Global Health Leadership and Communicable and Emerging Infectious Diseases with Claudia Hawkins, MD

• A native the UK, Dr. Hawkins set her sights on the U.S. after medical school because she was interested in HIV research and care during the height of the HIV pandemic and she found opportunities in Detroit and later at Northwestern University, where she completed an infectious disease fellowship under the direction of Dr. Murphy.
• Global health work was a priority for Hawkins after a transformative medical school experience in Zimbabwe where she witnessed the devastating impact of HIV there and the lack of global recognition of its toll at the time.
• Soon after embarking on her career in infectious disease and global health, Dr. Hawkins zeroed in on researching the prevalence and impact of HIV and hepatitis B co-infection in Tanzania and Nigeria. She published some of the first data on the prevalence of hepatitis B and C co-infection in HIV infected populations in these countries, as well as the effect of viral co-infection on liver disease progression itself and death. 
• Mentorship has been critical to her own success and Dr. Hawkins now runs programs focused on training young scientists in resource-limited settings and empowering them to lead impactful research projects in their own communities.
• Dr. Hawkins describes her leadership role at the Institute in bringing faculty together for global health research, emphasizing projects on HIV prevention, viral hepatitis, malaria, and emerging infectious diseases. For any students and young professionals interested in global health, she emphasizes the importance of seeking mentors, joining interest groups and attending global health events.

[00:00:00] Dr. Rob Murphy: 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.Today's guest, Dr. Claudia Hawkins, Professor of Medicine in the Division of Infectious Diseases at Northwestern University Feinberg School of Medicine, is a leader here at the Havey Institute for Global Health, where she's the Director of our Center for Global Communicable and Emerging Infectious Diseases, where she supports more than 125 Northwestern faculty and trainees doing important work in HIV, AIDS, tuberculosis, viral hepatitis, and other devastating, communicable, and emerging infectious diseases. Her own expertise includes HIV and viral hepatitis co infection. We welcome her to the show today to learn more about her path to global health and how she is making a lasting impact on the understanding and treatment of infectious diseases around the world. Welcome, Claudia.

[00:01:05] Dr. Claudia Hawkins: Thank you, and it's great to be here.

[00:01:07] Dr. Rob Murphy: Our listeners may detect a bit of an accent. You originally came from the United Kingdom, receiving your medical degree from the University of Southampton, before moving to the U. S. to further your training in internal medicine, infectious diseases, and global health. Tell me a bit more about your early years in the U. K., and was the U. S. always an academic destination for you? How'd you end up in the U.S.?

[00:01:29] Dr. Claudia Hawkins: I don't think I was necessarily intending to, end up in the U. S. for my medical career, but sometime during medical school I developed a pretty keen interest in infectious diseases and particularly HIV, which was in its peak in terms of diagnoses and deaths during my training, and I'd already heard about many of the advances in HIV treatment and care in the US, which were probably a bit further along at that point than in the UK so I was to really experience and learn more in another setting. And in the US as well, the infectious disease field in general seemed to offer a lot more opportunities for both research and practice, which I was interested in at that stage. I guess I probably thought I was going to go back at some point, but here I still am in Chicago.

[00:02:10] Dr. Rob Murphy: I understand in the UK that there really is no infectious diseases subspecialty or specialty training. It's kind of mixed in with uh, other disciplines. Can you comment on that?

[00:02:22] Dr. Claudia Hawkins: So yeah, so at the time I was training, infectious diseases wasn't really a clearly defined speciality like it was in the US. In the UK, if you were interested in ID, at least at that time, your career path was much more likely to be in medical microbiology where you'd combine clinical practice with a lot of lab work. And I don't know that I was totally cut out for that. So while I was taking my U. S. medical licensing exams, I had the opportunity to observe an I. D. practice at the Cleveland Clinic and see how the infectious disease speciality worked there and, and well, pretty much after that I was hooked.

[00:02:55] Dr. Rob Murphy: You did your internal medicine residency at the Henry Ford Health System in Detroit and then came to Northwestern for a fellowship in infectious diseases. First, tell us how you ended up in Detroit. For your training, and then, what was it about infectious diseases that drew you to Northwestern and Chicago?

[00:03:14] Dr. Claudia Hawkins: So yeah, so I ended up in Detroit partly as a result of my now husband who was working there at the time and partly obviously because of the interest I had in furthering my career in the U. S. So I interviewed at a few internal medicine residency programs and really liked Henry Ford where I ended up matching and residency for me was really a life changing experience.I worked with some incredible co residents from all over the world, connected with patients from many different diverse backgrounds than I was used to, UK and then managed, some of the Interesting pathologies saw some of the coolest cases. So during my residency, I continued to follow my passion for infectious diseases and tried to do as many ID rotations as I could and get involved in infectious disease research and then worked in an HIV clinic as well.And when I started looking for fellowships in infectious diseases, what I really wanted to find was a program with a lot of research and clinical opportunities in HIV, and something in an institution that served similar populations and communities and to what I was used to in my residency. And I was also interested in a program that offered opportunities to practice global health, having had some experience working in global health settings as a medical student.And as I recall, when I was looking at programs in Chicago, I came across your name and read about your work in Nigeria and called you up and said, Hey, I really want to work with you. Are you interested in taking me on as a fellow

[00:04:27] Dr. Rob Murphy: And I gave you a piece of paper and said, sign right here, we were really actively trying to recruit people interested in doing exactly what you wanted to do. So, I mean, it was just a perfect fit for infectious diseases plus the global aspect. Cause not everybody, not every American anyway, back then was really willing to do. Get up and go live in Sub Saharan Africa. And you'd already been there. Maybe it'll come out a little bit more in the next question I'm going to ask you. Was there a certain opportunity or experience you can point to that first sparked your interest in global health?

[00:05:01] Dr. Claudia Hawkins: So I had spent some of my time, growing up overseas, but what really sparked my interest in global health was an opportunity I had to go and observe alongside an infectious diseases physician at the Perinatawa Hospital in Harare, Zimbabwe as a med student.And I was there right at the end of the nineties when HIV related, and mortality was at its peak in sub Saharan Africa, but very little of this was recognized by the outside world. And just about every day we saw all about half of the admissions we saw every day were about HIV related.Most persons were presenting with very advanced HIV, things like severe wasting, opportunistic infections such as TB and Kaposi's and other infections that. We just didn't have the tools to diagnose. Most patients unfortunately died before leaving the hospital and there were no medications available at that time and remember, this was well before the establishment of any sort of HIV programs in country and well before. The U. S. president's emergency plan for AIDS relief PEPFAR, and the rollout of widespread treatment. So witnessing firsthand this huge toll HIV was having on the communities in Zimbabwe, with at that time, little help from outside was just really shocking to me and I knew then that the job I eventually ended up in had to be one where I was helping improve the health of communities both locally and globally.

[00:06:13] Dr. Rob Murphy: One of Northwestern's major accomplishments is in sending multiple students, actually 55 percent of the students, do an international rotation at some point in their training, just like you did in Harare. And it just, sometimes it just creates that spark, that interest that then people follow up just like you did yourself. Much of your research is conducted in Tanzania and Nigeria, where you have focused on HIV and viral hepatitis B and C co-infection, and research of that co-infection, and leading infectious disease research training program . Training is different from doing the research, but they're both incredibly important. Can you explain to our listeners the global health burden of chronic hepatitis B in particular, which is so common in Africa, and the dangers of HIV and hepatitis co infection?

[00:07:07] Dr. Claudia Hawkins: there are about 300 million people living with both Hepatitis B and C worldwide. About 254 million have Hepatitis B, and 50 million have Hepatitis C. Most of the work I do now is in Hepatitis B in Sub-Saharan Africa where the proportion of people living with Hepatitis B is anywhere between seven to 25%.And it roughly equates to about 82 million people living with this virus. , chronic hepatitis, for those who don't know, it causes a substantial morbidity and mortality if it's left untreated, and most of it is due to liver related complications such as liver cancer, fibrosis, and cirrhosis, which develop much later on in life.It's often why it's called the silent killer. And in most persons with HIV, liver disease can be significantly accelerated.

[00:07:50] Dr. Rob Murphy: You published some of the first data on the prevalence of hepatitis B and C co-infection in HIV infected populations in Tanzania and Nigeria, as well as the effect of viral co-infection on liver disease progression itself. and death. Tell me more about that work.

[00:08:06] Dr. Claudia Hawkins: So when I was working for the PEPFAR program in Tanzania, I was primarily involved with the clinical care of persons with HIV.And during those early days of PEPFAR, many of our patients presenting to the clinic were coming in with very advanced stages of HIV. And we noticed many of them were also co-infected with hepatitis B. And anecdotally, we were also seeing that many of these patients with co-infection were experiencing flares of hepatitis infection, especially after, soon after starting them on HIV treatments. And some of them did also die. So at that time, we really didn't know how much hepatitis B there was in people with HIV , let alone the population in general in Tanzania. And we also didn't know how much liver disease it was causing. So that prompted a physician colleague of mine from Tanzania and us and myself to write our first grant to, assess the, prevalence of hepatitis B in persons with and without HIV in our local community, and then assess also the feasibility of a serum marker called APRI to measure rates of liver fibrosis in these individuals. And ultimately, we found that over 7 percent of persons, both with and without HIV, were infected with chronic hepatitis B. And our prevalence data was some of the first to be published in the general population in Tanzania. We also found that a not insignificant proportion of persons with HIV and hepatitis B Hepatitis B had elevated liver fibrosis scores. So these APRI scores that we were measuring, although it quickly reversed after treatment and we sort of later determined that most of those elevated scores were not really due to fibrosis, but more HIV related liver inflammation. So I related more to HIV than hepatitis B itself. And then finally, we also looked at some mortality in these studies and found that persons with HIV and Hepatitis B, perhaps not surprisingly, had a much higher rate of mortality than those with HIV alone. So around 20 percent versus 10 percent over three years in this cohort, and those mortality rates were much higher in the first year after treatment. And again, this was probably more related to HIV than Hepatitis B, and again, and common in those with very advanced HIV stages.

[00:10:06] Dr. Rob Murphy: Yeah, that was really an incredibly difficult, challenging time back then. And the difference in mortality rates, as you point out, was just so dramatic. Fortunately that's improved over time with many, many issues. Co infection with hepatitis and the cancers associated with HIV. You also provided technical and clinical guidance to large HIV care and treatment programs in Sub Saharan Africa and mentored many junior faculty on HIV research through global health research training programs, mostly sponsored by the Fogarty International Center. How critical is mentorship in the field of global health?

[00:10:45] Dr. Claudia Hawkins: So mentorship is very critical in the global health field. One of the reasons I became involved with training grants was after working alongside many eager and enthusiastic and brilliant young scientists in both Tanzania and Nigeria, while I was doing my own research, and I quickly came to realize how little, the way they had in the way of resources and funding and training to be able to do the studies that were so needed in their settings. So applying for a Fogarty grant that would support the training and capacity building of these young trainees to be able to move forward and do their own research and advance academically in the HIV field seemed like the logical next step for me as I continued along my own academic career. So one of our HIV training grants that we have is with the Muhimbele University of Health and Allied Sciences in Tanzania on patient centered outcomes research and HIV has trained over a hundred masters, PhDs and postdoc level trainees. several who have been supported through formal training programs. also with the opportunity to come and do some of their research training at Northwestern. And it's been a real great privilege working with our trainees and collaborating faculty on these training grants and seeing our trainees grow into really successful researchers, getting their own grants, leading studies that have been so positively impactful in the local communities.

[00:11:56] Dr. Rob Murphy: You have spent the past 20 years here at Northwestern engaged in infectious diseases and global health research, as well as patient care. What might a typical day here in Chicago look like for you?

[00:12:07] Dr. Claudia Hawkins: So I'm laughing a little bit at that question. It's pretty varied, and very much depends on where I am in the world. At home, if I'm at home in Chicago, it typically starts around 5. 30 as I usually have about two to three morning calls most days with colleagues in Tanzania or Nigeria or other places I'm working. And then the rest of the day I might be working on other grants sitting on committees, study protocol teams, organizing training for our research training grants. Tracking down collaborators, which I seem to do a lot. Today I was putting out fires on a treatment trial protocol. I'm leading with the ACTG and hepatitis B, just as an example

[00:12:39] Dr. Rob Murphy: ACTG. That's the AIDS Clinical Trials Group. It's been in Northwestern for a long time. I used to head it. You've been involved in it, and you're still involved very much. It's an international group, and, uh, Claudia has a, has a great role in it, particularly with the co infection with hepatitis.

[00:12:55] Dr. Claudia Hawkins: Yeah. So work I do with the ACTG is primarily in infectious disease. division where I also work. There I usually, uh, will spend several times a year working, rounding on inpatients and about once a week I'll see patients in our infectious disease clinic.I will say while I really enjoy the research, honestly, my favorite part of medicine is interacting with patients. Patients, I always learned such a lot from them and love interacting with them. And I think most of my regular outpatients know I like to chat a lot. So usually around four, which is kind of the end of my day, I think, okay, I think usually thinking, okay, great, I can really start to focus and finally get to all the important stuff like papers or a grant that's due, which is probably what I should be doing earlier in the day.

[00:13:34] Dr. Rob Murphy: I think I have to remind our viewers of the time difference between Eastern Africa, where Tanzania is, and Chicago. It's it's at least nine hours. So, somebody is going to either get up early or be taking the calls very late. But congratulations on getting that done so early in the morning. Let me move on to our next uh, question. Can you tell our listeners about your role as director of the Center for Communicable and Emerging Infectious Diseases? And you can include some of the projects that are ongoing there.

[00:14:03] Dr. Claudia Hawkins: So my primary role in the center is to bring together faculty from Northwestern and international partners with similar interests in global communicable diseases under one roof. So help them really all connect with each other, provide our expertise, connect folks with resources and give them the opportunity to highlight their work. Sustainable and equitable collaborations are really important in global health and we're really, really there to kind of help forge those. So we have a lot of core faculty in our center who are doing some amazing work in global communicable diseases. Examples, Jaylene Jarridan, my associate director, does some great work in malaria modeling and surveillance in West Africa. Chad Arkenback, another Center Center program faculty, overseas and lead several studies developing point of care diagnostics for HIV and other infectious diseases. And then we obviously have the big program of viral hepatitis, which I lead, where we do a lot of epidemiologic studies, of point of care diagnostics, studies of biomarkers for disease monitoring and clinical trials of novel therapies. Also have several trainees from all over the world working through our training grants on many different areas, including HIV and aging, HIV prevention, HIV related stigma, and working with key populations like, pregnant women and LGBTQ.

[00:15:14] Dr. Rob Murphy: Now for something a little special we have a question from Donnell Moss, a second year medical student here at Northwestern. Donnell, let's hear your question.

[00:15:24] Donnell Moss: Hello, Dr. Hawkins. My name is Donnell Moss, second year medical student at Northwestern University's Feinberg School of Medicine. Your journey from medical school in the United Kingdom to residency and fellowship training in Detroit and Chicago, and ultimately to leading global infectious diseases training programs and research in HIV and viral hepatitis, is truly inspiring. How have these experiences across diverse healthcare systems in global settings shaped your approach to research and clinical practice? Are there insights from your international work that could improve how we understand and treat diseases in communities here in Chicago and the United States?

[00:16:00] Dr. Claudia Hawkins: So thanks Darnell for that question and lovely comment. I guess on a personal level, my experiences have made me much more uh, understanding and appreciative of different communities in different settings and, much more culturally aware. I was really fortunate to be able to spend two years of my academic career living in Tanzania and where I was able to gain much more appreciation of how health care systems function and how people live in different settings. It's made me definitely much more sensitive and understanding to challenges that arise with my research over there. You know, things that I would easily get frustrated with here. I'm less likely to do so there because I know much more about the context and, and how they arise and how difficult they are to navigate. I definitely really admire my colleagues for their dedication and commitment to science and how much they can really accomplish with so few resources. They've definitely taught me how to better problem solve and be more creative. And I try not to complain too much when we run out of something or my computer goes on the blink. working in other countries has also taught me a lot about how to approach my research, particularly conducting research in a country where you don't live or you're not from, you know, obviously things like communicating, well and, working with local communities are really key, to making a successful research, making the research a success as well as, strong relationships with collaborators on the ground. On the more medical side, there's a lot to be learned from other countries and their approaches to diagnosing and preventing and managing infections that we can definitely apply here. On the diagnostic side, it's interesting that many inexpensive, implementable and easy to perform rapid diagnostic tests have been available in Africa years before they became available here. And we have many lower cost, less complicated and efficient screening and diagnostic tests that we're currently developing for other infections in these settings that we could definitely benefit from in the U. S. and I wish they were more widely adopted. I always tell the story of how we had a FibroScan, a non-invasive diagnostic device that measures liver fibrosis in Nigeria, about five years before we had one here. And I remember it took several years to convince hepatologists that it was better doing, the Fibroscan and liver biopsy here in the U S and of course, Fibroscan has now been widely used across America, , for assessing liver fibrosis, in persons with viral hepatitis. And then on the prevention side, I guess we've seen many countries in Africa respond to COVID as an example with much more rapid, coordinated and aggressive responses to the pandemic that were probably far more effective than here. And I think we could learn a lot from that, especially with future sort of pandemics.

[00:18:29] Dr. Rob Murphy: One final question. What advice do you have for young people who are just now embarking or wanting to embark on a career in global health?

[00:18:37] Dr. Claudia Hawkins: Yeah, so there are many different careers you can have in global health. I'm going to probably keep it a little bit more focused on the academic side just because I'm more familiar with that area. But there are all sorts of things ranging from academics to public health to industry. Really depending on what sort of career you're interested in, definitely find that person who's doing that work and learn as much as you can about the job. So you develop your interests based on those conversations. If you're a student here at Northwestern, join your global health interest groups. If you're students from elsewhere listening, our residency program also has a global health interest group as well as infectious diseases. Again, it's a good way to make connections with people in the field, get to know what kind of work is being done, get to know a kind of typical day. For folks here at Northwestern or anyone visiting Chicago, join our Global Health Day. We have them twice a year. you can get a really great insight into what our institute is doing and certainly what our Center for Communicable Diseases is doing around the world, with regards to communicable diseases research. I think it's one thing reading the website, but when you come to see what, the, these meetings and actually see what's being done not just ourselves at Northwestern, but many of our global partners and trainees have done, in Sub Saharan Africa and beyond. I've had medical students approach me subsequent to some of these global health days and looking at some of the posters and said, Hey, I really want to work with this person. I think they're amazing. And we've been able to connect them. So, um, so yeah, we'll leave it at that.

[00:19:56] Dr. Rob Murphy: Well, Dr. Claudia Hawkins, thank you very much for joining us in your training in infectious diseases at Northwestern and staying on the faculty and all the work you're doing in global health, which is so critically important and in particular for training our students and residents and the trainees in Africa that we work with. Thank you very much.

[00:20:19] Dr. Claudia Hawkins: Thank you.

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