A decade of discovery and service in global health at DKU

Dr. Shenglan Tang still remembers the first time he stood on the large patch of unused farmland that would eventually house the vibrant, state-of-the-art Duke Kunshan University campus we know today.

It was January 2011 and the founding director of the Global Health Program at DKU had been invited to the site by Luke Li, who at the time worked for Duke University’s Fuqua School of Business and is now dean of China Enrollment Management at DKU.

“There was nothing to see at that stage so I just stood there for five minutes imagining working here one day,” said Tang, who back then was based at the World Health Organization (WHO) headquarters in Geneva, Switzerland, and was in China for an international conference in Shanghai.

Two years later, in September 2013, DKU was formally approved by China’s Ministry of Education. The new university soon collaborated with Duke Global Health Institute to establish the Global Health Research Center (GHRC), the first of eight such centers at DKU, for which Tang has served as founding director since the beginning.

In summer 2013, Tang and his post-doctoral researcher Qing Long were the only two faculty members on the program. They worked from a temporary 14th floor office of the Kunshan Industrial Research Institute.

By August of the following year, the faculty team had increased to five as they welcomed the inaugural class of Master of Global Health Program, also numbering just five.

Fast forward to 2023 and the program has just celebrated its 10th anniversary along with the university as a whole.

Over that past decade, the empty farmland stretching out before Tang has been transformed into a modern, beautiful campus, providing high-tech classrooms and laboratory space, residential housing and recreational facilities for over 1,000 faculty and students, all in sustainable buildings blending Eastern and Western architectural styles.

Students from the Global Health Program

In total, 112 master’s students have graduated from the Global Health Program, whose faculty and staff workforce has grown from five to 50. The program has had over 500 academic articles published in influential journals and established partnerships with more than 30 institutions in 20 countries.

Thanks to the outstanding research in global health and related fields, DKU has been ranked among the ESI Global Top 1% in Clinical Medicine for five consecutive years from 2018 to 2022, according to Essential Science Indicators (ESI) statistics released by Clarivate Analytics.

How has a new research institute become an emerging leader in its field within just 10 years? We interviewed leaders, faculty and students at the GHRC to discover what is behind the center’s early success.

Protecting disadvantaged populations

“Understanding socioeconomics is very helpful to us working in public health and policy research,” said Tang, an avid reader of newspapers.

In 1985, as a master’s student at Shanghai Medical University, he studied the screening of cervical cancer, the fourth most common cancer among women globally.

After doing the research, he wrote a policy brief proposing that China launch a national free screening program for women at higher risk of cervical cancer.

While similar policies are in place in many countries, Tang suspected that implementation might be more challenging in China. But that does not stop Tang continuing to make policy proposals based on his research.

“We conduct research to produce scientific evidence which serves as the basis for policy proposals,” said Tang. “As to whether or when they are adopted, it might take longer than a matter of days.”

In 1993, Tang wrote a report stating that “central government subsidies are essential for enabling rural areas in China’s central and western regions to implement universal health coverage, as it is implausible for local governments to fund the program”.

Ten years later, the Chinese central government launched a new initiative to gradually establish a New Rural Cooperative Medical System, reducing the financial burden of healthcare on rural residents.

Screening for cervical cancer has also gained fresh momentum. In January this year, over 30 years after Tang made the policy proposal on promoting screening and treatment, China’s central government outlined a long-term plan to accelerate the elimination of cervical cancer by 2030 to curb incidences of the disease and reduce the death rate.

Shenglan Tang

Over the course of his career, nearly every year Tang has carried out field research in rural China into infectious diseases, particularly tuberculosis (TB), vaccines and chronic diseases, but all centering on residents in rural areas or disadvantaged populations nationwide.

The only time he has not found time to conduct this type of research in China has been during stints abroad for his doctoral studies and when he worked on the WHO Special Program for Research and Training in Tropical Diseases (TDR), based in Geneva, where he was unit leader for TB/HIV and health systems.

Tang first started screening for cervical cancer in the mountainous region of Jiangxi, a landlocked province in southeast China, where he lived with villagers and learned to eat the local spicy food to build connections.

Once during a survey in a village, he spotted a child squatting on the ground with purple lips, the most common symptom of a congenital heart defect.

As the local medical facilities were insufficient, Tang helped the family contact experts at Shanghai Zhongshan Hospital for treatment. The child recovered and it gave Tang great satisfaction to see the youngster cheerfully running around again.

“After this experience, I focused my work on residents in poorer areas, the elderly, the weak, women and children,” said Tang. “I just want to do my best to help them.”

Driven by these aspirations, Tang gave up his tenured position at the WHO to join the fledgling Duke Kunshan University. Working at the WHO brought solid compensation and benefits, but there was no funding for the projects he really wanted to do, while at DKU, a brand-new Sino-U.S. university, Tang has the academic freedom to pursue research projects of his choosing and work with like-minded colleagues.

He is also passionate about leveraging decades of his own work experience to build and develop a young institution. This was the exciting plan in Tang’s mind when he stood in the winter of 2011 on the edge of the empty farmland, imagining what it would be like to work at DKU.

In 2014, Tang led a joint application of 10 research institutions across six Asian countries to become the research hub of the Asia Pacific Observatory (APO) of the WHO. In December, APO selected GHRC as the research hub for health policy and system research, one of three globally and the only one in China.

The APO-funded projects include the introduction and retention of rural primary health care workers in Asia-Pacific countries, prevention and management of cardiovascular diseases in poorly resourced areas, health systems for migrants and integrated care for chronic diseases, all with the shared aim of improving health in developing countries.

Graduate students from the Global Health Program

China is one of several countries with a high burden of tuberculosis. In 2009, China’s National Health Commission (NHC) and the Bill & Melinda Gates Foundation launched a three-phase program for the prevention and control of tuberculosis. Tang oversees the second phase focusing on developing and evaluating the funding model for TB/drug-resistant health services, and the third phase centering on monitoring and evaluating the implementation of an integrated model for TB prevention and control.

“The project has gone on for eight years,” said Tang, who has led the team to collect data from rural areas across China. “Many of our findings in TB control, treatment and prevention have now become national policies.”

“For instance, we found hospitals charge TB patients on a fee-for-service basis. The costs for X-rays, sputum smear tests and treatment are partly borne by the TB patients and partly by national medical insurance,” Tang explained.

“We proposed that the fee structure should be based on the costs for fully curing a TB patient, which will incentivize the hospitals and better control TB spread. Otherwise, a patient might stop further treatment after taking medicine for only two months and seeing the symptoms gone, which leads to lower efficiency in TB control as the original infection may relapse because of insufficient treatment.”

Tang and team made two important contributions. One was including TB screening, diagnosis and treatment into the national medical insurance program. Previously highly infectious diseases were administrated by the Chinese Center for Disease Control and Prevention (CDC) rather than the medical insurance system.

The other was establishing TB information system, which integrates TB prevention, analysis, treatment and management by automatically linking and capturing data from several existing hospital systems to improve data efficiency.

In 2021, Tang established the Innovation Lab for Vaccine Delivery Research (Vax Lab), with support from the Bill & Melinda Gates Foundation, to study ways of further optimizing China’s vaccine delivery.

The National Immunization Program (NIP), which offers 14 vaccines against 15 diseases for children aged 0-6, does not currently offer vaccination against human papillomavirus (HPV), haemophilus influenzae type B (Hib) and pneumococcal and rotavirus infections.

Tang and team have worked on five childhood vaccination projects: They included a survey on streptococcus pneumoniae in children under the age of five in Hainan province, an economics evaluation of pneumococcal vaccine and rotavirus vaccine in China, and a study on the experience and family burden of NIP vaccination across different types of families.

“Vaccination is a highly cost-effective tool in public health. For instance, many children are prone to pneumonia in winter, and vaccination can effectively reduce morbidity and mortality,” said Tang. “But the out-of-pocket expense for Pneumococcal Conjugate Vaccine (PCV) is as high as RMB 1,000. If PCV is included in the NIP, with government funding, subsidies, negotiating prices with manufacturers and investing in companies developing the vaccines, families will experience a much lower burden.”

The policymaking process often takes many years, during which advocacy and communication by the researchers behind the policy proposals play an essential role. On top of analyzing collected data and publishing findings, the Vax Lab has published nine online policy briefings presenting research findings in plain language and making recommendations to the government or the general public. “We want to actively participate in delivering social change,” said Tang.

In addition to health policy/systems and infectious diseases, chronic diseases and health environment are key priority areas of the GHRC. Dr. Lijing Yan, one of the first five faculty members and now head of non-communicable chronic disease research at the program, has teaching/research experience at Northwestern University, Peking University and the George Institute for Global Health, focusing on the prevention and control of chronic diseases and digital health technology.

Lijing Yan

Backed by a research grant from the Health Systems Research Initiative in the United Kingdom, Yan led a team carrying out a three-year stroke study involving 1,299 patients in 50 rural villages in Hebei province, north China.

Stroke is one of the leading causes of death and disability among rural adults in China, causing a huge social and economic burden. Yan’s team and her collaborators developed an innovative system-integrated, technology-enabled model of care for stroke patients.

The team trained village doctors and uploaded the tutorial materials to a smartphone app. Patient information including blood pressure records and medication are also accessible in the app and village doctors and patients receive reminders for follow-up visits.

The team aimed to convert specialized information from clinical guidelines for strokes into easily accessible formats, such as a picture-led manual, videos, audio, text messages, and digital health technology like smartphone apps and SMS.

“It is important to gain a deep understanding in order to meet a stroke patient’s needs, otherwise there is no way to bring about change and improve their health,” said Yan.

Yan described the intervention of equipping both village doctors and patients with training and digital health technology as “walking on two legs”. She believes the success of the project relies on support from leading domestic and international experts as well as the primary health care workers at county, town and village level.

Yan hopes to benefit stroke patients in other countries by sharing her experiences from this project.

“Though field research is conducted locally, the findings are global,” said Dr. Yunguo Liu, co-director and professor of the Global Health Program. “We must have global awareness and a global vision. The world is interconnected; we are affected by other countries all the time.

“Sharing research findings and lessons learned can help people in other countries with urgent needs to access better health services and expand the impact of our projects as a part of the larger global health system.”

Yunguo Liu

Liu held senior positions in China’s Ministry of Health for more than two decades before he worked in the WHO for 12 years, promoting universal health coverage in countries including Fiji, Laos, Cambodia and the Philippines.

He and his team worked with monks in Buddhist temples in Laos to spread health information on controlling dengue fever.

In Cambodia, Liu led a team who identified the high level of malaria risk that locals were encountering during wood-logging deep in the forest. They mobilized volunteers to perform malaria tests on the edges of the forests and provided timely treatment for those who were already infected, effectively controlling the spread of the disease.

Liu promotes cross-border research collaboration in the hope that findings by DKU researchers can benefit communities in other countries. This year, DKU’s Global Heath Program and the University of Health Sciences in Cambodia established a strategic partnership. In March, the two partners launched their first project focusing on funding for health security and case studies on chronic disease prevention and control, led by Dr. Marius Wamsiedel, assistant professor of global health at DKU.

Wamsiedel, a medical sociologist by training, conducts research at the intersection of society, culture and health. His works have examined the social categorization of patients, the structural and interpersonal barriers to health care, and racial health inequities. This year, Wamsiedel published a new monograph called “The Moral Evaluation of Emergency Department Patients: An Ethnography of Triage Work in Romania”.

Much of the work by global health faculty focuses on addressing the health challenges and needs of the poor and vulnerable in China, and then sharing the findings with the world to contribute to health equity globally. And under their guidance, DKU students throw themselves into similar causes with the same hard work and dedication.

It’s all about field research

Field research is an integral part of the Master of Global Health Program at DKU. Students quickly appreciate the importance of being on the ground to get to know the local culture and environment and of talking to people to understand their health challenges and needs.

Students are granted USD 7,500 to fund 10 weeks of field research in the summer for their faculty-guided independent study guided. To date, students in the program have traveled to over 20 countries on six continents.

Shangzhi Xiong, from the program’s Class of 2018, worked with the African Population and Health Research Center (APHRC) for his study exploring the relationship between family support and medication adherence among people with hypertension in informal settlements in Nairobi, Kenya.

Shangzhi Xiong and children in Kenya

In Kenya, he encountered many unexpected challenges. It took the local review board three months to approve his project, making him two weeks late for the start of the school semester.

Just one day into data collection, Nairobi was plunged into chaos due to presidential election disputes.

Public transport stopped and the hospitals he was partnering with were not responding to his messages. Xiong felt overwhelmed with anxiety listening to the protests, gunshots and ambulance sirens outside his dormitory window. With the support of Yan, friends and family, Xiong spent all 11 days indoors working at his desk before he was able to go outside and resume data collection when the situation had finally calmed down.

Xiong was often moved by the stories of his patients: A mother worried that she would pass on her hypertension to her son; a father guilt-stricken for not being able to afford his daughter’s high school education; and a middle-aged man hesitating to accept his handshake out of embarrassment for having a finger missing on his right hand.

Xiong visited families in slums and asked what they needed most. The father said they did not need money, they needed stable jobs, access to education for their children and good health insurance.

“Our research subjects are not just samples in the dataset; they are individuals with their own lives and stories. People get impoverished by disease and healthcare costs, which starts a vicious cycle that needs to be broken and can be broken,” said Xiong, talking about his 100-day field research experience in Kenya. “As a master’s student of global health, I want to do my part to make the change.”

During the COVID-19 pandemic, field research became difficult. Faculty at the Global Health Program did all they could to help their students continue their work.

Sage Wyatt, from the United States, completed her undergraduate studies at the age of 18 and came to DKU to pursue her master’s degree in global health. Interested in maternal and child health, she was looking to undertake field research in Sri Lanka. But the pandemic prevented the trip.

Sage Wyatt

Through her supervisor, Dr. Qian Long, Wyatt connected with Vijitha De Silva at the University of Ruhuna, Sri Lanka, who later introduced her to Dr. Truls Ostbye, professor of family medicine and community health at Duke University and DKU. All three professors worked as supervisors for her thesis.

Based in the U.S., Wyatt overcame the time difference to organize video calls with her supervisors in China, Sri Lanka and the U.S. to update them on her progress. Eventually, she completed her thesis titled “Predictors and occurrence of antenatal depressive symptoms in Galle, Sri Lanka: a mixed-methods cross-sectional study”.

“The whole thing was just incredible,” said Ostbye. “Sage could not get her visa to Sri Lanka for her field research, but that didn’t stop her from getting a good master’s education and completing an important study in another country. To make it happen required close collaboration between many faculty and staff.”

“DKU’s flexible model should get the credit, which offers so much help to students who can’t make it to campus. I feel honored to join DKU which combines the strengths of the West and the East.”

Homing in on a specific topic is a crucial step before conducting field research. Students in the Global Health Program often know which areas they want to focus on, but struggle to find the right angle into the subject. This is where their supervisors help, guiding them to identify a concrete research question.

In October 2022, two second-year global health master’s students, Yue Suo and Bolu Yang, with support from their supervisor Long, were invited to attend the World Health Summit in Berlin, Germany, and received research awards from the WHO.

Yue Suo(left)and Bolu Yang(right)

Yue Suo was interested in the control of sugary drinks when she started her master’s in global health, according to Long. But it is a very broad area; she needed to narrow it down to a very specific research question based on an understanding of what previous researchers had found in this field.

Yue Suo reviewed the literature on this subject and discovered that measures including increased taxation and extra labelling requirements had been taken to control sugar-sweetened beverages in low-, middle- and high-income countries.

But it seemed that very little had been done in China. Long encouraged her to think about whether those practices could be implemented in China, and if so, how. After several rounds of discussion, Suo focused her study on policies related to sugar-sweetened beverages for children and adolescents in China.

Bolu Yang also went through similar steps to identify her research question. She finally decided to focus on the uneven progress of smoking legislation and enforcement in China. China signed the WHO Framework Convention on Tobacco Control in 2003, but smoking control has progressed slowly. In her study, Yang aimed to identify factors contributing to the imbalance in smoking legislation and enforcement.

Long (second from right) and research team members

Carrying out research is not limited to master’s students. Undergraduates are also encouraged to engage in research activities, an approach which is a hallmark of the DKU education model.

Undergraduate student Hsien-Yao Chee, from Malaysia, conducted research in his freshman year. After analyzing massive amounts of health data with his peers, he found that adults aged 45 and older who slept less than six hours or more than eight hours had relatively weaker kidney function and faced a greater risk of chronic kidney disease.

Their research supervisor, Dr. Chenkai Wu, director of graduate studies for the Master of Global Health Program, encouraged them to submit their findings for publication. Chee was stunned that his work might appear in an academic journal so soon after entering college, but for Dr. Wu, who has already supervised a dozen undergraduates for their research projects, it is common practice.

“DKU students are hard-working, full of original ideas,” said Wu. “They are also fast learners. I hope they will produce more research findings by exploring topics of interest to them.”

Hsien-Yao Chee(far right) and partner Evelyn Lim (far left) with instructors Chenkai Wu (second from left) and John Ji

“One of the projects we did last year was to build an electronic system for diabetes, which connects various hospital departments to facilitate patient management and service,” said Dr. Meifang Chen, assistant professor of health policy, talking about how DKU supports undergraduate research.

“Several undergraduates were involved in this project, not just as assistants, but as real researchers. They were engaged in the whole research cycle, starting from developing project design, collecting data, interviewing patients and doctors in hospitals, to writing up the academic paper.”

Rather than assigning undergraduates to a specific task in the research process, Chen usually asks them to review the literature and develop their own research questions based on their expertise.

For instance, in Chen’s cancer-related project, students from various majors including economics, data science and environmental science approached the topic from different perspectives. The economics students focused on health costs for cancer, while the environmental science students explored cancer-inducing factors.

Through interdisciplinary collaboration, students build a broad knowledge base, learn to work with others and know how to find viable subtopics within a broad topic.

Meifang Chen (left) and student Fei Wu

In Yan’s project which leverages digital health interventions to prevent and manage hypertension in rural communities in Nepal, team members included students majoring in engineering, medicine and global health from Duke and DKU.

Among them was Nicholas Peoples, who joined Duke Kunshan’s spring 2015 Global Learning Semester, which immerses undergraduates from across the world into DKU’s international, research-inflected education model, one that is rooted in the liberal arts and sciences tradition, before pursuing his master’s degree in global health at DKU, which awarded him a Duke University degree.

While other students stayed in Nepal for 10 weeks, Peoples worked for four months and taught himself Nepali. He walked with large bags on his back when the road was blocked by rocks and was hospitalized twice with a bad cold.

“He is a person who is undaunted by hardship,” said Yan who led the project. “Learning he was sick, I was really worried about him.”

“Our graduates are well-placed for further education or employment. But I have always felt that they are outstanding students from the start. It is not that we make them outstanding. We just attract them to our program and create the opportunities to make their brilliance shine here,” said Yan.

Serve the people, serve the world

Efforts to promote health do not stop at academic research. DKU global health faculty and students are committed to serving the local communities with their knowledge.

In 2021, the GHRC worked together with the International Center for Communication at Tsinghua University and MSD (China) to launch the Health Knowledge Camp project, which aims to provide more cutting-edge, professional, and reliable health education, information and insights to journalists from over 30 media organizations, who then disseminate that health knowledge to the public in the form of cartoons or videos, or by organizing offline activities.

Peoples (left)

DKU faculty have popularized health science on issues of public concern, including lung cancer, liver cancer, infertility, respiratory infections and the COVID-19 pandemic. For instance, Chen has worked with undergraduate and graduate students to produce diabetes prevention and management guidelines. “How to communicate professional knowledge in an accurate and easy-to-understand manner is a challenge for our students, but it also provides a great learning opportunity,” said Chen, who leads the Health Knowledge Camp project.

Chen has initiated the Community Health Service Lab and worked with DKU students to help educate the public, including the Health Education for Youth project which teaches students in primary and secondary schools in Kunshan about sexual health, diabetes and how to use antibiotics.

Developed by DKU students, the course content was brought to life with designs produced by media and arts students and games that created an engaging environment to make learning fun and interactive.

This year, students working in the Community Health Service Lab launched a mental health project by collaborating with a non-profit organization and several communities in the town of Zhoushi, Kunshan. DKU faculty and students looked at whether the needs of mental health patients and their family caregivers were being met by community services while also examining questions of affordability and effectiveness.

The data will serve as a basis to help partner organizations develop intervention programs that combat prejudices against mental health patients, increase their social activities, and improve community integration for patients and families.

“The projects are well-received, which really fill a gap for some schools or communities,” said Chen, “DKU students have learned a lot by applying their classroom knowledge to real world problems.”

“We have been exploring how to translate research findings into health benefits,” said Yunguo Liu, who joined DKU after retiring at the end of 2020 from the position of director, division of programme management at the WHO Regional Office for the Western Pacific. “Informing policy is one approach; improving health literacy of the public is also very important, which leads to changing people’s habits.”

“I feel strongly that Asian countries whose mother tongue is not English are under-represented in the WHO, with personnel from these countries making up a very small percentage of its workforce. For instance, of the 1.9 billion people in the Western Pacific, the Chinese population accounts for 1.4 billion, but Chinese personnel in the WHO are fewer those from India or the Philippines.

“You can’t participate in global health governance without the full range of available talent. I hope more students will have internship opportunities at international organizations to understand how these agencies operate and what they’re doing, so students are well prepared to make a strong impact globally when they graduate.”

A key lesson DKU global health faculty teach their students is that “health is global, global health is local”, which students have been putting into practice over the past decade.

After leaving the Ministry of Foreign Affairs in 2013, Rui Wang, a former Chinese diplomat in the U.S., joined a non-profit organization that seeks cancer solutions. He traveled to rural villages to screen 1,000 heavy smokers for lung cancer free of charge and helped provide treatment to those diagnosed. Aged 38, he joined DKU to further his education in global health.

Wang worked on smoking control research during his study and after graduation; he now leads the China smoking control program of an international foundation. He hopes to make good progress in China and share the lessons learned to help people in other countries through a global health governance system.

Rui Wang at the North Carolina Global Health Conference

Faculty at DKU’s global health program work hard to create job opportunities for their students. “After analyzing the personnel by country of nationality in international agencies, I wrote a proposal and received funding to support five DKU students each year to intern at international organizations,” said Liu.

“Last year saw our first batch of three students interning at the Global Fund to Fight AIDS, Tuberculosis and Malaria, the International Organization for Migration, and the UNAIDS Beijing Representative Office. Students are now applying for this year’s internships. I believe that in the future we will be fully integrated into the international system and the global health mainstream.”

When discussing research findings and student development, global health faculty members often talk about the program’s vision and mission: To promote health equity and improve health for all in China and worldwide. All their initiatives – including the TB project, working for women, children or people in impoverished areas, or collaborating with neighboring developing countries – are helping to move toward this goal.

Since graduating in 2018 from the two-year global health program at DKU, Peoples has continued to make his mark on global health. As a Global Health Corps Fellow, he spent 13 months in Malawi leading various initiatives to prevent mother-to-child transmission of HIV. Back in his home city, Peoples serves as executive director of HOMES Clinic, a small clinic based in downtown Houston, Texas, providing free primary healthcare to those who are experiencing homelessness.

Peoples said he decided aged 18 that he wanted to be a “doctor for people who didn’t have doctors”, with the expectation he would go into family medicine.

Describing his spells at Duke Kunshan as “transformative”, he said, “DKU showed me how vast the world is and yet gave me the confidence – I would even say pushed me – to dream bigger about the good that can be accomplished on a global scale.”

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