Closer to Home

In the past year, faculty, staff and students from the Duke Global Health Institute worked in more than 40 countries to tackle health disparities. The list includes many distant places, including countries in Africa, Asia and Latin America that are facing severe challenges to the health of their most vulnerable citizens. 

But it also includes the United States, where many of those same challenges exist in a different context. 

“The temptation is to think of global health as happening somewhere far away, but the reality is that vulnerable communities experience health disparities right here in Durham,” says DGHI director Chris Plowe. 

In fact, as many as one third of DGHI’s current research projects involve partnerships with organizations in the Durham region. But while the Institute has had a longstanding commitment to working with local groups, it has recently launched new efforts to better support and amplify local work—and to better understand how global health tools and perspectives can be beneficial in addressing health disparities locally. 

As part of that commitment, associate professor Sumi Ariely has taken on a new role within DGHI to help coordinate local DGHI research and student training programs. Earlier this year, Ariely and Duke colleagues hosted a workshop in Durham for grassroots community-based organizations to share lessons, leverage strengths and identify areas where Duke faculty may be able to offer support. 

“The workshop was a first step in working to be mindful and thoughtful in how best to build engagement ethically and sustainably with local partners,” says Ariely. “We are hopefully in a better place of self-awareness and political awareness as we move forward.”

Part of that new awareness is questioning the notion that students need to go great distances to learn and apply global health principles. Ariely challenges her students to reflect on the role of a global health institute locally, and to explore their motivations--and often their preference--to travel abroad to do work that could be done down the street. 

“International travel has always been attractive for a variety of reasons,” says Ariely, “but when one thinks about health disparities, suffering here versus suffering in another country–the responsibilities we all have to our local neighborhoods and the needs that must be addressed are very similar.”

This past summer, DGHI launched two student research training programs in Durham: one at Triangle Residential Options for Substance Abusers, Inc., (TROSA), a residential substance abuse treatment and recovery program, and one at Bull City Fit, a community-based wellness and obesity prevention program led by Durham Parks and Recreation and the Duke Children’s Healthy Lifestyle Program. 

Ariely is working with local partners to identify more opportunities for students to learn about and potentially help address disparities in Durham. “Instead of primarily sending students overseas to engage with a health issue, how best can we involve a local community partner to build on a project over time and address issues here in a sustained way?” Ariely asks.

Kathryn Whetten, director of the Center for Health Policies and Inequalities Research at Duke, believes working with a marginalized or low-income community locally better equips students to understand “our own fault lines,” engendering humility and understanding when they work in other countries.
 
The experience can teach students that simply adopting approaches used in the United States is often not the best answer, particularly when the United States ranks poorly in many health outcomes. 

“It can also be uncomfortable to work in our own communities,” adds Whetten. “It’s about facing our history. When we face it here in Durham, we are responsible for it in some way, whether it’s our legacy or not. That can be hard and a powerful experience.”

Whetten says that her research over 20 years in Africa, Asia, South America and the U.S. Deep South has shown her that disparities are remarkably similar across boundaries and can benefit from similar interventions. 

“The university and Duke Health system are already doing so much in the community,” underscores Plowe. “DGHI has always had local partnerships and research, but it has become clear to us that we can do more to connect our students, faculty and staff with local partners and help create better health outcomes in our own community. And, as an interdisciplinary institute that confronts complex health challenges all over the world, DGHI has a unique perspective to offer.”

Faculty at DGHI are exploring how to apply lessons from international research to local challenges. In communities in Tanzania, for example, DGHI researchers have helped deal with a shortage of mental health professionals by training village health workers to provide basic counseling. Ariely suggests this form of task shifting could be applied to communities in the United States with few mental health resources.  

“We’re looking at lessons learned in terms of how children are treated for trauma and PTSD in resource-constrained areas,” says Ariely. “Our own kids and communities here in the United States face a host of traumatic events, such as the chronic stress of poverty, effects of climate change, mass shootings, police violence and mistrust, without enough access to school counselors or professional mental health workers. Why couldn’t we--shouldn’t we?--figure out how to more effectively apply task shifting here?” 

Another example of multi-directional learning stemming from DGHI’s global reach involves bringing international collaborators to Durham to work with local partners. Ariely would like colleagues from around the world to work with local community-based organizations to learn what health disparities look like in North Carolina. Exploring how local partners address challenges – similarly and differently – from healthcare providers in other countries could spark helpful new insights for both contexts, she says. 

Ariely is also asking researchers to be more explicit and upfront about the research process and outcomes when engaging local partners. Community-based participatory research, in which participants have an equal stake in defining research questions, is not unusual for researchers at Duke. However, scientists and non-scientists may have different goals and define research questions differently. A community partner may not understand why a researcher wants to do a double blind study, for example, and likewise, a researcher may have little understanding of the context of the community. 

She emphasizes that DGHI strives to forge partnerships that yield real value for community organizations, which sometimes requires thinking differently about what the outcomes of a project will be. “Knowledge, papers, and discovery generally benefit researchers,” she says. “The trickle-down effect may help the community directly or indirectly eventually, but it might not as soon or as well as the project intended.” 

“The ideal is a partner who is at the table every step of the way,” says Ariely, “and a researcher who wants to know what questions are most important to a partner and is open to tweaks and modifications.”