Figure.
Figure.
View of the Columbia University Health Sciences Center, New York City
© 2003 Columbia University, Centre for Biomedical Communications
Scott Hammer received his medical training at Columbia University's College of Physicians and Surgeons in New York City and completed his internal medicine residency at the Columbia Presbyterian Medical Center, where he was chief medical resident, and at Stanford University Hospital in California. He completed his infectious diseases fellowship training at the Massachusetts General Hospital in Boston before joining the faculty of the Deaconess Hospital (now the Beth Israel Deaconess Medical Center) and Harvard Medical School in 1982. Hammer rose to the rank of associate professor of medicine at Harvard Medical School and director of the research virology laboratory at the Beth Israel Deaconess Medical Center before being recruited back to Columbia in January 1999. He is currently Columbia's Harold C Neu professor of medicine and professor of epidemiology, and chief of the division of infectious diseases at the Columbia Presbyterian Medical Center.
Hammer's career has been devoted to improving the treatment of HIV infection in the USA and globally. As an AIDS Clinical Trials Group (ACTG) investigator, Hammer chaired the two largest national trials of antiretroviral therapy carried out by that group in the 1990s, studies that contributed to the current standard of care of HIV infection. In addition to his interest in the treatment of people with established HIV infection, Hammer is an investigator in the National Institutes of Health-sponsored HIV Vaccine Trials Network (HVTN), a multi-center organisation with the mission of developing an effective preventive HIV vaccine.
Hammer is a former chair of the Antiviral Products Advisory Committee of the US Food and Drug Administration and currently chairs the HVTN's phase I/II committee. On the international level, he is a member of the governing council of the International AIDS Society, and has served on the international advisory committees of the Swiss HIV Cohort Study, the French National Association for AIDS Research, and the HIV-Netherlands, Australia, Thailand Research Collaboration. He also serves on the editorial board of the New England Journal of Medicine.
TLID: What led you to become involved in HIV research and treatment?
SH: It really comes down to a very personal story. My brother, Glenn, is 3 years older than I and we share the same birthday, so that's a special aspect of our relationship. Glenn is also a physician and infectious diseases specialist, and was ahead of me as I was doing my medical training—so I didn't know if I should do infectious diseases or not, and even delayed the decision for a year mainly because I didn't want to do the same thing as my brother.
But then I decided I really did want to go into infectious diseases, and was fortunate to do my training at the Massachusetts General Hospital (MGH). This was a time of incredible leadership at that hospital. Morton Swartz was chief of infectious diseases, and he's basically an idol of mine. He's the nicest and most brilliant individual I've ever met, and studying under him just cemented my love for infectious diseases.
In my second year of fellowship, I went to work for an amazing mentor, Marty Hirsch, at MGH and trained as a herpes virologist. After more than 4 years of fellowship, I moved across town to be part of a new infectious diseases department under the leadership of two other idols, Robert Moellering and A W Karchmer at what was then the New England Deaconess Hospital. Then AIDS hit, and our hospital became one of the region's AIDS centres. Working there imbued in me not just a virological interest but also interest in applied research and antiviral therapy. While taking care of HIV-infected people, I naturally evolved into the HIV specialty arena, first from the virological side, then from the applied laboratory side, and ultimately I was increasingly pulled into the ACTG. This led me to get more involved in clinical research and trials.
Another interesting part of being at Deaconess is that we followed an “old school” model that is hard to maintain now: we had a relatively small division and tried to uphold a tradition of combining teaching, clinical care, and research by most, if not all, faculty members. We also had a successful fellowship programme, which we built from scratch. Until I moved to New York City in 1999, I had a substantial HIV practice because I felt you couldn't understand the disease or what you're doing with treatment purely from a clinical trials perspective.
Working with HIV-infected patients was an eye-opening experience, not just for me but for all infectious diseases specialists, because the classic infectious diseases physician had been traditionally an in-patient consultant without a primary care practice or ongoing patients in an outpatient setting. AIDS revolutionised the practice of infectious diseases and also turned us into more balanced physicians.
Physicians in the developed world have witnessed an amazing evolution in HIV disease in the past 2 decades. In the early years, we learned a lot about the ravages of this disease, about hospice care, and keeping people comfortable. Then, in the mid 1990's, effective therapies came on board that created many touching individual stories of revitalisation, which were reflected in the larger control of the epidemic. To witness all that in the span of one's career (just as I was getting my feet on the ground, the worst pandemic the world has ever seen hit) and then being part of what followed—working through the clinical description, learning about disease pathogenesis, developing treatments, controlling disease progression, and now moving on to vaccine development—all of this has provided me with a privileged career.
TLID: You recently returned from the 2nd International AIDS Society Conference on HIV Pathogenesis and Treatment in Paris. There seemed to be mixed reactions to the conference, with a number of people feeling that politics overshadowed the science. How do you think it went?
SH: Yes, there was an issue of politics, but I think the conference was a tremendous success. Scientifically, it was quite strong, particularly the plenary lectures. It didn't bring together a lot of brand-new science or earth-shattering breakthroughs, but that was not really expected; we have so many HIV meetings that we can't expect to have ground-breaking news at each one. The best and most powerful aspects of the meeting were the greater than expected attendance (about 6000), and the strong participation of investigators from developing countries. They brought a new excitement, energy, and commitment to the concept that the more and less developed nations need to work together scientifically and economically to solve the access issue, and that access is part of what we need to be doing in addition to our own research.
TLID: Where do things need to go now, coming out of that meeting?
SH: I don't have a specific prescription, but I think we need to move the agendas forward at both the global and individual country levels for solving access issues, improving infrastructure, providing training, and generating greater communication and cooperation. There are a lot of ways things get done. An important way is through major funders such as the National Institutes of Health (NIH), the Bill and Melinda Gates Foundation, the Global Fund, and the World Bank. But what I'd also like to see is some of the individual scientists and institutions who have bilateral relationships with colleagues in developing countries working more closely together, so that we have organisation, not fragmentation, in what we're doing.
We have the best intentions when we work to set up particular projects in particular countries. But we need a clearinghouse mechanism to spread the efforts and energy so that we're not tripping over ourselves in our efforts to help partnering institutions and countries with clinical research, treatment education and training, and care on the ground. This means we need to move forward on the governmental and non-governmental fronts, and with the global funders and research institutions that represent richer nations. But investigators also need to see what they're doing in a larger context—that our work has important social and political implications for advocacy, moving funds to the less developed world, and integrating our clinical research in an operational fashion. And so we need to ask, where is our work going operationally that will really make a difference in clinical care to the broadly affected populations in a few years?
TLID: How is this different from what has been happening up until now?
SH: In the past, in the face of lack of infrastructure in the developing world and lack of attention, it is clear that individual investigators and institutions were doing good things, but, even if they didn't feel it, they were somewhat isolated—often part of sporadic efforts, rather than being part of a true, ongoing global matrix. Now, even though the problems are huge (and no one should underestimate the challenges involved in delivering the kind of health care we're talking about for these regions), everyone involved recognises that an unprecedented level of attention is now being paid to the developing world, and thus an opportunity is being presented to the world community that must be seized.
The way investigators can make their research more relevant to the countries they're working in is to see it in the larger context of other efforts from other institutions, and even think about revising the agenda of what they're doing to fit into that more practical, operational role. We need resources going into a synergy of prevention—be it with behaviour, microbicides, or vaccines—and treatment, and we need to work together.
One of the salient ways this is happening is under the aegis of the NIH's division of AIDS. They're trying to encourage their major research programmes which have international components to work together—for example, the HIV Vaccine Trials Network, the HIV Prevention Trials Network, and the ACTG—for efficiency's sake. That way, when we do site establishment and clinical research training or treatment training, and we're not doing it for one NIH grant only, but potentially as a synergistic way to build a site that could also be primed for other, relevant research opportunities and be provided with sustainable infrastructure.
The bottom line is that investigators should feel a moral responsibility for what they're doing. There was always the sense that doing international research is important, and that it's crucial to respect the local populations and collaborators. But now there's an even larger moral imperative. There's a great experiment going on and if it fails, we will do millions of people harm; but if it succeeds, we will demonstrate that you can deliver treatment for a complex disease using a public health approach that can actually rebuild nations, keep families together, and create economic, political, and social stability.
TLID: How does this global perspective and larger imperative play out with respect to a newly emerging threat such as Severe Acute Respiratory Syndrome (SARS)? At the June 18 SARS meeting at the New York Academy of Sciences, you also underscored the need for international collaborations, particularly with respect to treatment trials (Lancet Infect Dis 2003; 3:400).
SH: In contrast to the AIDS pandemic, which has been with us for more than 20 years and is pervasive, continuous, and growing, the intriguing part about SARS is that it showed how vulnerable the world is to a public health crisis and how quickly a disease can spread, as well as the economic, political, and social impact an infectious agent can have I in a very short time. What's more, we I could literally sit and watch CNN and learn about the disease's impact on a day to day basis. The negative aspect is, of course, the high levels of anxiety that can be associated with this instant knowledge. On the other hand, it also showed the power of the internet and information technology, of ProMed, of modern molecular science, and ultimately—albeit in a 3 somewhat halting way—the ability of governments, WHO, and CDC to work together to control the outbreak. And it showed in an impressive fashion what can be achieved in a few weeks, once you mobilise the scientific community. Clearly, there was some competition, but I think there was more cooperation than competition.
The real challenge now with respect to SARS is that there are a lot of hypotheses about transmission, superspreaders, susceptibility, and treatment out there, but it's not currently before us as an ongoing problem. But this doesn't mean that we should sit on our hands and hope that it doesn't come back next year. If it does come back, we need to be ready with strict infection control manoeuvres, rapid diagnostics, and, if possible, treatments and clinical trials.
For human studies, the world needs to think about a number of issues. Do we have candidate drugs for which we can begin to obtain preclinical data and do pharmacokinetic and safety studies in healthy volunteers? Can we actually plan international protocols with good candidate agents? To do this, we need a protocol in place, Institutional Review Board approvals, and multiple potential countries in which to test the agents because we don't know where the outbreak(s) will occur. But if you wait for the epidemic to re-emerge and then say, “I'll do that protocol”, you've potentially lost the ballgame. Our advantage now is that we know the agent, we have molecular tests, and we'll have surveillance. But if we want effective therapies, we need to plan the necessary studies in advance and have them ready to go.
It would be nice to develop a new paradigm for global cooperation to combat new disease threats—private/public partnership models that also allow rapid, multinational regulatory approvals. SARS would be a perfect model to try because of its telescoped nature. Once we have that agreement, we would have the mechanisms in place for governments and industry to work together to think about liability issues, and so forth. There are times when emergencies should allow us to say, “if ethics boards for the WHO and CDC, for example, approve this protocol, then a particular university can go along with it”. And if we put a treatment protocol together and didn't have any cases next year, it would still be a success; the failure would be to have another 8000 cases and no organised plan for testing and analysing treatment.
TLID: How did you come to feel so passionately about this vision of global cooperation?
SH: There are two positive things that have come out of the AIDS pandemic. The first one, obviously, is the explosion of knowledge about retroviruses and their biology and treatment. We've learned so much scientifically that has tremendous benefits for medicine in general. We paid a huge price for it, but it created an enormous knowledge base.
But I think where my vision has come from is the second or “co-positive”, so to speak: the enormous level of respect I've come to have for our international collaborators. Over the years, investigators in Europe, North America, and Australia were brought together, and yes, there was competition among the trials groups, but more than that, there was an international sharing of science, opinions, and politics. That now has spilled over nicely into the commitment to working with scientists, clinicians, and educators in the developing world to assist them in getting somewhere close to the level where the developed world is.
The vision for me is the internationalisation of the response to infectious diseases, as viewed through this pandemic. I value deeply my collaborations and friendships with non-US investigators. The commonality of spirit with people such as Stefano Vella, Patrick Yeni, Michel Kazatchkine, Joep Lange, Praphan Phanuphak, and many others has been quite remarkable. For example, I have had the privilege of working with Stefano Vella on a number of international projects over the years.
TLID: Looking back, is there anything—personally or professionally—that you thought years ago would have happened by now, but didn't?
SH: To turn your question around, I never thought that I would have wound up as chief of the division of infectious diseases at my medical school alma mater. I never imagined that I would have those aspirations or that the opportunity would come to me.
TLID: Have you always wanted to be a physician? Was this your childhood dream?
SH: No, actually I didn't know what I wanted to be as a child; my thoughts were random. In college, I did the minimum required to be premed; I majored in art history. But as I really began to explore things, I found I was lured more to science, again influenced by my brother because he was more of a science-oriented person. I delayed my decision so that I wouldn't just follow in his tracks, but ultimately, I went into medicine because I was intrigued about science and saw it as a career that had wide opportunities. It was a career in which you could be a clinician, researcher, or public health official, and there was a wide range of specialties in all of these areas. So the spectrum of opportunity is what also drew me to the field of medicine.
TLID: What is your relationship like with your brother these days?
SH: We have a close relationship. I think we're both quite happy that we're living in the New York area. We do very different things as far as how our careers are structured—he has a full-time practice at the Mount Sinai Medical Center in Manhattan—but the fact that we are involved in the same subspecialty actually brings us closer together, because we respect what we each do, and we often call each other asking for advice on a particular case or issue.
TLID: How do you unwind at the end of the day? Do you have any hobbies?
SH: My passion is downhill skiing. My wife and I try to make at least two trips out west yearly. We love Jackson Hole, Telluride, Snowbird, and Alta. In the winter, I constantly think about skiing. The majesty and beauty of the mountains, the physical activity, and the fact that it's a sport in which everything leaves your head combine to make it an incomparable experience. When you're going down the slope, you leave everything else behind you. For me, it's the biggest distraction in the world and one of the most rewarding sports.