CrossingBoundaries
2020-21 Impact Report
Facts, figures and field reports documenting the impact of the Duke Global Health Institute’s mission to advance health equity for communities around the world.
Facts, figures and field reports documenting the impact of the Duke Global Health Institute’s mission to advance health equity for communities around the world.
Five projects that embody DGHI’s spirit of transcending boundaries to address complex health problems
Sixty to seventy percent of the infectious diseases that affect humans start in animals, a formidable lineup that includes plague, Ebola, West Nile, Lyme disease and many forms of influenza. And as the COVID-19 pandemic has so painfully shown, when a novel virus breaks loose in human populations, it can cause chaos.
Infectious disease experts Linfa Wang, Gregory Gray and Gayani Tillekeratne are among a community of scientists who say we can do a better job anticipating and preventing new viral threats. By investigating the interfaces where animals and humans interact, these researchers are working to understand how viruses jump from animal species to humans – and how to give public health systems an early warning when novel viral threats surface.
For more than a decade, DGHI psychologist Eve Puffer has traveled to western Kenya to train church and community leaders to support neighbors who are struggling with family and relationship issues. But when COVID-19 made those trips impossible, Puffer found a way to apply what she has learned closer to her own backyard.
With funding from DGHI and Duke’s Bass Connections program, Puffer teamed with DGHI colleague Rae Jean Proeschold-Bell to create Coping Together, a peer-led therapy model aimed at helping families who are running on empty after more than a year of pandemic disruptions. Working with North Carolina community groups, the team has trained facilitators chosen from the community to lead an eight-week program for families to address stress, strengthen coping techniques and improve family communication.
On his regular trips to Vietnam, DGHI physician Walter Lee saw that many frontline clinics don’t own a flexible nasopharyngoscope, a common, but expensive device used to spot signs of throat cancer. Lee, a specialist in head and neck surgery, knows this is an all-too-frequent barrier doctors in low-resource settings confront: No matter their training, they are limited by their tools.
“If the local doctors had a flexible scope, they could pick up cases earlier and get them referred for treatment,” says Lee. “I think we’d see better patient outcomes.”
For the past several years, Lee has been working with biomedical engineering professor Bob Malkin and his Duke engineering students to create just that – a low-cost nasopharyngoscope better suited for places like Vietnam. This year, the team took a huge step toward realizing that vision.
When Deborah Koltai and Tony Fuller led one of the first country-wide surveys to understand knowledge and beliefs about epilepsy in Uganda, they found that two-thirds of Ugandans believe the seizures associated with epilepsy may be caused by spiritual forces. And that makes the role of traditional healers a unique and challenging variable in Uganda’s efforts to address its growing burden of epilepsy, a chronic, but treatable disorder that frequently goes undiagnosed in low- and middle-income countries.
As part of a decade-long partnership in Uganda, the Duke Global Neurosurgery and Neurology division is working to address those gaps and improve epilepsy diagnosis and care. Now, thanks to Koltai’s outreach with traditional healers, understanding and respecting the influence of healers may become an asset to improving biomedical care.
As a student in DGHI’s Master of Science in Global Health program, Kuleni Abebe wanted to explore the cross-cutting relationships between human health and the environment. Her thesis research probed one of those thorny intersectional issues, examining the use of wood-burning stoves in Madagascar. Harvesting wood for cooking contributes to deforestation on the ecologically fragile island, but it also carries health impacts on household cooks who breathe in woodsmoke day after day.
“This project touches on so many aspects of health, environment and behavior,” Abebe says. The opportunity to work with experts in a range of fields – including ecology, infectious and chronic diseases, environment, statistics and public policy – taught her to think across disciplinary boundaries when taking on complex problems.
A look at some of the key data points from our research, teaching and global outreach in 2020-21
Externally funded research grants earned by DGHI faculty in 2020-21
Total annual funding of all DGHI research grants in 2020-21
Countries where DGHI faculty have active research projects
Despite travel restrictions, 78 students participated in global health research during summer 2021, working with partners in 15 countries
Students pursuing DGHI global health programs at all levels in 2020-21
DGHI has enrolled students from 35 countries in its Master of Science in Global Health program since 2009
DGHI funding sources, 2020-21 ($ in millions)
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DGHI’s 168 core and affiliate faculty members come from 8 Duke schools, in addition to DGHI primary positions
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Notable breakthroughs, innovations and accomplishments from across our missions
During the past year, researchers across the Duke Global Health Institute continued their efforts to examine the full scale of the COVID-19 pandemic and envision solutions to the myriad challenges created by the novel coronavirus and efforts to control it. To spark new collaboration on pandemic-related research, DGHI funded a series of pilot grants in the summer of 2020. Funded projects included:
A unique tool, the Launch and Scale Speedometer, developed by DGHI’s Global Health Innovation Center (GHIC) in 2019, was used this past year to compile and analyze publicly available data on COVID-19 vaccine manufacture, procurement and distribution. Led by GHIC director Krishna Udayakumar, the speedometer project is guiding decision-making by global health leaders in multiple countries, including the U.S., Canada, Peru and Germany, as well as the World Health Organization. Its up-to-date tracking of vaccine quantities has been cited by dozens of international media organizations and NGOs, helping call attention to inequities in vaccine purchasing and allocation affecting many low- and middle-income countries.
DGHI professor Shenglan Tang and Can Zhang of Duke’s Fuqua School of Business compiled a report providing recommendations for a COVID-19 vaccine distribution plan in China. The report was submitted to the China CDC and the Development Research Center of the State Council in China and informed the government’s vaccine rollout policies. Tang, a professor of population health sciences and DGHI’s deputy director, also analyzed the response of seven countries in Southeast Asia to COVID-19 to better understand their initial success in beating back the virus during the first wave of the pandemic. He noted that their experience with previous pandemics, such as SARS and MERS, informed swift responses that were highly coordinated among national, regional and local officials and relied upon clear and consistent communication.
In the summer of 2020, William Pan, associate professor of global environmental health, and a team of analysts sifted through data from all 3,142 U.S. counties and the District of Columbia to analyze the relationships between the timing of coronavirus policies such as lockdowns and mask mandates and the resulting number of COVID-19 cases and deaths. Their findings demonstrated that only the strictest measures effectively prevented the virus from propagating.
Research by Linfa Wang, a virologist at Duke-NUS Medical School in Singapore and a DGHI professor, led to the development of a test to detect antibodies to SARS-type coronaviruses in bat droppings and urine, enabling the hunt for genetic relatives of SARS-CoV-2. Wang has successfully traced the origins of past outbreaks, including the original SARS virus 17 years ago, and throughout the pandemic he has been engaged in research that is vital to preventing future viral threats from spreading.
DGHI professors have continued to contribute timely expertise and analysis to the public dialogue about emerging issues throughout the pandemic. In addition to participating in more than 140 interviews and media stories, as well as several Duke-organized media briefings, faculty wrote dozens of commentaries and opinion articles on pandemic policy and public health measures, including organizing a joint letter signed by several top global health organizations urging leaders of the G7 nations to more aggressively donate COVID-19 vaccines to low- and middle-income countries. DGHI’s Global Health Innovation Center organized a series of webinars addressing topics related to vaccine manufacture, financing and distribution, which were viewed by a global audience of more than a thousand people.
With COVID-19 cases spiking in India, DGHI’s Global Health Placement of Life-Saving Usable Surplus (PLUS) Program led the in-country distribution of more than 150 boxes of PPE and equipment to healthcare workers in New Delhi. Funds and equipment were donated by colleagues across Duke Health in the departments of anesthesiology, perioperative services, pharmacy, surplus, supplies and more, as well as friends and family members.
Gavin Yamey, director of DGHI’s Center for Policy Impact in Global Health (CPIGH), developed the first working paper on the global financing and manufacturing of COVID-19 vaccines and continued research on strategies to increase equitable distribution of the vaccines. Yamey teamed up with the Duke Human Vaccine Institute and David McAdams of Duke’s Fuqua School of Business on a project using game theory to demonstrate how wealthier nations could be incentivized to participate in COVAX, the entity formed by the World Health Organization to ensure global vaccine distribution. Their results were published in Nature and BMJ Global Health.
Examining 301 archived pneumonia cases from 2018, a team led by Gregory Gray, professor of medicine, global health and environmental health, identified a novel canine coronavirus that appears to cause illness in humans. If further research confirms it as a pathogen capable of infecting humans, it will be the eighth unique coronavirus known to have jumped from animals to humans. The team used a molecular diagnostic tool that it developed in 2020, which Gray says potentially enables the detection of new viruses before they have a chance to spread.
DGHI associate professor Marc Jeuland led a large, multi-national team in documenting the impact of energy transitions on low- and middle-income countries. Involving synthesis of more than 80,000 research studies related to energy use, the massive project, published in ScienceDirect, documented positive and negative impacts from national and global energy transitions on a range of factors, including household health and well-being, national energy use and policy, and environmental conditions. The research provides a road map of the complex issues and challenges inherent in energy transitions and points to policies that favor positive impacts on health and environment.
Kristin Schroeder, assistant professor of pediatrics and global health, and her team developed and implemented mNavigator, a digital health application to improve provider compliance with evidence-based lymphoma treatment guidelines in Tanzania. Preliminary results show that the implementation of mNavigator resulted in a 20% increase in compliance, and treatment abandonment decreased from 25% to 12%. The digital tool is one aspect of Schroeder’s multifaceted approach to treating pediatric cancer patients and their families in Mwanza, Tanzania, where her program has helped produce significant improvements in health outcomes for children with cancer.
Community health workers in Kisumu, Kenya, are now using an app designed by global health students and faculty to aid cervical cancer screening in the region. The app, known as mSaada, was developed by students working with the DGHI Center for Global Reproductive Health to provide educational and counseling resources, patient tracking tools, and notifications of test results and service reminders for community health volunteers conducting cervical cancer screenings. Recently, the County Health Management Team in Kisumu approved use of the app, paving the way for implementation among some 900 community health workers operating in the region.
For the 2.7 million people each year bitten by snakes and other venomous creatures, the timely delivery of antivenom can save life and limb. But the availability of antivenom is far from universal, particularly in areas where snakebites are common. Joao Vissoci, assistant professor of surgery, neurosurgery and global health, has developed an innovative way using data and mapping systems to identify where antivenom care and supplies are most critical, and in the past year he has engaged communities in the Brazilian Amazon to improve timely access to antivenom care in remote, low-resource clinics. Wider application of these tools could help prevent the more than 35,000 deaths and 400,000 cases of permanent disability that occur globally due to snakebites and venom.
Health systems in low-resource settings sometimes do not have the personnel or the cultural expectation to prioritize palliative care, which seeks to relieve pain and provide comfort for those with serious illnesses. Peter Kussin, professor of medicine and global health, worked with colleagues at Moi Teaching and Referral Hospital in Kenya to test a tool that can assess palliative care needs among patients recovering from surgery. Their pilot study demonstrated that the seven-step tool is a simple, effective method to identify patients who can benefit from palliative care in low-resource settings.
Catherine Staton, associate professor of surgery and global health, has implemented a new intervention aimed at addressing alcohol use as a leading cause of injury among young adults in low- and middle-income countries. In a pilot study at Kilimanjaro Christian Medical Centre in Moshi, Tanzania, nurses engaged in a brief intervention with patients who arrived at the emergency department with alcohol-related injuries. Staton designed the study to help address the growing problem of alcohol use, and the subsequent increase in alcohol-related accidents and injuries, in countries such as Tanzania, where alcohol treatment and support services are scarce.
Although it is a genetic condition, sickle cell disease is influenced by a number of environmental factors that suggest it should be studied from more than just a clinical perspective, asserts a paradigm-shifting analysis led by DGHI professor Charmaine Royal. A professor of African and African American studies, biology, global health and family medicine and community health, Royal and her colleagues reported on an array of factors – including climate, air quality, poverty, access to healthcare, diet, exercise and psychosocial factors – that shape the course of the disease. Their research, published in Advanced Genetics, seeks to encourage providers to better understand disease complexity and how environmental factors can influence outcomes.
Since 2018, a DGHI student-led working group has been advocating for faculty to include more voices from low- and middle-income countries in their curricula and to examine the colonial roots of global health. Part of an international movement to decolonize global health practice, research and training, these efforts were recognized as a priority by DGHI’s Equity Task Force, which was formed in 2020 to advance anti-racism efforts and dismantle institutional barriers to equity across the institute’s missions. In fall 2020, DGHI launched its first course specifically focused on decolonizing global health, led by Kearsley Stewart, professor of the practice in global health and cultural anthropology. The institute has also initiated efforts to aid faculty in incorporating decolonization themes and discussions into global health courses and ensure equitable partnerships in research and training activities.
A Bass Connections team mentored by Sarah Armstrong, associate professor of pediatrics and DGHI affiliate, and Emily D’Agostino, assistant professor in family medicine and community health, studied the distribution of urban greenspaces and its association with health outcomes in Durham County. Hiwot Zewdie, a 2021 global health MS graduate who led the team, conducted geospatial analysis to explore where Durham youth engage in physical activity. Findings will help inform the city’s efforts to revitalize neighborhoods and promote physical and mental health among marginalized communities. A paper about the project was published in a special issue in the Annals of Epidemiology on geospatial analyses and health.
A team of Duke students enrolled in an interactive DGHI Global Surgical Care course working with surgeons at Makerere University in Uganda won the top prize at the 2021 Bay Area Global Health Innovation Challenge. Their innovation makes it possible for doctors in low-resource settings to perform life-saving surgery on infants with gastroschisis, a rare birth defect in which babies are born with their organs outside their body, by preserving and protecting the organs until surgery can be performed. Taught by associate professor of surgery and global health Tamara Fitzgerald, the specialized course generated scholarship in Annals of Global Health.
The “Help Desk,” a Bass Connections project launched in 2018 to connect Durham-area residents with social services related to their medical care, blossomed during the pandemic. Led by Janet Bettger, DGHI associate professor and health services researcher, the project shifted gears as many social services closed or limited access during pandemic lockdowns, deploying students to aid local residents in accessing resources and care. Students kept detailed information on available services and how to find them, which enabled many residents to receive support throughout the pandemic. The overall aim of the project is to reduce the rate at which patients fail to follow up on medical providers’ recommendations by providing reminders and help connecting with services.
Professor of global environmental health Randy Kramer developed and taught Duke’s first course on Planetary Health, a new interdisciplinary field looking at the interplay of human activity, environmental changes, human health impacts and policy interventions. Case studies included climate change, biodiversity losses and food security. The course attracted students from environmental sciences, global health, engineering, public policy, psychology and economics.
A Bass Connections team led by Liping Feng, associate professor of obstetrics and gynecology and DGHI affiliate, collaborated with scientists in China to research the global health effects of e-waste recycling. They collected samples from an e-waste site in Taizhou, China, and wrote a policy brief on the issue, highlighting the discrepancy between national policy and practice. As part of the project, the team built a Duke website to advocate for recycling e-waste. Ongoing work involves a review paper focusing on e-waste exposure and health in early life stages.
In an example of the creativity and adaptability demonstrated by global health faculty, staff and students during the pandemic, DGHI associate professor Eric Green convened a course in Duke’s Jack Coombs Field in order to offer in-person instruction while complying with COVID-19 safety protocols. In addition to offering Green the unique opportunity to display lecture notes on a Jumbotron, the course underscored the commitment of the institute’s professors and instructional staff to continue to provide transformative educational experiences for students during the pandemic. When travel restrictions prevented many global health students from completing planned field research projects, mentors and educational staff scrambled to create opportunities for students to engage in research projects remotely with global and local partners.
DGHI joined with the SingHealth Duke-NUS Global Health Institute in Singapore and Duke Kunshan University in China to host a workshop to prepare health systems in the Asia-Pacific region to respond to COVID-19 and other pandemic threats. Sixteen faculty from the host institutions participated, along with collaborators from Vietnam, the Philippines, China and Sri Lanka. The workshop launched four projects aimed at improving molecular diagnostics and surveillance of novel infections, as well as studies of the impact of COVID-19 on tuberculosis and diabetes in vulnerable populations. This was the sixth formal meeting organized by DGHI in the past seven years to foster research collaboration with global partners.
Over the past year, DGHI adjunct professor John Crump and associate research professor Matthew Rubach conducted research on diseases that produce fevers in Tanzania that included vital capacity-building in Pathology at Kilimanjaro Christian Medical Centre (KCMC) in Moshi. Investments included human capacity-building and capital equipment to enable telepathology. The project was a major catalyst in linking KCMC with the American Society for Clinical Pathology’s initiatives in telepathology and histology capacity-building, a highly successful resource for bi-directional learning and consultation.
The pandemic did not deter the Hubert-Yeargan Center (HYC) for Global Health from continuing the first and only general cardiovascular disease fellowship in Kenya. Led by Cynthia Binanay, HYC’s director of operations, the fellowship is a collaboration between HYC, Moi University, and Moi Teaching and Referral Hospital. The first two Kenyan Fellows enrolled into the Cardiovascular Diseases Fellowship program in the fall of 2019, and two more joined in January 2021. Throughout the pandemic, more than 120 lectures were delivered remotely three days a week (often at the crack of dawn) by a committed team of faculty, fellows and staff from universities around the world – ensuring training, research and clinical care continued.
Duke faculty lead two ongoing surgical specialist training programs in Uganda. The Duke Global Neurosurgery and Neurology Program, led by DGHI professor Michael Haglund, has for the past decade offered a training program for neurosurgical residents in Uganda, which has greatly expanded the number of trained neurosurgeons in the country. In the past two years, the program has created training and resources for diagnosis and treatment of epilepsy, which frequently goes untreated in Uganda. Similarly, Tamara Fitzgerald, associate professor of surgery and global health, leads a program for fellows in pediatric surgery that has increased the number of pediatric surgeons in Uganda from one in 2013 to eight in 2020, with four more in training.
A program designed to build clinical research skills among Chinese physician-scientists has graduated more than 250 clinician researchers. The Duke-Beijing Friendship Hospital (BFH) Fundamentals of Clinical Research Training Program, hosted jointly with the Duke Clinical Research Training Program, is delivered twice yearly to physicians participating across China. The program is designed to bridge cultures by offering a blended learning approach, and its alumni often remain engaged with each other to support professional development and continued learning.
The Health Professions Education Partnership Initiative has created and harmonized competency-based medical and nursing school curricula across a consortium of training programs in Tanzania. Organized by John Bartlett, professor of medicine and global health, along with a number of Tanzanian partners, the initiative has to date supported the training and mentored research of 12 young faculty members while fostering community among Tanzanian researchers and clinicians.
To expand Sri Lanka’s ability to track COVID-19, Gayani Tillekeratne, assistant professor of medicine and assistant research professor of global health, helped establish SARS-CoV-2 testing and surveillance at the University of Ruhuna in Sri Lanka. The project included purchasing additional RT-PCR machines and reagents, technical knowledge transfer, funding a local laboratory technician, and supporting two local investigators in obtaining local grants for SARS-CoV-2-related research. The site conducts SARS-CoV-2 testing of samples sent by the Sri Lankan Ministry of Health for diagnostic and surveillance purposes.
Gavin Yamey, director of DGHI’s Center for Policy Impact in Global Health (CPIGH), and Osondu Ogbuoji, assistant research professor of global health, were part of a team who wrote a policy brief for the G20 arguing that public health is a crucial global public good – particularly as evidenced by the global response to COVID-19. The G20 Leaders’ Declaration included several recommendations from the brief in sections B10 and B11. It recognized the importance of global public health goods and the need for resilient health systems, global pandemic preparedness and universal health coverage.
A team of global researchers including William Pan, associate professor of global environmental health, created an award-winning technology to capture dangerous mercury vapor from artisanal and small-scale gold mining. In addition to technology development, Pan’s team partnered with scientists in Peru and Colombia to draft new proposals for testing mining technologies and evaluating new research questions linking exposure to chronic and developmental diseases. Pan also joined the Minamata Convention Effectiveness Evaluation Team to guide signatories in establishing human, air and biota biomonitoring of mercury.
Since May 2020, the DGHI Global Health Innovation Center (GHIC), led by Krishna Udayakumar, has worked with a consortium composed of seven organizations in Kenya to reduce the impact of non-communicable diseases. GHIC’s efforts, as an Impact and Evaluation Advisor, have strengthened significantly the consortium’s data reporting and evaluation plans as well as the capabilities of program leaders and managers to measure and generate greater impact from their activities.
Are there negative environmental and health consequences if a government taxes clean cooking technology? Associate professor of public policy and global health Marc Jeuland developed a beta version of a tool – BAR-HAP (Benefits of Action to Reduce Household Air Pollution) – to evaluate such energy policy questions. Developed for the World Health Organization, the tool analyzes the economic and financial case for policies aimed at facilitating transitions to cleaner household cooking technology. The tool has been applied to a policy analysis for Nepal and Kenya and is being upgraded to be user-friendly and incorporate a global data set.
A 2021 U.S. House appropriations bill sponsored by Rep. David Price (D-NC) includes a $5.5 million appropriation for a pilot test proposed by DGHI professor Jeffrey Moe and colleagues to incentivize the development of next-generation insecticides. The pilot would deploy expedited review vouchers to remove obstacles and create incentives for manufacturers to develop new insecticides that can be effective against mosquitoes that have developed resistance to existing formulas while reducing environmental impact.
Led by Mary Story, professor of global health and family medicine and community health, the national program Healthy Eating Research published findings related to federal childhood nutrition policies in a special issue in the journal Nutrients. The issue explored progress schools have made in promoting healthier lunches and food offerings and sought to fill information gaps on issues such as how the school food environment influences children’s dietary behaviors and weight.
Our students talk about challenges and rewards of learning during an extraordinary year for global health
It is important to use our ears more than our mouths and listen; the empathy that comes from it is invaluable. ...Thank you, Duke, for exposing me to this world of global health and giving me something to be relentlessly passionate about.
Deepti Agnihotri T'20, MS'21
I've learned that the global health community needs reflexivity and checks in order to best empower the people we seek to help. I want to take that humility and reflexivity wherever I go and work with the training I've received.
Michelle Rojas MS'21
(I have learned) the importance of tackling global health through local efforts. Just as there is a diverse global community with unique health needs, there are equally complex challenges locally that can be taken on using global health principles.
Vincenzo Malo AB'20, MS'21
During COVID times and while working on rural India's problems, I have come to realize that doing research in areas where it is needed the most gives a sense of gratification that can help you feel a bit more purposeful.
Siddesh Zadey MS'21
Coming to Duke has made me realize that there is no question that is too big to answer nor is there a world that is too good to be true...
Hansol Hyon MS'21
I found the passion that I was searching for when I first applied. I learned to appreciate difficult times as they were opportunities for immense growth.
Emma Joo MS'21
The COVID-19 pandemic holds many lessons for those of us in global health. But none is more important than its powerful reminder that we live in a deeply interconnected world. National boundaries mean nothing to viruses, which too often find safe harbor among unprotected, marginalized communities. If the relentless grip of COVID-19 has taught us anything, it should be that global threats demand global responses.
This is true for many of the world’s biggest health challenges. The ways in which we divide ourselves – geographically, economically, socially and even scientifically – can become barriers to collaboration and cooperation. At the same time, the most significant breakthroughs often come when we transcend those boundaries, working across borders, disciplines, cultures and experiences and creating space for new ideas and innovations.
I hope you have seen from this report that at the Duke Global Health Institute, we encourage and celebrate those who dismantle the boundaries that inhibit progress. We nurture students and scholars who challenge the status quo, but who also empower those who can challenge their assumptions and expand their perspective. It is this unique mix of ingenuity and humility that allows us to work in true partnership in so many places around the world.
I am deeply grateful for all those who have made the work reflected in this report possible – from our talented faculty, staff and students to our gracious and thoughtful global partners to the many funders and donors who support our work. Thank you for all that you do to advance our mission of achieving health equity for communities around the world.
Dennis A. Clements III
Interim Director, Duke Global Health Institute
