PROS by the Stony Brook University 2022 iGEM Team

The diagram below shows our Integrated Human Practices cycle, our methods and approach, and how we effectively addressed stakeholder needs in our project.

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The Problem

Protein S Deficiency

Protein S deficiency is an inherited autosomal dominant disorder of blood clotting. People with this condition have an increased risk of developing abnormal blood clots, including a deep vein thrombosis (DVT) that occurs in the deep veins of the limbs (NORD). A DVT can further travel through the bloodstream and lodge in the lungs, causing a life-threatening clot known as a pulmonary embolism (PE).

Protein S deficiency is caused by a variation in the PROS1 gene. This gene provides instructions for making protein S, which is found in the bloodstream and is crucial for controlling blood clotting. Protein S blocks the activity of other proteins that promote the formation of blood clots (Medline).

Most mutations that cause protein S deficiency change single amino acids in protein S, disrupting its ability to mediate blood clotting. Individuals with this condition do not have enough functional protein S to inactivate clotting proteins. This results in an increased risk of developing abnormal blood clots. Protein S deficiency can be divided into types I, II and III based on how mutations in the PROS1 gene affect protein S (Medline).

In order to learn more about PROS1 gene variations, and how protein S deficiency affects different communities and populations, we did a thorough literature review.

Risk in African American Communities

After thorough research, we learned that venous thromboembolism (VTE), consists of DVT and/or PE, and has an annual incidence of 300,000 to 900,000 cases in the United States every year. Thus, it is a significant cause of mortality and morbidity (Beckman et al. 2010, Raskob et al. 2010). African Americans have a 30–60% higher incidence of VTE than individuals of European descent (Roberts et al. 2009, Zakai and McClure 2011). However, the typical genetic risk factors in populations of European descent are nearly absent in African Americans, and population-specific genetic factors influencing the higher VTE rate are not well characterized at all.

Protein S plays an important role in anticoagulation as a cofactor of the anticoagulant enzyme, activated protein C. Protein S is also reported to have independent anticoagulant activity (Heeb et al. 1993, Garcia de Frutos and Fuentes-Prior 2007). In European populations, damaging mutations in Protein S are rare (Gandrille et al. 1997, Rosendaal and Reitsma 2009). However, significant variants have been found in Japanese and African American populations.

In the Japanese population, the Protein S Tokushima K196E is associated with increased risk for VTE. It has a population prevalence of 0.9% to 1.6% (Kimura et al. 2006, ten Kate and van der Meer 2008). In African American populations, the variant PROS1 V510M, which also causes protein S deficiency and is associated with increased VTE, has a population prevalence from 0.5% to 1.42% among African Americans and African descent populations, and is virtually absent in other populations (Daneshjou et al. 2016).

Despite this, genetic risk factors for this disorder, which have been thoroughly studied in European populations, have not been well characterized in African American communities or other populations (Daneshjou et al. 2016). African American representation in clinical studies is necessary to gain a more comprehensive understanding of how VTE and protein S deficiency affect this community.

Risk in Indigenous Populations

Long Island has a large Indigenous population, due to the historical presence of around 13 different tribes and 2 reservations in the present-day (one which is federally recognized). According to the Suffolk County Office of Minority Health, Native Americans suffer disproportionately from barriers to healthcare access and delivery (Office of Minority Health).

In particular, the rate of diagnosis of VTE among patients discharged from Indian Health Services hospital care from 1980 through 1996 was considerably lower than rates reported in African Americans or Whites. According to a study done in 2004, the observed relatively low incidence of VTE in American Indians is due to undetermined genetic factors. There is a significant lack of research done to address the health needs of American Indians, particularly in respect to VTE and protein S deficiency (Stein et al. 2004).

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Our Approach

We wanted to engage with these communities that have been disproportionately affected by protein S deficiency and characterization, and integrate human practices within our project, specifically addressing how synthetic biology can contribute to bridging healthcare disparities, which are extremely prevalent and critical in the diagnosis and treatment of protein S deficiency. Healthcare inequity is a consequence of human practices that stem from implicit bias and systemic racism. Despite the fact that the United States has become increasingly more ethnic and racially diverse since 2010, we still live in a eurocentric society that prioritizes our White population over Black and Brown populations. We see this pattern repeatedly within our healthcare system where the disparity is far too large and African American and Indigenous communities are suffering unnecessarily as a result (McCurdy et al. 2022).

After speaking with many scientists and community members, we learned more about a common issue: poorly characterized disease states in the African American and Indigenous communities. We conducted a literature review and specifically learned about Factor V Leiden (FVL), which is a mutation that causes protein S deficiency. This mutation is seen almost exclusively in individuals of European ancestry, and it is nearly absent from African American populations (Limdi et al. 2006). A google search for “Factor V Leiden” gathers 1.79 million results. In contrast, a search for “PROS1 V510M,” the mutation seen mainly among African Americans with increased risk for VTE, gathers only 194 results. Additionally, there is significant lack of research done to address the health needs of American Indians, particularly in respect to VTE and protein S deficiency, with no genetic characterization of these disorders within this community at all (Stein et al. 2004).

This simple google search effectively highlights the immediate need that we have for more inclusive clinical studies. We fully recognize that a lack of trust exists between Black and Brown communities and physicians due to historical trauma. This is not an issue that is easily fixable. We believe that the first step in seeing equity in healthcare is to educate ourselves and the community on the impacts of disparity in healthcare.

Our main objective was to learn more about protein S deficiency and VTE in minority communities, reach the communities and individuals who are impacted by this disorder, learn how to improve our project to address their needs, and introduce our project and the use of synthetic biology as a tool to create more accessible and inclusive treatments in order to get their feedback and advice.

In order to lessen the devastating impacts of this disease, we also sought to inform our communities about the prevalence of protein S deficiency, and provide support about this disorder. We sought to increase awareness about synthetic biology, our project, and iGEM, especially as these things relate to addressing healthcare disparities.

Genetic engineering sometimes falls within the limits of bioethical dilemmas. The precautionary principle generates panic in people that are not informed about the topic. To circumvent this, we established positive dialogue with institutions and organizations, while always thinking of involving local communities in the understanding and development of molecular biological solutions to health issues. We want to help establish a precedent by showing that synthetic biology can impact our country and change our lifestyle.

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Stakeholders

We were interested in knowing the human context of protein S deficiency in minority populations, especially in African American and Indigenous populations in Long Island and the Greater New York region. The dynamic between the public perception and our attempt to present our project as a first step in addressing protein S deficiency, particularly in these communities, was a real challenge. This is why we decided to contact different experts and meet with them. They helped us to decide which approaches were the most appropriate.

We engaged in discussion with government entities and health providers. Thus, we were able to better understand the impact of protein S deficiency and VTE on these populations, and could approach them in a systematic way. They also further helped us contact local communities and organizations, where we could directly learn more about the impacts of protein S deficiency and VTE.

We contacted scientific experts in different fields such as biochemistry, cell biology, molecular biology, biotechnology, hematology, chemistry, biomedical engineering, synthetic biology, medicine, healthcare, and health science. All of them helped us develop the technical aspects of our project. We learned a lot about the PROS1 gene and protein S. We also learned more about protein S deficiency, how proteins can be expressed, which cell types and parts to use, how to create a mechanism for the expression of protein S, parts assembly, etc.

Scientific Experts

We consulted many scientific experts in the fields of genetic engineering and healthcare, and iteratively improved our design with their feedback. They helped us fine-tune our project and guided us on how to express protein S efficiently, safely, and effectively.

Michael V. Airola, Ph.D. Assistant Professor in the Department of Biochemistry & Cell Biology at Stony Brook University. We met with Dr. Airola and various members of his lab. After we pitched our idea to him, he helped us understand the technical aspects of our project. Through discussion with Dr. Airola, we were able to determine what cell types we should use (SF9 insect cells), how to make them competent, how to arrange expression of the protein, and what vectors to use. Specifically, he helped us learn about how to transfect insect cells effectively using the Bac to Bac technique. Finally, Airola advised us on which type of donor vector to use (YMBac-1) and generously offered to donate both the YMBac-1 plasmid and SF9 cells. He also advised us to express a near-mature form of the protein (with introns deleted from the gene of interest, and truncated if needed), which is exactly what we did. He recommended that we keep the protein signaling peptide in the gene of interest if it is cleaved off post-translationally using a simple peptide bond cleavage. He informed us that SF9 should be able to carry out that peptide bond cleavage. The Airola laboratory also helped us design our protocols, and demonstrated wet lab techniques to our team.

Katarzyna Jankowska, Ph.D., biochemical researcher at Food and Drug Administration (FDA). Dr. Jankowska works at the FDA’s office of Tissues and Advanced Therapies. She has experience researching genetic mutations that lead to common blood disorders. We reached out to Dr. Jankowska to learn more about researching blood disorders and how to better implement our project. She helped us further determine what cell lines are most viable for us to use, recommending we use SF9 cells for expression. She also advised us to start with transient transfection before stable to determine expression behavior, and this is what led us to use transient transfection in our project. Finally, she advised us on the types of assays we can use, recommending that we utilize commercially available methods, and pointed us to binding, kinetic, and ELISA assays for our project. Time permitting, we planned on following her advice.

Steven E. Glynn, Ph.D., Associate Professor in the Department of Biochemistry and Cell Biology at Stony Brook University. Dr. Glynn helped us further solidify our choice of using SF9 cells. We had previously been considering doing cell-free expression, but after discussing with him, chose not to pursue this idea due to time and resource constraints. Dr. Glynn also advised us to research whether the protein is spliced or undergoes post-translational proteolysis, and to determine whether that would affect our experiment. As a result, we learned about the mature form of protein S, and a signaling peptide that is cleaved off. Dr. Glynn then advised us to keep the signaling peptide in our sequence and rid the gene of introns. He informed us that the signaling peptide proteolysis is a simple peptide cleavage which SF9 should be able to do, agreeing with Dr. Airola’s advice. He advised us not to truncate the gene of interest of the signaling peptide sequence, since the peptide is needed for expression. We followed his advice. He also advised us to determine whether protein S is secreted and what cells secrete it.

Gábor Balázsi, Ph.D., Henry Laufer Professor of Physical & Quantitative Biology at Stony Brook University and Rafal Krzyszton, Postdoctoral Scholar in Balázsi Lab. Dr. Balázsi and Dr. Krzyszton helped discuss our choice and use of plasmid, and aided with cloning and protocols. They recommended that we not use restriction enzymes for cloning, advised us to use PCR instead, and even offered to help us design PCR primers for our gene of interest. They also informed us of the 2031 bp coding DNA sequence of the PROS1 gene, which is the sequence without any introns. This was extremely helpful, because it meant we did not have to focus on splicing, and we could use E.coli in addition to SF9 cells. They provided us with resources that helped us learn more about the SF9 Baculovirus system. Additionally, they advised us to establish a kill curve, for both ampicillin selection in E.coli and Gentamicin in SF9.

Timothy Miller, M.D., Resident in Internal Medicine at Stony Brook University Hospital. Dr. Miller spoke to us about how he treats patients who are losing blood, or having trouble with their blood clotting. He described how he either treats patients with purified plasma that has all of its components or gives them very expensive Kcentra, which has factors II, VII, IX, X, proteins C and S, antithrombin III and human albumin. He discussed with us how costly these treatments can be, and emphasized the need for cheaper alternatives. Dr. Miller also mentioned other blood clotting disorders that we could research to gain a greater understanding of coagulation and protein S deficiency. These included Von Willebrand Disease, which helped us gain a greater understanding of blood coagulation disorders in general.

Mei Lin (Ete) Chan, Ph.D., Assistant Professor of Biomedical Engineering at Stony Brook University. Dr. Chan helped us with the dry lab portion of our project. She spoke to us about how to model the 3D relationship between protein S and its binding partner. She also discussed how we could make a mathematical model by identifying the components involved in the project in order to predict what will happen. She told us to consider variables that would affect the production of protein S. Specifically, Dr. Chan reminded us to model both the production of the protein, but also the degradation of the protein naturally. The variables she told us to consider included the different cell lines we were using, the temperature, concentration, and pH. She also helped teach us how to get started in MATLAB, and connected us with other researchers who could help us with this portion of our project.

Christopher Helenek, Graduate Student in Biomedical Engineering, Balázsi Lab. Chris was on the 2019 Stony Brook iGEM team as the former team leader. He helped us significantly in the dry lab portion of our project. Specifically, he helped us determine what parameters and variables we should aim to model, how to find the literature constants for those parameters, taught us how to translate those into a system of ordinary differential equations, and instructed our team on how to use MATLAB.

Brookhaven National Laboratory Tour. Our team members attended a tour of the National Synchrotron Light Source II (NSLS-II) and the Center for Functional Nanomaterials (CFN) at Brookhaven National Laboratory. At the NSLS-II, researchers use ultrabright x-ray beamlines to study materials on a nanoscale level in many fields such as structural biology and physics. We are interested in utilizing the beamlines to gain a comprehensive model of our synthesized protein using x-ray crystallography. This model could help us determine if our synthesized protein is functional by analyzing its structure. By studying the side chains of the amino acids found in the protein, we can study the chemical bonds and determine if the protein has the correct binding abilities, which play a role in its functionality in preventing overcoagulation. Hence, we are interested in using the NYX (19-ID) biological microdiffraction facility to examine and analyze the laboratory synthesized Protein S. This is something that we aim to do in the future, after crystallization of our protein.

Outreach Goals

Dr. Sangeet Honey, Ph.D., Research Assistant Professor in the Department of Microbiology and Immunology at Stony Brook University. We met with Dr. Honey about the outreach aspect of our project. We described our project and how we are eager to not only work on a therapy for individuals with protein S deficiency, but that we also aim to reach out to the community to raise awareness for the inequity that exists in healthcare, and learn how to better tailor our project to address their needs. He advised us to be more specific in our outreach efforts to effectively see change. Taking this into account, we decided to focus on the lack of characterization of this deficiency in the African American and Indigenous populations. Being that Dr. Honey is a part of the department of Microbiology and Immunology, he also offered to advise us as we move along further in our project and begin wet lab.

Government and Institutional Entities

We reached out to government organizations and politicians who could give us insight into our project; they helped us communicate with communities of color, and put us into contact with local organizations. They also helped us distribute our infographic about health disparities in blood disorders and a survey we had designed. This survey was used to gauge the needs of Indigenous communities and African American populations, and then adjust our project to better address those needs.

Dr. Gregson H. Pigott, MD, MPH, Health Commissioner of Suffolk County. Dr. Pigott has served as the Director of the Office of Minority Health (OMH) in the Suffolk County Department of Health Services since June 2009, and is the current Health Commissioner of Suffolk County. The office of the Commissioner has taken a purposeful, proactive role in Suffolk County to improve the health and well-being of the county's 1.5 million residents. Having been involved in addressing healthcare disparities in Suffolk County and Long Island, we thought he would be an informative person to speak with in order to gain some insight to our project. After listening to our project and our outlook, he provided us with advice and possible logistics we may face. In particular, Dr. Pigott explained to us how African American and Indigenous communities are often distrusting of physicians due to generational trauma, and advised us to approach these communities with that understanding. He also advised us to approach these communities using understandable and easily accessible language that was not too technical. Understanding that our project may have the potential to address protein S deficiency and provide cheaper therapeutic methods that are more widely available to minority populations, Dr. Pigott was fascinated, and he helped us meet with more members of the local government.

Adesuwa (Obasohan) Watson, MPH, Director of the Office of Minority Health.Adesuwa Watson has been with the Suffolk County Department of Health Services - Office of Minority Health (OMH) since 2008, and currently serves as the director. In this capacity, Mrs.Watson sits on multiple committees and is a coordinator and educator for several community based initiatives, which address health disparities, health promotion and community collaboration. She helped us get in contact with various organizations on Long Island. She also helped review our infographic and presentations, and helped us distribute them in local communities.

Grace Magaletta, Representative of NY State Senator Chuck Schumer. We reached out to the office of Senator Schumer in order to gain a better understanding of how we can reach the Greater NY region and tailor our project to better address the needs of our communities. The representative of the Senator offered us help in distributing our infographic and journal to a wider audience in NY state. She also helped us connect us with the Long Island Regional and Deputy Directors for Senator Schumer; they put us into contact with local organizations with whom we could discuss the implications of VTE and protein S deficiency in minority communities. The Senator’s office expressed great interest in our project and the production of our competition deliverables, asking us more about iGEM, synthetic biology, and how they could potentially support us in representing NY state on an international platform.

Michael Iannelli, Long Island Regional Director, and Anneliese Marcojohn, the Long Island Regional Deputy Director for the United States Senate. Through the Senator’s Office, we got in contact with Mr. Iannelli and Mrs. Marcojohn, who helped us connect with more organizations and communities in the Long Island region.

Suffolk County of Human Rights Commission. The Suffolk County Human Rights Commission's mission is to work toward the elimination of bias and discrimination. They agreed to help us distribute materials to inform our local communities about healthcare inequity on Long Island and the way that disorders such as VTE and protein S deficiency disproportionately impact people of color. They helped us circulate an infographic, designed by our team, to our local communities and hospitals.

Jill Santiago, Director of the Center for Social Justice and Human Understanding. Jill Santiago is the director of the Center for Social Justice and Human Understanding, who develops educational programs and works with many community organizations to promote diversity and inclusion. In addition to her work for the Center for Social Justice and Human Understanding, Jill teaches in the history and humanities departments at Suffolk County Community College. With the work that Jill Santiago does within the Long Island community, she was able to connect us with Veronica Treadwell, who is a member of the Unkechaug Nation and also serves on the Board of Directors for the Center for Social Justice and Human Understanding.

Corporate Stakeholders

Alexander Knight, SVP Business Development for Cooley LLP. Cooley is a global law firm that was ranked a top law firm for US venture capital financings. Alexander Knight serves as senior vice president, leading Cooley’s global DEI-driven business development efforts. Passionately committed to seeing a more diverse entrepreneur and venture capital ecosystem, Alex plays a vital role in elevating the Cooley platform to serve the unique challenges and opportunities of underrepresented minority founders, investors and executives. He is a “go-to” adviser and connector to Black, Latinx and other underrepresented founders of high-growth companies – assisting them with targeted introductions to venture capital, executive talent and other high-impact resources that accelerate company growth. About half of their clients are in the life science sector, including healthcare tech companies, and because of this, we felt that having Alexander’s input would be beneficial as we navigate the target market for our injectable therapy, PROS.

After achieving successful results by expressing protein S in E.coli, we felt as a team that we needed to develop a business model that would not only deliver this therapy directly to the patients who are in need, but also consider the affordability and accessibility of PROS injectable therapy. Alexander, who has a background in working to increase the opportunities of BIPOC company founders and startups was an ideal expert in the field to communicate with. His first piece of advice was to classify the members of our team as specialists. For early stage founders it is critical to have a diverse team that specializes in different areas. He emphasized the importance of our story, and how that story will resonate with stakeholders. A large component of our project is highlighting where clinical research falls short in terms of the characterization of disease states in underrepresented communities.

On behalf of our team, Alexander reached out to the following companies:

Britt Gerald, Sr. Manager, Clinical Trial Diversity & Inclusion for Moderna. Moderna Inc. is an American pharmaceutical and biotech company based out of Cambridge, Massachusetts. Moderna develops mRNA therapeutics for use in vaccines and they conduct clinical stage trials using mRNA science to produce therapies for infectious, immuno-oncology, rare and autoimmune diseases. Currently, Moderna is using mRNA science to develop prophylactic vaccines for the flu, SARS-CoV-2, Respiratory Syncytial Virus RSV, human metapneumovirus and parainfluenza type 3 (hMPV/PIV3), cytomegalovirus CMV, Epstein Barr virus (EBV), HIV gp160, Nipah, germline HIV, and Zika VLP. Recently Moderna has reported positive data from clinical trials of their RSV vaccine and from their CMV vaccine. Moderna is also further increasing resources for their COVID-19 vaccine to create a wider pipeline.

Steve Worthy, Vice President, Business Development for Aetion. Aetion, based out of New York City, is a healthcare analytics company that presents data to manufacturers, pharmaceutical companies, purchachers, and medical treatment and technology regulatory companies. They utilized data science driven technology to help healthcare companies make strategic decisions that ultimately impact patients. Aetion developed the Aetion Evidence Platform (AEP), which is a software that quickly analyzes data to produce real-world evidence scaled to meet market needs.

Ingrid Green Jones, Esq. Sr. Corporate Counsel, Diversity Clinical Development for Pfizer. Pfizer is one of the world’s leading biopharmaceutical companies. They discover, develop and manufacture healthcare products, including vaccines and medicines. In 2021, their revenue was around $81.3 billion, with products sold in over 125 countries, 79,000 employees worldwide and 104 projects in their pipeline as of July, 2022, with 34 in phase 1, 34 in phase 2, 28 in phase 3 clinical trials, and 8 projects in registration. Pfizer has established The Pfizer Multicultural Health Equity Collective (MHEC), which works to better health equity of racial groups and underrepresented communities through advocacy and access, social determinants of health, diversity in clinical trials, and disease awareness.

Local Communities and Organizations

We persisted with our efforts to visit minority communities and populations. The health centers and communities we engaged with were diverse, and our visits were done specifically to interact with them and observe their needs in a closer way.

At the end of each of these events, we were able to draw conclusions such as: they do not have much information regarding protein S deficiency and diagnosis, nor are these populations trusting of their healthcare providers. We were able to hear the specific testimonies of people regarding these issues.

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Our Findings

Through meeting with stakeholders, interacting with African American and Indigenous communities, and based on the results of the evidence we collected, we learned many things that we aimed to integrate into the execution and implementation of our project.

In view of the evidence collected, we recognised:

There is a lack of proper diagnosis, care of diagnosis, and in some cases, treatment, for protein S deficiency in African American and Indigenous communities due to a variety of different factors including a lack of awareness about protein S deficiency and insufficienct/inadequate healthcare.
There is a complete lack of knowledge about protein S deficiency in minority populations, and lack of genetic characterization or research to address their needs regarding protein S deficiency and VTE.
There is a significant distrust between communities of color, the healthcare system, and health providers. This is due to historical precedent, but also because of the lack of representation for people of color in the healthcare field.

We learned these things through communicating with many different individuals and institutions. Consequently, we decided to research these phenomena and aimed to make changes to our project that would address them.

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Researching Policies and Practices, and Ideating and Implementing Our Solutions

Lack of Diagnosis and Awareness

We learned there is a significant lack of diagnosis and awareness in communities of color which can partially be attributed to genetic differences that exist between different racial populations. As highlighted above, in African American populations, the variant PROS1 V510M, which also causes protein S deficiency and is associated with increased VTE, has a population prevalence from 0.5% to 1.42% among African Americans and African descent populations, and is virtually absent in other populations (Daneshjou et al. 2016). The lack of characterization of this deficiency among the African Americans population is echoed in the official entry in The Online Mendelian Inheritance in Man (OMIM). OMIM is a comprehensive digest of human genes and genetic phenotypes (About OMIM - OMIM). In the Protein S; PROS1 entry- families of Chinese, Italian, and Spanish backgrounds are mentioned, with African descent missing (Lewis, 2016).

Protein S deficiency can be either hereditary or acquired and there are conditions along with gender and age that can cause protein S levels to vary from person to person. In our research, we learned that there are three different types of protein S deficiency. In type I, there are low levels of free protein S (FPS) and total protein S (TPS). In type II deficiency, there are normal levels of TPS and FPS. In type III, there are normal levels of TPS and low levels of FPS. In type II deficiency, protein S levels are normal, but protein S activity is diminished (Gupta et al. 2021). The assays that are typically used to detect protein S levels and activity based on coagulation timing are not sensitive enough to accurately diagnose type II deficiencies. There are also a number of medications and pre-existing conditions such as a chronic infection, pregnancy, and diabetes (Marlar et al. 2014) that can interfere with the protein S immunological assays. All of these components need to be considered when addressing a patient with a possible protein S deficiency.

Our Response

Proper assessment for protein S deficiency can be complex due to factors that need to be considered prior to diagnostic testing, testing methods, and limitations that exist in commercial assays. After doing a thorough literature search, we determined that there was a need for a more comprehensive algorithm for protein S deficiency testing, that includes information about the pre-diagnostic stage and factors that should be considered before testing such as pre-existing conditions and drug interactions. We designed this algorithm, and distributed it to healthcare professionals as a guide to proper assessment of protein S deficiency. We also included an expense analysis of our proposed algorithm that eliminates the need for unnecessary testing, lowering the cost per patient.

Lack of Characterization and Inclusion in Research

Through interacting with healthcare professionals and various members of African American and Indigenous communities, we learned that there is a complete lack of knowledge about protein S deficiency in minority populations, and lack of genetic characterization or research to address their needs regarding protein S deficiency and VTE. This was unfortunately, not surprising. In the United States, African Americans are at an increased risk for developing cardiovascular diseases, stroke, cancers, and diabetes among others (OMH Resource Center) compared to Whites, but according to the AAMC, only 5% of participants in clinical trials identify as Black.

The first issue we see as outlined by these statistics is that we have a large population of people who are experiencing diseases at a disproportionate rate, yet they are not being represented in clinical trials. This is a significant issue; for example, if the majority of clinical research participants are White males, we may not necessarily know how a particular drug may be metabolized in the body of an African American male due to differences in genetic ancestry. Overall, there are a variety of different factors that contribute to this lack of inclusivity within clinical research such as: logistical barriers, including but not limited to, cost of transportation to the site of the study, not being able to miss work to participate, and the need for childcare. Aside from these logistical barriers, there may be a lack of trust in the healthcare system as well as language and communication limitations preventing participation.

Our Response

In response to these findings, we sought to help further the development of more inclusive research studies that aim to address the needs of African American and Indigenous populations. After researching what leads to non-inclusive trials, and how to overcome these obstacles, we created a guide on how to design more inclusive research studies and distributed it to researchers and scientists. Our guide can be used by researchers to ensure that clinical trials are more inclusive to those from underrepresented communities, so we have the opportunity to tailor therapeutic interventions and provide better care for all. Our six principles are:

Create an inclusivity panel.
What are the barriers?
Are research personnel representative of the population?
Re-evaluate trial design to eliminate logistical barriers.
Engage the community.
How are the exclusion criteria inhibiting inclusivity?

To see involvement in a trial from underrepresented communities, it is essential that the inclusivity of participants be considered from the preliminary design stage through the conclusion of the trial. The lack of inclusion of African-Americans mirrors the health disparity that is seen by this community, through limited access to healthcare, and implicit bias by providers that may affect treatment.

You can view the guide we created here

We also aimed to make our own project and research more inclusive. In order to accomplish this, we expanded the implications of the dry lab portion of our project:

We sought to help increase the genetic characterization and understanding of this disorder in African American communities. After reaching out to our local African American communities, and hearing about how widely and deeply impacted they were by issues such as protein S deficiency and VTE, we wanted to take a step forward in research that was designed to address their needs. We decided to specifically model the PROS1 V510M mutation, a mutation that causes protein S deficiency and is found primarily in African American populations. This can serve as a foundation for additional research and characterization of this genetic variant, and acts as a starting point for studies that better address the needs of the African American population. You can see the results of our work here.

This initiative in the modeling aspect of our project was our team’s attempt to help kickstart greater understanding of the genetic interplay behind protein S deficiency and specifically how it affects communities of color. We recognize that our contribution was small, and that there is still a lot of work to be done. We hope that our efforts will convince healthcare providers, scientists, and researchers to look into these issues and be more conscious of the applications of their work and which communities they are addressing.

Distrust of Healthcare System

Through discussion with various individuals, we learned that many individuals in the African American and Indigenous communities have a significant distrust of the healthcare system, and of their health providers. In an October 2020 Nationwide poll, 7 of 10 Black Americans said they're treated unfairly by the health care system and 55% said they distrust it (Commonwealth Fund 2021). Mistrust may prevent people from getting care, and can act as a significant barrier to treatment.

The mistrust within these communities, we learned, can largely be attributed to their previous experiences with the health care system, and racism within the healthcare system itself, but also the lack of representation that these communities have in healthcare and in STEM fields in general (Kennedy et al. 2007). According to the Association of American Medical Colleges (AAMC), among active physicians, 56.2% identified as White, 17.1% identified as Asian, 5.8% identified as Hispanic, and 5.0% identified as Black or African American. Only 0.3% identified as American Indian or Alaskan Native (AAMC 2018).

This is also true in STEM fields more generally. According to the National Science Foundation, Hispanic or Latino, Black or African American, and American Indian or Alaskan Native workers are severely underrepresented in STEM fields:

STEM workforce, by degree level and race or ethnicity: 2010 and 2019 (National Science Foundation 2019).



Our Response

In response to what we learned, we decided to integrate an inclusivity aspect to our project. We wanted to help promote diversity in STEM for minority students. To accomplish this, we reached out to organizations and clubs aimed at increasing diversity and inclusion in STEM fields. We also started a podcast designed to empower underrepresented students and teach them about how to pursue their passions in the sciences. We also started planning and implementing a bridge research program between our school and a local community college. A more comprehensive overview of our inclusivity initiatives can be found here.

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Conclusion

Overall, our project had one uniting idea- how can we manipulate synthetic biology directly address the needs of the patient? Part of phase one of our project included conducting extensive research on what protein S deficiency is, how protein S deficiency is treated, who is affected by this disorder, and how we can create a novel therapy to address it. We did this by conducting comprehensive literature searches, discussing with various individuals, government agencies, organizations, institutions, and business-people. Through our interactions and our research, we learned how we can improve our project. We learned how to optimize our business plans and strategies, and how to better design our project to be successful. However, the greatest revelation that came from our discussion and interactions was the finding that people from communities of color are disproportionately affected by protein S deficiency and that historically, little has been done to address this disparity.

The health disparity that exists in minority communities encompasses a broad range of issues that contribute to this inequity. Research revealed that the effects of protein S deficiency is very well studied in European populations, and lacking in African American and indigenuous populations. Some connecting issues at the root of this discrepancy are exclusive clinical trials and lack of trust that is oftentimes observed between communities of color and the healthcare system. After learning of the alarming statistics, our team created a guide to more inclusive clinical trials aimed to help researchers re-evaluate and redesign how clinical trials are conducted in the US and how that impacts the health of communities of color. As a team, we also decided to model the PROS1 V510M mutation that is primarily found in African American patients. We are optimistic that between the work we did in outlining the necessary principles for inclusive clinical trials and the foundational work completed on modeling the PROS1 V510M mutation, that both of these initiatives will drive research efforts in favor of characterizing protein S deficiency in different racial and ethnic populations.

Our team collaborated and tried to think of ways in which we could help address the mistrust that exists between communities of color and the healthcare system. A component of this issue, we learned, is the lack of representation of people of color entering into healthcare professions in the United States. Communities of color are poorly represented in STEM fields and increasing this number would help to establish trust between these communities and healthcare providers. The ways in which we sought to broaden diversity and inclusion in STEM fields were:

1. The creation of a podcast series that is designed to empower students from underrepresented populations and offer advice on how to pursue their scientific interests.
2. Met with various student organizations who are dedicated to helping underrepresented students.
3. Started planning and implementing a bridge research program between our school and a local community college.

Overall, our main objective throughout our Integrated Human Practices cycle was to learn more about protein S deficiency and VTE in minority communities, reach the communities and individuals who are impacted by this disorder, learn how to improve our project to address their needs, and introduce our project and the use of synthetic biology as a tool to create more accessible and inclusive treatments in order to get their feedback and advice.

We established positive dialogue with institutions and organizations, while always thinking of involving local communities in the understanding and development of molecular biological solutions to health issues. We want to help establish a precedent by showing that synthetic biology can impact our country and change our lifestyle. Our activities expanded the purpose of our project beyond designing a therapy, and helped us discover ways to make that therapy more available and viable to all kinds of people.

We are excited to go beyond the scope of the iGEM competition and see how we are able to further aspects of our project to create a long lasting impact on our local communities.

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References

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Team
The members of the 2022 Stony Brook University iGEM Team
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Description
Introduction to our project.
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