Duke Global Health Institute

Durham, NC, United States

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Durham, NC, United States
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News Article | May 15, 2017
Site: www.sciencemag.org

If a serious infectious disease blossomed across the globe today, the U.S. death toll could be double that of all the casualties suffered in wars since the American Revolution. Those 2 million potential American lives lost to a global pandemic is just one sobering statistic cited in a new report released today by the U.S. National Academies of Sciences, Engineering, and Medicine that urges sustained U.S. spending on global health initiatives. It also calls on the federal government to develop a new “International Response Framework” to guide the nation’s preparation and reaction to intercontinental epidemics and global pandemics. “While global crises have largely been avoided to date, the lack of a strategic [U.S.] approach to these threats could have grave consequences,” the report warns. “If the system for responding to such threats remains reactionary, the world will not always be so lucky.” The next epidemic—whether from nature or bioterrorism—is a question of “when,” not “if,” according to the authors of the report, titled Global Health and the Future Role of the United States. They say the 313-page tome is intended to send a strong message that investing in public health beyond U.S. borders is more than a philanthropy project; it’s also a matter of economic stability and national security here at home. “I have long argued that it is not just being altruistic to address these issues on a global basis, because sooner or later [they] will impact us,” says Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota in Minneapolis and a member of the panel that wrote the report. (Osterholm has also recently written that President Donald Trump’s proposed budget cuts to the National Institutes of Health miss the mark on “the greatest national security threat of all: our fight against infectious disease.”) The report’s authors make 14 recommendations for intervening in global health across four broad areas: prepping for global disease outbreaks; sustaining funds for responding to AIDS, tuberculosis, and malaria; improving women’s and children’s health; and reducing incidence of cardiovascular disease and cancers in low- and middle-income countries. It also calls for “the creation of an International Response Framework to guide the U.S. response to an international health emergency.” Osterholm tells Insider that the structure of such a framework was left intentionally open-ended, to give officials leeway to think about how to avoid duplication of effort and wasted resources. Federal law already enables U.S. agencies to respond to domestic disease outbreaks, Osterholm notes, but “it is more complicated when you get into other countries.” For example, at the height of national concern several years ago about the Ebola virus outbreak in West Africa, former President Barack Obama named a temporary “Ebola czar” to oversee the U.S. response. But report author Michael Merson, director of the Duke Global Health Institute in Durham, North Carolina, says the United States needs to “have a more stable system or framework in place so we would not have to do things on an ad hoc basis in the future.” The report also argues that steady federal spending on disease preparedness—rather than the reactive and often delayed infusions of funds prompted by the recent Ebola and Zika virus outbreaks—would save money and increase effectiveness over the long haul. The report notes that even a “moderate influenza pandemic” that reduces global economic output by 2% could cost the world economy between $570 billion to $2 trillion. Good health can also equal greater political stability, the authors argue. “When one thinks of global health, one often thinks of disease, humanitarian needs, and the moral imperative,” Merson says. “But now there is evidence that countries with good health are more secure and have less terrorism. So we tried to explain the benefits of global health from various perspectives: It is an economic issue, it is good for markets, it is important for diplomacy.” The report comes as the Trump administration has proposed deep cuts in public health and foreign aid programs in the 2018 fiscal year that begins 1 October. Key members of Congress have been cool to those proposals, but final spending levels are not expected to be set until late this year at the earliest.


Finkelstein E.A.,National University of Singapore | Finkelstein E.A.,Duke Global Health Institute | Graham W.C.K.,National University of Singapore | Malhotra R.,National University of Singapore | Malhotra R.,Duke Global Health Institute
Pediatrics | Year: 2014

BACKGROUND AND OBJECTIVES: An estimate of the lifetime medical costs of an obese child provides a benchmark of the potential per capita savings that could accrue from successful childhood obesity prevention efforts. We reviewed the literature to identify the best current estimate of the incremental lifetime per capita medical cost of an obese child in the United States today relative to a normal weight child. METHODS: We searched PubMed and Web of Science for US-based studies published within the 15 years preceding May 2013 from which lifetime medical cost estimates can be extracted or imputed. Two reviewers independently screened search results and extracted data from eligible articles. All estimates were inflated to 2012 dollars and discounted to reflect costs from the perspective of a 10-year-old child today. RESULTS: We identified 6 studies. The incremental lifetime direct medical cost from the perspective of a 10-year-old obese child relative to a 10-year-old normal weight child ranges from $12 660 to $19 630 when weight gain through adulthood among normal weight children is accounted for and from $16 310 to $39 080 when this adjustment is not made. CONCLUSIONS: We recommend use of an estimate of $19 000 as the incremental lifetime medical cost of an obese child relative to a normal weight child who maintains normal weight throughout adulthood. The alternative estimate, which considers the reality of eventual weight gain among normal weight youth, is $12 660. Additional research is needed to include estimates of indirect costs of childhood obesity. Copyright © 2014 by the American Academy of Pediatrics.


Green E.P.,Duke Global Health Institute | Blattman C.,Columbia University | Jamison J.,Consumer Financial Protection Bureau | Annan J.,International Rescue Committee
Social Science and Medicine | Year: 2015

Intimate partner violence is widespread and represents an obstacle to human freedom and a significant public health concern. Poverty alleviation programs and efforts to economically "empower" women have become popular policy options, but theory and empirical evidence are mixed on the relationship between women's empowerment and the experience of violence. We study the effects of a successful poverty alleviation program on women's empowerment and intimate partner relations and violence from 2009 to 2011. In the first experiment, a cluster-randomized superiority trial, 15 marginalized people (86% women) were identified in each of 120 villages (n=1800) in Gulu and Kitgum districts in Uganda. Half of villages were randomly assigned via public lottery to immediate treatment: five days of business training, $150, and supervision and advising. We examine intent-to-treat estimates of program impact and heterogeneity in treatment effects by initial quality of partner relations. 16 months after the initial grants, the program doubled business ownership and incomes (p<0.01); we show that the effect on monthly income, however, is moderated by initial quality of intimate partner relations. We also find small increases in marital control (p<0.05), self-reported autonomy (p<0.10), and quality of partner relations (p<0.01), but essentially no change in intimate partner violence. In a second experiment, we study the impact of a low-cost attempt to include household partners (often husbands) in the process. Participants from the 60 waitlist villages (n=904) were randomly assigned to participate in the program as individuals or with a household partner. We observe small, non-significant decreases in abuse and marital control and large increases in the quality of relationships (p<0.05), but no effects on women's attitudes toward gender norms and a non-significant reduction in autonomy. Involving men and changing framing to promote more inclusive programming can improve relationships, but may not change gender attitudes or increase business success. Increasing women's earnings has no effect on intimate partner violence. © 2015.


Liu P.,Peking University | Guo Y.,Peking University | Qian X.,Fudan University | Tang S.,Duke Global Health Institute | And 3 more authors.
The Lancet | Year: 2014

China has made rapid progress in four key domains of global health. China's health aid deploys medical teams, constructs facilities, donates drugs and equipment, trains personnel, and supports malaria control mainly in Africa and Asia. Prompted by the severe acute respiratory syndrome (SARS) outbreak in 2003, China has prioritised the control of cross-border transmission of infectious diseases and other health-related risks. In governance, China has joined UN and related international bodies and has begun to contribute to pooled multilateral funds. China is both a knowledge producer and sharer, offering lessons based on its health accomplishments, traditional Chinese medicine, and research and development investment in drug discovery. Global health capacity is being developed in medical universities in China, which also train foreign medical students. China's approach to global health is distinctive; different from other countries; and based on its unique history, comparative strength, and policies driven by several governmental ministries. The scope and depth of China's global engagement are likely to grow and reshape the contours of global health. © 2014 Elsevier Ltd.


Messer L.C.,Duke Global Health Institute | Vinikoor-Imler L.C.,U.S. Environmental Protection Agency | Laraia B.A.,University of California at San Francisco
Health and Place | Year: 2012

The purpose of this research was to assess the consistency of associations between neighborhood characteristics and pregnancy-related behaviors and outcomes across four nested neighborhood boundaries using race-stratified fixed-slope random-intercept multilevel logistic models. High incivilities was associated with increased smoking, inadequate weight gain and pregnancy-induced hypertension (PIH), while walkability was associated with decreased smoking and PIH for white women across all neighborhood definitions. For African American women, high incivilities was associated with increased smoking and inadequate gestational weight gain, while more walkable neighborhoods appeared protective against smoking and inadequate weight gain in all but the smallest neighborhoods. Associations with neighborhood attributes were similar in effect size across geographies, but less precise as neighborhoods became smaller. © 2012 Elsevier Ltd.


News Article | November 19, 2016
Site: www.theguardian.com

Ask about the fish in restaurants in the centre of Puerto Maldonado, the biggest town in Peru’s south-east Amazon, and you’ll hear all kinds of things. Some people will shake their heads and say there isn’t any fish on the menu “because of the contamination” or “out of protocol”. Others might say there is fish available, before sometimes hastily clarifying that it comes from farms along the Inter-Oceanica Highway running to Brazil, or from the Pacific coast, or even, according to one chef, all the way from Vietnam. Why such problems with the fish in this part of the Amazon? Answer: alluvial gold and the mercury required to extract it. The gold-rush in the 8.5m hectare Madre de Dios region began in the 1980s and, by 2012, miners had destroyed more than 50,000 hectares of forest, effectively dumping 100s of tons of mercury into the rivers while doing so. In May this year Peru’s outgoing government announced a pathetic 60-day “declaration of emergency”. An image of a unpublished map obtained by the Guardian, based on “preliminary results” from studies of local inhabitants by the Duke Global Health Institute in the US, provides some idea of how widely-spread and severe the mercury contamination is across Madre de Dios. Arguably the map’s most alarming revelation is that the most contaminated area of all is upstream from the mining: the stretch of the River Madre de Dios between towns called Boca Colorado and Boca Manu, a significant part of which is in the buffer zone of the Manu national park, which Unesco calls the most biodiverse place on earth. “It is noteworthy that some areas with high averages of mercury are upriver from the mining zones,” states the map, which was shown to Health Ministry officials earlier this year. The map suggests the second worse-hit area is inside the Manu park itself, immediately upriver from Boca Manu, along the River Manu’s left bank. The right bank is affected too. William Pan, the study’s lead researcher, told the Guardian “we didn’t sample people in Manu national park”, but explains the map on the basis that his teams have sampled several communities “along that bend of the river (Rio Manu/Rio Madre de Dios)” and “the map smoothing method creates a 10km buffer around the study sites and the exposure is extrapolated”. How come people upstream are the most contaminated? Or maybe the mercury there has little or nothing to do with gold? As acknowledged by a 2011 report by the Environment Ministry, titled Gold-mining and Mercury Contamination in Madre de Dios: a Time-Bomb, mercury stored naturally in Amazon soil and vegetation is released when the forest is cut down or burnt and then leaches into the water. Pan describes the mercury levels recorded by Duke as “very high” and says Madre de Dios is experiencing a “chronic mercury epidemic.” The contamination upstream was, he says, “the most surprising finding of our human Hg [mercury] assessment.” “The communities near the confluence of Rio Manu and Rio Madre de Dios have the highest exposures in the region,” Pan told the Guardian. “When we tested fish, water and sediment, none of the values were high. So we were surprised when people were detected with high levels. We have several hypotheses that we are evaluating.” According to Pan, those hypotheses are the people in that region migrate downriver to work in the mining, and that they are more dependent than the rest of Madre de Dios on local agriculture, fish and meat because there are no roads. Another is that “due to reliance on fish consumption, they are likely eat larger fish, which will have more Hg just naturally”. Pan says the map was “supposed to be confidential with the Ministry of Health” because it is “unpublished data and we have not fully analysed all the samples,” calling it “very crude” and far from final. He told the Guardian it is based on three distinct studies conducted between May 2014 and June 2016, and the final results will include samples from almost 72 sites. He says the Health Ministry has “real monetary constraints right now due to expenditures of the prior ministry”. Previous research by Pan and colleagues argued that mercury contamination is generating “significant health risks” for communities in Madre de Dios “hundreds of kilometres” downstream from the mining, particularly among children and indigenous people. “Children living within the central portion of the [Madre de Dios] watershed cannot safely consume carnivorous fish without exceeding recommended international [mercury] body burdens,” stated an article by Pan et al in Environmental Science in January 2015. “Deforestation and mercury release are an immediate threat to both local and distant downstream communities, many of which do not benefit economically from [the mining].” The law announcing Peru’s declaration of emergency in May stated that many people in Madre de Dios have “higher than the maximum recommended limits” of mercury, which causes “serious, chronic and complex health problems, particularly in children and pregnant women.” “[M]ercury contamination of the air, water, sediment and fish is the result of inadequate practices by illegal and informal gold-miners during the extraction and working of alluvial gold,” the law stated. “In addition, there are people located beyond the mining extraction zones that are at high risk of being contaminated with mercury because of the high levels of it detected in the environment and in certain fish species, especially Mota Punteada, which is part of the daily diet of Madre de Dios’s population.” The social and environmental tragedy unfolding in Madre de Dios has been known about for many years: the Ministry of Environment dubbed it a “time-bomb” five years ago, but the bomb was ticking long before that. Will Peru’s new government, led by president Pedro Pablo Kuczynski, now take sincere, sustainable, non-violent steps to address the problem - not just in the Boca Manu region, obviously, but across Madre de Dios and Peru’s Amazon as a whole? What steps can the government take to initiate a massive public health campaign and inform those who are contaminated, or are at risk, and provide access to treatment – and if it doesn’t have the funds do so, who can provide them? What forms of alternative employment can be created, so those who find themselves forced to mine and handle mercury have other options? What steps can those buying, selling, hoarding, working and wearing Peruvian gold take to ensure they stop contributing to the devastation of huge swathes of the Amazon and the contamination of 1,000s of people living there? The World Health Organization calls mercury “one of the top ten chemicals or groups of chemicals of major public health concern”, and states that human activity, including gold-mining and coal-fired power stations, is the “main cause of mercury releases.” Peru is one of the world’s biggest gold producers, with the main importers being Canada, India, Switzerland, the UK and the US. A report published in April by the Global Initiative Against Transnational Organized Crime argued that 28% of all gold in Peru is illegal, with illegal gold-mining across Latin America increasingly controlled by drugs traffickers and “organized crime” groups. In January Peru ratified the Minamata Convention on Mercury, a legally-binding global treaty which commits parties to regulate artisanal and small-scale mining, among other things, and states that “parties may cooperate with each other” to stop altogether the use of mercury or mercury compounds in such mining. Switzerland and the US have ratified the Convention too, but Canada, India and the UK haven’t. Peru’s Health Ministry did not respond to questions.


News Article | February 16, 2017
Site: www.eurekalert.org

Rural farmers in Madagascar make up for lost slumber with a more regular sleep routine DURHAM, N.C. -- Screen time before bed can mess with your sleep. But people without TV and laptops skimp on sleep too, researchers say. A Duke University study of people living without electricity or artificial light in a remote farming village in Madagascar finds they get shorter, poorer sleep than people in the U.S. or Europe. But they seem to make up for lost shuteye with a more regular sleep routine, the researchers report in the American Journal of Human Biology. Americans sleep less than they did a generation ago. The decline is largely attributed to artificial light before bedtime wreaking havoc on our ability to stay in sync with the 24-hour day. Our bodies are particularly sensitive to the short-wavelength "blue" light emitted from smartphones, TVs, computers, LED bulbs and other devices. Staring at bright bluish light before bed sends a signal to the brain to secrete less melatonin, the hormone that makes you sleepy. "I think we can safely assume that our ancestors weren't staying up late at night cruising Facebook or looking at their e-readers," said David Samson, a senior research scientist in evolutionary anthropology at Duke. "It makes falling asleep much harder." To better understand our natural sleep patterns, Samson, Duke professor Charles Nunn and colleagues went to the remote village of Mandena, in northeastern Madagascar, where most households do without electricity. A farming community where people grow rice and cash crops such as vanilla, this tiny town at the outskirts of Marojejy National Park is one of the few remaining places on Earth where light pollution is not a problem. The villagers of Mandena are among more than a billion people worldwide who live without artificial light. Instead of switching on a light when the sun goes down, most people in Mandena spend their evenings in relative darkness. Nights are lit by the glow of cooking fires and kerosene lamps, or, when it's clear, the natural light of the moon and the stars. The Duke researchers analyzed sleep-wake patterns in 21 people aged 19 to 59 while they slept at night and napped during the day. The participants wore watch-like devices with built-in light and motion sensors that tracked subtle changes in their body movements and light exposure from one minute to the next, for 292 total nights of data. Nine of these people also took a sleep test called a polysomnogram to determine how deep and restful their sleep was. The test uses sticky electrodes on the skin's surface to measure and record electrical activity in the brain and muscles. The data revealed that even without artificial lighting to disrupt their rest, people in Mandena get less sleep than most adults in the U.S. and Europe. The villagers usually turned in around 7:30 p.m., two hours after sunset, and woke up around 5:30 a.m., about an hour before sunrise. But only 6.5 of those hours were spent sleeping -- 30 minutes to an hour less each night than people in the U.S. or Italy. What sleep they did get was fragmented and light. Mandena villagers sleep together in houses with bamboo walls and tin or thatched roofs that do little to buffer noise. "On a nightly basis there are parties, dogs, roosters, children crying. It is a challenging environment for getting a good sleep," said Nunn, director of the Triangle Center for Evolutionary Medicine and professor of evolutionary anthropology and global health at Duke. The participants frequently woke up in the middle of the night, sometimes to use the bathroom, and then stayed up for an hour or two before returning to sleep. They also spent less time in deep sleep and the dream state known as REM sleep compared with Western populations. Yet rather than complain about being bleary-eyed or foggy-brained, 60 percent reported they were happy with their sleep. People in Mandena compensate for lost nighttime sleep by napping during the day, often for up to an hour. That's nearly twice as long as the average catnap for Westerners, Samson said. More importantly, Samson said, their sleep patterns were more consistent than most Westerners from one day to the next. Even when the researchers gave 10 people an LED camping lantern for a week, they still slept and woke at virtually the same times each day. "Sticking to a schedule may be just as important as getting a solid night's sleep," Samson said. The findings support other studies suggesting that humans were shortchanging their sleep even before the advent of electronic gadgets. Diaries, court records and other historical documents suggest the ideal of getting seven to nine hours of uninterrupted sleep didn't come about until recently. In preindustrial times broken sleep was the norm, according to research by sleep historian Roger Ekirch of Virginia Tech. Samson plans to continue studying sleep patterns in traditional societies across the globe. "My ultimate goal is to build a global data set of traditional sleep," he said. This research was supported by Duke University's Bass Connections program and the Duke Global Health Institute. Other authors of this study include Melissa Manus and James Yu of Duke, Andrew Krystal of the University of California, San Francisco, and Efe Fakir of the Bahcesehir University School of Medicine. CITATION: "Segmented Sleep in a Non-Electric, Small-Scale Agricultural Society in Madagascar," David Samson, Melissa Manus, Andrew Krystal, Efe Fakir, James Yu and Charles Nunn. American Journal of Human Biology, Feb. 9, 2017. DOI: 10.1002/ajhb.22979


Merson M.H.,Duke University | Curran J.W.,Emory University | Griffith C.H.,Duke Global Health Institute | Ragunanthan B.,Duke University
Health Affairs | Year: 2012

The Presidents Emergency Plan for AIDS Relief (PEPFAR) has made a major contribution to the reduction of the global HIV/AIDS burden. The program initially focused on rapidly scaling up treatment and prevention services in fifteen low-income countries, then transitioned to an approach that emphasizes sustainability, defined as the capacity to maintain program services after financial, managerial, and technical assistance from the United States and other external donors essentially ceases. Today, PEPFAR continues to expand its HIV prevention, treatment, and care activities while also supporting capacity building initiatives, coordination efforts, and implementation science. The latter is research focused on improving service delivery, maximizing cost-effectiveness, and achieving public health impact. Recent advances in both scientific knowledge and the provision of prevention, treatment, and care services have bred cautious optimism about greatly reducing the spread of HIV. However, success will require a substantial increase in resources, strengthened health systems, renewed commitment to HIV prevention, and well-financed efforts to develop an effective HIV vaccine. © 2012 Project HOPE-The People-to-People Health Foundation, Inc.


Jeuland M.,Duke Global Health Institute | Whittington D.,University of North Carolina at Chapel Hill
Water Resources Research | Year: 2014

This article presents a methodology for planning new water resources infrastructure investments and operating strategies in a world of climate change uncertainty. It combines a real options (e.g., options to defer, expand, contract, abandon, switch use, or otherwise alter a capital investment) approach with principles drawn from robust decision-making (RDM). RDM comprises a class of methods that are used to identify investment strategies that perform relatively well, compared to the alternatives, across a wide range of plausible future scenarios. Our proposed framework relies on a simulation model that includes linkages between climate change and system hydrology, combined with sensitivity analyses that explore how economic outcomes of investments in new dams vary with forecasts of changing runoff and other uncertainties. To demonstrate the framework, we consider the case of new multipurpose dams along the Blue Nile in Ethiopia. We model flexibility in design and operating decisions - the selection, sizing, and sequencing of new dams, and reservoir operating rules. Results show that there is no single investment plan that performs best across a range of plausible future runoff conditions. The decision-analytic framework is then used to identify dam configurations that are both robust to poor outcomes and sufficiently flexible to capture high upside benefits if favorable future climate and hydrological conditions should arise. The approach could be extended to explore design and operating features of development and adaptation projects other than dams. Key Points No planning alternative is likely to dominate across plausible future conditions We present a method for generating information for the selection of robust planning alternatives Downside and upside metrics can assist enhanced decision making © 2014. American Geophysical Union. All Rights Reserved.


Morley C.A.,Emory University | Kohrt B.A.,Duke Global Health Institute
Journal of Aggression, Maltreatment and Trauma | Year: 2013

The experience of child soldiers during postwar civilian reintegration is recognized as a major contributor to mental health. For some children, postwar social relations may be more important than war trauma in determining psychosocial well-being. Mixed methods incorporating epidemiology and qualitative case studies were employed to evaluate the effects of family, peer, and community relations after reintegration on psychosocial outcomes: hope, functional impairment, and post-traumatic stress disorder (PTSD). Participants were 142 child soldiers, including 9 qualitative case studies. Peer support predicted increased hope, decreased functional impairment, and decreased PTSD symptoms. Conversely, problems with peer relations predicted less hope and more PTSD symptoms. Maximizing peer support and minimizing stigma from peers should be prioritized within psychosocial reintegration programs, especially among former child soldiers with PTSD. © 2013 Taylor and Francis Group, LLC.

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