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Tag: global health

Post-COVID Public Health is in a Trust Fall

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

Cancer Stigma, Contraceptives, Covid-19: 2022 Global Health Research Showcase

Last Monday, Oct. 17, Duke University students who had conducted global health research had the opportunity to present their work. From North Carolina to Sub-Saharan Africa, the 2022 Global Health Research Showcase featured works that tackle some of the world’s most pressing health issues. Over 40 undergraduate, Masters, and PhD student projects examined a broad range of issues, determinants, and phenomena in countries from almost every continent. Here’s a few project highlights, in case you missed it:

Maeve Salm, pursuing her Master of Science in Global Health, went to Tanzania to study contraceptive use. Tanzania’s youth are highly impacted by teen pregnancy, and Salm wanted to understand desires for contraceptive use among adolescents affected by HIV. She learned that, much like in the U.S., stigma influences access to sexual healthcare for adolescents. This qualitative study aimed to support young people in achieving their desired health outcomes and reducing HIV transmission by examining barriers and facilitators to family planning. Findings indicate that youth agency in reproductive health is of utmost importance.

Maeve Salm presenting her poster at the 2022 Global Health Research Symposium.

Wondering about the Covid-19 response in other countries? Master of Science in Global Health Candidate Stephanie Stan explored the barriers and enablers to the pandemic response in Peru. Per capita, Peru experienced the highest mortality rate form the disease compared to any other country. Due to several challenging factors, they were slow to receive COVID-19 vaccines. However, they implemented highly successful vaccination campaigns once vaccines were obtained. What can be learned from Peru’s pandemic response? Prolonged and proactive collaborations between sectors (healthcare, academics, and government) enable swift public health responses in a crisis. It’s important to have elected officials who are empowered to make decisions promoting science.

“Definitely meeting all the incredible people that I interviewed and learning about their work and involvement in Peru’s pandemic response. Learning about what happens moving forward from their point of view.”

Stephanie Stan, when asked about her global health research experience

Winning the first-place Graduate Student Research Award, Judith Mwobobia’s project examined the stigma of cancer in sub-Saharan Africa. Stigma is a huge barrier to receiving treatment, which is a problem considering that 70% of global cancer deaths originate from Africa. Perceptions of financial stress, misconceptions about cancer, and fear of death were common attitudes driving cancer stigma. Proposed interventions included education and policy recommendations for low-resourced communities. Mwobobia is pursuing her Master of Science in Global Health. Clearly a supportive group, her classmates erupted in cheers when the award was announced.

By Victoria Wilson, Class of 2023

Is it Time to Decolonize Global Health Data?

In the digital age, we are well-acquainted with “data,” a crouton-esque word tossed into conversations, ingrained in the morning rush like half-caf cappuccinos and spreadsheets. Conceptually, data feels benign, necessary, and totally absorbed into the zeitgeist of the 21st century (alongside Survivor, smartphones, and Bitcoin). Data conjures up the census; white-coat scientists and their clinical trials; suits and ties; NGO board meetings; pearled strings of binary code; bar graphs, pie charts, scatter plots, pictographs, endless excel rows and columns, and more rows and more columns.

However, within the conversation of global health, researchers and laymen alike would more often than not describe data collection, use, and sharing as critical for resource mobilization, disease monitoring, surveillance prevention, treatment, etc. (Look at measles eradication! Polio! Malaria! Line graphs A, B, and C!)

Thanks to the internet, extracting health data is also faster, easier, and more widespread than ever . We have grown increasingly concerned, and rightfully so, about data ownership and data sovereignty.

Who is privy to data? Who can possess it? Can you possess it? As you can see, the conversation quickly becomes convoluted, philosophical even.

Dr. Wendy Prudhomme O’Meara is an associate professor at Duke University Medical School in the Division of Infectious Diseases, visiting professor at Moi University, and the Co-Field Director of Research for AMPATH. Her research focuses on malaria. 

Dr. Wendy Prudhomme O’Meara, moderator of the Data as a Commodity seminar on Sept. 29 and associate professor at Duke University Medical School in the Division of Infectious Diseases, discussed bioethical complexities of data creation and ownership within global health partnerships.

“We can see that activities—where data is being collected in one place, removed from the context, and value being extracted from it for personal or financial benefit — has very strong parallels to the kind of resource extraction and exploitation that characterized colonization,” she said in her introductory remarks.

Data, like other raw materials (i.e. coffee, sugar, tobacco, etc.), can be extracted, often disproportionately, from lower-middle income countries (LMICs) at the expense of the local populations. This reinforces unequal power dynamics and harkens to the tenets of colonialism and imperialism.

This observation is exemplified by panelist Thiago Hernandes Rocha’s research which focuses on public policy evaluation and data mining. He acknowledges that global health research, in general, should prioritize the health improvements of the studied community rather than publications or grant funding. This may seem somewhat obvious to you; however, though academic competition often fosters nuances in the field, it also contributes to the commercialization of global health. Don’t be shy, everyone point your finger at Big Pharma!

Though Dr. Rocha’s data mining technique refers to “pattern-searching” and analysis of dense data sets, I find “mining” to be an apt analogy for the exploitative potential of data extraction and research partnerships between higher income countries and LMICs.

Dr. Thiago Hernandes Rocha joins the discussion via Zoom. He is an advisor on health data analysis for the Pan American Health Organization.

Consider the British diamond industry in Cape Colony, South Africa, and the parallels between past colonial mineral extraction and current global health data extraction. Imagine taking a pickaxe to the earth.

Now consider the environmental ramifications of mining, and who they disproportionately affect. Consider the lingering social and economic inequalities. Of course, data is not a mine of diamonds (as your Hay Day farm might suggest) nor is it ivory or rubber or timber. It’s less tangible (you can’t necessarily hold it or physically possess it) and, therefore, its extraction also feels less tangible, even though this process can have very concrete consequences.

Data as a power dynamic is a rather recent characterization in academic discourse. Researchers and companies alike have pushed the “open data” movement to increase data availability to all people for all uses. You can see how, in a utopian society, this would be fantastic. Think of the transparency! I’m sure you can also see how, in our non-utopian society, this can be exploited.

Dr. Bethany Hedt-Gauthier, a Harvard University biostatistician and seminar speaker, described herself as “pro ‘open data’ … in a world without power dynamics” — an amendment critical to understanding research as a commodity itself.

She justified her stance by referencing the systematic review of authorship in collaborative health research in Africa that she conducted in collaboration with others in the field. They found that even when sub-Saharan African populations were the main sites of study, when partnered with high-income, elite institutions (like Duke or Harvard), the African authors were significantly less likely to be first or senior authors despite the comparable number of academics on both sides of the partnership. To what can we attribute this discrepancy?

Dr. Bethany Hedt-Gauthier is a biostatistician in health systems research that focuses on the optimization of care and health outcomes in sub-Saharan Africa.

Dr. Hedt-Gauthier describes forms of capital that contribute to this issue, from cultural capital (i.e. credentials) to symbolic capital (i.e. legitimacy) to financial capital; however, she poses colonialism (and its continuity in socioeconomic and political power dynamics today) as the root of this incongruity from which the aforementioned forms of capital bud and flower like poisonous oleander. In recent years, institutions, including Duke, have increased efforts to “decolonize” global health to achieve greater equity, equal participation, and better health outcomes overall. 

Dr. Hedt-Gauthier briefly chronicled some of her own research in Rwanda at the start of the COVID-19 pandemic. Within her research partnerships, she recollected slowing down, thoughtfully engaging in two-way dialogue, and posing questions like the following: “Who is involved [in the partnership]?” “Are all parties equally represented in paper authorship?” “If not, how can we share resources to ensure this?” “How can we assure that the people involved in the generation of data are also involved in the interpretation of its results?” “Who has access to data?” “What does co-authorship look like?”

Investing time and energy into multi-country databases, funding collaborative research infrastructures, removing barriers within academia, and training researchers are just some of the methods proposed by the speakers to facilitate equitable partnerships, data sharing and use, and continued global health decolonization.

Dr. Osondu Ogbuoji is an Assistant Research Professor at Duke Global Health Institute (DGHI) and Deputy Director at the Center for Policy Impact in Global Health at DGHI.

Dr. Osondu Ogbuoji, the final panelist, puts it best: “… We should ensure that the people in the room having the discussion about what values the data has should be as diverse as possible and ideally should have all the stakeholders. In our own research, sometimes we think we have an idea of what data to collect, but then we talk to the country partners and they have a totally different idea.”

Though the question of data ownership may feel lofty or intangible, though data legality is confusing, though you may feel yourself adrift in the debate of commodity and capital, the speakers have thrown you a buoy, grab on, and understand that generally:

It is necessary to engage with “data” in a communicative and critical manner; it is necessary to build research partnerships that are synergistic and reciprocal; and, finally, it is necessary to approach global health via these partnerships to advance the field towards greater equity.

Post by Alex Clifford, Class of 2024

Watch the recorded seminar here: https://www.youtube.com/watch?v=wRmFzif8a1c

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