番茄社区

In this video interview, Claire Panosian Dunavan, MD, of the University of California Los Angeles, interviews Robert Breiman, MD, of Emory University in Atlanta and the University of Witwatersrand in South Africa, about his public health programs in Africa.

The following is a transcript of their remarks:

Panosian Dunavan: Hello and welcome. I'm Dr. Claire Panosian Dunavan.

A few weeks back I wrote a column for 番茄社区 featuring Dr. Rob Breiman. Today, I'm interviewing him about his long and remarkable career in domestic and particularly global public health, spanning senior jobs at CDC and Emory and many international assignments.

What were some of the highlights from your work in the slums outside of Nairobi? Paint a picture of Kibera and your population-based studies.

Breiman: So, for me, the underlying theme of the work I've done throughout my career has to do with inequities and addressing those sorts of imbalances.

So when we started our program in Kenya with CDC and the Kenya Medical Research Institute -- so CDC and KEMRI work -- we wanted to understand what the drivers were for disease burden. How much of this was related to people living in desperate urban slums, or what are called "informal settlements"? How does that compare with diseases that occur in more rural settings? At that time -- and still is -- there was a lot of movement from rural to urban, but there also was some back and forth. So we wanted to understand disease transmission also between urban and rural areas.

We built two population-based surveillance systems built around a clinical care facility with a defined population in a catchment area where we had community health workers visit every household every 2 weeks, so it was a very intensive kind of surveillance. But by visiting every 2 weeks, we got around the issue of whether diseases were actually being seen in the clinic, because sometimes people don't go to the clinic. They might go to a traditional healer or they might figure out some other way they want to manage. Maybe they can't afford clinical care.

One thing we did was we made sure that everyone within the catchment area had free care, which was not routine elsewhere. We helped to build a clinic within the Kibera area, which at the time was one of the world's largest, Africa's largest informal settlements. They had no government infrastructure, no water, no sanitation. We established a system -- both systems still exist in both the rural areas of western Kenya near Lake Victoria.

Very different environment than the urban slum where the population density is almost unimaginable. You walk into Kibera or some of the other informal settlements in Kenya, and you try to imagine what life would be like there.

Panosian Dunavan: You hosted many important visitors. But there was a particular senator, I believe, who came and had a life-changing moment visiting.

Breiman: We often had political leaders visit. Barack Obama visited while he was senator in 2006. But one of the things that was most memorable to me, one of the visits, was by Sen. Johnny Isakson, who is retired now but was a very stalwart Republican, a little bit to the right senator from Georgia, probably more than a little bit to the right. And I was actually worried when he was visiting that he might come in and see what largely might appear to be humanitarian work that we were doing. We were doing research and filling knowledge gaps, but we were doing good too. We were providing clinical services to people that didn't have clinical services and so on.

I thought he would come and say, "What? U.S. taxpayer money is going to this? Stop this right now!" But I could tell that he was moved through the visit and at the end of the visit, he kind of grabbed me by my elbow and he said, "You've changed my life. What you guys are doing here is..." I think he said something like, "is God's work." And he was very, very proud of the fact that the U.S. government was supporting these kinds of efforts.

Panosian Dunavan: That's very moving. In closing, because I know our time is limited, you have certain points to make about your current work, which is based out of South Africa, and the need for an international response to support it.

Breiman: So I was asked to do something very unique, very challenging, and people thought, again, was a little bit crazy, which was to build an institute at the University of Witwatersrand -- which is a world-class university that few people know about, but it's very much like Harvard in South Africa -- to build an institute that puts infectious disease and cancer research together and understand the levers, especially for cancer, that come from infections.

We already know that the poster boy for that is cervical cancer and HPV [human papillomavirus]. If we didn't know that HPV caused cervical cancer, which certainly was not known when you and I were in training, we wouldn't be able to prevent 90% to 95% of cervical cancers now with the vaccine against the virus, HPV.

And there are many more of those out there. And those can be transformative, especially for Africa. We can prevent HPV, we can prevent cervical cancer now in Kinshasa as well as we can in Beverly Hills because we have this vaccine, and we're looking for more of those.

So for me, it's the model. If you're trying to address inequities, cancer in Africa is going through the roof. Cancer prevention, and especially therapeutics, are stuck in the late 20th century. They don't have access to the kinds of cutting-edge capabilities that exist in the United States. So I've chosen to focus on that.

We have world-class scientists there, and we are going to make progress in that arena.

Panosian Dunavan: We hope you get some large international donors to support that.

Breiman: Yeah, and we often say that it is really a great opportunity for people that are looking for their personal legacy, because this is wide open. Everyone's been focused on the conventional problems, the infectious disease problems that I've largely focused on for my career. But what we're doing now is very unique.

There's no institute like this in the world, and it's great to me that it's based in Africa where the problem is, rather than sitting in the United States and transporting it to where the problems are the greatest. So we're very excited about that.

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