Institute (DGHI) brought together three leaders in global health to discuss what those next steps should be.

The panel discussion, which was moderated by Dr. Krishna Udayakumar of the DGHI, was titled “The COVID-19 Endgame: Where are we headed, and when will we get there?” The panelists were Dr. Ann Lindstrand, who is the World Health Organization’s unit head for the Essential Program on Immunization; Dr. Ayoade Alakija, who is the co-chair of the African Vaccine Delivery Alliance and founder of the Emergency Coordination Center in Nigeria; and Alberto Valenzuela, who is the Executive Director of the Pan American and Parapan American Games Legacy Project.

Dr. Lindstrand began by setting the stage and highlighting what are undoubted successes on a global level. 6.5 billion doses of the vaccine have been administered around the world, and the vaccines have impressive effectiveness given the speed with which they were developed. Yet undergirding all of this is the elephant in the room that, sitting in a 1^st-world country, we don’t think about: high-income countries have administered 32 times more doses per inhabitant compared to low-income countries.

This vaccine inequity has been exacerbated by already weak health security systems, vaccine nationalism, and lackluster political commitment. And while the WHO is slated to enormously ramp up supplies of vaccines in Q4 of 2021 and Q1 of 2022, it doesn’t mitigate the damage to the socioeconomic welfare of people that COVID-19 has already had. Dr. Lindstrand outlines the three waves of socioeconomic impact we will see, but expressed concern that “we’re already beginning to see the first wave pan out.”

Dr. Alakija took this discussion a step further, asserting that COVID-19 is poised to become the disease of low-income countries. “If you’re living in the US or EU,” she remarked, “You’re heading into the ‘Roaring 20s’. If you live in the Global South, COVID-19 is going to become your future.”

To this point, Dr. Alakija emphasized that the only reason this is the status quo is because in her eyes, the world failed to do what was right when it should have. In her home country of Nigeria, she highlighted that out of a population of 210 million people, 5.1 million people have received the vaccine – and of those 5.1 million, just 2 million — one percent — have been double-vaccinated. “It really is a case of keeping those down further down, while giving booster doses to those that have already been vaccinated,” she said. “We don’t have diagnostic data, so people are slipping underwater and the world has no idea.”

It’s worth noting that Nigeria houses some of the megacities of the world, not just in the African continent. So according to Dr. Alakija, “we don’t solve this with a medical lens, we solve this with a whole-of-society lens.” We must, she argued, because in an interconnected world, no one exists in isolation.

Alberto Valenzuela’s work is a great example of this. In 2019, his team led organizing efforts for the Pan American Games in Lima, relying on extensive partnerships between public organizations and corporations. In 2020, though, as the world shifted, the government called on the team to transition into something much different – COVID-19 relief efforts in the country.

The results are staggering. In just 5 weeks, the Pan American and Parapan American Games Legacy Project built 10 hospitals in 5 regions of the country. The implementation of 31 vaccination centers throughout the country resulted in a tripling of the number of people vaccinated per day in Lima. To him, this work “proves what’s possible when private and public sectors merge.” In other words, remarkable things happen when all of society tackles a societal issue.

So where do we go from here? Perhaps the biggest thing that stood out was the need to empower low-income countries to make decisions that are best for them. In Dr. Alakija’s words, “we need to lose the charity model in favor of a partnership model.” Dr. Lindstrand pointed out that there’s a deep know-how in the Global South of how to roll out mass-vaccination efforts – but only when we “lay down our organizational hats” can we move to what Dr. Lindstrand termed “more coordination and less confusion.” Valenzuela emphasized the need to integrate many sectors, not just healthcare, to mobilize the COVID-19 response in countries. But above all, Dr. Alakija said, “there will be no endgame until we have equity, inclusion, and health justice.”

Post by Meghna Datta, Class of 2023