Lessons Learned from Pandemics with Carlos del Rio, MD

• Del Rio comes from a long line of physicians in Mexico. He attended Emory University for his residency, thinking he wanted to be a cardiologist. However, the AIDS epidemic broke out at the same time, and it was then that he felt a calling toward infectious diseases and public health. 
• Eventually, he returned to Mexico to work for the National AIDS Program where he became involved with both treatment and policy-making in Mexico around HIV-AIDS, learning public health on the ground. 
• After being hired as a professor at Emory University,  del Rio began building a foundation for himself in both research funding and developing international collaborations with countries like the former Republic of Georgia, Rwanda, Zambia, Kenya, and Thailand.
• According to del Rio, PEPFAR, or the President's Emergency Plan for AIDS Relief, is the most successful public health program that the U.S. has ever implemented globally.
• He served as a member of the WHO and CDC advisory teams during both the influenza H1N1 pandemic and the COVID-19 pandemic.
• During the COVID-19 pandemic, del Rio made a total of 391 national media appearances and 120 local media appearances, a challenging experience. 
• Reflecting on lessons learned, del Rio shares the HIV epidemic demonstrated the importance of involving and listening to the communities one is trying to help. He also discusses the integral relationship between science and policy as well as the importance of global health equity in response to pandemics. 
• del Rio is the recipient of the Ohtli Award, one of the highest honors given by the government of Mexico, and was publicly recognized by Georgia Senator John Ossoff for his research and leadership.
• For young people interested in pursuing global public health, del Rio discusses the value of humility, the necessity of supporting communities in achieving success on their own, and the power of developing meaningful personal relationships.

[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. The Havey Institute for Global Health at Northwestern University recently hosted our 2023 Global Health Day, which featured a World AIDS Day panel, as it was on December 1st, a poster session, and a keynote address from today's guest, Dr. Carlos Del Rio. His very well received address entitled "Lessons from the HIV Epidemic Applicable to Future Pandemics," gave us a glimpse into his career as a physician scientist who has conducted research, led policy development, and disseminated scientific findings through countless media appearances regarding public global health crises, such as COVID-19 and HIV prevention. Today, we're going to dig a little deeper into his career in global health and choices he made to land where he is today. He's the Leon L. Haley, Jr. MD, Distinguished Professor of Medicine and Interim Dean at Emory University School of Medicine, as well as Professor of Epidemiology and Global Health at the Rollins School of Public Health, also at Emory, and Interim Chief Academic Officer for Emory HealthCare. Welcome Carlos.

[00:01:28] Carlos del Rio, MD: Happy to be with you, Rob.

[00:01:30] Rob Murphy, MD: You come from a long family lineage of physicians and pharmacists in Mexico. Can you tell me a little bit about your background and how your family influenced your decision to become a doctor?

[00:01:41] Carlos del Rio, MD: You know, it's hard to know exactly when I decided that I wanted to go into medicine, but I can tell you that I was always interested in science and, like for many people, reading books made a big difference. And for me, Microbe Hunters is, like for many other people, is a book that really got me excited about medicine and infectious disease. I started to express an interest in medicine when I was in high school. And then, you know, between high school and college/medical school -- in Mexico, you go directly from high school to medical school in a six year program. I spent time with a cousin of my dad, a second cousin of my dad, who's a practicing pathologist in Houston. And I spent a summer working with them in their lab and, you know, looking at slides and getting involved in autopsies and I really thought it was really fascinating. So I thought I was going to become a pathologist. I really thought it was really cool to do that. But then during medical school, some of my best mentors were cardiologists. I was very impressed with the cardiologists. I love the physiology. I love the physical findings, et cetera. So I actually came to Emory for residency, primarily because I wanted to be a cardiologist. I wanted to work with J. Willis Hurst, who was then the Department of Medicine Chair here at Emory, and my goal was to be a cardiologist, but, you know, I started my residency in July of 1983, and as a resident of Internal Medicine, hoping to be a cardiologist, but at the same time, a new epidemic was starting, as you and I know, you know, the HIV AIDS epidemic was beginning to be described and beginning to be talked about, and it was also happening right next door to me in the Center for Disease Control. So I really became fascinated by this disease. I became fascinated by the science, what was happening. And I think something that really also got me excited was, you know, it felt a little bit of a calling. There were people my age who were sick, who were dying. They looked like me, and really that led to me ditching my interest in cardiology and becoming interested in infectious disease. Clearly mentors were important. I spent part of my residency at Hopkins and John Bartlett was critically important, but there was also here at Emory a guy named Sam Thompson who was very important David Rimbland and other people that really became very important in teaching me, not only infectious disease, but really teaching me HIV, at a time where we didn't have antiretroviral therapy, right, at a time that, that our tools were very limited and were limited to taking care of people and to really being compassionate and caring. And I think learning a lot about the care of the patient. So I finished my resident, my fellowship in infectious disease here at Emory in 1989, and I wanted to go into public health, so I applied to CDC, to the EIS program, and got accepted, but because of my visa situation, I was not able to take that position in the United States Public Health Corps, so I was trying to decide what to do, and decided to go to Mexico and I started to work there, initially in prior practice, but later very quickly starting to get involved in the national AIDS program, and working closely with a friend of mine who was the Undersecretary of Health, Dr. Jaime Sepulveda. I think that's when I started to become interested in global health and I learned that I didn't go into global health; global health found me. And that's how I realized how critical it was to work with communities, to work with others, to understand what really global health is all about, but I never really thought it was going to be somebody working in global health.

[00:04:48] Rob Murphy, MD: There really was no such entity. I mean, there was tropical medicine. and that was primarily people involved in laboratory diagnostics for, you know, unusual tropical diseases. But yeah, there was no, like, global health. Nobody did foreign rotations. Yeah, it was a very different time. You received your medical degree from La Salle University in Mexico City. As you mentioned, you did your residency and fellowship at Emory, and then you went back to Mexico to work as executive director of CONASIDA, the agency of the Mexican government responsible for AIDS policy. Can you tell me about the decision you had after finishing your residency to return to Mexico and to get into the policy part of the AIDS epidemic?

[00:05:31] Carlos del Rio, MD: Part of it, as I said, had to do with the fact that I couldn't stay in this country because of my visa, so I was going to Mexico for two years, but then, you know, this opportunity to work at the National AIDS Program emerged from a sort of a conversation I had with Jaime Sepúlveda, who was then Undersecretary of Health, and I would be working with him, and really, Jaime offered me the job saying, look, you know, you have a lot of clinical experience seeing patients with AIDS, you know, the clinical experience is going to shape policy. So, first of all, I was allowed as a government employee to also continue my practice because I said it's going to be critically important for me to see what happens to the patients and what happens in real life. But second, I started to work with people who, you know, was very focused on prevention and very focused on developing recommendations and policies. But again, this was, you know, I started doing this in 1991, there was really very little as far as treatment. But then, we had an HIV diagnostic center. And we started setting up HIV testing centers throughout the country, and pretty soon it became clear that we also had to do something with people who were diagnosed as living with HIV. So we started doing antiretroviral therapy, and by the time 1996 rolled around and Indinavir appeared, we were really the first place outside the U. S. that actually started using Indinavir. And I remember, you know, incredibly like it was yesterday. How amazing thing was that people where they were near death, all of a sudden they were turning around. So it became really.. I learned on the job. Nobody taught me how to do government employment or public health or anything like that. I had no training in that. So a lot of it was peer to peer mentoring. People I was working with, I learned a lot from them, is being always trying to learn something. When I had opportunities to do other things. I mean, I remember when Mexico had the opportunity to become a member of the Global AIDS Program Coordinating Body of WHO uh, I applied, and I got elected to that, and I did that. And that eventually led to me being one of the persons that was involved in launching UNAIDS and, you know, my relationship with people like Jonathan Mann, Mike Merson, Peter Piot, really goes back to those early years of the global response to HIV. And I say that Jonathan, who has now died, unfortunately died in that SwissAir crash, but Mike Merson and Peter continued to provide me with career advice, with mentorship, and of course, with friendship.

[00:07:43]Rob Murphy, MD:  In 1996, you joined Emory University as faculty, and you've been there for 27 years and counting. Can you tell me about when you first joined the faculty there, what made you decide to return to Emory and start working in the U. S. and later becoming a citizen as well?

[00:07:56] Carlos del Rio, MD: Part of it was, looking for different opportunities and wanted to do something different. There had just been 1994, 95, 96, there had just been an election in Mexico and, you know, we went through a significant economic crisis, the National AIDS Program got slaughtered to really a small portion of what it was. And it was really a tough time to be in the government. So I started to look for other opportunities. And then in different discussions, talking to Jim Kern here at Emory, was now the Dean of the School of Public Health, Jim said, why don't you come join us at Emory. So really they created a job for me at Emory. And again, as you mentioned, my job initially was to be the director of the inpatient HIV service. I had not had really a research career, right? I hadn't never written a grant. I'd never written a K, but I was also told, you know, you got to start developing a research career and you've got to start developing a funded research career. So that led me to get involved in two important programs. Number one, you know, in 1997, 98, I wrote our CFAR grant, and I got it funded. And then I wrote an AITRP, an AIDS training grant, and I got that funded. And I think those two grants really started to define my career path in global HIV. And Istarted to develop international collaborations beyond Mexico. I started to work in the former Republic of Georgia, in Rwanda, in Zambia, and in Kenya, and in Thailand, and, you know, started working really in multiple countries as a result of those interactions and working with different faculty and colleagues. So I also started a much more robust career in global health at that point in time.

[00:09:23] Rob Murphy, MD: You mentioned AITRP, the AIDS International Training and Research Program funded by the Fogarty International Center. Carlos has had quite a success in running those grants and the successors to those grants. We actually both worked together on the PEPFAR program. So PEPFAR stands for the President's Emergency Plan for AIDS Relief. That's such a huge and important program. Can you share with our audience the role you played in PEPFAR?

[00:09:49] Carlos del Rio, MD: PEPFAR was a critically important program to get off the ground, right? And I remember when, you know, Tony Fauci, Mark Dybul, and many other people were having the initial conversations and then how that program got launched by President, George W. Bush. And there was a lot of skepticism, and then, you know, at that point in time, I was having a lot of discussions with our Colleagues here at CDC. This was starting something that was focused on treatment, right? The global efforts up to that point, including major successful global efforts like the eradication of smallpox, were preventative programs. There had never been a treatment program. And that's why I say that, as Alan Brandt wrote in a study in a perspective in the New England Journal of Medicine some years ago, you know, the HIV epidemic and through PEPFAR is really what invented global health, right? If it hadn't been for that, there would be no global health movement. As you say, there was international health, there was tropical medicine, but global health incorporates care, incorporates treatment into public health. And that was a totally new thing, right? And a lot of people had skepticism that this would ever function, that this would ever be successful. And what has happened since then is that PEPFAR has been In my mind, the most successful program that the U.S has ever implemented globally. This has saved millions of lives, has really helped build health systems, information systems, and so many things that have been positive beyond HIV, right? The response, the global response to the COVID pandemic would have been much worse had we not had the infrastructure that PEPFAR built in places like Africa.

[00:11:14] Rob Murphy, MD: And nobody thought it was going to work.

[00:11:16] Carlos del Rio, MD: Nobody thought it was going to work. But it was also a very different type of grant, right? It wasn't a research grant. It was an implementation grant. Again, it was critical to develop partners. And I think one of the things that, when I talk to young people about global health and I said, you know, what kind of advice can you give us? One of the things is to listen to the local people, take them seriously. Treat them as equal partners, work with them, because that's how you become successful. PEPFAR really has become successful because it has developed those local partnerships that now, over the years, are actually taking over the clinics and taking over the funding. but through PEPFAR I've been involved in what's called the MEPI program, Medical Educational Partnership Initiative, but my current role at PEPFAR for the last 10 years has been To be a member of the PEPFAR Scientific Advisory Board, and I have chaired the PEPFAR SAB for the last 10 years. Again, PEPFAR is informed by science and data and really has allowed PEPFAR to really have an amazing group of scientists both from the US and globally, who are really looking at the data and forming the programs and really challenging the PEPFAR leadership to do things that otherwise they would have not done, had there not been the science to support it.

[00:12:19] Rob Murphy, MD: You've been the co-director for the Emory Center for AIDS Research, CFAR since 2005. Can you tell me what you've been doing there and how you shaped the AIDS research and clinical care at Emory?

[00:12:32] Carlos del Rio, MD: CFAR, Center for AIDS Research Grants, are NIH funded grants that really are there to provide infrastructure to do the things that typical R01s and other NIH funded programs cannot do. So we've done several things with our CFAR grant. Number one, we built infrastructure for, you know, collecting specimens and storing specimens and facilitating clinical trials and enrollment in studies like ACTG and HPTN and HVTN and, you know, and then helped a lot in recruitment of scientists and in developing scientists. I think that one of the things that CFAR has done incredibly well is really developed young scientists and develop a cadre of investigators to become the next leaders in the field. And it's really fantastic to see how our developmental awardees have become successful, become R01 funded and now become the leaders that are following going forward. I think the CFAR really has been, it's one of those glues that brings everybody together, that allows investigators to do more than they would do on their own, and to really share the knowledge and develop those multidisciplinary teams that otherwise would have never happened.

[00:13:34] Rob Murphy, MD: You've been involved in the CFAR. You've been involved with PEPFAR. You've also served as a member of the WHO and CDC advisory teams during the influenza H1N1 pandemic and the COVID-19 pandemic. What did you contribute to those teams and how did you manage being involved with those teams, plus your role at Emory.

[00:13:55] Carlos del Rio, MD: Well, you know, during the 2009 influenza pandemic, you have to remember that first of all, the disease was first detected in the border of the U. S., Mexico, right? And Mexico was a site that it started, so I was very involved from the very beginning in going down to Mexico and talking to people there, and really becoming a conduit of communication between the Mexican government and the U. S. government and CDC and what was going on. And then, I served in an advisory capacity to CDC and trying to do the response and to think about how to do a global response and we learned a lot from that pandemic, but obviously that pandemic was, you know, quite frankly, kids play compared to what followed, right? COVID, I don't think none of us would have ever suspected... I mean, COVID became our jobs and, you know, when people frequently ask me do you want COVID to end? I said look what I want is my job back. Our HIV research our clinical trials unit became a COVID treatment and vaccine studies unit. Really we all became COVID investigators, COVID scientists, and we work, you know, 24/7. And because of my expertise and a lot of circumstances, I started to do a lot of advising, both locally and nationally, and really trying to shape the response. And I tell you one thing that I think we learned in COVID, and I think we need to continue to remind ourselves is the importance of humility, right? I mean, I tell people that the most important words I learned in COVID is, I don't know. How frequently do we have to say we don't know, but again, science gave us the answers. We don't know, but this is the studies we're doing to give us a response. This is the things that are happening in science. And the way that science has really transformed the response was really amazing. And that's why, to me, sort of the way that science has lost this luster and its recognition and positioning in society. It worries me because the reality is is science is critical in getting outta problems.

[00:15:42] Rob Murphy, MD: Also, the pandemic involved a lot of media.

 and we both were involved in a lot of media presentations and that wasn't the easiest thing. How did you deal with all that?

[00:15:55] Carlos del Rio, MD: I've always been interested in media and I actually have been trained on media. So I had been doing it regularly

. I've done things with media, even during the 2009 pandemic of influenza. I was very involved with being in the media and working with CNN and others, but COVID took it to a different level. Just to give you an idea, my first COVID media appearance was in January. I was down in Miami and CNN Espanol called me and said, could you comment on this disease? It was January of 2020. So it was very early on. And from then on, I did a ton. I mean,between March and November or December of 2020, I did a total of 391 national media appearances and 120 local media appearances. So, it was tough because frequently I got attacked. Almost immediately after a media appearance, especially late in 2020 and throughout 2021, I could almost guarantee that I would get an email, a hate email, or one or more hate emails. So sometimes the media appearance is a tough thing. It wasn't doing the media appearance, it was dealing with the follow up of the media appearance.

[00:16:58] Rob Murphy, MD: You really get some thick skin because of those experiences.

[00:17:03] Carlos del Rio, MD: It was negative pushback, and there was negative comments, but there were also very positive ones, and many people were thankful, and many people appreciated that you were doing this, so I think it makes a big difference that, to have that, right?

[00:17:14] Rob Murphy, MD: Oh, yeah, you definitely have both sides it wasn't all bad.and just like you, Carlos I figured, you know, this is a once in a lifetime experience where public health people who aren't afraid of being in the media really can have a positive impact.

[00:17:28] Carlos del Rio, MD: Absolutely.

[00:17:29] Rob Murphy, MD: Carlos you joined us on campus on December 1st for our annual Global Health Day, as I mentioned which also happened to be World AIDS Day, and you were our keynote speaker, fabulous speaker, by the way and you shared lessons from the HIV epidemic and how those lessons can be applied to future pandemics. Can you tell me about your research and what you shared with our campus community and how you intertwined those pandemics.

[00:17:54] Carlos del Rio, MD: I think the HIV epidemic has shown us a lot of things, but one of the things that you and I know really well is that the HIV epidemic really taught us the importance of involving the community, affected community, and listening to the community. So I think, working with community, listening to community, making community part of the solution, I think is critically important. Number two is how science informs policy, right? How, as we advance the science, we change the policy, and that has happened in HIV. You know, we went from saying we don't recommend breastfeeding to saying, Hey, now you can breastfeed because you're virologically suppressed. So we change policy as we advance science, and I think, we saw that play at very fast speed in COVID, but we've done it in HIV for a long time. Science has changed, and it's not that we were wrong before. It's like the science changes and we have new information and we change policies. The third one is the importance of global health equity, right? As we talked about PEPFAR, HIV is the only disease for which most of the treatment is where most of the burden of disease is. And global health equity has always been at the center of the HIV response. And equity needs to be at the center of the response to any pandemic. And then is the importance of data to guide science, right? Data has been critical in the HIV response. It has allowed us to know where to do testing, where to implement programs, how to do prevention. And data and surveillance and detection has to be part of the response to a pandemic. And then finally, there's the approach that we learned in HIV very early on. Well, it took a while to figure that out, but the importance of harm reduction approach, you know, telling people say no to sex has not been very effective in preventing HIV. But there's harm reduction approaches to drug use and to HIV transmission. And using a harm reduction frame of mind in approaching pandemics, I think it's going to be very important. Telling people, don't do this, or you have to do this, or you have to do that doesn't work. You need to give people options, and options are very important. And a harm reduction approach is really the way to go.

[00:19:43] Rob Murphy, MD: Couldn't agree with you more about that. Just kind of wrapping up here a little bit. You received the Ohtli Award in 2016 is one of the highest honors given by the government of Mexico. Last year you were recognized by Georgia Senator John Ossoff for your research and leadership. You were recognized actually officially in the congressional record. Can you tell me a little bit about these awards and what those awards meant to you?

[00:20:07] Carlos del Rio, MD: They're incredibly humbling and important awards, right, because the reality is that there's nothing better than when what you do leads to recognition by political leaders The Ohtli Award is an award given by the government of Mexico for people who have worked in the benefit of Mexican communities and outside of Mexico. And that work has nothing to do with HIV. When I was chief of medicine at Grady, you know, there's a lot of Mexicans working in construction industry and other industries that they can get injured and working on helping repatriation, helping those people that had been severely injured get their families up here, really trying to do the kind of humane treatment of those individuals, I think, was really very important, and that's what it was recognized with that award that I really feel, you know, very, very honored by being recognized by Senator also being recognized, you know, by Atlanta Mayor Keishon Lance Bottoms for my work here in the city. Again, it really shows that there's politicians that have noticed that you're doing this work and, you know, a lot of this work is, as you and I know, people would ask people, how much you paid for this COVID advising you're doing here and there, but like, you're not paying nothing, you're doing it because it's the right thing to do, and I think that, again, at the end of the day, we all want to have an impact and to be recognized for having an impact that makes a big difference, right?

[00:21:20] Rob Murphy, MD: Oh, absolutely. I've got one more question. I asked this of every person that comes on this podcast. Can you tell me what advice do you have for young people who are listening, who are just now embarking on a career and are considering global health?

[00:21:35] Carlos del Rio, MD: Well, Rob, the first thing is I tell people to listen, to work as partners with your collaborators globally, right? You're not there to teach them, you're there to work with them and you're going to learn as much as you can teach people. So, we sometimes go into a place and we think we know it all and the reality is that we don't. And I think learning, that is very important. Number two is help them be successful, you know, encourage them to be successful. Many years ago, I was talking to Warren Johnson who was, you know, the Chief of Infectious Disease at Cornell. We were at an international site through our NIH sponsored visit, and I was talking to Warren. I said, Warren, how will I know when I've been successful with an international side, with an international collaborator. And he says the moment that they can write papers and write grants without you being a co author, that's when you've been successful. So you gotta let them grow. You gotta let them be successful on their own. You, you cannot, it's like you're trainees. You need to help them be successful. Number three is that develop personal relationships. You know, one of the things that I enjoy about the global health work that we do is that it's not just working on the science. It's really develop personal connections with people, knowing their families, going to their homes, getting to know the local culture, the local food. All that is incredibly important. You develop friendships, you develop trusted relationships. And then finally is to have fun and don't take yourself too seriously. You know, there's going to be failures, there's going to be bumps in the road, and you make the best out of them, and you learn as you go. and again, don't take yourself too seriously. This is not about you. This is about really making a difference and making an impact.

[00:23:03] Rob Murphy, MD: Carlos, that's a great answer and great advice. I can't thank you enough for joining us today and thank you very much.

[00:23:10] Carlos del Rio, MD: Pleasure being with you, Rob.

[00:23:15] 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.