Hi students. It's great to see you again and we're continuing our series of interviews with experts. I'm really pleased today to have Dr. Chris Plow with me. Welcome. Thank you David. Dr. Plow is the director of the Duke Global Health Institute. And he's actually Professor of Medicine Molecular Genetics Microbiology and Global Health here at do. As always, we'll have all of our interviewees biographies and CVs linked onto these interviews. But it's really exciting to me to have Dr. Plow here today because he really is one of the world's most acclaimed malariologists and has been working for years on the issue of malaria and finding ways to eliminate it. He's worked in Africa and also in Asia as well in countries ranging from Mali and Malawi in Africa, all the way to China, Bangladesh, and Myanmar in Asia. So with that, I would like to ask him a few questions as well. So first Chris, it's really a pleasure to have you here. Great to be here. It's an exciting opportunity for the students to get to meet you and to know more about your work but I want to just move back a little bit first and ask you what got you started in global health? Well, I was a philosophy major as an undergraduate and I got to medical school thinking I might go into psychiatry, just working on the mind and thought and so forth. I did a couple of summer jobs doing psychiatry research but then it was really struggling in my basic science courses, biochemistry. I'd taken the bare minimum of science to get into medical school. I was really turned on by lecture on public health on the first year of medical school the idea of working on the health of populations as opposed to individuals just really intrigued me and it was more interesting than the Krebs cycle at that time. So I ended up doing research that summer for that professor who was an internist and a psychiatrist and an addiction specialist working in a methadone clinic doing research. I was on the glide path toward becoming a shrink basically and his name was Bob Dylan. Bob was talking with me during my second year of medical school and I said Do you have any ideas what am I to do the next summer for researching. He said "Well, Chris we could set you up with another research experience in psychiatry or substance abuse research. But I've got this friend named Steve Hoffman who's doing these really cool studies on typhoid fever and malaria over in Indonesia, maybe you should go work for him." I had to go look at the globe and see where Indonesia was. Honestly it was really a chance for a naive kid from South Dakota who had never been out of the country to go see something of the world. I went and did that and did another similar experience overseas in doing work on malaria in Kenya as a fourth year medical student. I just fell in love with working in the tropics working with some of the world's poorest populations who are afflicted by in diseases like malaria and I felt malaria as a calling. That time it was just the very early days of the AIDS epidemic and this was the world's biggest killer and still is going to historically. It just it seemed like why would I want to work on anything else. Well and infectious disease. I still remember being back in college and when I was growing up and being taught that by the 21st century when everything was supposed to be perfect. By the 21st century in particular, infectious disease to be a thing of the past. We've won the war on infectious disease. Well, the students who've taken this course know that while yes it's true. If you look at DALYS that non-communicable diseases do even globally except in the most underserved and resource countries really take up the primary number of DALYS. But infectious diseases still around and I'm afraid it's here to stay for a while and then really it increasingly deadly reforms. That would make me asked you, what is it in particular about malaria that makes it so difficult to eliminate? We just studied the malaria cycle by the way. So the students have some basic information. I will give you at least two answers to that. Maybe one is biological and one is more social and economical and political. Biological answer is that, compared to most of the other pathogens that we deal with in infectious diseases, this is a big organism. It's got a big genome, it's got 5,000 genes. It's got a very complex life cycle that involves both sexual recombination between male and female parasites in the mosquito as well as asexual multiplication in the host as there's lots of opportunity for evolution and indeed the parasite evolves to escape our immune system, it evolves to escape the drugs we use to try to treat the infection, and we've shown that it evolves to escape the vaccines that we're trying to develop to emulate and improve upon the natural immunity. So it's just a constant evolutionary race against the parasite. Historically, the parasite has won again and again. The other side of the answer to your question is that this is a disease of poverty. Sure. When there was global eradication campaign in the 1950s and '60s, it was actually very successful in much of the world. We had already eliminated malaria from the United States where it used to be a big problem, for much of Europe and the eradication campaign we got rid of it in Southern Europe, some of the Northern African countries, the USSR, the former USSR used to have quite a bit of malaria. So we really shrunk the malaria map. But in sub-Saharan Africa, in the poorest countries, the country with conflict and civil unrest, we just didn't make progress and that's a pattern we see today in Myanmar where we work in other countries in Southeast Asia where you see malaria now is in the areas where there's conflict, in the areas where there is no public health system, in the gold mining areas, the plantations, the opium areas. That's where we see it and we need good surveillance and we need intact health systems in order to address so many global health problems including malaria. So this is the importance in global health in the biopsychosocial model. So it's very rare that biological and medical treatment alone would be sufficient without taking into account social political economic environmental contexts especially among what we call high pops in hotspots especially in these low-resource areas. Now, would you tell us a little bit about your own work with malaria elimination, what you're doing, what your hypotheses are? Fascinating to know these. So I worked for many years in Africa mainly in Mali and then in Malawi doing a lot of clinical trials of drugs and vaccines and a lot of what I would call genomic epidemiology or molecular epidemiology, looking at genetic changes in the parasite that do that confer resistance to drugs or vaccines and understanding how that evolved and the implications especially for surveillance. About 10 years ago, I really shifted my focus to Southeast Asia because of the emergence of resistance to the artemisinin drugs now that the first-line therapy around the world. That initially was regional and then we've focused more and more on Myanmar which had the most malaria in the region and there what we're doing is partnering mainly with the government. It's a challenging area to work and the government of Myanmar obviously has some very serious human rights issues including currently. But our understanding is that the only way to eliminate malaria is to do it with the governments, and so we're using malaria as a way to actually bring together people and the government and some of the groups they're actually still inactive armed conflicts precisely because malaria is in these conflict areas, and we have to work with people who have access to the areas even including the Myanmar military. The focus of the work in partnership with the government and other ethnic health organizations, NGOs, is mainly focusing around surveillance. So one thing that we've done is worked with our partners to set up two molecular surveillance labs. One in the Ministry of Health and one in the ministry of defense and we're doing studies in different states and regions around the area trying to understand asymptomatic malaria. We have a very sensitive molecular test that can detect infections in people who are completely healthy to our appearances, but may have infections at a low level that doesn't make them sick but can still transmit parasites to the mosquito. So well, we've managed to eliminate malaria in parts of the world without detecting these very low level infections. We hope we can accelerate elimination by identifying these pockets, hot pockets and hotpots and where are these remaining residual foci malaria. Then along with that, we're trying to come up with new approaches for forecasting where these residual foci will be, where parasites may move. That's a combination of this genomic epidemiology as well as geo-spatial modeling and mapping, trying to predict and look at travel routes based on remote sensing data where the mosquitoes are likely to be made the perfect storm, the right conditions for the mosquitoes, humans who can be infected, and then lack of access to diagnosis and treatment that lets the pairs it's continued to assure for it. What's so fascinating about this as well, I think you'd be a great point about how major global health issues. There is almost no discipline that's not involved, whether it's doing geo-spatial design to epidemiology to working at the genetic and the genomic level, but at the same time it all comes back to the epidemiologic triad. Sure. Yeah, so it's interesting how we keep both basic models in mind and these larger issues, and they should also bring in the fact of how global health can be used as diplomacy as well. It seems there is some of this going on is your work as well. So why should people in other parts of the world be concerned about artemisinin resistance say in Southeast Asia? Why is it such an issue? Well, one issue is that the resistance to chloroquine, to sulfadoxine, to pyrimethamine, to mefloquine, all these anti-malarial drugs that have worked for decades has arisen first in that part of the world, in every case it has spread from there to Africa. If artemisinin resistance hits Africa in a significant way, it would be a global health catastrophe because there are still hundreds of thousands of people dying from malaria every year, they're millions and millions of lives are saved by the effective treatment with artemisinin-based combination therapies. So it would have a real global impact. Moreover, if you're a traveler and you get malaria, whether you're a diplomat or a tourist or for whatever reason, you're going to need to be treated with these drugs and this is what we use to treat people back here in the US. So I think that's one answer is that it is a global world that we live in and we're all at risk of these diseases. But, I think the most important argument is really the social justice arguments should Melinda Gates made very eloquently when she and Bill Gates called for renewing the global eradication campaign about 10 years ago. That is that we used to have malaria in this country, our children in the US no longer die from malaria, we have the tools, we have the approaches that we need to eliminate it, and have done so in many parts of the world, how can we not do it elsewhere? Shocked me that kids die from malaria in Nigeria and in Cambodia. Absolutely, it's the death, it's the impact on families time lost from work. I mean, human can think about all of these things with Malaria and disability and families fathers, mothers can't work, and then there's no food for the kids. So this cycle of poverty and user nutritional he said their issues just continue as well. I'm trying to remember that malaria was basically eliminated in the US was at the 20 to. Thirty to the last cases. I think I showed the map to the American South and then actually but then it was gone. Yeah, my grandmother had malaria. She's actually talked about it. Yeah, alternating chills and fever. It's a different world, though of course. The part of the country where I grew up in the South didn't know rediscovered hookworms. So that's a conversation for another time. We've talked about, you've been talking about your starting in global health and also some of these issues and the drivers of malaria resistance, but does your current work or does current work in general on malaria elimination, and let us hope on the eradication. Does it hold any lessons for other infectious diseases? I'm sure it does. I think one would be the importance of surveillance and that's where, especially as you drain the lake, I like to say and I have remaining puddles and where are those, and for any late-stage elimination surveillances is really critical as polio and smallpox have shown very clearly. What I think we really need to see more of is integration of surveillance. There's a lot of work being done at the Duke Global Health Institute on diagnosing different pathogen, different causes of fever mainly through collecting samples at the point of care and hospitals and clinics. What we're doing it in Myanmar, China, and Bangladesh is more active surveillance go out into the community, We're in early stages of thinking about, can we collect the same sample? Ideally, just something very simple, like a dried blood spot, that you can store and transport at room temperature, and do very sensitive molecular and even serological assays to detect different pathogens or with a serology to detect antibodies to different pathogens. As well. Right. So it's not that we're going to diagnose this person is infected, and we're going to deliver this treatment. It's more we're going to look in the community, is there a signal of recent infection from malaria, recent infection dengue, chikungunya, other pathogens that will let you more efficiently target your interventions to the places where these relatively rarer diseases are actually causing a problem? Sure. That would be important as well because people would then ultimately you'll know how to provide the appropriate treatment. Because we talked a little bit in this course about, one, how antimicrobial resistance comes from inappropriate treatment or insufficient treatment. But also the issue of basically fake drugs. Some people getting drugs that aren't working. So it's exciting to think about the work that you're doing, and work that's also being done around the world to try to find ways to verify whether drugs are real or not because it's going to be yet another driver of the resistance that you've talked about. I actually remember that you wrote a really powerful op-ed for The New York Times, maybe around a year ago. I think we will link that as well for the students in the course to read. Now I wanted just move back a little bit from malaria, just to your work in global health in general. Sure. You've been working in global health for several decades now. Yes. Since 1984 I would say. That's when I first went to Indonesia. 1984. All right. So what are the big changes that you've seen in global health in that time? I think the biggest change is the funding. We didn't talk about global health so much back then. We talked about tropical diseases. Yes. But if you look at the funding for malaria, for HIV, for non-communicable diseases, the slope went up very sharply in the late part of the last century, and especially the first decade of the 21st century. We've hit a plateau. Yeah. So that's been one really noticeable trend. The Global Fund, the Gavis and the real investment that mainly the northern countries have made. The other more recent trend that's really noticeable is that, as these economies in the developing world, the lower, middle-income countries rise, there's much more contribution of the countries themselves of their own economies. Sure. You go to places like Kenya, like India where DGHI has a lot of faculty, and staff and students working. It's completely transformed from what it looked like 20 or 30 years ago in terms of the manufacturing and the economic activity. So these countries are in some cases graduating out of eligibility for some of the traditional forms of aid. But that's a very positive trend, that they're really taking ownership of these issues. That's really ultimately what's going have to happen for diseases to be eliminated and eradicated, it's where the countries themselves say, "This is something that we're doing, we're committed to, we own it and we're going to make it happen." That really drives our philosophy of, we're not going in there as scientists to do our research and get our data and come back and publish it. We're going there to partner with the governments and the other people in the country and to work with them, set up labs, not in some separate research institute, but really provide technical support for labs that are run by people in the country. Sure. Yeah. It really sounds like your philosophy is that of partnership, collaboration, enhancement because that's the real benefit to everyone. I think also said that even while malaria is not something we find all over the world, all at risks for these diseases in various ways as well. Where do you see global health going in the future? If you just had to put on your tolkein your crystal ball, put on your magician's hat, what do you think would be the major trends in the next few decades? Well, one of the trends, I think it's one I just mentioned, that more local leadership and ownership around the world. I think one trend is that, it's increasingly recognized that global health doesn't just mean in the lower-middle income countries. Global health is all about health equity, social justice, and we have plenty of health disparity in the richest countries including right here at home. Right here. Yes. Exactly. Where we live. You can just look at ZIP codes, and you see major differences. The larger trend of globalization is absolutely changing the way we think about and practice global health, to the extent that one important element of our new strategic plan as an institute is saying that Durham and the surrounding region in the American South is one of the places where we work and where we do our global health. Another exciting trend is the trend toward big data and data science. Sure. Of course. There's a real push for that, machine learning and artificial intelligence in the health sector. A lot of the push in the US is coming from changing models for healthcare reimbursement, from treating people when they're sick to keeping people well. That particular economic driver isn't necessarily at play yet in many of the other countries where we work. But we see real potential for taking these technologies out. But also where they're already being applied, there's a really interesting work with mHealth and different approaches that are being tried in Kenya, in India and elsewhere that could actually be brought back to the US and help us keep our communities healthier here. Sure. Yeah. I'll be doing a couple of interviews with some of our colleagues who are actually working on these various issues as well. But I've just said, it's kind of the outer limits of mine. I know enough about this to know what's important, but, yeah, you should talk to real experts. But it was a great entree actually for things I'd want to use. I appreciate that. That's the role of the director of an institute, to also bring other people into the fall. Yeah. I'm a good ambassador for the great work that our faculty, and staff and students are doing. Yeah. It's really an exciting place to be with everything that's going on.
