Leveling the Playing Field: Maria Marquine’s Mission to Advance Latino Health Equity
September 13, 2023 | By Liz Switzer
Originally published on Duke University School of Medicine Magnify
María Marquine, PhD, grew up playing field hockey in her native Uruguay with the intention of having a career in the sport, until she was permanently sidelined by an injury. So, Marquine turned to another subject she loves as much as sports—science: “the way we understand the world,” as she puts it.
The decision was a major turning point for Marquine—even if she did come to it somewhat serendipitously—and it marked the beginning of a career that has put the neuropsychologist at Duke University School of Medicine at the forefront of national change.
A bilingual expert in cross-cultural neuropsychology, health disparities, and neurocognitive aging, Marquine is giving clinicians across the country the tools they have long needed to identify neurocognitive disorders in the Latino population.
Her research is advancing clinical care for an estimated 40 million native Spanish-speakers across the country, the fastest-growing population in the United States. It is a critical step toward addressing disparities in Alzheimer’s disease and related dementia (ADRD) and promoting health equity for this group, which exceeds the population of many Latin American countries.
“Estimating a person’s cognitive status is key to diagnosing and tracking conditions such as Alzheimer’s disease or HIV-associated neurocognitive disorder,” said Heather Whitson, MD, MHS, professor of medicine, director of the Duke Center for the Study of Aging and Human Development, and co-director of the Alzheimer’s Disease Research Center. “Dr. Marquine is a leader in national efforts to ensure we can administer and accurately interpret cognitive assessments in Spanish-speaking populations in the U.S.”
Accurate detection of ADRD among Latinos requires consideration of the demographic and sociocultural factors that impact performance on diagnostic neuropsychological tests.
Until Marquine, an associate professor in the Division of Geriatrics, created them, there were no comprehensive neuropsychological testing tools for diverse groups of U.S. Latino adults.
Not only were there few tests for Spanish-speakers, but she also added, the data and knowledge needed to appropriately interpret the results from such assessments for Latinos were not there. Assessments tailored for white Americans had been around for decades, but the dearth of tools for the Latino population compromised diagnostic assessments for that group—until Marquine stepped up to level the playing field.
"Seeing a group of people, my community, not being served like they should be is what motivates me to do this work. For me, it's leveling the playing field.”
“A person’s performance on cognitive test is a key element for the diagnosis of certain brain disorders or dysfunctions, but that performance is also a reflection of their life experiences, how they see the world and how the world sees them,” she said. “While trying to serve Latino patients early on in my career as a clinician, I couldn’t do my job because I didn’t have the tools. That’s an injustice. I don't like injustice and inequity. Seeing a group of people, my community, not being served as they should be is what motivates me to do this work. For me, it's leveling the playing field.”
While the language barrier is a big piece of the diagnostic puzzle that Marquine has been working to solve for the last decade, it is just as exciting to her to bring a culture that is not mainstream American into the forefront of its science. “The development of new tools and ideas that improve our ability to care for our patients is very important. It has been exciting to put the Latino community at the forefront of science versus being an afterthought somewhere down the line,” she said.
Marquine’s mission to level the playing field has meant not only tackling language and translational barriers—itself a monumental task with all the sub-dialects and variants of Spanish—but examining key contributing factors for neurocognitive test performance to accurately interpret the results of cognitive tests, such as education level and culture. Identifying these factors has been one of the big challenges.
“There are pros and cons from every approach and that's why I love diversity,” said Marquine. “You want people that operate and think in different ways to be on your team. This is crucial to develop the best science.”
The Long Game
As an international student, Marquine’s own experience with diversity goes back to 1999, when she had the opportunity to come to the U.S. as part of an undergraduate exchange program at Eckerd College in Saint Petersburg, Florida. It was at Eckerd that she found strong mentors who encouraged her to pursue academics.
She followed the advice, earning a PhD in clinical psychology from the University of Arizona in 2008, followed by a residency in clinical psychology at Rush University in Chicago, then in 2010 a fellowship in clinical neuropsychology at Duke’s Memory Disorders Clinic.
Marquine might have remained at Duke, but a tenure-track position that would allow her to do both clinical and research work and provide a path towards U.S. citizenship drew her to Rush and then on to the University of California San Diego (UCSD) in 2012 and finally back to Duke in 2022.
While working as a clinical neuropsychologist at Rush University Medical Center, where most of her patients were Latino, Marquine became acutely aware of the health disparities in the U.S. when she noticed a number of cases involving Spanish speakers who had been misdiagnosed because of the lack of tools and knowledge for accurate diagnosis in this population.
Marquine recalled one woman in her mid-fifties who had been misdiagnosed with early onset Alzheimer's disease. The woman and her family had planned for the worst-case scenario for five years until Marquine re-evaluated her and discovered the misdiagnosis.
“One case is an oddity,” she explained. “Two is a bit concerning, but when you see it over and over again, it’s a pattern.” Determined to break this pattern she decided to focus her efforts on developing the tools needed for Latinos. She found at UCSD the mentorship and resources needed to start this work.
“We cannot begin to close the known treatment gap for people from underrepresented racial and ethnic groups living with dementia until we can accurately diagnose neurocognitive decline and identify the multifactorial reasons underlying it,” said Cathleen Colón-Emeric, MD, MHS, chief of the Division of Geriatrics and associate dean for research mentoring at Duke School of Medicine.
“With new biologic treatments now being approved for Alzheimer’s disease, Maria’s foundational work in this area is especially critical,” she said.
Closing the Gap
It is Marquine’s dedication to health equity that has put the prolific researcher at the forefront of national change.
In 2020, with colleagues at UCSD and others across the country, she led the development of normative data on a comprehensive battery of neuropsychological tests for U.S. Spanish-speakers, the Neuropsychological Norms for the U.S.- Mexico Border Region in Spanish (NP-NUMBRS) project, which provided a multidomain cognitive test battery in Spanish and norms for Spanish speakers from the U.S.-Mexico border region. She was also a co-investigator in a project that developed normative data on the National Institutes of Health (NIH) Toolbox Cognition Battery for Latinos in the U.S.
Earlier this year, in collaboration with a national team of colleagues, Marquine led the development of neuropsychological normative data among Latinos on the Uniform Data Set Version 3 Neuropsychological Battery, the neuropsychological battery that has been used since 2015 by Alzheimer’s disease research centers across the country. She is now about to launch her newest study which will collect neuropsychological normative data for the first time among Latinos in North Carolina.
Marquine working with former UCSD research colleagues, is currently a multiple-principal investigator of an NIA-funded R01 Independent Investigator Award aimed at determining whether data collected passively via mobile devices might aid in the early detection of ADRD among Latinos.
The R01 is like working with biomarkers but they are digital markers, she noted. It’s also a new way of identifying neurocognitive disorders by using technology that is widely available and easy to use, which could be especially advantageous in reaching socioeconomically disadvantaged people.
LISTEN: Marquine’s Podcast Neuropsychological Norms for Spanish Speaking People in the U.S.
As part of Marquine’s involvement with the International Neuropsychological Society over the past year, she has been working with a group of neuropsychologists to develop guidelines for the adaption of neuropsychological tests for different languages and cultures. A manuscript based on the work is currently under review. She was also recently appointed as the Chair of American Psychological Association Presidential Task Force on Neuropsychological Test Norming in Diverse Populations, which aims to develop a research agenda to advance the field of neuropsychological assessment in diverse cultural groups.
In addition to being a renowned researcher, Marquine is passionate about teaching and training the next generation and she has earned National Institute of Health funding to support her work as a mentor at the Duke Aging Center, where she serves as the associate scientific director for research career development and has recently stepped up to co-lead the center’s postdoctoral program.
“Though Marquine has been at Duke for less than a year, she is already providing research mentorship and leading initiative that will diversify the research workforce working to improve health disparities,” Colón-Emeric noted.
Mentoring and work force development for Marquine are natural extensions of her clinical and research work on health equity, and just as crucial as she works to bring in people from diverse backgrounds to create science that applies to everyone.
“Part of the reason these assessment tools were not developed to begin with is people were not thinking about it, and they were not thinking about it because Latinos were not involved in the development of the tools,” she said. “I can count with one hand the number of Spanish speaking Latina neuropsychologists that are doing research funded by NIH. There is no line of people waiting to do this work. So, for me, it was just step up and get it done.”
Science is so much fun, she added, finding new things out there in the world that people haven’t yet discovered, and there is a team aspect to it as well that Marquine loves.
The former coach turned researcher said: “You can only win if you're doing it together, if you have a good team around you, the right people to play with, and you're working towards a goal.”