As a Black woman and a medical student, I am frightened and frustrated by stories about the concerns of Black women being dismissed during prenatal visits, labor, or postpartum checkups, resulting in poor maternal health outcomes. My desire to help address this public health crisis led me to become a volunteer doula at UNC Hospitals.

In that role, I saw the value that doulas bring to the birthing experience by solely focusing on supporting the mom and their well-being. But public policy has not kept up with the clear positive impact a doula can provide. In North Carolina, it is essential that legislators extend Medicaid benefits to cover doula care.

The benefits are many.

Take “Emma,” a mom I met who was experiencing anxiety in the midst of an unplanned C-section. Although her delivery did not go as expected, I helped her make the most of the situation by providing unwavering encouragement, playing her favorite music, taking pictures for her family, and serving as her advocate with the healthcare team. Emma’s primary need in that moment was the essential emotional support that doulas provide to patients.

Doulas offer other advantages as well. According to NIH research, women who had doula support experienced fewer delivery complications and had more success with initiating breastfeeding compared to those that did not work with a doula.

Despite the proven benefits of doula care, many pregnant people do not have access to it due to the high costs associated with private doulas, the scarcity of volunteer doula programs, and the absence of insurance coverage for doula services in North Carolina. Emma’s birth story may have unfolded quite differently if she had delivered at any other hospital in North Carolina, as most do not have volunteer doulas or staff that can focus their attention on one patient.

Reimbursement of doula services through Medicaid would help overcome these limitations by enabling disadvantaged populations, who need these services the most, to access them for free while also ensuring that doulas receive well-deserved compensation. With Medicaid coverage, people like Emma could elect to work with a doula and enhance their likelihood of feeling safe and supported during their pregnancy and childbirth. That, in turn, would help combat maternal health disparities.

This would be a financial win for everyone. Beyond improving birth outcomes, doula-assisted deliveries could reduce healthcare spending in North Carolina. A study published in the Birth journal revealed that doula care was associated with a decreased risk of preterm birth compared to those without a doula. And, among full-term patients, doula care was linked to a lower risk of cesarean delivery. Offering doula services through Medicaid could reduce the rates of preterm and cesarean births, both of which impose heavy financial burdens on patients and the health care system.

Although North Carolina lawmakers have proposed bills on Medicaid coverage for doula care, none have ever passed. And yet, as the rate of preventable maternal deaths continues to rise, the need for the implementation of new policies is evident. Many Black women who had traumatic births are courageously opening up about their experiences, and it is imperative that legislators listen. Additionally, it is crucial for lawmakers to collaborate with community programs and doulas who consistently advocate for pregnant people. Together, they can determine the best path forward and develop a Medicaid coverage plan that will benefit doulas as well as the most vulnerable populations.

Siera Lunn is a medical student at Duke University and a 2023–24 Schweitzer Fellow.

To everyone who thinks they have to stop breastfeeding when they return to work — you don’t. According to the federal PUMP Act, enacted in December 2022, lactating employees have a right to pump their breast milk at work.

As a Duke medical student and NC Schweitzer fellow who is studying lactation, working for Breastfeed Durham, and volunteering as a birth and postpartum doula, I spend a lot of time supporting human milk feeding. When the Providing Urgent Maternal Protections for Nursing Mothers Act became law, those of us in the lactation world celebrated. This legislation extended the Break Time for Nursing Mothers law to nearly nine million more workers, requiring employers to provide reasonable break time and a private, non-bathroom space for breastfeeding employees to pump during the workday.

For several months, I naively assumed everyone — from factory workers, to baristas, to doctors — was aware of the new law. However, I still hear “I want to breastfeed, but I can’t because I have to go back to work soon” from new parents. I hear medical residents say that the only place they can pump during the workday is the bathroom. Shockingly, even healthcare professionals that specialize in providing breastfeeding support are unfamiliar with the PUMP Act.

So, in honor of the recent first anniversary of this bipartisan law, here is a reminder of the key points of the PUMP Act. Currently, for all workers except flight attendants, pilots, and railway workers:

• It is your right to pump at work.
• Your employer must provide break time and space to pump your breast milk.
• If you are not completely relieved from your duties during pumping time, you must be paid.

Why is this important? The World Health Organization and American Academy of Pediatrics recommend exclusive breastfeeding for the first six months of life, followed by continued breastfeeding with appropriate complementary foods for up to two years and beyond. Breastfeeding has many health benefits for all parties involved. The Cost of Not Breastfeeding tool estimates that breastfeeding can prevent nearly 600,000 childhood deaths from infection, 1 million cases of childhood obesity, and 100,000 maternal deaths from cancer or diabetes worldwide. And breastfeeding has been projected to save families thousands of dollars and the global economy $341 billion.

Exclusive breastfeeding for 6 months might sound reasonable on paper. But the truth is that feeding an infant their parent’s human milk either requires close physical proximity between the infant and parent or adequate time for the parent to regularly express and store their milk, as maintaining breast milk supply depends on frequent milk removal. Living in the only developed country in the world with no national paid leave policy, 1 in 4 women in the US in 2020 returned to work 10–14 days after giving birth, according to the Bipartisan Policy Center. The US Bureau of Labor Statistics reported that only 6% of women in the lowest income bracket had access to paid leave in 2021. Even parents who do have paid leave in North Carolina tend to have less than 12 weeks. So, for parents who must return to work to financially support their families, the right to pump breast milk at work afforded by the PUMP Act is vital to their ability to feed their infants in line with global health recommendations.

How can you help raise awareness about nursing parents’ rights and promote human milk feeding in the workplace?

1. Talk with your family, friends, and colleagues about the PUMP Act.

2. If you are expecting and planning to feed human milk, discuss your plans with your Human Resources office early, preferably in the prenatal period. This allows for productive conversation around expectations and space that will be available to you.

3. Remind your peers that it is their employer’s responsibility to provide accommodations. If you need to file a complaint against your employer, follow these instructions.

4. Congratulate your lactating colleagues for undertaking the labor of love that is pumping at work.

5. North Carolina is one of 37 US states that do not have a paid family leave policy. Sign petitions and write to your local policymakers about passing paid leave policies.

Nicola Young is a Duke medical student and a 2023–24 NC Schweitzer Fellow.

The Durham City Council is deeply divided over the demands of our striking sanitation workers.

Though sanitation workers announced Monday they would head back to work, the core issues remain. Strikers were asking for $5,000 bonuses — not cushy working conditions or enough extra money to buy a second home. They just don’t want to have to work a second job to pay the bills. Sanitation worker John Burwell, who has kept our city clean for 14 years, works four jobs just to make ends meet, and he still can’t afford to live in Durham.

As Solid Waste Department Maintenance Tech Antonio Smith told WRAL last week, the aim of the strike is “so we can actually live in the city that we keep clean.”

This is a profound statement about how much Durham has changed. When a largely African-American group of municipal employees can’t afford to live in the city that used to be home to Black Wall Street and renowned activists like Pauli Murray and Ann Atwater, we should ask ourselves how we can best carry forward the legacy of our proud city. Do we want to be a city that fails to treat our own sanitation workers with dignity? Do we want to be a city where only the wealthy can live? Do we want to push every working-class Black person out?

The sanitation workers’ strike is important to me; many members of my blue-collar family have strong careers and good salaries thanks to their unions. I am a history professor at Duke and one of the academic fields I engage in is discard studies, the critical analysis of everything we discard or treat as without value. This field calls attention to the human tendency to disregard and disdain the people who work with things we think of as “trash” or “filth” — garbage collectors, custodians, burial workers, etc. We must consciously work against this subconscious equation to keep our policies and beliefs in line with basic human rights for all.

Scholars and activists in discard studies also assert that waste work is care work, meaning that basic maintenance of any community requires a lot of attentive care, and the task of carrying away and processing waste is a core part of that. We need only imagine how our homes might look and smell if trash accumulated for several weeks to know that sanitation workers are essential workers. They care for our city, and our city has a responsibility to care for them. As sanitation worker Herman Moore said Monday to Durham city council members, “We’re called essential workers. Treat us like essential workers.”

Mayor Elaine O’Neal and two other council members support the strikers, but they are in the minority. Mark-Anthony Middleton, Mayor Pro-Tempore and Ward 2 council member, says the city can’t afford the $5,000 bonus the strikers are asking for without dangerously depleting its resources. While it does seem like unwise fiscal policy to cover the salaries of essential workers with a rainy day fund, we might move beyond this disagreement by thinking of this payment not as a bonus, but as regular payment of salary in arrears. That’s effectively what it is, a structural adjustment to make up for lost pay as cost of living has risen 23% while wages have only risen 15% since 2019.

This kind of structural adjustment — essential for our city’s essential workers — could be supported with an increased assessment on homeowners and businesses for municipal trash pick-up. Rising costs of living should result in rising fees for services, so that the people who perform those services don’t have to face the brunt of the financial squeeze alone.

Our city council members should work with the Public Works Department to consider implementing a graduated fee assessment so that those of us in higher income brackets pay more than lower-income households. If we value our sanitation workers, our payment for their essential services should reflect that.

Nicole Elizabeth Barnes is an associate professor of History and Gender, Sexuality and Feminist Studies at Duke University. She lives in Durham.

I hadn’t recognized her underneath the swelling, bruises, and lacerations. I had been her delivery nurse eight months earlier, when she had begged for a tubal ligation that we could not provide.

The patient’s pregnancy was full term and she had signed the consent form 23 days prior, seven days shy of sterilization eligibility according to the Centers for Medicare and Medicaid. She was discharged with the intention of receiving an interval sterilization procedure. This visit, she was a victim of intimate partner violence and at 19 weeks pregnant, she was suffering from a placental abruption and hemorrhage. The fetus had no heartbeat.

Childbirth may be the only time some patients access care, and the immediate postpartum period is a safe time to obtain permanent contraception. Bureaucratic federal policies, however, stand in the way. If a Medicaid beneficiary desires sterilization, they must sign the consent form and uphold the stipulations as described here. These regulations were published in the Federal Register in 1978 in response to a harrowing history of involuntary sterilization. The policy details a mandatory waiting period, forcing the patient to wait at least 30 days for the procedure after signature. The only exceptions are for preterm deliveries or emergency abdominal surgeries, in which the waiting period remains inconvenient at 72 hours.

When announcing these rules the agency admitted that the waiting periods chosen were arbitrary, and that “existing information does not permit precise predictions as to the effects of the proposed choices.” Today, there is abundant evidence that the policy paradoxically discriminates against the publicly insured by imposing barriers that restrict reproductive autonomy.

Between 50 and 60 percent of postpartum sterilizations are unfulfilled, and up to 47% of those forced to delay may have an unplanned pregnancy within one year. Failure to possess a valid and timely Medicaid consent is one of the most cited reasons for this. Patients who are discharged with unfulfilled sterilization requests are at an increased risk of unintended, short-interval, and subsequent high-risk pregnancies. Adverse outcomes associated with these include preterm labor/birth, low birth weight, uterine rupture, hemorrhage/blood transfusion, cardiovascular disease, hypertension, thrombotic events, interpersonal violence and more.

Women with unfulfilled sterilization requests report feeling frustrated, angry, dissatisfied, and anxious regarding their inability to prevent repeat pregnancies. They deserve better.

Medicaid covers nearly half of all births in the United States. Most subscribers identify as black and Hispanic, and are more likely to be of fair or poor health, single mothers, those of low-income, and be without a high school diploma. Sterilization rates among Medicaid beneficiaries are lower than privately insured individuals, even after controlling for hospital and patient factors. And when the sterilization interval was extended to include sterilization up to 90 days postpartum, only 46% of Medicaid enrollees compared to 65% of the privately insured received sterilization.

Scheduling this procedure as an outpatient is also problematic. If it has been longer than 180 days from consent signature, the patient will need to sign the consent again, and the clock gets set for the 30-day wait once more. Still, in 14 states where postpartum Medicaid coverage has not been extended to 12 months, the coverage period expires 60 days after birth and the family will be uninsured if they do not meet the state Medicaid eligibility levels.

The policy as it currently stands not only limits individual agency, but reinforces current racial and economic disparities in a country with an already staggering maternal mortality rate. A cost-effectiveness model estimated that upon revision the number of fulfilled sterilization requests would increase by 45%, leading to more than 29,000 unintended pregnancies being averted, and saving $215 million.

Abolishing or significantly reducing the waiting periods would ensure more equitable access independent of insurance status. A supplemental shared decision-making tool should be created to assist in assuring informed consent. Agency officials should collaborate with clinical experts and patients with lived experiences when revising this policy. Systems for tracking unfulfilled sterilization requests at the state and federal levels should be adopted, including adding criteria to PRAMS surveys. Clinically, providers in obstetrics need to make a point to ask about postpartum contraception as early the first trimester.

To support these changes, people should stay vigilant for invitations for public comment in the Federal Register and Unified Agenda, submit comments on Regulations.gov, request meetings, mail in written petitions, and reach out to their state’s CMS medical consultant for women’s health. While the history of involuntary sterilization is critical to reflect on, it is imperative to consider changes to policies that, even when initially benevolent, currently obstruct patient sovereignty and advance inequity. This regulation needs to be amended to safeguard evidence-based, patient-centered, equitable, and ethical health care.

Amanda Cassidy, MSN, APRN, WHNP-BC, CLC is a Women’s Health Nurse Practitioner in Maternal Fetal Medicine and an August ’23 Doctor of Nursing Practice graduate at Duke University School of Nursing. She resides in New York City.

By Kyle Beardsley

When my family and I were first asked “How are you going?” — which was almost immediately upon our arrival into Australia — we did not quite know how to respond or what to make of it. After a few more friendly greetings of this sort, we finally figured out that it essentially means the same as “How are you doing?” in the US. But the ethos is not exactly the same, and I think the difference between a concern for how one is “going” versus a concern for how one is “doing” says something about the different cultures.

I think there is also a deeper lesson here to be learned by Americans from Australians regarding how to make the most of, say, a Fulbright scholarship or academic life in general. Let me explain.

The American emphasis on “doing” coincides with longer work hours than much of the rest of the world and a general focus on personal achievement. While there are many positive things that can come from such a culture — especially when the achievements (the “doings”) are oriented toward social goods such as finding solutions to society’s biggest problems — there are also many negative things including unhealthy stress and relational friction. In contrast, the Australian emphasis on “going” coincides with professional cultures that are more likely to prioritize a work-life balance, in which there is opportunity to enjoy the journey and not just the achievement of the goals.

As one particular example, it is striking that faculty at most US universities do not have to report time off to their departments. Our professional lives so easily spill over into our personal lives because there are few clear boundaries between when we are working and when we are not. My understanding of universities in Australia, however, is that faculty do have time-off allocations that they are expected to take. Aside from this one example, I experienced many other informal norms during my time at Australian National University which point to a higher value for the quality of the journey (the “going”) over the prestige of the achievement (the “doing”).

As I near the completion of my Fulbright scholarship, I recommend that future scholars, especially those traveling to Australia, should consider the opportunity as a “going,” a journey with destination unknown. The scholarship experience is not something that is simply to be “done.” I gained the most from my time when I allowed myself to be curious of the excellent work being conducted around me. I am glad that so many new friends and colleagues were willing to share a coffee or a meal with me so that we could discuss both research topics and broader life topics. I come away from my Fulbright scholarship with a draft book chapter that I did not originally intend to write; I let it be part of the journey as my fellow travelers shared their ideas and I came to see how my research related to their work.

When we arrived in Australia, one of the first things we did was to see a play at the Sydney Opera House. It was a cute adaptation of Alison Lester’s “Are We There Yet?” which tells the story of a young family’s journey around Australia in a camper trailer. The feeling that the play and the book evoke is one of discovery — both of the country and of the relationships in the family. Too often we academics ask “Are we there yet?” as we try to “do” the next degree, article, book, grant, etc. Of course we’ll never get to a “there” and we’re likely to miss the opportunities to truly explore new ideas and to develop meaningful collegial relationships unless we slow down and appreciate the journey.

After my time in Australia, I’m glad that I’ll have some friends who will occasionally check in, reminding me to enjoy the journey when they ask me “How are you going?”

Kyle Beardsley is a political science professor at Duke University and served as a Fulbright Distinguished Chair in the Social Sciences at The Australian National University from January through June 2023.

“Go to the doctor,” we’re told when we get sick. But what about our neighbors who can’t? A growing segment of the United States population can be described as “homebound”, or those who cannot leave their homes without significant help. National studies of people 65 years and older have shown that the number of homebound adults has more than doubled in the last decade. These older adults have many chronic diseases but don’t have easy access to primary care, leading to more frequent emergency room visits and hospitalizations.

As a medical student at Duke University, I’ve seen firsthand how our health care system is not set up to meet these patients’ needs. My grandmother is 92 years old and has difficulty getting around because of her knee pain. While studying for an exam during my first year of medical school, I received a frantic call from my family that my grandmother wasn’t feeling well but they couldn’t figure out why. They didn’t have the ability to carry her outside, transfer her into the car, and drive her to see a doctor. They saw no choice but to call an ambulance to take her to the hospital to be evaluated. She was admitted and found to have a urinary tract infection and constipation. She was treated and taken home.

While I was relieved she didn’t have anything more serious, I was frustrated that my family had to go through the stress of the hospital system for something any primary care physician could have diagnosed and treated in the office. Hospital-based care is not only inconvenient but also significantly more expensive than office-based care: Blue Cross NC estimates that emergency room care costs almost 12 times more than visiting the doctor’s office. While a financial burden to patients, these expenses also contribute to rising health care spending in the United States.

There must be a better way to provide medical care to these patients who need it the most, and there is. Home visiting programs have been shown to reduce emergency room visits, hospitalizations, and overall health care costs for patients with complex needs. In Durham County, Lincoln Community Health Center launched the Just for Us program in 2002 to provide in-home primary care to low-income elderly adults and those with disabilities living at home who are not able to get to a primary care provider. Dr. Howard Eisenson is the current medical director of this primary care home visiting program. As I joined Dr. Eisenson on home visits, I saw a model of care that upended the hospital- and clinic-based care I provided through my medical school rotations.

In my medical and public health training, I’ve often heard the expression “to meet patients where they’re at” as a key part of addressing health disparities and inequities. It always seemed like a hypothetical, abstract goal: we can’t meet our patients where they’re at without leaving our offices. The Just for Us program takes that expression literally to carry out its meaning and mission. Through home visits, we know exactly what medications our patients have, who their caregivers are, if they have healthy food in the kitchen. We know how, despite all the hardships life has thrown at them, they utilize their unique strengths and resources to live out their lives. When we are invited into our patients’ homes, we can take better care of them.

Kelly Goo, MPH, is a medical student at Duke University and a 2022–23 NC Schweitzer Fellow.

Do we have two pandemics circulating around the world under the same name? Covid-19, which is the name we all recognize, and a twindemic of the Western “lifestyle” disease states associated with Covid-19’s worst impacts?

The Covid-19 pandemic has been called the “great equalizer.” And yet in an unfamiliar twist, it is the most developed and Westernized societies that have experienced the highest Covid-19 mortality rates, despite their advanced biomedical systems. To a startling degree, the risk of poor outcomes and mortality from Covid-19 is enhanced by the panoply of conditions that have flourished in the West, known as “lifestyle diseases.” We know them intimately in the United States, because they are a part of most of our families: hypertension, diabetes, chronic kidney disease, and coronary artery disease.

Lifestyle diseases were originally called “diseases of affluence” in the early twentieth century due to their association with privileged access to rich foods and freedom from physical labor. They were renamed “lifestyle diseases” when it became clear, in the 1970s, that they were a generalized feature of the Western lifestyle. In recent decades in the U.S. and the United Kingdom, the original class alignment has flipped, and those experiencing socioeconomic burdens have become particularly prone to these diseases once associated with affluence.

But rich or poor, in the United States, we are all at high risk for lifestyle diseases like diabetes. Scientists have noted that higher death rates from the COVID-19 pandemic were preceded by “a silent but significant pandemic happening in the background, the obesity pandemic [….] Over 30% of adults are obese in the United States, the country with the highest number of COVID-19 mortality.” The COVID-19 pandemic intersected with this pre-existing metabolic pandemic caused by the Western style of capitalist development, and created a disease experience unique to culture.

For the generations living in a culture of junk food radically different from the dietary exposure of earlier eras, the creation of a lifestyle that will not be prey to lifestyle diseases is a highly intentional, often laborious, costly project, of uncertain long-term outcome. Lifestyle disease risk factors (smoking, unhealthy diet, physical activity) are theoretically modifiable, but structurally unavoidable. We are inevitably exposed to hyperpalatable, highly processed foods, to the aggressive marketing and omnipresent availability of addictive substances like alcohol and tobacco, to endocrine-disrupting chemicals in merchandise, and to occupational efficiency models that reinforce a sedentary lifestyle and screen time.

Let’s face a troubling reality: the globalization of dietary trends associated with Western development, is a pandemic in itself, spreading not microbially but through fast-food chains and the like.The comorbidities of Covid-19 have brought into dramatic relief an aspect of environmental change in the modern industrial era that has, in the space of less than a hundred years, altered the ecologies of our own bodies.

The costs of chronic lifestyle-related disease are extremely high, not just in the United States where they are especially prevalent, but globally. A recent report from the Global Panel on Agriculture and Food Systems for Nutrition “an annual loss of 10 percent of global GDP from diet-related illnesses.”

As we, a cohort of Gen Z students in a “Pandemic Humanities” class at Duke University, look towards the future, we see the potential for policy changes to bring concerns about lifestyle disease and health inequality to the forefront of planning. The westernized lifestyle pandemic is not inevitable if we recognize it for the recent, cultural, exportable phenomenon that it is. Societies with low rates of lifestyle diseases have experienced much less excess mortality among demographics older than 60 years during the Covid-19 pandemic. In contrast to the U.S., Japan, with a notably high aging ratio, has experienced far less excess mortality during the pandemic, because its aging population experiences less food-related chronic disease.

The notion of “lifestyle diseases” is a misnomer that blames individual lifestyle choices for structural health risks. Yet the chronic food-related diseases the expression points to are all too real, and all too important in our losses from Covid-19.

This essay was written as part of a Duke University course called “Pandemic Humanities.” It was co-authored by Professor Deborah Jenson, T.A. Hélie Vigor, and students Chantel Abdulai, Chinmay Amin, Sidd Amirneni, Isaiah Boyles, Anna Everhart, Natalie Kubicki, Eugene Lee, Anna Muthalaly, Sejal Patel, Alex Stickler, Charlotte Tannenbaum, and Hannah Zelinger.

Thank you for notifying me that the Russian Ministry of Culture has awarded me a medal (“The Great Russian Writer F. M. Dostoevsky”).

This is a great honor; I am profoundly moved and grateful that my Dostoevsky scholarship and service, into which I have poured so much thought and energy over the years, have been recognized in the writer’s homeland. It has been rewarding for me to spend my life reading and writing about Dostoevsky. It has been a privilege to teach his writings to generations of students, to discuss with them not just the big questions of ethics, theodicy, faith, reason, and justice that he raises in his works, but also the fine nuances of the language and poetic structure of his writing. I have also been proud to translate and publish the works of my brilliant Russian colleagues, and to increase awareness of their contributions among literature specialists worldwide. In 2019 I was able to travel across Siberia, where many fine scholars and museum professionals welcomed me with generosity and good will. Last year, 2021, was particularly rewarding as we joyfully celebrated the writer’s bicentennial with conferences, lectures, films, exhibitions, and special events in every corner of the globe. As I have come to realize now more than ever, I am just a small part of the conversation that began with Dostoevsky’s writing and will continue long after all of us are gone.

It is therefore heartbreaking for me to have to decline this honor, which means more to me than words can say. Along with the rest of the world, I have watched with horror over the past year as Russia has invaded, brutalized, and tortured its neighbor Ukraine. Internally, it has arrested and terrorized brave, thoughtful individuals who have spoken out against the war, driving many of them away from their homeland. Given my respect for the profundity of Dostoevsky’s artistic writings, I am distressed that public figures have quoted from his non-fiction to justify this war. By doing so, they are doing irreparable harm to the writer’s reputation and trivializing what it is in his works that has reached readers worldwide. For me, accepting this award from the Russian government would too easily be taken as complicity in these crimes.

In making this statement, I am speaking as an individual, not as a representative of any organization. I continue to nurture a deep love and respect for Dostoevsky’s works, and for the writings of my colleagues in Russia and around the world. Together with them, I cherish hopes for better times, for mercy, reason, and peace.

With respect,

Carol Apollonio

Professor of the Practice of Slavic and Eurasian Studies, Duke University

A recent DEA warning about deadly fentanyl-laced rainbow pills that look like candy is another reminder that overdoses are killing our kids at an accelerating rate.

This is a national emergency — and few of us are even aware. Young people and their families need more information and intervention to reduce the risk of overdose. Fortunately, programs do exist that can address the problem effectively.

Overdoses account for approximately 20% of all deaths among 15- to 24-year-old Americans. That’s 2.5 times the figure from just 10 years ago — a dramatic increase. The number of young people using drugs is higher than many of us want to admit. A 2020 study found that between 10% and 20% of all high school seniors have used illicit substances other than marijuana. And many use more than one. This use of multiple substances accelerates adolescent overdose deaths.

Why? Because besides the “candy”, other illicit drugs are laced with fentanyl, including heroin, methamphetamine, cocaine, and counterfeit prescription pills like benzodiazepines. With young people using, and using more than one drug, their risk of unintentional fentanyl exposure and overdose has never been greater. The reality of elevated risk is particularly concerning for communities of color, who experience inadequate access to and quality of care. Since 2010, overdose mortality has increased more than five times for Latino adolescents and six times for Black adolescents.

There is a dangerous disconnect between healthcare organizations, providers, and our capacity to respond to the needs of adolescents and their families. Even as we have tried to increase the number of healthcare providers trained and equipped to address substance abuse, the number of providers actually prescribing medication-assisted treatment remain relatively few. And though a raft of evidence shows the influence of parents on young people’s drug use, few programs focus on how best to engage families, particularly parents.

Many organizations are trying to close this gap, however. At the Duke University School of Nursing, where I am dean, we use a nurse-led, family-focused model for adolescent substance abuse prevention. It engages Latino and Black adolescents and their parents in preventing substance use and overdose deaths among youth. It’s evidence-based and can be reproduced elsewhere successfully.

In our program, community health workers and nurses help parents talk to their kids about substance use, encourage strong parent-teen relationships, and review effective parental monitoring and involvement strategies. Each session is personalized to the family’s specific culture and context. These techniques are designed to make it easier for a teen to say no to drugs and foster open exchange between parents and their adolescent children. Adolescents and parents using these substances are referred for comprehensive treatment at a community-based organization. The nurses also teach parents and other family members overdose first responder tactics, including how to administer Narcan and how to use fentanyl detection strips.

These sorts of programs are vital elements in a more informed and effective response, but they must be implemented broadly across the country, and particularly in those areas with high incidence of overdose already. Healthcare leaders and public health officials must take immediate and aggressive action to pilot or implement family-focused, nurse-led programs. The models exist. What’s lacking thus far is the urgency and initiative to follow them.

The dramatic increase in overdoses and deaths is a wake-up call that our young people are struggling. They’re struggling with behavioral health concerns including depression. They’re struggling with anxiety. They’re struggling to see futures with opportunity, hope and meaning. We must take their emotions and the real economic and social challenges facing youth and their families across the United States seriously. Tackling the troubling factors driving substance abuse is the first step to keeping our young people safe and alive. They’re counting on us.

The future of our nation is largely determined by how well youth are able to grow up and become healthy and fully contributing members of society. As a country, we cannot afford to let them down.

Vincent Guilamo-Ramos is Dean and Bessie Baker Distinguished Professor at the Duke University School of Nursing and Vice Chancellor for Nursing Affairs, Duke University. He was also a member of the National Academies of Sciences, Engineering, and Medicine’s committee to develop the workshop entitled, “Family-Focused Interventions to Prevent Substance Use Disorders in Adolescence.”

In national public health emergencies like monkeypox, our sensitivities around not stigmatizing people can keep us from our goals. We don’t deliver helpful information or use language that doesn’t resonate with the intended audience.

The result? We lose valuable time.

And we don’t have time to waste. The U.S. has more monkeypox cases than any other non-endemic country. But it doesn’t have to be that way.

A non-stigmatizing harm-reduction approach is the most effective way to reduce exposure and infection.

We must avoid continuing the misperception that monkeypox is a “gay disease” so our message reaches the most people — particularly, racial and ethnic minority communities including men who have sex with men. While most people exposed in the latest outbreak are MSM, the virus isn’t classified as a sexually transmitted disease nor limited to this group.

Monkeypox in the current epidemic is primarily spread by close skin-to-skin contact. Because people will and do have sex, public health officials and healthcare providers must do everything we can to reduce risk.

We can start by changing how we communicate. Asking someone if they have, in the past 90 days, had anonymous sex or sex with multiple partners is the wrong way to do it. This approach potentially shames people. The stigmatization often makes it harder to come forward because people don’t want to be blamed or judged.

Instead, we can ask people if they have had sex in the past 90 days with someone they recently met or don’t know well. Or if they are sexually active and not in a monogamous relationship. Reframing in this way is less judgmental and invites conversation and an opportunity to support sexual health.

The CDC has effective materials to help sexually active people reduce risk. The agency’s Director of the Division of HIV Prevention, Dr. Demetre Daskalakis, MD, MPH, is one of the people getting messaging right. His official CDC videos, tweets, and interviews are plain-language, sex-positive messaging appeal to MSM and young people with guidance that is easy to understand and relatable.

We also need to provide clearer guidance to partners, close family, and friends.

It’s vital to encourage open communication before sex and other intimate contact. If you’re sexually active, talk to your partner/s about whether they’re feeling sick. Do they have a fever, muscle aches, a sore throat, or an unexplained rash or lesion? Are they experiencing difficulty swallowing, a sore throat, or trouble defecating? When anyone answers yes, refrain from sex and other close skin-to-skin contact — and seek testing from a trusted healthcare provider.

Families also need support managing the virus in their homes. If you live with someone who’s been exposed or has monkeypox, you can lower the risk of the virus transmitting within your household. Don’t kiss, hug, cuddle or have sex with anyone who has monkeypox. Avoid touching their rash or scabs and their clothes, bedding, and towels. And wash your hands frequently, especially before eating.

Nurses play a critical role in operationalizing harm reduction and slowing the spread. We are the boots on the ground and our sheer numbers make us a force multiplier in screening, testing, and vaccinating. This is especially important since the vaccine was approved for intradermal (between layers of the skin) administration, which requires less per shot and increases available doses fivefold.

And, as the most trusted professionals in healthcare, people feel comfortable talking to nurses about their health and disclosing behaviors. Since they see us as reliable sources of accurate, fact-based information, we have a direct impact on their decision-making and actions.

The current approach, in effect, subjects people to shame and blame to get a vaccine that preserves their health and prevents forward transmission. This practice perpetuates health inequities and encourages the spread.

We have a narrow window to make progress on monkeypox. The recent national emergency declaration creates opportunities for rapid escalation of our response, innovation, and partnerships with communities at greatest risk. Let’s capitalize on it.

Let’s make sure we’re reaching the right people with targeted messages. Let’s get shots in arms at an accelerated pace. Let’s share observed data and current evidence in a way that encourages sexual health instead of reinforcing stigma and arbitrary dichotomized positions.

Vincent Guilamo-Ramos is dean of the Duke University School of Nursing, vice chancellor of nursing affairs, and a distinguished professor of nursing at Duke University. A nurse practitioner, he specializes in the prevention of HIV/AIDS, sexually transmitted infections, and improving the lives of sexual minorities and other youth receiving HIV prevention and treatment.