Leading DGHI into Global Health’s New Reality

Chris Beyrer, MD, MPH, won’t officially begin his tenure as director of the Duke Global Health Institute until Aug. 30, but he’s already been popping up around Trent Hall as he makes his transition to Duke and Durham. Beyrer, who was the Desmond M. Tutu Professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health, recently moved to Durham and has been busy coming up to speed on his new environs, including seeking out the best Duke Forest running trails and lining up tennis partners.

We caught Beyrer on a recent morning in Trent to talk about his formative experiences in global health, his work on HIV/AIDS and COVID-19, and how he sees global health education and research changing in the wake of the pandemic. This transcript has been edited for length and clarity.

You’ve just moved to Durham. How are you settling in?

Well, I've found it very welcoming. I'm excited to be here. I'm just getting to know the Institute and its people and its wonderful work. And I'm just getting to know this marvelous new city.

What’s foremost on your mind right now as you begin making the transition to Duke and DGHI?

I think first and foremost for me is really getting to know the people and the wonderful work they've been doing. I recognize with all humility that I will have a steep learning curve at the start of my time here. I've already grasped some of the extraordinary range and depth of the work that's going on here in global health, and the commitment of the people. I've also now had the good fortune to visit two Duke international collaborative sites, one in Bangkok, Thailand, and one in Cape town, South Africa. And so I’m just learning the centrality of our international collaborators and partners.

Often the first question asked of someone in your position is why now? What was it about this opportunity that attracted you?

I think we're at an extraordinary moment in global health. We've all lived through the most extraordinary pandemic since the great influenza in 1918-19, and that has really opened up the incredible importance of global health work. And so when this opportunity arose, it was clear to me that the Institute had great strengths and has really important roles to play in the next phase of global health.

It's also a really challenging time in our field. There have been funding gaps. There have been big impacts on every aspect of public health and human wellbeing because of the pandemic. And so I think we're in a period of extraordinary challenge, and a place like DGHI can really help us all rise to that challenge.

As you are learning more about the institute, what stands out to you? What are the unique strengths on which we can build?

Duke is a great research university that has an extraordinary array of people working on innovative cutting-edge efforts across health and medicine, but also across fields like engineering, economics and policy. DGHI has the potential to really bring together like-minded people committed to this work of addressing health equity globally, and doing so in a truly multidisciplinary fashion. So I think that's an extraordinary strength. There are few institutions that have such depth and breadth across these disciplines.

It's clear to me also that the students are an absolute treasure. I am meting alumni and current students wherever I go who talk about how their experiences with DGHI and with global health transformed their careers and changed the trajectory of their lives. The faculty are a remarkable collection of people who share commitment to this vision of addressing health equity, both globally and for the underserved in this country and in Durham. And so I've found them to be an inspiring group of people. I'm just getting to know the staff, but I feel that people are committed.

We're of course all facing and thinking about the challenge of what return to work is going to look like. We're still in this pandemic, it's not over, but I think many would agree that at least for now the worst of it is over. And so it's really time to think about how we're going to create a vibrant, lively workplace that can accommodate people. And I really look forward to doing that with everybody who's a part of DGHI.

Let’s talk a bit about your background. You’ve said that the opportunity to do fieldwork in Sri Lanka during your senior year in college was instrumental in sparking your interest in global health. Can you talk about that experience?

In my last year at Hobart College, I did a six-month field assignment in Sri Lanka. I thought at the time that I was going to be interested in medical anthropology, so this was field work with two traditional Ayurvedic physicians working in rural communities. And it just opened my eyes to how extraordinarily diverse people's lives and livelihoods are. I found the richness of the culture and the connections I made with people really profound, and I came away thinking I have to have a career in which I can continue to do this kind of work.

When I finished college, I ended up working in a Tibetan refugee camp in north India, and that was really the place I decided to pursue a career in medicine. That led me eventually to international health at Johns Hopkins and then a fellowship in infectious diseases. I have worked globally ever since, for 30 years now.

You were completing your medical training at the height of the AIDS epidemic in the United States. How much of an influence did that have on you?

I started medical school in Brooklyn at SUNY-Downstate, which was the only public medical school in the city. And I walked right into the unfolding AIDS crisis. HIV was essentially untreatable. We didn't have any antivirals. The early trials were very unpromising. And so we witnessed an extraordinary amount of suffering and a lot of loss of life. And of course, very few people from that era survived.

I'm a gay man. I'm a New Yorker. My partner was one of those people who started to become ill in the mid 1980s. We lived together through medical school, internship, residency and fellowship, and he died just at the end of my training at Johns Hopkins. So I really committed from that point onward to working in the fight against global HIV, and I've never stopped.

As AIDS therapies were developed, they took a long time to reach many low-income countries. What did you make of those disparities?

It was 15 years and 800 clinical trials until we actually had effective antiviral therapy. That was 1996, when protease inhibitors began to become available. And that was just transformative. It was a period that people referred to as the Lazarus effect, because people literally rose up off their deathbeds and went back to work and school and parenting and to life. But it emerged very quickly that more than 90 percent of the patients on antivirals were in the U.S., Western Europe, Australia and other wealthy countries.

All of us will remember the great Peter Piot, the head of UNAIDS at the time, saying, “Millions of dollars are not going to address this. We need billions." I think a lot of us thought, “Who’s going to pay for that?” But then in 2003, George W. Bush announced the creation of the President's Emergency Plan For AIDS Relief (PEPFAR). And now, more than 60 percent of people living with HIV worldwide have access to antiviral therapy. It's not 100 percent, but we've made huge headway.

That terrible period of enormous loss of life from AIDS has really turned around. We have a long way to go, but it is one of the great achievements of global health. It’s unprecedented, and it’s a model for so many other diseases we need to address, including COVID-19, tuberculosis, malaria and so many others.

Can you talk about your HIV research in Thailand? What did the AIDS crisis look like on the ground there?

When I finished my training at John's Hopkins, my first position was based at a new field site in Chiang Mai in northern Thailand, Chiang Mai had one of the highest HIV burdens in Asia, and at the time I was there, from 1992 to 1997, there were essentially no antivirals. We could treat people for other infections and we could try and alleviate their symptoms and their suffering, but essentially we only had prevention as a tool. And so that's what we focused on.

Thailand had extraordinary success with something called the 100 Percent Condom Campaign. I was working also with the Royal Thai army, and we did behavioral interventions to reduce HIV risks in that community, which had enormous impacts. Even without antiviral therapies Thailand was still able to turn that epidemic around. It was done with the very limited set of tools we had at the time--behavior change, condoms and really very little else.

And now you’re on the frontlines of another pandemic. How did you start working on COVID vaccine trials? And are there lessons from your HIV/AIDS research that have proved helpful in this work?

People often ask how we got to the COVID vaccine so quickly, and a very large part of the answer to that is because we used the infrastructure that was created for HIV vaccines and HIV prevention trials. So in March 2020, as the world was shutting down, there was a call with the leaders of the HIV vaccine network where it was announced that the government was going to create a COVID vaccine network based on the same infrastructure as we had for HIV. They wanted to do five Phase III efficacy trials with 30,000 volunteers each in the next six months, and they didn’t have the bandwidth to pull it off. They were looking for volunteers, and I immediately said I would be happy to pivot to work on these trials.

I spoke with Larry Corey, who was leading the COVID Prevention Network (CoVPN), and he said where they really needed help was in enrolling people in the trials who represent the demographics of the country. So I stepped into the leadership of the community engagement program for the CoVPN and worked on all the trials that were done through the network. The first one was Moderna and we reached those targets, And that was so important because we were able to say the vaccine was equally effective in Black Americans, White Americans and Latino Americans, and that it worked for older people and people with chronic conditions.

So I've contributed 50 percent of my effort to doing the COVID vaccine trials. And of course my work on HIV has continued, as well as running a training program at Hopkins and the Center for Public Health and Human Rights. But for so many scientists, COVID became our daily bread. It’s a global pandemic emergency and we had to respond.

Will you be continuing your research at DGHI?

I have brought just a few of my own research projects and collaborations. I'll be continuing one major Phase III efficacy trial here, which is focused on addressing the social determinants of health for African-American gay and bisexual men in the south. We have sites in Texas, Florida, Georgia, Alabama, Mississippi, South Carolina and Washington, D.C. So I’m looking forward to continuing that work from Durham.

My view has always been that there is a great deal we have learned from our partnerships in other countries that can be brought home to address health equity issues in the U.S.  So I'm very committed to that work and I hope that it really can make a difference.

The development of COVID vaccines was such a huge victory for science and public health, but it came at the same time as what many see as some really frustrating failures to navigate a public health crisis. How do you reconcile those contrasts?

We're going to be parsing this and studying this reality for a long time. The development of the mRNA technology and the other technologies that led to these COVID vaccines is really one of the spectacular scientific breakthroughs of our time. And the era of mRNA has arrived and it's going to be used in cancer and in other vaccine developments. It's already being used in developing early stage HIV vaccines.

Where we started to fall down was on delivery. We don't have a national health system, so we did not have a preexisting way to deliver vaccines to people. And we underestimated the social and behavioral aspects of all of this. We underestimated how much vaccine hesitancy there would be, and how much misinformation and disinformation were going to play a role.

The anti-vax movement was fueled by a relatively small number of people deliberately spreading disinformation, and many more people unwittingly spreading misinformation. And that has led to a terribly divisive situation that we still can't get over. We have not been able to do better than about 70% immunization in this country. And that is one of the reasons why we have lost more than one million Americans to this pandemic.

Do you think global health research and education will look different after the pandemic?

Well, it has to change. I think we all have learned that we cannot ignore the social, behavioral and cultural aspects of global health. That is critically important. And that again is a reason why we need multidisciplinary work. And one of the reasons why DGHI is so well poised to engage in this next generation of global health work.

Secondly, I think we have to be much more sophisticated about disinformation and misinformation, because it is a clear barrier to achieving our global health goals. And it's not just an American problem, there has been an enormous amount of disinformation and misinformation in developing countries, as well.

Global health has to take a leadership role in saying that people have a right to scientific evidence. They have a right to the truth. It's not just that it's better for people's health. It's a fundamental human right. And I think we've underappreciated that, and we have to fight a lot harder for it.

You see global health as deeply connected to social justice. Can you talk about that connection and how it drives your approach?

The idea of global health equity is rooted in the belief that it is fundamentally unjust and wrong for people to be denied the basics in a world where we really can afford to provide them. For people not to have access to healthcare is inconsistent with the fundamental principle of human rights, which is the principle of dignity.

It is unseemly that women should die in childbirth because they can't get antibiotics or a blood transfusion. Or that children should still be being crippled by polio in a world where we have cheap and widely available polio vaccines. That's the kind of crux social justice, equity issue that drives global health. I think it motivates everybody who's in this field. And we know that we can and have to do better.

I think global health innovations and implementation science are going to help us do that more efficiently by using resources more effectively, bringing in simple, low-threshold technologies. And giving a lot more power to people. We have had very top-down health systems in much of the world. And we've seen with COVID that people are very willing and able to do self-screening and at-home testing. There are many more low-threshold ways to empower people and let them have more agency in their own health and wellbeing. And I think that's going to be a very big part of the next generation of global health efforts.

Global health has been in the midst of a reckoning about its colonial roots and the power dynamics around global health decision-making. How do you think the field needs to change to respond to those critiques?

I think we have to respond by understanding that much of the global health infrastructure is a colonial infrastructure, and we're living in a different world. We have the largest cohort of adolescence in human history right now, we have an enormous youth wave in much of the world. They're a different group of young people. They're interconnected in a way that people never have been before. They are not tolerating colonial infrastructures. They want to see real equity. They are a very aware and very engaged cohort about inequities and discrimination of any kind, including racial and ethnic and religious discrimination, but also around sexual orientation and gender identity.

We have to think about the ways that we can restructure international collaborative work so that it is on more egalitarian footing--that we are really working with partners and that they're benefiting in ways that make sense for the health of their people and their countries. There needs to be a much greater recognition of our interdependence.

I will also just add that I know how important diversity equity and inclusion are, and I'm very committed to expanding that effort here. The university made it very clear to me in our early conversations that this was a critical aspect of what Duke needs to do, and they have committed the resources we need to do it. And so I am looking forward to advancing those goals at DGHI.

So how can DGHI, as part of a Western university in a wealthy country, lead the way in achieving greater equity?

DGHI has to be a leader in that new model. In my view, one critical strength of DGHI in this new world is its longstanding established, collaborative partnerships. They are really the jewel in the crown. Those partnerships need to continue to flourish, and to be mutually beneficial to everyone involved.

DGHI has a reputation for not trying to cover the whole planet, but rather having a number of longstanding, focused collaborative partnerships that really have made a difference. And those become models for how to do it right across larger communities and to reach more populations. And I think that is still the right model for a great research university, to build and sustain those active, genuine partnerships and collaborations. And to do them in a way that benefits our students, their students, their faculty, our faculty, everybody -- and of course most importantly the people we all seek to serve.