Hosted by Dr. Paul Farmer, with guests Dr. Nimmi Ramanujam of GWHT, Dr. William Pan, and Dr. Joao Ricardo Vissoci By Incoming Duke University Student: Rachel Neha Shaw
On May 27, 2021, Duke Global Health Institute (DGHI) sponsored a discussion led by Dr. Paul Farmer (’82, P ’19) centered on ongoing global health projects in Latin America and the Caribbean. During this event, Dr. Farmer shared his background and work in global health and then highlighted the work of Dr. William Pan, Dr. Nimmi Ramanujam, and Dr. Joao Vissoci in Latin America. All three of these researchers actively pursue solutions to the most pressing of health challenges in this region.
Dr. Farmer initially became involved in global health in Latin America while attending Duke as a biochemistry major who later studied anthropology. In 1980, he became interested in migrant health workers while writing for student publications, publishing an in-depth story on migrant farm workers from Haiti living in the Durham area. As a result, upon graduation, he travelled to Haiti prior to medical school with funding from Duke. During his time in medical school, he became further involved in Latin America with work in Peru, and his experiences allowed him to found Partners in Health, which delivers medical care and materials to areas in need of them. This global health organization is now involved in eleven countries across four continents. In addition to his work with Partners in Health, Dr. Farmer is an infectious diseases doctor and a medical anthropologist who has helped communities in the world’s poorest places combat epidemics, including Ebola, AIDS, tuberculosis, and, now, COVID-19. As he reflects on his career, he strongly believes that the connections and serendipity stemming from his time at Duke that ultimately led him to Latin America have kept him and his work there. Dr. Farmer attributes much of his work to his experiences within and perspectives gained at Duke, and he believes that his entire career was laid out in many ways for him there.
Health Impacts of Gold Mining in the Amazon Basin The first guest panelist, Dr. William Pan, has been working in the Amazon basin for more than twenty years, beginning by studying land use change and eventually studying disease and malaria spread in the region. Particularly, Dr. Pan’s research has led him to the health impacts of gold mines and mercury exposure in the La Pampa and Mazuco regions of Peru.
While studying these mines, he found major environmental destruction, returning to Duke with this question: Why is gold mining so impactful? He found that we consume about 4,500 tons of gold annually. About 20–30% of this gold production comes from artisanal and small-scale mining, but the majority of the gold we consume is produced illegally. This illegal production has led to compounded detrimental effects, including tuberculosis, human trafficking, and other larger issues arising from this mining.
Gold mining contributes to 38% of all global mercury emissions as well, occurring in erosion during excavation, tailings during gravimetrics, and emissions during burning in which the gold is refined into pure gold. Mercury enters the food chain as a highly potent aerotoxin; children exposed experience an irreversible 15% decline in cognitive performance. Dr. Pan’s team conducted an exposure assessment (from 2012 to 2016) finding that 41% of the population in Peru have Hg levels exceeding the WHO safe tolerance level. His team has partnered with the administrative environment in Peru and has compiled a repository including seasonal changes in Hg exposure risk.
Dr. Pan also shared that immediate reduction of Hg pollution can result from regulation of corporations contributing to pollution. He also highlighted mercury capture systems as an efficient and effective solution, which capture more than 95% of Hg in the amalgam in gold shops. This has led to a 10,000 fold reduction in Hg concentrations in gold shops, and they estimate a 30–90% reduction in total Hg pollution.
Empowering Technology to Prevent Cervical Cancer In 1951, Henrietta Lacks’s diagnosis of cervical cancer was a devastating one. Today, in Australia, cervical cancer death is nearly eliminated; however, in Latin America, women remain in Lacks’s shoes. Women in underserved communities have a large lack of access to preventative care, and in Peru, cervical cancer is the number one cause of death for women. The WHO predicts that increasing screening and diagnosis by 70% will lead to a 35% reduction in deaths within a decade. In Lima, Peru, Dr. Patty Garcia began Project HOPE after seeing advanced lesions of cervical cancer when screening women. With HOPE, Garcia developed a kit for women to screen and take preventative measures against HPV, a disease that is most commonly a cause for cervical cancer.
Both Dr. Garcia and guest panelist Dr. Nimmi Ramanujam have become aware of how vastly inaccessible resources in hospitals are for women to confirm a cervical cancer diagnosis. Because of this, Dr. Ramanujam has worked to train a new generation of inventors to create technologies that are more accessible. One such technology is a unique design of the speculum that allows women to view their own cervixes. The clinical colposcope is used in highly specialized healthcare facilities, making it costly and less available. The pocket colposcope brings the viewer closer to the cervix than a clinical one can, reducing cost and size of the instrument. Dr. Ramanujam’s team used a pocket colposcope with a calla lily shaped tip connected to a cell phone in order to create a screening device that women can more easily access and more comfortably use. With this device, a woman can swab and image her cervix simultaneously, and the device uses a “virtual expert” and AI algorithm that has outperformed three experts in order to provide results.
In Peru, the city of Cajamarca has the highest cervical cancer mortality rate. Dr. Ramanujam’s team created a pilot scale in this area, and they are currently collaborating with Dr. Garcia to pair the Project HOPE HPV test kits with the new pocket colposcope. Her partnership with Dr. Garcia and her team has been essential in putting elements into practice. Learning from women and their lived experiences has allowed her to make women, rather than hospitals, the center of their experience.
Using Data to Improve Healthcare Access
While in Brazil, Dr. Joao Ricardo Vissoci, the third guest panelist, encountered a child who was injured by a snake bite. Fortunately, antivenom was free for the patient; however, the young boy had to travel through the winding riverways in his area for a lengthy amount of time to reach a facility that provided antivenom. Because he was unable to reach care in time to get the antivenom, the child lost part of his leg from necrosis. Dr. Vissoci thus became aware of the issue of increased distance to reach healthcare causing diminished access to care in low resource areas. The large amount of travel time can be especially harmful in cases of time-sensitive, acute events like a snake bite or cardiovascular event. On top of this, care facilities may not have access to necessary resources depending on material distribution. Dr. Vissoci’s team has been leveraging available data to understand where healthcare resources are, how they are distributed, and how they meet the needs of the populations they administer care to. His goal is to optimize care and availability of resources/care in these areas so that everyone in the area is within less than 3 hours of receiving acute care, like antivenom. This is also demonstrated by COVID-19 vaccine distribution; his team has created a database that can combine maps of care facilities and distance from these facilities with maps of the population in the area to identify highly populated areas that are unable to access vaccines.
Resonating Themes The primary underlying themes throughout each project in this discussion revolve around collaboration. A reliance on partnership across disciplines resonates strongly in each research team. Understanding the extractive traits of colonialism, such as mining and conflict, is important to understanding why health is impacted in these countries. Dr. Ramanujam’s approach to being involved in the cascade of a diagnosis and treatment also is an effective one. Additionally, universities as a backdrop for this kind of global health research play a role in demonstrating the positive effects of interventions that the government and NGOs are not always able to play. It creates a forum for innovation outside of anything political.
Funding through philanthropy and other funding mechanisms is also necessary to get these groups started with their projects. There is often an incongruity between biomedical innovations and their impacts. When getting initial funding, evidence and a case is often first presented. As the process continues, the case is now to invest in the success of the device and demonstrating the actual impact of the work that people already invested in as well. Each project involves long-term engagement, and lived experience alongside community-based solutions and treatment hold immense power.
Cultural humility also plays a huge role in collaboration in other countries. The principle of cultural humility is difficult to instill in someone until that person experiences their assumptions being debunked. An example is the period after the earthquake in Haiti, when people came in with beliefs that they could fix everything and then ended up quickly leaving. Decolonization of global health also plays a part in this, especially when students in these areas join the team and begin also conducting research. Pan observed that even Peruvian students in Lima gained cultural humility when they went into remote areas and partnered with indigenous populations. Cultural humility is not something we can read about; it is something that people must experience for themselves in the field.
The discussion closed with the idea that you do not need to be a nurse, physician, or basic science researcher to get involved in global health. Duke was founded with this interdisciplinary approach in mind, and these collaborations across disciplines have created effective responses, as demonstrated by Dr. Farmer, Dr. Pan, Dr. Ramanujam, and Dr. Vissoci.