Q&A with Rebecca Rubinstein, MD/PhD Candidate in Epidemiology

Rebecca Rubinstein

What was your background before prior to coming to Gillings?

I first became interested in global health while studying biology and Spanish at Wellesley College. I had phenomenal professors who encouraged me to explore challenges for future population health in my coursework—like climate-related factors associated with childhood stunting and genetic sterilization of mosquito vectors of dengue fever. I was lucky enough to participate in the Madeleine Albright Institute for Global Affairs at Wellesley, where I attended a monthlong training in global issues and then spent the summer of 2014 conducting chikungunya surveillance in the Dominican Republic, work I was fortunate to continue after college.

After returning from abroad, I was struggling to decide between studying medicine or epidemiology. To help make my decision, I enrolled in an MPH at the University of Texas Medical Branch at Galveston, who had supported my work in the DR. After studying alongside clinician classmates and conducting chart reviews for outcomes of intrauterine Zika exposure at a local health department, I ultimately decided to pursue interdisciplinary training in both disciplines so that I could straddle both worlds, develop the skills necessary to tackle problems in global infectious disease burden, and work with individual patients.

Can you tell us about your MD/PhD program?

In the UNC MD/PhD program, I completed 2 years of the preclinical med school curriculum and am now in my PhD in Epidemiology at Gillings. UNC is one of the relatively few institutions around the country that encourages MD/PhD candidates to pursue their PhD in public health or the other social sciences. That, and the amazing breadth of faculty and research interests represented at Gillings, especially within global health, is what attracted me to UNC. As a medical student, I’ve gotten to participate in programs such as a longitudinal medical Spanish elective, the student-run free clinic Student Health Action Coalition (SHAC), and other activities. Our MD/PhD community is very close-knit and most of us have friends across multiple cohort years. We get to spend time with one another in Wilmington each summer, as well as during Monday night seminars and case conferences. They are an amazing resource, and some of my closest friends in NC are in the program. It definitely made weathering the pandemic easier!

Will you tell us more about your global health work in Nicaragua?

Yes! I’m about to spend 3 months in Leon, Nicaragua this fall, and will return in 2023. My friend Camille Morgan (another MD/PhD candidate who was also featured in the Global Health Folx Q&A series) and I received NIH Fogarty global health fellowships to fund 12 months of global health research abroad for our dissertations! In Leon, I will work with the Principal Investigators of the UNC Program in Nicaragua, microbiologists Drs. Filemon Bucardo and Samuel Vilchez, of the National Autonomous University of Nicaragua—Leon (UNAN-Leon). They have collaborated with my US-based mentor, Dr. Sylvia Becker-Dreps (Associate Professor in Epidemiology and Family Medicine, and the director of the UNC Program in Nicaragua) for over a decade. I will be measuring serum secretory IgA against live oral rotavirus vaccine in a cohort of Nicaraguan infants. In Nicaragua and other LMICs, oral vaccines often do not produce as strong an immune response in children, putting them at risk of serious infections like rotavirus. I will also be evaluating whether genetically-determined breastmilk contents, such as human milk oligosaccharides, are associated with the rotavirus serum IgA response. I will also determine if children’s risk of diarrhea, enteric infection burden, microbiome composition and growth differ by their mothers’ breastmilk oligosaccharides. This work will help us better understand the role of human milk oligosaccharides in modulating children’s gastrointestinal health, important information given public health support of breastfeeding worldwide.

Will you share your experience conducting surveillance on chikungunya and Zika viruses both in the United States and the Dominican Republic? What is the “Local is Global. Global is Local” connection you saw working in both locations?

I saw many connections between global and domestic health. During the chikungunya epidemic in summer 2014, the attack rate was so high in the Dominican Republic that at times it seemed like everyone had the fevers and arthritis characteristic of the infection. During this period, many hospital staff were out sick and as a result, some patients did not have good medical records, especially if they remained in the ER and were never admitted. This somewhat compromised our work, because we sought to characterize the symptomatology of the east Asian strain of the chikungunya virus, and determine how many individuals were correctly diagnosed versus misdiagnosed with chikungunya. I’m often reminded of these experiences today, as we battle Omicron waves of SARS-CoV-2 and shortages of healthcare workers here in North Carolina. Even at the UNC SHAC clinic, we had to rely on many backup providers as several of us were out sick or exposed. Chikungunya, like COVID-19, can also cause chronic symptoms in infected people, though I’m not sure how long arthritis can last in patients. It remains to be seen how much of a burden the chikungunya epidemic and COVID-19 will have in the coming years on global health and wellness.

My experience working at a Houston-area health department during the Zika epidemic in 2017-2018 really encapsulated the ‘global is local’ nature of global health. Texas was one of just two states (the other being Florida) to experience local transmission of Zika virus, meaning that local mosquitos in the Rio Grande Valley could transmit Zika virus to individuals who had never left the US. So some cases we followed were individuals who resided in South Texas, or had a sexual partner from the area. We also followed birth outcomes of many pregnant people who had immigrated to the US from Latin America. These cases were challenging and fascinating because at the time, serologic tests could only reliably detect Zika infection up to 12 weeks after exposure. Whereas many of the pregnant women we followed had spent more than 12 weeks, or the majority of their pregnancies, in countries with endemic Zika. This meant that we often never determined whether a fetus was exposed to Zika during a woman’s pregnancy. Some of these mothers were understandably afraid to speak with us, a government agency, given the national rhetoric and policy around immigration at the time. All the while, we had to juggle constantly-shifting public health recommendations around Zika testing and counseling from the local, state, and federal health agencies. Although we were based in the US, we were working through a public health crisis that was impacted by global phenomena, like globalization, immigration, and other factors. To make matters worse, many of us were already burnt out from working through the Hurricane Harvey recovery period, where we conducted syndromic surveillance for communicable diseases in hurricane shelters.

Ultimately, these two experiences were a harbinger of what was to come during the COVID-19 pandemic. Multi-national public health emergencies require flexibility, courage, grace, and strong investment in public health programs and personnel long before crises hit. This is essential to building resilience within public health institutions, as they are likely to be hit with non-stop stressors like monkey pox, future COVID-19 variants, antibiotic resistance, vaccine-preventable diseases like measles, and climate change.

What does “global health” mean to you?

To me, global health encompasses the burden of infectious diseases due to underinvestment in sanitation, food security, vector and animal control and other causes worldwide, especially in Global South countries impacted by colonialism, neocolonialism, and other structural factors. Global health also includes many chronic diseases and sources of injury, like road traffic safety, heart disease, and diabetes that affect both the Global South and Global North, though they may hit the Global South even harder than the Global North.

What drew you to the Gillings School of Global Public Health?

The breadth of research opportunities in global infectious disease control, the epidemiologic methods, and the relaxed environment at my interviews with faculty! Additionally, I was really attracted to the decades-long collaborations that UNC has had in Malawi, Nicaragua, Zambia and elsewhere.

What is your dream job?

This is a hard one because I don’t know if I’ll stay in academia or transition to another sector. But ideally, I’d love to work as a pediatrician and epidemiologist conducting research in Latin America at an academic medical center either in the US or abroad. Alternatively, it would be really interesting to work at a governmental public health agency like the CDC or a state health department, or an NGO.

What tastes do you associate with summer?

Passion fruit, cold beer, and ice cream.