Combating Global Cancer Burden Attributed to Infections with Robert Breiman, MD

• Breiman shares his career path into medicine, shifting from an aspiring lawyer to a focus on medicine. Choosing to specialize in infectious diseases was appealing for Dr. Breiman because of the ability to potentially completely cure patients.
• Breiman’s entry into global health started as a lab researcher. He later became interested in outbreak investigations and epidemiologic studies at the CDC's Epidemic Intelligence Service (EIS).
• While at the CDC Dr. Breiman considered a life in academia but his career grew with an EIS fellowship and a pivotal appointment as chief. 
• As the Director of the Emory Global Health Institute, Breiman focused on building the next generation of global health scholars and leaders.
• Research has been central to Breiman’s career, from respiratory diseases to various global health issues, including typhoid fever, Nipah virus, and ultimately the Child Health and Mortality Prevention Surveillance (CHAMPS) project addressing childhood mortality
• At the new institute in Witwatersrand, Breiman studies the link between infectious diseases and cancer, such as the role of human papillomavirus and cervical cancer, and emphasizes the potential to prevent cancers triggered by infections.
• Breiman describes how the Institute is building capacity as well as the next generation of scientific leaders in Africa, with hubs across Sub Saharan Africa and collaborations that enhance epidemiology and laboratory skills.
• He offers advice to young professionals, stressing the importance of listening and making sure they understand the value of their unique roles and skills. If students are interested in health inequality he suggests they consider addressing inequities domestically first before entering global health.

[00:00:00] Rob Murphy, MD: Welcome to the Explore Global Health Podcast. I'm Dr. Rob Murphy, Executive Director of the Havey Institute for Global Health here at Northwestern University Feinberg School of Medicine. It's a treat to welcome today's guest, Dr. Robert Breiman, to the show. Dr. Breiman is an internationally known researcher whose career in global health, infectious diseases, and epidemiology has taken him around the world and into many leadership roles within the CDC. I had the pleasure of working alongside him when he was the CDC Kenya Country Director. Today, he is combining his many skills and interests to address the growing cancer burden in Africa, by establishing the Infectious Diseases and Oncology Research Institute at the University of Witwatersrand in South Africa. I'm thrilled to have Dr. Rob Breiman on the show today to talk about his career path in global health and ambitious plans ahead. Welcome, Rob.

[00:01:01] Robert Breiman, MD: It's great to be connected with you again. I've always enjoyed the opportunity to work with you and been impressed by all of your accomplishments and the work you've done in Africa and elsewhere.

[00:01:12] Rob Murphy, MD: Thank you, Rob Let's start at the beginning. What drew you into the field of medicine?

[00:01:17] Robert Breiman, MD: So, my path to medicine, it's not your typical path. I certainly didn't start and finish high school and college, expecting that I would have a pathway that would lead me to what I'm doing now. Initially,I wanted to emulate the great lawyer, Clarence Darrow. That's who I wanted to be. He focused a good part of his career on the socially disenfranchised, the impoverished, and trying to address issues of equity. And I sort of envisioned myself as a lawyer who would do that sort of thing. And then many of your listeners won't even know about this history, but somewhere in the middle of my college career, Watergate happened. And, I suddenly had a very acutely different view of what it might mean to be in that sphere. And so I made a very sudden pivot and focused on a different option where I thought I could help people, which was medicine. I mean, this highlights the fact that career paths are often not linear. Initially I admired people who had that kind of tunnel vision where they knew, like in high school, that they wanted to be a surgeon, or something like that. But for me, it took a lot of inputs along the way to get to a point where I knew what I wanted to do.

[00:02:28] Rob Murphy, MD: You pivot to medicine, and you did training in internal medicine and infectious diseases, which of course brings you to sub Saharan Africa and many things of what you're doing now. What was it that turned you into infectious diseases; switched you into that direction?

[00:02:43] Robert Breiman, MD: I had decided out of medical school that I wanted to go into internal medicine. But then during my time as an internal medicine resident, which I loved, got pretty skilled at caring for patients, I realized that in none of the disciplines except one, could you actually completely cure a patient.All of these subspecialties that I was engaged in and I was leaning towards, whether or not it was cardiology or oncology and a variety of others, you manage patients. You could make them feel better, you could help them through their difficulties, but there seldom was an actual cure. But infectious diseases is a little bit like pediatrics in general, in the sense that you can, use your mind, use your intuition, laboratory tests, your ability to synthesize information, and potentially completely cure a patient. So that's what drove me towards ID.

[00:03:36] Rob Murphy, MD: And then, of course, HIV came along.

[00:03:38] Robert Breiman, MD: Yeah, So, I started my ID fellowship in 1983, which was very early in the HIV epidemic, and that did change the construct completely that I had started with because, that was obviously in the pre ART days and suddenly major part of what infectious disease doctors were doing was something that was not curable.

[00:03:57] Rob Murphy, MD: Yeah, when I started my fellowship, there was no outpatient infectious disease activity at all. Everything was just inpatient consults or laboratory stuff. Yeah and certainly changed. All right, so then, we have infectious disease and how did you get into global health?

[00:04:13] Robert Breiman, MD: So I started as a lab rat, actually. So, when I was doing my ID work, I worked in the lab of a very sophisticated molecular immunologist, Marcus Horowitz, a leader in the field at the time who had just come from the Rockefeller. Marcus is still at UCLA doing great work in the area of TB research. So I spent three years in the lab and was doing molecular immunology of Legionella, which was a relatively new pathogen at the time. And Marcus was very well known and skilled, and really it was his effort, not mine, that led us to get a long-term grant that would have supported my continued research in the lab, after my fellowship was over. And so before I've finally committed myself to that, I had been very curious about epidemiology and CDC. I oftentimes would sit with him during lunch. And he had worked at CDC as an EIS officer for a couple of years before he started his lab. And I found that I was much more interested in what he was telling me about outbreak investigations and epidemiologic studies than the reason we were having lunch together most of the time, which was to talk about what gels we had produced and what our next research protocol was going to be. And so at the last moment, I went off and interviewed at CDC for EIS. Just kind of on a lark, just to see what it was all about. And I was interviewed by five people. I got to know all of them very well afterwards. But I remember saying to one of them, so they pay you to do this? Because it just seems so incredibly cool to me. And so when I came back, I was flying back on the plane, I was thinking to myself, Oh my God, I didn't put anything into this. I'm probably not going to be accepted. But then I subsequently was accepted and had some tough conversations with Marcus. It took a few years before he understood that I was going that other direction. But while I was at CDC early on, I was working in respiratory diseases and working primarily on pneumococcal disease, which was before there was PCV, so it was preparing for PCV and we were quite involved in setting up trials for PCV, providing some consultancy in The Gambia and actually also here in South Africa as there was a long-term preparation for that. And that and some work I did in Indonesia that had to do with antimicrobial resistance and training community health workers on recognizing and treating pneumonia with certain antibiotics, where I got kind of hooked on the potential impact of global health. And you know that's where it all came full circle to me, where I realized I had wanted to do this sort of Clarence Darrow like work that I had envisioned back in high school and college, focusing on social injustice and inequities that somehow I was managing to do that kind of work in a very meaningful way, addressing inequities that exist in impoverished settings, in places where people have much less opportunity than they have in the United States. So I basically started doing global health work about 34 years ago now. And my interest hasn't waned. It's Grown and flowered in multiple different directions.

[00:07:20] Rob Murphy, MD: It certainly has. Part of your 26 year career at the CDC, you were Director of CDC Kenya. Then you were head of CDC's Global Disease Detection Division in Nairobi and also director of the National Vaccine Program Office at CDC headquarters. How did you grow into those director levels? Those are big levels, by the way.

[00:07:40] Robert Breiman, MD: Yeah. It's interesting. When you start doing a lot of those things, you don't think you have grown enough. A lot of it is trial by fire. But just to make it clear, I didn't do all those things at the same time. So, you know, what really happened was, I don't know if your listeners are familiar with the Epidemic Intelligence Service at CDC, but it's kind of like a two year fellowship where you get immersed in epidemiology and public health. There's some didactic, but most of it is what you would call on the job training. And I absolutely loved that. That two years was amazing. I investigated probably about eight outbreaks and, you know, led those investigations in multiple locations and had some long term studies. And so at the end of my EIS, I was thinking about going into academia. I was interviewing for positions at Wash U, St. Louis, University of Iowa. Those are my leading candidates. Great people there at the time. But then my supervisor in respiratory diseases, my chief, suddenly decided to leave and took a position in Canada. And so the branch was in upheaval as they were trying to think of how to replace this leader. And ultimately, as they saw that I was about to head off into academia, they offered me that position as chief.  It was a little too quick. I wasn't by any means ready for that, but I grew into it over the subsequent years, and step by step that led to growing into those other positions that you mentioned.

[00:09:03] Rob Murphy, MD: Yeah, the thing that's come out of this podcast and the people that I interviewed, it's a very common theme that the growth in the career was organic. I think that's a very important point for people interested in global health. You don't have to have the entire thing mapped out on day one, you know, it just grows. And as long as you have the passion and have the training, opportunities open up. Let me ask you kind of a more practical personal question, if you don't mind. You've lived outside the United States for a long time. I've met your lovely wife, who I actually worked with also in Kenya. How did your family take to living outside the United States and what were the issues involved there?

[00:09:35] Robert Breiman, MD: So, you mentioned the National Vaccine Program Office. I was fortunate to be its director. The National Vaccine Program Office ended during the Trump administration, the support for it stopped. But prior to that it was the organization that linked all of the vaccine work for essentially all of the U. S. government entities involved with vaccines. So that include NIH, FDA, CDC, USAID, HRSA, and even the Department of Defense. I had an office in multiple locations actually at Washington and also at CDC and was doing policy work that was an incredible amount of fun. So I did that for about five years and well into that time, having a chance to interact at levels that I hadn't before and make a difference, I decided I wanted to get back to research and working in the field. And a position opened up at the world famous, world class International Institute, ICDDRB in Dhaka, Bangladesh. And that time, ICDDRB stood for International Center for Diarrheal Disease Research in Bangladesh. Very famous for developing ORS and also for doing cutting edge cholera work. But it had moved from being a diarrheal research institute to being more like CDC, doing research in all sorts of entities. And they wanted me to come out there seconded from CDC to lead a new  program on infectious diseases and vaccine sciences. I loved the idea of doing that, but I didn't know if my wife would like living in Dhaka, Bangladesh. And so, before accepting the position, Jennifer and I went out and visited Dhaka that spring. At that time, it was the most densely populated country in the world, one of the five poorest countries in the world and just a very challenging place to come to from the United States. My wife fell in love with Dhaka from almost the moment she landed. And she did very meaningful things there. We had four kids at the time. And our kids age range between 5 and 15.And we had no idea if this was going to work at all, but it turned out that it was great for the kids. They loved the school that they were in. They loved the friends that they made out there. That continues to the present time, and what we thought was going to be a really challenging thing for our family ended up being a great thing because by requirement we sort of did everything together. There weren't soccer matches in one part of town and piano lessons in a different part of town, everything seemed to happen around our house. So we ended up having a much closer family time during that period. So I was having a chance to do very meaningful work. And meanwhile, our family was thriving as well. Another thing we have in common actually is that you were once Director of the Global Health Institute at Emory. I'm the Executive Director of the Havey Institute for Global Health at Northwestern. Can you tell me a little bit, when you took that particular position, what were some of your goals for the institute?

[00:12:39] Robert Breiman, MD: Thanks for asking about that. The founding director is Jeff Copeland, who was the Director of CDC between 1998-2001. And he left CDC, initially he spent time at Prudential, but then ultimately ended up at Emory University and Vice President for Global Health. And then he started what's called the EGHI, Emory Global Health Institute. After six or seven years, he was looking to move off that position as being director and recruited me to come. And my interest at that time was very much like what I think you're interested in, Rob, which was to build sort of a next generation of global health scholars, leaders, scientists, also to think about ways to do global health from wealthier, equitable and fair countries where that work is being done so to ensure that team science occurs and that leadership and control is not one sided. EGHI was an opportunity to do that sort of thing and raise consciousness about global health in students. I'm sure at Northwestern, like is in Emory, there was already a great deal of interest in global health among undergraduate students.

[00:13:48] Rob Murphy, MD: Oh yeah, we have the same.

[00:13:49] Robert Breiman, MD: You know, the master's program, there's quite a substantial number of students who choose that as their emphasis.

[00:13:56] Rob Murphy, MD: Research has always been central to your career and you've been principal investigator on many projects. You've studied child mortality, COVID 19 vaccine messaging, typhoid fever, and more. Can you tell me just a little bit how your research has evolved over time?

[00:14:14] Robert Breiman, MD: I started off with a clear focus on respiratory diseases because that's what I had done during my ID fellowship. And when I went to CDC, I was in the respiratory diseases group, and it was very natural for me to focus on the epidemiology of especially bacterial respiratory infections. And that, again, led me to working in global arenas, especially around pneumococcal disease and vaccines. But as I got more involved with global health, issues arise depending on where you're working. They're different than what your expertise is. So when I was in Bangladesh, it was like the home at the time, especially in the population based areas we were working of typhoid fever. So, I knew nothing about typhoid fever when I went to Dhaka. But we discovered that the incidents of typhoid, especially in children under 5 all the way up to 10, was such that about one in five children would have typhoid fever by the time they reached 10 years of age. It's an incredible figure if you think about it, because if a couple of cases was to occur in Chicago, that would probably be headline news. Because it wouldn't be accepted, and yet this was entirely accepted in that setting. So I got involved with that. Also, we ended up having these major outbreaks of Nipah virus encephalitis in Bangladesh when I was there. In fact, the first outbreak, originally it had been in Malaysia, you know, in Singapore back in the late 90's and then in 2001, the first outbreak of Nipah in Bangladesh occurred and there have been many, many occurring in what is now the Nipah belt of South Asia, mostly in Bangladesh. And so I got very deeply involved in Nipah. Again, I would have had no idea that that was going to happen before I went there. So sometimes you have to address the issues that are right in front of you and establish the partnerships and collaborations and build the expertise and the skills necessary to fill knowledge gaps and make some progress.

[00:16:07] Rob Murphy, MD: I guess you could say the same thing about COVID There were very few coronavirus experts in the world. I mean, there was a little blip with SARS, and then there was MERS, and then, there was still no interest in coronaviruses, and then everybody was asked to really pivot, including yourself and myself as well in the diagnostics area to focus on that. It's a great example how career growth, research interests, really are organic, and your skills that you already had just had set you up perfectly to address these new, very important diseases.

[00:16:39] Robert Breiman, MD: Yeah, I am an internal medicine guy, but most of the things I've focused on since I've gotten involved in global health has been child health. And Nipah had its greatest impact when I was there on children with like 85 percent mortality, and for those that survived no one survived without neurologic sequelae. And then in a whole set of other areas that I've worked in, they've been on essentially preventing severe childhood disease and mortality, and that ultimately all came together towards the end of the time that I was at Emory working with a very generous and substantial funding from the Gates Foundation to study the actual specific causes of childhood mortality in Sub Saharan Africa and South Asia, where the vast majority of under five deaths occur. And, you know, up until this project occurred, which is called CHAMPS, Child Health and Mortality Prevention Surveillance Network, most of the information about what's killing kids came from verbal autopsies. You know, these post mortem questionnaires of mothers or parents of children who have died, which you can imagine, are very nonspecific and don't give you a target if you want to reduce childhood mortality. But these post mortem studies now that involve minimally invasive tissue sampling and then elaborate and sophisticated testing in the lab, has really shined a very bright light on the causes of death in children under five, and that is already leading to pivots in terms of how to prevent the childhood mortality. So you're asking how it all, what it all led to. I think ultimately all these individual, highly focused areas led to this broad initiative to understand the major causes of death in children through CHAMPS and that's how it all came together for me.

[00:18:25] Rob Murphy, MD: Oh, it's fascinating. You're now focusing on studying the link between infectious diseases and cancer at a new institute at Witwatersrand. Let's talk about the strong correlation between infections and certain cancers. How'd you get into this position and what do you know about it now?

[00:18:40] Robert Breiman, MD: Yeah. So you know, when you and I were early in our training,if either of us back, let's say in the early 80s had stood up in a meeting in a crowd of clinicians and said, Hey, I think we could prevent the scourge of cervical cancer with a vaccine against some virus, I think we would have been thrown out on our heads.

[00:19:02] Rob Murphy, MD:  We would have been sent to the nearest mental ward, I can tell you that.

[00:19:06] Robert Breiman, MD: Right. And it was just not fathomable. And it turns out, as you know, that maybe up to 99 percent of cervical cancers are due to various serotypes of human papillomavirus. And that work was led by a German scientist named Harald Zurhausen, who ultimately won the Nobel Prize for that. But he went through a decade of resistance and then oftentimes ridiculed about this. And now we're at a point where WHO is pushing to eliminate cervical cancer, as a public health problem through better use of HPV vaccine. And you know, there are other examples. The first really was Burkitt's and EBV. But then, there's bladder cancer and schisto and then gastric cancer and helicobacter pylori, but there's plenty of evidence out there that more cancers, more oncogenesis is triggered by microbes, whether they be viruses or bacteria or potentially microbiota, you know, with a certain type of presence or diversity that increases the risk for cancer. And this is sort of consistent with these other global health themes that you know so well and I think has driven a lot of your career. Cancer is another one of these examples in Africa where it's not that the incidence is massively greater, but the mortality to incidence ratio is much, much higher. And that's because of poor access to care, but importantly, poor access to early diagnostics and to preventatives, but importantly to therapy. You're not going to get chemotherapies that are really changing the game for cancer in the United States. You're not going to get those kinds of things here for probably decades, unless there's a changing construct. But again, you could prevent cervical cancer just as well in Luanda as you can in Beverly Hills. And so we think one way to level that playing field is to find more of these associations where you eliminate or reduce the risk of cancer at its trigger. And when I was asked by the Dean here, and lead this new institute, at first I thought it was a little crazy actually, but the more I thought about it, the more I talked about it with him and then with the others, I realized it's a tremendous opportunity. There's not a lot of institutes out there that are trying to do that, and we think we're in the right place. By the way, in the past, up until the recent time, most heavily funded research was led in the United States or in Europe, but involved doing work globally. I'm talking about global health research. And there is a movement, as I know, your global health institute, I think, is very involved in, in what is called decolonizing global health or also this concept of more fairness in the way research is carried out or the research fairness initiative. And there's a change in the way that funding's occurring. I think that this is the right time to build an institute like this, right where the problem's happening, and that should lead to funding that could be pivotal. Direct funding into VITS, which has world class scientists and can do a lot of this work well with that type of funding. That's the kind of thing we're hoping it will be a perfect storm and that everything will come together nicely for.

[00:22:08] Rob Murphy, MD: And that really involves in a big way strengthening scientific capacity in Africa and other low and middle income countries. Can you focus just a little bit on that component of the Institute's work and what you're doing in that area?

[00:22:22] Robert Breiman, MD: Yeah, it's a big thing for us. We have three major objectives and a very big one is to build the next generation of scientific leaders in Africa. We're based at the University of Witwatersrand in Johannesburg. But, the way we describe our work is with hubs throughout Sub Saharan Africa. And we are working with collaborators now in Rwanda and Uganda, as an example, to build a coalition to train scientists on skills related to epidemiology and laboratory skills that are core to this infectious disease and oncology work. And we're building collaborations elsewhere in Africa to do that. Looking for funding, there are funders out there that share this vision to build that kind of capacity and make it sustainable. You know, we're writing a lot of research funding proposals to do that.

[00:23:12] Rob Murphy, MD: It's really fascinating what you're doing with this new institute. I hope we really can collaborate with you in the future. We've got a quite a big program at Stellenbosch University and are starting our own kind of hub there, and I'm sure we can collaborate. We're already working on one grant together, as you know. And then my final question to you for today's podcast is very general question. What advice do you have for young people listening who are just now embarking on a career in global health?

[00:23:42] Robert Breiman, MD: It's a pivotal time to be asking that question because it's a very different environment if you're coming from the United States to do global health now than it was when you and I got started in this field. So more than ever, you really have to think about the unique role that you may have coming from, let's say, an academic institute in the United States, or maybe from an NGO, or maybe some of early career folks end up at places like USAID or CDC And there's a lot more listening that has to happen now, and you know, willingness to allow others to lead, and figuring out how you can add maybe perspective and then bring in technical expertise that may not exist. And then again, what was the case for instance, when I started the construct was, you come up with the idea, you help to make sure a study gets done, you lead the analysis, writing up of the results and you publish it, maybe with some local authors. During the time I was based in Kenya, we forcefully changed that so that the leadership was facilitated so that it was local and that we figured out how we could add. But It's more important now than ever to understand how you want to contribute. And oftentimes I hear people say this,and I really agree with it. If the reason to go into global health is to address inequities, which I think it is for most people who get into this field, there are plenty of inequities in the United States that need to be addressed. And so I often think that the right place to start is looking at those issues right in the homeland and understanding what you can do about some of those things and then come prepared with special skills when you work in the global health arena.

[00:25:34] Rob Murphy, MD: Yeah, we certainly learned that lesson about the capacity development during the height of COVID, in that our programs didn't stop, and I was very proud of the work we've done in developing the capacity, it's so encouraging to see. We've got a lot more work to do, obviously, but that's definitely the way to go. And thank you very much for that answer, because I think you're spot on. Thank you, Rob, again, for sharing this time with us and for your insights in career development and all the projects that you're working on, and I'm sure we'll be working together in the future.

[00:26:08] Robert Breiman, MD: You are such a fun guy to talk to, Rob. I'm really thrilled that I had the chance to be on this podcast.

[00:26:14] Rob Murphy, MD: Follow us on Apple Podcasts or wherever you listen to podcasts to hear the latest episodes and join our community that is dedicated to making a lasting positive impact on global health.