Redefining the Unacceptable

Guiding the Next Generation of the Public Health Workforce with Dr. Jim Curran

Contagious Conversations  /  Episode 13: Redefining the Unacceptable

Why the best time to study public health is now

What does our nation need from the next generation of the public health workforce? Emory University's Dr. Jim Curran discusses the demands ahead and how our universities, associations and employers are preparing people to meet them. Dr. Curran also discusses his work at CDC during the very early days of the HIV/AIDS epidemic, how far the world has come since that challenging time, and the road to eliminating the disease entirely.



(View full transcript)





Below: Dr. Jim Curran at the Emory University Rollins School of Public Health where he has served as dean for more than 25 years.





Pierce Nelson: Hello and welcome to Contagious Conversations. I'm your host, Pierce Nelson. Every episode, we hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.

Joining me today is Dr. Jim Curran, who has served as dean and professor of epidemiology at the Rollins School of Public Health at Emory University since 1995 following 25 years of leadership at the Centers for Disease Control and Prevention. Dr. Curran is co-director of the Emory Center for AIDS Research and he holds faculty appointments in the Emory School of Medicine and the Nell Hodgson Woodruff School of Nursing.

In this episode, Dr. Curran discusses our nation's needs for the next generation of the public health workforce and how our universities, associations and employers are preparing individuals to meet those demands. Dr. Curran also discusses his work at CDC during the very early days of the HIV/AIDS epidemic, how far the world has come since that challenging time and the road to eliminate the disease. Welcome, Dr. Curran.

Dr. Jim Curran: Hello, Pierce. How you doing?

Pierce Nelson: Doing well, thanks for being here. You've had a long career in public health, leading early work on HIV/AIDS at CDC and now as the Dean of Emory University's Rollins School of Public Health. Tell us how you got your start and what sparked your interest in public health.

Dr. Jim Curran: I graduated medical school in University of Michigan at around 1970 and began what I thought was going to be a career in OB-GYN and reproductive health and family planning. As sojourn with the CDC at Memphis, Tennessee, for two years, in working on the complications of gonorrhea in women and the economic costs of that told me that perhaps public health was a better career for me.

CDC sponsored my career development at Harvard for two years. Then, I was assigned to Columbus, Ohio, where I was also an assistant health commissioner and an assistant professor at Ohio State to design our countywide STD control programs. I really got the public health bug and stayed with CDC, transferring then to Atlanta in 1978 to be chief of the research branch of the STD division.

Pierce Nelson: That's great. Now, you've been at Rollins for 25 years. Tell us a little bit, how has the school evolved during that time, both in terms of your students and the types of programs that are offered here?

Dr. Jim Curran: Our graduate public health programs are now about 40 years old, but we have become one of the largest schools of public health in the world with now 11,000 alumni and about 1,400 graduate and professional students, 205 full-time faculty working in a wide variety of areas in research and discovery in infectious disease, chronic disease throughout the world. We are very fortunate to have 250 adjunct faculty, many from the CDC itself but also from CARE and the Task Force for Global Health and the Carter Center in state and local health departments.

Pierce Nelson: You know, you bring up something that's very interesting. A lot of people maybe outside of the Atlanta area don't realize just how important global health is in Atlanta and what a center for global health we have here with CDC, with Rollins and with the organizations that you just mentioned. What about the research that's going on here at Rollins, with your faculty as well as with your students, what are they focusing on today? Is there something that you find particularly intriguing?

Dr. Jim Curran: I think that, we find that our faculty work in a large numbers of areas with lots of different methods and populations. We do have a very large center for AIDS research here at Emory with over 120 faculty working on 70 million dollars per year of projects throughout the world, both in the area of basic science as well as behavioral science and global health. As a matter of fact, two of the most commonly used antiretroviral drugs, emtricitabine and lamivudine, were invented here at Emory. Emtriva is a name for Emory, if you will, Emtriva.

We work a lot in global tuberculosis, influenza and infectious diseases. We have a lot of work going on with diabetes, cancer prevention, cardiovascular disease prevention. And finally, you have a center for opioid misuse prevention. Our faculty work in a large number of areas, I think, of great importance to the country and the world.

Pierce Nelson: Yeah, both chronic and infectious disease as you point out. Many people today believe that society is facing a public health workforce shortage in the United States. Do you agree with that? And if so, how do you believe we should address it?

Dr. Jim Curran: Well, I think that we are committed to helping fill that shortage with our students. Our students find themselves pretty rapidly employed when they graduate, which means that they have options to work throughout our health industry.

United States has about 18 percent of its GDP employed in health. That requires lots of people who understand population health in healthcare systems, hospitals, community organizations, nongovernmental organizations, as well as their traditional public health organizations like the CDC and state and local health departments.

There's a great need for people who can understand the efficiency of health and the important aspects of population health throughout our society.

Pierce Nelson: Do you feel like at this time that as you look ahead, do you feel like we will be appropriately staffed for the needs in the future with the workforce that we have in the pipeline right now? Or do you have some concerns as it relates to maybe states and state budgets and even federal budgets?

Dr. Jim Curran: Well, I think that there's always going to be tension with governmental budgets. State and local budgets are dominated by education and Medicaid spending and healthcare spending. There's tension at the federal level between balancing deficits, military budgets and domestic discretionary budgets. We have to keep on pointing out to people the importance of public health and the importance of reducing costs and saving lives and maintaining health in the United States.

It's quite disturbing that the life expectancy in the United States has not been going up in the last few years. We are almost singular among well-developed wealthy countries in having a decline in life expectancy. That should disturb all of us and make us look at public health approaches to change that.

Pierce Nelson: If you look at the public health workforce today and you compare it to the past, how does it look different and how is Emory helping to grow and strengthen that workforce for the future?

Dr. Jim Curran: I think we're getting to a point where people are understanding the importance of public health and the importance of population-based work. I can remember when I first came here as dean 25 years ago, most of the students would say their parents want to know what public health is, how do they come over here to study this? Now, I think, they can have conversations with their parents and with other people who understand the importance of population health, the importance of other things in society other than simply waiting to cure people, to prevent disease and to do this.

I think that that's an opportunity we have to take these kinds of principles of prevention, principles of understanding social determinants of health, principles of detecting early infectious diseases and chronic diseases and curing them before they become terrible burdens. Understanding the onset of new epidemics, whether it's pulmonary diseases due to vaping, whether it's new strains of influenza, whether it's Zika virus, and to jump on those right away to make a difference.

Pierce Nelson: I know that you're plugged in with CDC as well as with state and local health departments and nongovernmental organizations and nonprofits. What are the greatest needs that you hear from a human resource perspective to tackle some of these really challenging health threats that you've just spoken about?

Dr. Jim Curran: Well, I think there are going to be needs in the high tech areas everywhere, particularly bioinformatics, molecular biology and genetics. There's a lot of areas where there are new technological areas and there are going to be shortages in the workforce to deal with these. Many state and local health departments are greatly constrained by their budgets and by their salary levels. I think that it's important that citizens at these areas realize just how crucial it is to have highly-trained, excellent people in these areas.

Pierce Nelson: I'd like to take a turn for a moment if I could and go back to earlier in your career when you were at CDC, you mentioned that earlier on in our discussion today, at CDC you led the HIV/AIDS work and you were a pioneer really in the field of HIV/AIDS and one of the first scientists to recognize the infectious nature of the disease. Can you take us back to that time, 30 or 40 years ago? What were the greatest challenges that you saw at that time?

Dr. Jim Curran: Pierce, I'd love to do this. It's mixed memories for me with how much we potentially underestimated this epidemic and begin with. CDC likes to investigate epidemics which can be sort of gotten over with rather than turn into worldwide pandemics. Of course, whenever you're talking about the past and you're part of it, you have to recognize there's a bias. I take my inspiration from that famous book called A History of the Civil War: A Southern Perspective. So you have to always listen and try to get different opinions.

From 1978 to 1981, I was chief of research in STDs. Ronald Reagan had become president in 1981. There was high inflation, high unemployment. There was a hiring freeze at CDC and other parts of government. Parts of the public health service were being closed down and we had very little travel budget, but we had a committed workforce at CDC to respond to new emergencies.

We dealt with Legionnaires' disease and toxic shock syndrome in the past decade. When the first five cases of pneumocystis pneumonia were reported from Los Angeles among gay men, we immediately formed a task force and I was asked to be detailed for 90 days to work on that task force, which lasted about 15 years, actually, as it turned out.

I think the first thing we did at CDC that was so important was to develop a case definition of what we were studying. Preliminary investigations showed that they were not only these fatal, opportunistic infections, but also a very, very rare cancer called kaposi sarcoma occurring in young people. We were careful not to define this as a gay disease because what we'd wanted to do was find out who did get it? Was it increasing? Who was susceptible and who wasn't? And importantly, what caused this? We came up with a case definition that was very, very specific.

Now, each case, each person was so desperately ill and it was so unusual that any doctor that saw a case said, "Oh my God, I've never seen anything like this in my life." It was inevitably invariably fatal over a period of time. The case definition was very specific and it allowed us to point out in the beginning that the epidemiologic pattern was of increasing disease. Retrospective investigation said that we could find no cases before 1978. They were increasing rapidly and they were inevitably fatal.

Then we also could point out that there were certain patterns that not only were they sexually active gay men, but it looked like there were heterosexual injecting drug users who had this, sexual partners of injecting drug users, some of whom were women, some of whom were men. And then the breakthrough was that cases were occurring in persons with hemophilia. When that occurred and we investigated them very, very carefully... a physician named Dale Lawrence, a former EIS officer, spent weeks with each person with hemophilia. They had no other risk. They were no other pattern, but they receive blood from hundreds of thousands of donors with their clotting factor concentrates each year.

This was a pattern, which very much like hepatitis B, pointed to infectious transmission through sexual contact, through injecting drug use and through the blood supply. Soon after, there were other cases related to transfusions.

What this allowed us to do, I think, the first breakthrough was to issue prevention recommendations both for healthcare and laboratory workers who were very afraid of acquiring the disease themselves and also for the general public, through sexual contact, through avoidance of blood donation, as blood donors, and through needle sharing.

The prevention recommendations came out before the cause was discovered. And perhaps this series of investigations were the most important thing in the beginning that the CDC did.

Pierce Nelson: That's very interesting. I imagine it was a very challenging and scary time because you didn't know exactly what was happening, but you did have some idea of what was the effect of it. Of course today, we are at a different point. The discussion has changed from simply controlling HIV to talk of elimination and that's not just with HIV/AIDS but with other diseases as well. You encouraged by the focus on making elimination of HIV/AIDS a reality.

Dr. Jim Curran: There've been a lot of breakthroughs since those early days and they're balanced by a sober recognition of the extent of the problem. When the virus was first discovered, we could find out that the iceberg that we saw with the very sick people on top of the iceberg was matched by millions of people who had yet to become ill. And then once you were infected with HIV, you were infected with it for life. This has led to 40 million deaths throughout the world, and another 40 million people still infected with the virus chronically.

The breakthrough of the drugs that were discovered and the finding that Highly Active Antiretroviral Therapy by 1995 could lead to a fairly long and fairly normal life for people who could afford it and who accessed the drugs, gave us a lot of encouragement and encouraged President Bush and others with PEPFAR to expand these benefits to tens of millions of people throughout the world.

The question is where do we go from here and how can we make sure that all those tools that we have now, Highly Active Antiretroviral Therapy, can be applied to as many people as possible in the United States to prevent them from dying and to make sure they live as normal life as possible and also to prevent transmission to others? Because taking drugs, suppressing your viral load can reduce transmission to other people.

The challenge is to make these things available to as many people to reduce the number of deaths due to HIV. I think we should be able to say there should be no deaths due to HIV in the United States and that we should be able to provide these tools to everybody and eliminating these deaths should be an aspirational goal for us. We should be able to reach everybody, we should be able to make sure they have adequate health insurance to receive this. That we have adequate follow-up so that they can be on therapy. If there are other barriers to their being on therapy, perhaps drug abuse or mental health issues or lack of health insurance, we should address all of these barriers. I think the current president's commitment to assisting CDC and HRSA and others to do this, along perhaps with Medicaid expansion in many of the states where it needs to be done, would be very, very helpful to eliminating these deaths.

We still do, however, need additional scientific tools to help us eliminate and eradicate HIV from the world. One of these is curative therapy that eliminates the need for lifelong antiretrovirals and can then permanently do that, as we have with hepatitis C, curative therapy. Then we also need a safe and effective vaccine to prevent the billions of people who may be at risk in the future from acquiring this and a better pre-exposure prophylaxis approach, I think, would also be effective. There's a need to commitment to science as well as a commitment to use the tools we have to minimize transmission and to virtually eliminate deaths due to HIV in the United States.

Pierce Nelson: Dr. Curran, are there particular audiences that are harder to reach with HIV protection?

Dr. Jim Curran: Well Pierce, Dr. Sullivan and his prison research group here has worked with CDC on this particular issue, particularly with African-American men who have sex with men. It has been shown that while they have high risk of HIV, potentially, they are less likely to use pre-exposure prophylaxis, for example. His group has studied that, along with the CDC, to find out some of the reasons. Some of them are financial, some are related to trust, some are related to convenience.

They are doing studies to make this important intervention more accessible to the populations who are at greatest risk. This can be done through online apps. It can be done through, perhaps, other internet-based things or by having convenient clinic hours in places, for example, in Atlanta, near the MARTA station, where people can easily come and go and receive their advice.

It begins with learning what the barriers are and then addressing those barriers in a systematic way to make sure we can get reduced disparities in availability of important prevention tools.

Pierce Nelson: We'll be right back with Dr. Curran.

Since this is a show about Contagious Conversations, we want to hear from you. Each episode, we ask you a question. And this episode's question is about those who impact you and have the greatest influence. What's the best career advice you've ever received? We invite you to share your thoughts with us. Just email to answer. That's And if you answer the question, you'll have the chance to win some CDC Foundation merchandise.

Now, back to our conversation with Dr. Curran.

When you look ahead to the future of health in the United States, where do you see opportunities? Similarly, where do you see challenges?

Dr. Jim Curran: The whole focus of public health and of epidemiology involves taking a population perspective and looking into the future. I sometimes describe epidemiologic studies and epidemiologic methods to our students as the curse of vision. A lot of times, you can see where things are going and be very troubled by these trends, but you know they're going to happen. But that curse is also an opportunity.

When we look at populations, we see health disparities. Health disparities automatically mean that there are differences, by some populations are worse off than others in terms of health. That gives us an obligation to change that, but it's also an opportunity to find out why. A lot of those reasons why are the opportunities to improve health. That's part of the curse and the opportunities and obligations of the vision of looking forward.

As we look forward in the United States to what's happening and to the world, I think we have to maintain our Contagious Conversations and to think about the current threats of infectious diseases. HIV is not over. HIV has 40 million people in the world infected now with one or two million more each year becoming infected.

Tuberculosis is a major worldwide problem. There are some breakthroughs in dealing with tuberculosis, but billions of people have latent infection throughout the world and drug resistant TB remains a big threat.

Influenza is, in many ways, the scariest of all infectious diseases because of the way it rapidly can go around the world with new strains. I think we desperately need better vaccines for influenza and many people are working on that now, but that's very important.

We're going to see other new infections emerge. If you look at the history of CDC, it's kind of one after another. Ebola wasn't recognized until 1976 and its importance wasn't really recognized fully until the major West Africa outbreak. Now, it's continuing on in a threatening way. SARS, Zika virus, lots of other things keep occurring.

But if you look forward into the future of the planet and the future of the country, we see an aging world and that aging world tells us even more about the importance of chronic diseases. The good thing is that the world is getting richer and it's getting more able to care for itself and deal with a lot of these chronic diseases. Chronic diseases don't come alone. They hang out with each other and many people have more than one as they get older. That requires a healthcare systems and healthcare financing that can better facilitate the management of these things.

A lot of these chronic diseases are preventable. That's where CDC and public health comes in, to recognize that we need not get diabetes. We can prevent many, many cancers. Cardiovascular disease has been going down, but it should be more of a thing of the past. And even dementia itself is often related to the same risk factors as cardiovascular disease.

There are a lot of opportunities as we look forward to these as the future threats that can make the world a better place. We have to remember that we can't just accept the status quo. I can remember when I was young and my father was one of the 50 percent of men in the United States who smoked cigarettes. People just said, "Well, everybody does that." Well, we still have almost half a million people dying of cigarette-related diseases in the U.S., but cigarette smoking has plummeted to no more than 20 percent of the population, or even less.

We have to have the courage to constantly redefine the unacceptable. That's the way to improve the health of populations. I'm optimistic that we can do something about a lot of these problems. We're going to have an aging of the population. I'm personally convinced that I'm part of that. And as we age, and the younger people try to approach our problems, people in public health and people at CDC will be at the forefront of using the very best science and commit themselves to action to prevent health and disease.

Pierce Nelson: I'd like for you to put your dean hat back on again. What advice do you have for those who are thinking about a career in public health?

Dr. Jim Curran: Well, I think that the time has never been better to study public health and practice public health. Throughout the world, people are recognizing the importance of health. In any political conversation, you hear people concerned about health and concerned about healthcare.
People are recognizing that we shouldn't wait until people get sick to be concerned about their health. There are many other factors, whether it's diet, prevention of smoking, concerns about opioid use, the interactions of social determinants in health that impact how healthy our society is. That understanding and the opportunities to make a difference is for public health leaders and students of the future. I think there could not be a better time to study public health than now, except maybe in the future.

Pierce Nelson: Based on your experiences, you've talked about your work here at Rollins, you've talked about work at CDC. Can you discuss the role of collaboration and how that's made a difference in improving the field of public health?

Dr. Jim Curran: I think it's very important in public health to have partnerships. One of the things that I mention to our students is that one of their most important personal characteristics will be the ability to network. Now, great breakthroughs can be done alone in a laboratory, but in general, when you want to implement these breakthroughs, you need partnerships both with community organizations, the populations most affected, and industry who either develop or promote these things.

When you look at the history of AIDS, for example, we would be nowhere without working with the infected community, the gay community, minority communities and industry, the developers of the important pharmaceutical drugs and the governments, whether it's the U.S. government, with PEPFAR, state and local governments or governments of many of the countries where their citizens are most affected. In order to get this done, you have to be able to work together. You can't simply say, "Well, you're right and I'm wrong."

One example of how we do this at the Rollins School of Public Health is our Interfaith Health Center. The Interfaith Health Center recognizes that in Africa, for example, 30 to 70 percent of all health facilities are faith-based. Now, they might be faith-based in Catholic, they might be Evangelical, they might be Islamic, they might be Indigenous Religions. They don't agree necessarily about their doctrines and how to best reach the afterlife, but they have a very similar social gospel and social mission. They all want to improve the well-being of the people on the ground, in the cities, and you can bring them together around that mission. So instead of engaging people in their differences, you engage people in their similarities of mission. That's part of what public health is all about, working together to improve the health of populations.

Pierce Nelson: That's great. Well, thanks so much for your time today, Dr. Curran. We appreciate it.

Dr. Jim Curran: Thank you, Pierce.

Pierce Nelson: Thanks for listening to Contagious Conversations, produced by the CDC Foundation and available wherever you get your podcasts. Be sure to visit for show notes and bonus content. And if you like what you've just heard, please pass it along to your colleagues and friends, rate the show, leave a review, and tell others. It helps us get the word out.

Thanks again for tuning in and join us next time for another episode of Contagious Conversations.