Trailblazing a Path in Global Health with Lisa R. Hirschhorn, MD, MPH

• Hirschhorn is an expert in public health, implementation science, and HIV research. She grew up as the child of two physician-scientists, which profoundly influenced her career choice and curiosity in medicine.
• She began her medical career at Columbia University during the emergence of HIV and later ran the HIV medical care program at the Dimock Community Health Center for 15 years.
• Sexism in the field sometimes made Hirschhorn’s early years in the field a challenge, yet she found support in peer mentoring. She now mentors young women herself on the topic, including how to balance career and family life for women who want children. 
• As her career shifted towards global health, Hirschhorn took opportunities to practice in Zimbabwe and Malawi with a focus on improving the quality of care and access to treatment.
• Hirschhorn later worked at Ariadne Labs and Harvard Medical School, directing the Implementation and Improvement Science Platform. She worked with several colleagues and mentors who helped shape her views on global health and practices during this time.
• After 30 years at Harvard University, Hirschhorn moved to Northwestern University in 2016, with the aim of expanding collaboration and research in global health. Her projects in Africa, Central America, and other low-income areas now address a variety of global health issues.
• Hirschhorn advises young people interested in global health to “learn to listen and listen to learn” — to approach their work with passion, humility, and a commitment to sustainability.

[00:00:00] Rob Murphy, MD: 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. I'm delighted to have one of our own center directors and close colleague of mine on the show today, Dr. Lisa Hirshhorn. She's a physician scientist and global health leader with expertise in public health, implementation science and HIV research. Here at the Havey Institute, she is the director of the Ryan Family Center for Global Primary Care. Lisa is also Professor of Medical Social Sciences in the Division of Implementation Science and of Psychiatry and Behavioral Sciences at Northwestern University, Feinberg School of Medicine. Today, we're going to discuss her career in global health, her research, and how she's been a catalyst for advancing women's leadership in the field. Welcome to the show, Lisa.

[00:00:58] Lisa R. Hirschhorn, MD, MPH: Thanks so much, Rob. I'm absolutely delighted.

[00:01:01] Rob Murphy, MD: Let's start at the very beginning. You grew up on the East Coast as the child of two renowned physician scientists, Dr. Kurt and Rochelle Hirshhorn, who each made major contributions in the field of genetics. What was your childhood like and how did your parents influence your career choice to become a physician scientist?

[00:01:17] Lisa R. Hirschhorn, MD, MPH: Both of my parents were indeed physician scientists and were involved in what we now call early translational research. So they were bench to bedside and bedside back to bench. Many evenings, they'd come back with stories of problems that people didn't know how to solve and how research could then move things forward. So whether it was early genetic testing or understanding adenosine deaminase deficiency or more later, why there were children who were not doing well, which turned out to be some of the first pediatric AIDS. It's really driven me to sort of understand how can medicine help address some of the challenges that people were doing. Plus I thought it was very interesting. I did go a slightly different route because I was interested in infectious disease, not in genetics. But aside from that, I think really made me realize that I could do something to help move both knowledge as well as, health and well being of people forward.

[00:02:08] Rob Murphy, MD: You graduated from Harvard University and started medical school at Columbia University in New York City, right during the emergence of HIV. How did this timing impact your career trajectory? If you look at when I graduated from college, it was right around the same day as the first description of what we now know to be AIDS, in the CDC publications. And I came to Columbia planning to go into bench research, thought this was the way that one got to answers. And I still recall very distinctly some of the patients that I saw, even just as a first and second year medical student, but particularly third and fourth year, you know, their names still haunt me and their faces. The first person that we treated for pneumocystis pneumonia, one of the things that was killing people. I did a lot of my time at Harlem Hospital, which had very, very high rates of HIV and realizing the role and the importance of not just the research, but the clinical care. So it really started my shift from understanding bacterial pathogenesis, what made bacteria particularly nasty to thinking more about how to do HIV. And that really I think then informed where I chose to do my residency as well as then ultimately the field that I went into.

[00:03:17] Rob Murphy, MD: I understand that you ran the HIV medical care program at the Dimock Community Health Center for 15 years. Can you talk a little bit about Dimock?

[00:03:25] Lisa R. Hirschhorn, MD, MPH: Sure. It was very difficult to get off the path that you had chosen that you wrote about to get into medical school. And during that time, as a resident, and then as a first year fellow, I began to take care of more and more people with HIV. Half of the people coming in for care were people my age who were dying of HIV. Because remember, there was no treatment. And really began to think about, was this the right choice for me? I got an NIH grant, went to go work in a lab looking at the pathogenesis of why B. fragilis, bacteroides fragilis was particularly nasty, but also then spent a couple of months working in Zimbabwe. So this was in 1989 and really was just overwhelmed by the absolute need and so left the lab and luckily had somebody take pity on me and gave me a slot into a training grant, which is how I got my MPH. And at that point, really wanted to figure out how I could begin to do more clinical work in HIV. And was asked to --actually was my first moonlighting job to work at Dimock Community Health Center as their HIV clinician. They had probably about 5 or 10 people in care. They were one of the first recipients of the Ryan White Care Act grants to provide primary care for people living with HIV. And so that's how I started was working on Tuesday nights there. And then ultimately when I finished my fellowship looking at issues around disparities and quality for HIV care with Paul Cleary, one of my really sort of inspirational people at that point, ended up going to Boston city, but working halftime at Dimock and then ultimately moved to work there while I was still doing work with the AIDS clinical trial group. So I was doing phase one, phase two clinical trials, and then going back and working in the community and being really struck by the gap in access and knowledge of that community versus the people that were coming in for clinical trials. And again, that really sort of drove me towards figuring out how do we do research and clinical care to address some of these gaps and make sure that as these new innovations, which were coming out fast and furious at that point, were being accessed by everybody everywhere, which for me meant in Boston. Wasn't thinking global health at that point.

[00:05:28] Rob Murphy, MD: At this time in your career in the 1990s, you were also raising young children with your husband Bennett Goldberg. He is also now a professor here at Northwestern University in Physics and Astronomy. Can you tell me how you balanced your work and personal life during this time?

[00:05:42] Lisa R. Hirschhorn, MD, MPH: I had the privilege of having been raised in a two career family when that was not actually the standard by a mother who was one of the first tenured professors at NYU. And it was not easy for her. And remember some of the advice that she gave me about, you know, there's your work, there's your family, and then there's everything else and sort of choose two out of three. And luckily I married somebody who shared the vision of how to raise children with working parents. So a couple of things that I think were really critical. So the first was you know, having a partner that valued what I was doing. Finding good help that was probably something that I really learned from my mother because at that point I was doing a lot of clinical work. So this was before 1995 when we finally had some treatment that worked. So we're spending a lot of time in intensive care units, doing home hospice, Then was also attending, which at that point meant often you were not home for dinner. So really had to figure out how do you balance that? When my kids were old enough to understand, to bring them into what I was doing they would come and visit in the clinic. They got to meet and got to know some of my patients. You know, they went on the AIDS walks. And so, you know, having them understand what I was doing and why I wasn't home. So it wasn't easy. But again, if you have the privilege and the luxury of being passionate about your work it really helps when you leave in the morning, when there's somebody who's clinging to your leg and telling you not to go at that point. The other piece of advice that I got from somebody else was, if you can, live in a community where there's other two career families.And I was, again, lucky to have chosen a community that had a pretty strong dual career culture. We started a afterschool program, I was on the board of directors for that. And each of us had about 10 different people who were allowed to pick up our kids so that as you were racing home at six o'clock at night, cause you had to go and make a side trip to the hospital, there was somebody else who was raising your children. So it really was a community that got together to raise our kids.

[00:07:32] Rob Murphy, MD: You've said during that time that mentors were hard to come by. I'm quoting some past things that you've written particularly for women leading teams. You noted back then that women dressed in a more masculine fashion so as to signal their role. How did that experience shape you as a mentor and leader today?

[00:07:50] Lisa R. Hirschhorn, MD, MPH: No, I think it's a really important point. There were certain things that you weren't supposed to talk about. Like you weren't supposed to talk about that it was hard to raise your kids. You weren't supposed to say, it's five o'clock, I need to go because I have to go pick my kids up from daycare. That was really very much frowned upon. And similarly there would be, two male medical students and a male fellow and instantly everybody turned to them. And so you learn to sort of dress in a particular way, which showed authority. So a little bit more formal than you would expect. I didn't wear a tie, but I wore scarves all the time to the point where my patients used to give me scarves for the holidays. So I had, you know, buttoned down shirt with a scarf instead of a tie, always wearing pants or longer skirts and trying to sort of dress with some authority. It was difficult. Debbie Cotton was I think the first female mentor that I had. She was a junior attending when I was a fellow, now went on then to a strong career in HIV. But I think there was a lot of peer mentoring. So I was lucky to be with a group including people like Judy Currier, also went into HIV, Carolyn Block, who went into oncology who were residents and fellows with me. And so we shared how to move things forward, how to address harassment and other things like that. So I try to share this with the people that I mentor now, particularly if they are thinking about having kids or raising kids, you know, how do you make that type of balance? How do you find your voice? And be counted, be heard, and had some really fun experiences with people, you know, texting in the background about amplifying other people's voices. So I think it really is creating a community looking for mentors where you can and looking to your peers who can often provide really important insights. Later on, I had the honor of having a couple of other mentors who actually were, both of them were men, but were very I think able to recognize where people needed help. So one of them was Paul Farmer, now sadly left us almost exactly two years ago, who I worked with for a number of years and really was a great person to push one to sort of think outside the box and to be bold. And the other person, Atul Gawande, who I've worked for and with for four years, who remains now as a mentor for me in terms of getting me to think a little bit outside my comfort zone to be bolder, to take risks in what I do you know, academically, as well as , helping to continue to move forward.

[00:10:01] Rob Murphy, MD: In 1996, after we had a much more effective treatment regimen for HIV, we stopped seeing so many deaths and the hospital. I mean it was really quite dramatic between 1996 and 97.

 Can you tell me about that pivotal time?

[00:10:17] Lisa R. Hirschhorn, MD, MPH: It's really remarkable to think about that year. We were celebrating people's lives through their funerals you know, every month and all of a sudden it just, it really stopped. But we really had to switch in terms of, how do we focus on people's quality of life and viral suppression? And then went to the AIDS conference in Durban, which was the first time that the international HIV conference was held in a country in Africa, and was really very starkly reminded of where we had come from. Jerry Friedland, another person who worked at Dimock Community Health Center, sort of had each of us get up and say, okay, what are you going to do in the next year? You've been able to work to achieve this success in the U.S. and now we have this just unbelievable gap in terms of access. And so I was asked by an activist in Boston, if I would be willing to go to Malawi to help them write their guidelines. And I said, well, what do I know about that? You know, I only work at Dimock. He says , yeah, well, you work at Roxbury, resource limited setting. You worked in Zimbabwe for a couple of months. So why don't you come and do what you can do? And so I went there and helped them write sort of very simple ways of doing this and did some training, came back and somebody said, well, we're doing some work in Zimbabwe. Would you help? And I said, well, what do I know about Zimbabwe? And they said, Oh, you've worked in Malawi and I thought this is the, you know, in the land of the blind, the one eyed person. Andfinally, you know, between PEPFAR and Global Fund, there was the ability to get this really life saving care out to many more people. And so that's how I ended up in global health through probably the world's most vertical program through HIV.

[00:11:39] Rob Murphy, MD: After your time at Dimock Community Health Center you became the Director of Implementation and Improvement Science Platform at Ariadne Labs and Associate Professor of Medicine at Harvard Medical School in the Department of Global Health and Social Medicine, where you still serve as a senior advisor. Can you tell me about that move from directing a program at a non profit health center to what was a first of its kind innovation center and how your career transformed during that time?

[00:12:06] Lisa R. Hirschhorn, MD, MPH: It was definitely a leap and a little bit of a leap of faith. So, around 2006 or so, went to go work with Partners in Health and worked in Rwanda, Malawi, a little bit in Lesotho and in Haiti to really begin to dive deeper into how do we improve quality. And that's how I got into implementation research originally. And was still trying to figure out how do we accelerate change and went to go talk to Atul Gawande, because I'd read the checklist manifesto and was inspired by this ability of simplifying improvement. And he asked me to come work for him and really start this new platform. And the idea was how do we take these emerging methods of implementation and improvement science and apply them across multiple different areas, whether it was improving childbirth with the Better Birth Project, improving end of life care through the Serious Illness Project, improving surgery. And really gave me the ability to dive deeper into how do we take these methods? How do we teach them and move forward? So I gave up clinical medicine. It's something that I still miss. I still think it was, aside from being a parent, probably the most rewarding thing that I've done in my life. But I felt like at that point it was time for me to really focus on how do I help other people do their job better, improve better. And then building capacity in the countries where we were working to have other people take these methods and apply them, whether it was in research or in practice.

[00:13:25] Rob Murphy, MD: You've been a leader in improvement science and implementation, science and global health. Can you tell me about this interest and was there a particular experience that drew you into this work?

[00:13:36] Lisa R. Hirschhorn, MD, MPH: It was probably a couple of experiences, one of which is like how to go fast. But how to go fast with quality and equity, which I think is the challenge. And I remember one country I was working in where the minister of health sort of said, quality is important, but if it slows us down, I don't know if we can afford it. Moving forward with people like Margaret Kruk and the Lancet Commission and other people made us realize that we have to go fast and good at the same time. And so really trying to figure out how do we learn from people that are doing well, positive outliers, and how do we take that information and have people understand where the change is needed, whether it's at the national level for policy, the systems level, be it supply chain or staffing, and at the individual level, whether it's, competency or motivation to be able to make those changes. And how do we balance this need for local change with also this need to produce more generalizable and what I call actionable knowledge. And so I think that's where my real interest was from that and trying to think about how do we not just have one clinic do well, but have that one clinic do well and improve. And how do we better test the interventions? I mean, one thing that Atul has always taught me is that all the innovations that have been developed in the last century, how do we get them you know, everywhere to everyone. And so became much more interested in innovation of delivery rather than the development of innovations, I really, I think, transitioned to this idea about that the innovation we need now is in delivery and how do we make sure that, it gets to people and how do we learn from it more quickly and more efficiently to be able to spread that.

[00:15:04] Rob Murphy, MD: Let's move on to your arrival here at Northwestern University in 2016. What brought you here to Chicago from the East coast, and what were your goals when you arrived?

[00:15:15] Lisa R. Hirschhorn, MD, MPH: I grew up in New York city. We'd lived in Boston for 30 years. I was dyed in the wool North Easterner. And my husband actually had been in physics, was very successful doing research, but was really inspired to figure out how do we actually teach better. So really had made a transition from physics into innovation and teaching and learning and was offered a position as the director of the Searle Center here. And so was interested whether I was willing to move, you know, leaving Ariadne Labs, working with Atul and, And so we came to sort of poke around and see what it would be like. and was really convinced that it was a place that could really continue to expand and grow in implementation research, creating new collaborations. And so I think that was my hope was to see what would happen if I moved into a new place. A little scary, I've been at Harvard for, you know, 30 years. But what would it be like to move to a new environment, new collaboration, new city? And delighted that I came. 

[00:16:10] Rob Murphy, MD: Well, we're certainly very happy that you arrived. Your team is now working on a series of projects in Africa, also Central America, and some other low income areas across the globe. These projects don't solely focus on one theme, but rather tackle everything from eye health, hypertension, malnutrition. Can you tell us about what you're learning from such a vast range of global health issues?

[00:16:34] Lisa R. Hirschhorn, MD, MPH: First of all, thank you for giving me a home along with the department of medical social sciences and Bob Havey, shout out to him and the Ryan family for funding the center. You know, I had always done primary care and HIV, but not more broadly primary care. And one of the sort of great opportunities I had back when I was still at Ariadne Labs was working with an initiative called the Primary Healthcare Performance Initiative, PHCPI, which was really one of the first big initiatives to sort of say, look, we have to stop looking at just vertical programs. So instead of somebody is a person with HIV, it's a person who happens to have HIV and hypertension and other things as well. And so I think that's where it shifted my vision to how do we, you know, put the person in the center and then look across the lifespan. And it's been really fun for me because it allows me to learn from other people about content areas that I know very little about. A couple of examples is I've recently begun working with the NEST 360, which is a big initiative that you've been involved in to improve neonatal mortality in five countries now in Africa, which crosses from biomedical engineering to quality to, neonatal help. So on the other extreme have had the pleasure to work with the professor at University of Birmingham, Justine Davies on healthy aging. And so as a result of that, through the Institute and through my center, we've funded some work in Lagos to develop interventions to improve aging in primary care in that country. And then more recently through the Institute with one of the global innovation challenges to understand what are the challenges in Rwanda, a country that I've worked in for many years, who have succeeded in dropping under five mortality and reducing HIV but now are faced with the challenge that everybody, including here in the U.S, which is an aging population and understanding what are their needs and how do we move that moving forward? I find it fun. I learned something new every day. I partner with people who are experts in their field to really understand, how do we move care? How do we move treatment and how do we move research forward?

[00:18:27] Rob Murphy, MD: Let's talk about mentorship a little bit. And it is not only the importance , but how can it successfully be carried out, such as ensuring there is face to face and in person time. Basically, how can mentees and mentors alike achieve stronger bonds in this global virtual world?

[00:18:43] Lisa R. Hirschhorn, MD, MPH: It's a really important question that you ask and something that I spend a lot of time thinking about. And I think, it's evolved, which I'm very glad about from the concept that a mentee should aspire to become their mentor. It's really a concept of having a mentorship team so that you have multiple people who are providing care to somebody to listening to what your mentee wants to do, where they want to go and what their priorities are. And then sort of helping to design a mentorship approach that goes not just in their research, but also things like interpersonal skills and how do they do work-life balance and how do they prioritize what they need to do to move forward to sponsor them. So, you know, if I get asked to do something, how do I bring somebody along with me? And then I've learned an enormous amount from colleagues in other countries, because, you know, the Institute has had tremendous success in the D43s, the Fogarty funded research capacity building. And that's a really great opportunity to learn how to mentor people from very different backgrounds, very different settings, and also to train people in mentorship. So we've been working the faculty there to develop better mentorship training programs. Actually, it's probably the first time ever that Bennett, my husband and I have been able to collaborate together, which has been a lot of fun, you know, bringing some of his pedagogy skills to some of the work that we're doing there. But I think it is a really important thing. It's, as Paul Farmer used to say, sadly being true now, it was his retirement plan was how you actually do that type of training and mentoring to create the next generation.

[00:20:08] Rob Murphy, MD: You've also discussed the need for extending compassion to those with whom you work. That's a need often ignored in traditional settings. What is it about your research and your experience that has made you identify compassion as an important trait for mentors to have in your mission?

[00:20:23] Lisa R. Hirschhorn, MD, MPH: I think probably both my experiences, the lack of compassion that I've had from some mentors and then in exchange the compassion that I've had from other people, particularly from peers. And then I think probably the experience and the struggles that I've had, choosing this career and moving this thing forward and what's been painful for me. And then I think some of it really goes back to my clinical experience, which was really learning how to listen. I tell people you learn to listen and you listen to learn and what I learned from the people that I had the absolute honor of taking care of and what they taught me about resiliency, what they taught me about challenges. And how much just having somebody to listen with respect and with compassion meant something, and then to try to offer whatever advice you might be able to do, or to advocate for them to be able to reach out for other resources that might be available.

[00:21:11] Rob Murphy, MD: Final question, Lisa, and I ask this to every one of my guests. What advice do you have for young people who are just now embarking on a career and interested in global health?

[00:21:22] Lisa R. Hirschhorn, MD, MPH: I would say go into this as a partnership. Learn to listen and listen to learn. Don't go in thinking you have the answer but go in there and try to understand what are the questions people think are important? And then what is the role that you can do to help to move things forward? How do you think about learning as a bi-directional approach? You're not there just to, you know, to teach or to give, but to really share and to learn. How do you make sure that what you do is something that is sustainable? Not just a sort of two week project that then goes away as soon as you leave, but how do you fit into an ongoing process and environment. And that it's okay to start small and start slow to really be able to learn. You should be passionate about it. It's not easy to leave family, to leave friends, to go to new places, and that not all people who contribute to global health are people who go overseas, but that there's other people who are equally important. I'm going to make one further pitch, which is for primary care. So for people who are going into medical school or just finishing, you know, we desperately need stronger and better primary care here. I think there's an enormous amount that we can learn from the countries that we are partnering with. And so would also encourage people to be open to experiences to learn, not necessarily to go over and work in other countries, but to bring back those models of care, the approaches, whether it's using community health workers or task sharing or some of the other things that we're learning from other countries. But to think about that as you go over is, what can we bring back and how can that inspire people to meet the really growing gap that we have here in the U.S for primary care.

[00:22:51] Rob Murphy, MD: More great advice from Lisa Hirshhorn. Lisa, thank you so much for joining us today. We really appreciate you being here.

[00:22:58] Lisa R. Hirschhorn, MD, MPH: Thanks, Rob, so much for the opportunity. It's always great to talk with you.

[00:23:01] Rob Murphy, MD: Follow us on Apple Podcasts or wherever you listen to podcasts to hear the latest episodes and join our community that is dedicated to making a lasting positive impact on global health.