The big picture
Once focused on treating individual patients with tuberculosis, Christopher Whalen now is determined to prevent the disease from spreading in populations
It’s a Thursday morning in early December, and Christopher Whalen is on the phone. The halls outside his office in UGA’s Coverdell Center are quiet—final exams are under way, and students are scarce. An academic gown hangs on the door of his office, a reminder of next week’s commencement ceremony. But at the moment, Whalen is not preparing to celebrate the academic successes of UGA students. Instead he’s delivering news to Moses Joloba, a microbiologist colleague based at Makerere University in Uganda.
There’s good news and bad news. The good news is that the grant proposal they submitted to the National Institutes of Health placed in the 10th percentile. The bad news is that despite the high rating, they’re not getting funded. Last year the top 10 percent automatically received funding, but budget cuts mean that this year only the top 8 percent will be funded.
The project in question is one that evolved from Whalen’s line of research for the last 20 years—the interaction of tuberculosis (TB) and HIV. The project, which would allow Whalen and Joloba to study how TB is transmitted in Ugandan communities, has long been in development, but they will have to make substantial changes before resubmitting it. Speaking about it later, Whalen is disappointed but philosophical.
“Good ideas need to be followed through, and eventually people recognize good ideas,” he says.
Whalen, the Ernest Corn Professor of Infectious Disease Epidemiology at UGA’s College of Public Health, has become accustomed to looking at the big picture. He began his career by earning a degree in medicine, learning how to treat disease in individual patients. Since then he’s shifted to a public health perspective—looking at how to prevent disease in large populations. In addition to medical treatment, public health can involve tackling politics and cultural norms. It’s a big challenge, and he’s accustomed to losing a few battles on the way to winning the war.
“You never give up,” Whalen says. “That’s the bottom line.”
In the early 1900s TB killed one out of every seven people living in the United States and Europe, according to the Centers for Disease Control (CDC). Starting in the 1940s, scientists discovered the first of several medicines now used to treat TB, and the rates declined in the U.S. until control efforts were neglected in the 1970s and early 1980s. There was an increase in the number of TB cases between 1985 and 1992, but more funding and attention led to a steady decline since 1993.
Although TB is still present in the U.S., it doesn’t usually make the news except in the context of airline travel. In 2007 an Atlanta man with drug-resistant TB traveled to his wedding in Greece and back via seven flights on three airlines. The U.S. government ordered him quarantined—the first since a smallpox case in 1963—and health officials around the world scrambled to round up any passengers that may have had contact with him for testing. Despite a no-fly list created by the CDC after the 2007 incident, similar episodes happened in 2008, 2009 and 2010. There is some disagreement about the risk of TB transmission while flying, but the CDC recommends that anyone with active TB not travel by commercial airplane. Duncan Krause, director of UGA’s Faculty of Infectious Diseases, says erring on the side of caution is a good policy when compared to the threat of an epidemic.
“If we’ve learned anything in the area of infectious diseases over the last 60 years, it’s that given the opportunity these sorts of things are going to happen,” he says.
He gives several reasons why TB research is relevant at UGA and in Georgia.
“We can’t restrict our vision to our own backyards, our own communities, our own state, because the world is such a small place now. That’s answer one. Answer two is it’s extremely difficult to get rid of. The treatment is prolonged and miserable, and it’s difficult on the patient,” he says. “And answer number three is we’ve seen time and time again how drug resistance is going to happen. You’re talking about an individual with active TB—if it’s not controllable, the outcome is death.”
Whalen teaches an Introduction to Epidemiology class in the Biological Sciences Building on campus. Whalen is the Ernest Corn Professor of Infectious Disease Epidemiology. The professorship was established in 2010 with a gift from Abby and John Irby and other family members in honor of Abby’s grandfather Dr. Ernest Corn, who practiced medicine in Macon for more than 50 years.
Christopher Whalen grew up in Windham Center, Conn., a small town with a population of less than 1,000 that he describes as “classic New England.” He was the second of three boys and two girls born to parents who met at Yale medical school—his father was a surgeon, and his mother was a nurse. Whalen and his brothers started swimming at summer camp and later joined a swim team; at age 14, Whalen was ranked top 10 in the country in his specialty events. His father was a Rotary member, and during summers the family opened their home to exchange students. Most were from Europe—France, England, Wales, Switzerland—but there was also a woman from Tanzania who had a dramatic impact on the family.
“She really loved my sisters and spent a lot of time with them and taught them African dances,” Whalen says.
“I think my parents opened up our house in an international sense. They weren’t xenophobic in any way, and so as kids we were growing up with people from other parts of the world.” “I think that’s when the seeds were sown of interest in a global view of things.”
Despite a childhood that sounds idyllic, Whalen’s adolescent years were not without adversity. He was successful in the pool and in his classes—particularly math—but the one subject he could not conquer was English. He struggled with writing assignments in high school and later at Stanford.
“In college, and to some extent in high school, virtually every assignment I turned in was used as the example of how not to write,” he says. “So I was embarrassed regularly in front of my peers.”
Whalen had chosen Stanford both for academics and for the swim team. He joined the team as a walk-on and trained hard, but during his sophomore year he didn’t make the cut to compete at the trials for the 1976 Olympic Games. The disappointment ended his motivation to stay on the team, though he missed the camaraderie and rejoined as a senior.
Also during his sophomore year, Whalen found that theoretical math no longer held his interest. He looked around for a new major and made a surprising decision. Rather than taking something that would be easy, he chose an old nemesis—English.
“I was determined to leave college being a good writer,” he says.
Looking back, that was a fortuitous choice.
“I ask myself what prepared me the best for what I do today,” Whalen says. “The writing that I did was incredibly helpful because really what I’m paid to do is write papers and grants as well as teach, but teaching really involves quite a bit of writing.”
Whalen first encountered HIV-associated TB in medical school at Case Western Reserve University. During his senior year at Stanford, he had applied to 15 medical schools and received 15 rejections.
“That really kind of rocks your confidence,” he says.
On the advice of a mentor, Whalen took some time before reapplying. He enrolled in courses at Stanford’s medical school and worked in a sleep lab. He volunteered to work with a new faculty member establishing a neurobiology lab, eventually getting his results published in Science. The second time around Whalen’s applications were more successful, and he chose to attend Case Western in Cleveland, Ohio.
He began medical school in 1980, a year before the CDC published the first official report of what would become known as the AIDS epidemic. At Case Western Whalen became interested in infectious diseases and epidemiology, a quantitative science built on probabilities and calculus. He found himself pulling out his old math textbooks. And he earned a master’s degree in epidemiology and biostatistics while he completed his medical training.
During his fourth year of medical school, Whalen worked at an infectious disease clinic. The clinic had been around for years and typically encountered patients who were international travelers, who had unusual or chronic infections or who needed hospital follow-up. But the clinic suddenly was overwhelmed with patients, many of them young homosexual men. Since Whalen and his colleagues were infectious disease specialists, it fell upon them to care for these patients.
“I was actually on the front lines of the epidemic, before we knew what HIV was, as a medical student,” he says. “There was no standing behind the attending [physician] while they examined a patient. The line was out the door, so it was all hands on deck.”
After medical school Whalen took a fellowship and worked on research that explored survival issues in HIV patients. One predictor was infection with a mycobacterium that was a close relative of TB, which had a growing presence nationally. The coexistence of HIV and TB was a familiar topic. In the late ’80s Case Western had established a research and training program in Uganda, where HIV and TB were closely intertwined. Back then 65 percent of TB cases in Uganda involved patients who were also HIV positive; these days the rate is about 35 percent.
Though TB is not big news in the U.S. these days, that’s not the case around the world. The CDC estimates that one third of the world’s people are infected with TB. Each year nearly nine million people become sick with TB, and there are almost two million TB-related deaths worldwide. TB is the leading killer of people who are HIV infected.
Caused by the bacterium Mycobacterium tuberculosis, TB is spread through the air when a person with active TB of the lungs or throat coughs, sneezes, speaks, sings or spits. People nearby that breathe in these bacteria can become infected, but not everyone that is infected becomes sick. Some have a latent infection—they test positive but don’t have symptoms and can’t spread TB. Without treatment for the latent infection, however, they may become sick years later if their immune system is compromised by another condition like HIV or diabetes.
“The interface with the general population is more regular than you might think,” Krause says. “[Tuberculosis] doesn’t spread particularly well, that’s the good news, but it does spread, and when it does you’ve got problems.”
Asiimwe and Juliet Sekandi, a doctoral student in epidemiology, work on a board in their office in Miller Hall. Sekandi was trained as a physician in her native Uganda, but her work with Whalen has led her to adopt a public health perspective. “If you were to summarize public health in one sentence, or in one word, it’s prevention,” she says. “As a clinician we think about, ‘How do I cure this patient that’s in front of me? How do I cure this disease?’ The public health paradigm is, ‘How do I prevent this patient from getting the TB?’”
In 1991, Whalen began working with Ugandan students who were studying epidemiology at Case Western. He became director of the training program, working to secure additional grant funding and traveling to Uganda several times a year.
In the 20 years since, he’s developed a strong philosophy about conducting research in a foreign country. He works in partnership with Ugandan researchers because a native is more likely to get accurate information and because he wants the work to be valuable for the host country.
“Going in, taking and coming out is safari research,” Whalen says. “But if you train and you leave more than what you take, leaving a trained individual is leaving the country the capacity to build and the capacity to do research.”
He’s also committed to helping Ugandan students who earn degrees at UGA.
“You can’t train a lab scientist here and send him back to no lab,” Whalen says. “So if you train a lab scientist you’re kind of committing to helping him build a lab when he gets back.”
Whalen has two training grants—one on TB and one on HIV—that focus on capacity building in Uganda. During the past 20 years these grants have allowed him to train more than 65 graduate students. One such student is Juliet Sekandi, a native Ugandan who was trained as a physician in her home country and then earned a master’s degree under Whalen at Case Western. She’s now enrolled in the epidemiology doctoral program at UGA.
“He’s such an excellent mentor, I can tell you,” Sekandi says. “He really pours his whole experience and life and all the knowledge that he has into his students.”
Many of Whalen’s graduates have returned to Uganda, where they’re making a difference. Five trainees now have appointments in Makerere University’s Medical School and School of Public Health. Others have leadership positions in the Ministry of Health, and one was voted into Parliament on a public health platform.
“The depth of Chris’s passion is unusual, and the commitment in time and energy that he makes to advancing that passion,” Krause says. “Most of us train graduate students—he developed the doctoral program in epidemiology and is actively involved in training epidemiology students in Uganda.”
Grants come and go, says Whalen. What remains are the papers he published that shape the field.
“The other thing that shapes the field is people that you train,” he says. “They last a long time, and they have this amplifying effect. If you train one person, they go back and train 10 more.”
Whalen prepares for a ride with the Winter Bike League in December. He rides several times a week, sometimes more than 50 miles. “If there’s something that I decide I need to try to resolve, I can do it on the bike,” he says.
In 2005 UGA began recruiting for seven faculty positions that were part of a Board of Regents initiative to grow the university’s capacity for research in infectious diseases. Christopher Whalen was a perfect fit for the new College of Public Health and the Department of Epidemiology and Biostatistics, founded the same year, and later the Faculty of Infectious Diseases, founded in 2007.
“Hiring Chris added an important new dimension… in that now we’ve got an interface with the people that are actually contracting and suffering from tuberculosis,” Krause says. “The ability to expand our perspective on TB and move from the basic science at the bench to applications in the field I think is significant.”
Whalen was impressed with the strategy and set of ideas that were being implemented at UGA.
“It was something that was extremely unique to me, to see that a school was making that kind of commitment to the study of infectious diseases,” he says.
Over time he’d come to believe that he could make more of a difference by approaching TB from a public health perspective. It lacked the more immediate gratification of treating patients, but it offered an opportunity to effect more significant change long term.
“I felt as though to control TB I needed to move up from individual patient care to broader interventions at a systemic level,” Whalen says.
Whalen and Sekandi have completed a project in Uganda that emphasized getting health care providers out of their comfort zones and into communities to find TB patients before they typically come in—when they’re already sick and have spread the disease to those around them. Whalen is convinced that moving TB case detection into the community, where the transmission occurs, is the best way to address the problem. Many of his current projects address this issue from different perspectives.
“Chris is reassessing dogma in ways that move outside the box, to borrow an overused expression, to rethink patterns of spread and address the question, ‘Why aren’t we doing better?’” Krause says.
In January Whalen returned to Uganda to teach a course on grant preparation at Makerere University’s Medical School. And in February, he got good news. The NIH grant proposal that initially got rejected will be funded after all. The original decision to fund the top 8 percent was expanded to cover the top 10 percent, so he will be able to move forward with his project.
Whalen is looking forward to investigating whether Ugandan social networks—not the online kind, but the social interactions that make up daily life—promote TB transmission.
“To me it’s critical that we rethink how we control tuberculosis,” he says.
“If you can block transmission, the disease will go away. But if you don’t block transmission, it just keeps rumbling on.”